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Even Before Pregnancy, Your Health Matters: Mom’s Obesity Linked To Higher Risk Of Baby’s Death

(Ernesto Andrade/Flickr)

(Ernesto Andrade/Flickr)

You know how it goes: The moment the pregnancy test is positive, you give up alcohol, you cut out coffee, you try to make every bite count and limit your weight gain to healthy norms. You’re suddenly responsible for two.

That’s the usual strategy. But new data suggest that perhaps it’s time to rethink that logic — it could be, by the time you get that pregnancy test result, you’re already late for the train.

Why? According to a recent study based on a sweeping analysis of more than 6 million births, there appears to be a robust link between a woman’s weight even before she gets pregnant and her baby’s risk of dying in her first year.

The numbers are small, but the researchers say they are significant:

Among normal-weight moms, about four in 1,000 babies die after birth; among moderately obese moms, that rises to nearly six babies per 1,000 and among morbidly obese moms, it’s more than eight babies per 1,000 live births.

(To be precise, “normal weight” for a 5-foot-4 tall woman before she’s pregnant is defined from 110-144 pounds; moderately obese is considered 175-204 pounds, and morbidly obese is 235 pounds or more.)

Obesity And Infant Deaths

Eugene Declercq, the study’s lead author and a professor at the Boston University School of Public Health, puts it this way: If you are truly obese, with a Body Mass Index of 40 or above before pregnancy, your baby has a 70 percent higher mortality risk compared with a normal weight woman. (This holds true even after controlling for a wide array of risk factors in the study, including race, ethnicity, education, insurance coverage, diabetes and hypertension, he said.)

“Since this involves pre-pregnancy obesity it emphasizes the importance of thinking of women’s health in general and not just when they’re pregnant, which has too often been the case.”

– Eugene Declercq

It’s the persistent association between BMI and infant mortality that makes the research compelling, Declercq said: As BMI increases above normal, the infant death rate increases consistently too.

“This links up women’s health and kids’ health in a really important way,” Declercq said in an interview. What it suggests, he adds, is that pre-pregnancy BMI still had a pretty strong relationship to both neonatal mortality (death in the first 28 days) and post-neonatal mortality (death in the first 28-365 days). “No matter how you cut it, that relationship is robust.”

The researchers also wondered whether pre-pregnancy obesity was related to a specific cause of death: notably, prematurity, congenital abnormalities or SIDS. As it turned out, obesity was a problem in all of those categories.

“The really powerful finding would have been if all of the higher rates of infant mortality were explained by a single cause of death, but that wasn’t the case here,” Declercq said. “The implication, essentially, is it’s not one thing we have to worry about — obesity is a multifaceted problem in terms of outcomes.”

An ‘Alarming’ Rise In Obese Women

And clearly, the implications are broad. The American College of Obstetricians and Gynecologists recently reported an “alarming” increase in the number of obese women of reproductive age in the U.S.: More than half are overweight or obese.

“A major hope in initiating this project was to get the focus on women’s health throughout her life course and not just when she’s pregnant,” Declercq said.

Lizzie, a 32-year-old chiropractor in Medford, Massachusetts, who asked that her last name not be used, says although she’s not obese, she’s definitely above her ideal weight.

Recently, Lizzie’s ob-gyn told her that if she wants to get pregnant (which she does), losing 10 to 20 pounds would be a good idea. “Even though I knew it intellectually, it was very hard to hear,” Lizzie said in an interview. “What bothered me the most was she said it but didn’t give me anything else, she didn’t talk about what I should do, no specifics about exercise or nutrition.”

With a family history of diabetes and a sister who had gestational diabetes during pregnancy, Lizzie says she’s trying to lose weight before conceiving, but it’s not easy.

“I desperately don’t want to repeat what my sister went through,” she said. “But it’s been a challenge … I’m a big sugar person — that’s my downfall, and a daily struggle.”

A Fraught Discussion

Actually getting women to lose weight before they’re pregnant is far easier said than done, says Dr. Naomi Stotland, a co-author of the recent Declercq study, and an ob-gyn at University of California San Francisco.

About half of pregnancies are unplanned, she says, which makes it hard to get the message across at the right time.

In addition, says Stotland, also on the faculty at San Francisco General Hospital, pressuring women to lose weight can be tricky for both doctors and patients. “Even if a physician is motivated to talk about it, the woman might not be in the right place to hear it.” she said.

For example: If a patient has an appointment to get birth control, it may not feel appropriate for the gynecologist to say, ‘Hey, maybe think about losing weight for that future, theoretical birth you’re not planning to have any time soon,’ she said. Also, doctors’ own issues about weight complicate the matter: Thin doctors often feel awkward and non-compassionate urging patients to slim down, and overweight doctors feel they have little credibility, Stotland said.

A small 2010 study of pregnant overweight and obese women, called “What My Doctor Didn’t Tell Me,” concluded that women often don’t feel their doctors are providing appropriate or helpful (or any) information on weight.

A Too-Accessible McDonald’s

And the complications only increase when poverty is also in the mix, says Dr. Nidhi Lal, a primary care doctor at Boston Medical Center. She says in her practice, which includes hundreds of reproductive age women, with about 30 to 40 percent who are overweight or obese, access to healthy food is a major obstacle because many live in so-called “food deserts” where nutritious food is scarce and fast food and convenience stores proliferate.

“McDonald’s and Dunkin’ Donuts and 7-11’s are more accessible and affordable than shopping at Stop and Shop or Market Basket,” Lal said.

She said there are often deep misconceptions about food and pregnancy. For instance, some women assume that they need to start eating for two as soon as they start planning a pregnancy. “And these are women who are already overweight to begin with,” she said.

And there are cultural issues too.

“Women who are raised in the U.S. want to be thin, but they don’t always have the resources to get there and so they’re reluctant to talk about body weight,” Lal said. “They think I’m judging them or not being empathetic.” Women from certain other cultures, she says, prefer being heavy: “It’s a sign of attractiveness and prosperity.”

For doctors, then, it’s a tough path to navigate.

“It really requires a relationship of trust, a very non-judgmental kind of communication,” Lal said. “I try to make my patients well informed, tell them as many facts as I can: ‘This is why I want them to do this and how it can effect their pregnancy outcomes’ — a mother will do anything for the her baby. I try not to be negative, and say, ‘Oh no, you gained weight.’ It takes a lot pre-visit planning.”

Lal also tries to get her whole medical team involved, including consults with a nutritionist and prenatal nurse. Still, she adds: “It is hard to do everything in an empathetic manner in 15 to 20 minutes because despite what you say, they have their own sense of success and failure. Some are very discouraged because they are doing what they can but some things they can’t control.”

But the problem isn’t going away. A slew of recent studies suggest that obesity before and during pregnancy can cause enduring health woes.

A study published in January found that children born to mothers with a combination of obesity and diabetes before and during pregnancy may have up to four times the risk of developing autism spectrum disorder compared to children of women without the two conditions.

And late last year, the American College of Obstetricians and Gynecologists, calling obesity the “the most common health care problem in women of reproductive age,” issued new recommendations on obesity and exercise during pregnancy. It cited a list of problems associated with obesity mainly during pregnancy, including a higher risk of miscarriage, premature birth, stillbirth, birth defects, cardiac problems, sleep apnea, gestational diabetes, preeclampsia and venous thromboembolism, or blood clotting in the veins.

‘I’m Just A Fried Clams Girl’

But telling women to change their personal behavior in an across-the-board manner sometimes gets public health officials in trouble.

For example, there was a massive backlash against the Centers for Disease Control and Prevention when, earlier this year, it issued a blanket warning that sexually active woman of childbearing age and not using birth control should stop drinking alcohol — completely.

So, hitting the right tone when it comes to talking to women about their weight is key.

“Conveying the message is tricky since I wouldn’t want it to be another case of blaming mothers,” Declercq, the researcher, said. “Since this involves pre-pregnancy obesity it emphasizes the importance of thinking of women’s health in general and not just when they’re pregnant, which has too often been the case.”

Interestingly, his study, published online last month in the journal Obstetrics and Gynecology, also found that established recommendations from the Institute of Medicine on weight gain during pregnancy were largely not being followed. Those recommendations suggest that obese women limit weight gain to between 11 and 20 pounds during pregnancy, regardless of the severity of the obesity. However, there was essentially the same infant mortality risk among obese women who followed those guidelines compared to those who didn’t, the study found.

That finding raises several questions: Do the guidelines need rethinking? Or is there something about the genetics of obese women that persists through pregnancy even if some amount of weight is lost?

This study didn’t address those issues, but one thing is clear for any future public health efforts: Women remain far more motivated if they think they’re doing something for their babies, Declercq said. The trick is to get them to think about their own health as deeply as their kids’ — and well in advance.

Take Amy, a mom from Arlington, Massachusetts, who gave birth to three children through IVF (and also asked for confidentiality). Between pregnancies, she says, it got harder to lose the weight. Now, while considering a fourth child, she says she should lose about 22 pounds.

Like many moms, Amy is vigilant about feeding her children healthy meals, but when it comes to her own diet: “I can’t overcome my cravings for meatball subs…I don’t really enjoy eating a salad.” She said that while some people find pleasure in “racing cars or smoking” her downfall is high calorie foods. “You know what you’re supposed to do, but actually doing it is the hardest part,” she said. “If I have the choice between romaine lettuce and fried clams? I’m just a fried clams girl.”

Culture Clash: U.K. Embraces Homebirth As Best For Some Women

Sarah Parente shortly after the homebirth of her daughter Fiona (Courtesy of Leilani Rogers)

Sarah Parente shortly after the homebirth of her daughter Fiona (Courtesy of Leilani Rogers)

By Jessica Alpert

Sarah Parente, an Austin, Texas-based doula and mother of four, gave birth to her first child in the hospital with no complications. But then she decided to make a shift: Parente delivered her next three babies at home. “For women with low-risk pregnancies, home birth can be a great choice,” she says. “You have less stress because you are in your own home surrounded by a birth team of your choosing.”

Though home birth has recently gained cache in the U.S. — with some celebrities trumpeting the benefits of having their babies at home  — the practice remains uncommon and the majority of pregnant women give birth in a hospital setting. Still, Parente may be getting a little more company, albeit slowly. Data released by the Centers for Disease Control (CDC) earlier this year shows the rate of homebirths in the U.S. has increased to 0.92 percent in 2013 and the rate of out-of-hospital births (including home) has increased 55 percent since 2004.

Experts in the United Kingdom are saying that’s a good thing.

The London-based National Institute for Health and Care Excellence (Nice) recently released recommendations that homebirths and midwife-led centers are better for mothers and often just as safe for babies as hospital settings, the BBC reports. Of the 700,000 babies born in England and Wales each year, nine out of 10 are born in obstetric-led units in hospitals. Continue reading

True Birth Wisdom: 10 Pearls You Won’t Find In Your Pregnancy Guide

(Wikimedia Commons)

(Wikimedia Commons)

Any pregnant woman wants a how-to manual on her nightstand — and for good reason. But for all their usefulness, books like “What to Expect When You’re Expecting” can’t speak to the infinitely intimate, lived experience of labor and delivery.

As Dani Shapiro puts it in an essay that’s part of a new anthology, Labor Day: True Birth Stories by Today’s Best Women Writers, “the inner life of a woman about to give birth is a world textured and complex and all its own.”

Here, editors Eleanor Henderson and Anna Solomon share 10 lessons taken from these writers’ harrowing and sometimes hilarious stories, which range from delivering twins to a 10-pound baby, from scheduled C-sections to a birth in the back of a car.

1. Your birth experience is unlikely to match up with your birth “plan.”

Julia Glass (courtesy)

Julia Glass (courtesy)

Even when labor and delivery go smoothly, there will be bumps, surprises and probably setbacks you didn’t imagine. Julia Glass looks back on the birth of her second child and sighs: “I should have known better than to make any plans.” But if you can be open to what you or your baby wind up needing, you may find your laboring self far more flexible than you imagined. As Susan Burton, who wanted but didn’t get a drug-free birth, puts it, “the IV fluids I hadn’t wanted were better than ice chips.”

2. Choice can be empowering. But it can also paralyze you.

We’re lucky to live in a time and place of such endless options, but the options can be overwhelming –and can often come to feel like ethical and political choices. As Marie Myung-Ok Lee writes: “People espoused breathing techniques, epidurals, the Bradley Method, the narcotic Stadol, doulas, a morphine drip. Each person’s feedback took on the fervency and faith of a Moonie wedding; it was thus hard to know what was ‘normal.’ You have to get an epidural. Don’t get an epidural; they cause C-sections. Make sure you––” Try not to let the chorus drown out your own voice. What do you really want?

3. Understanding what your body is actually doing during labor really can help — if not with the pain, then with the fear. Continue reading

What If Autism Risk Could be Diagnosed At Birth?

(Illustration: Patrick Lynch, Yale University)

(Illustration: Patrick Lynch, Yale University)

By Karen Weintraub
Guest Contributor

In what might ultimately be a game-changer for managing and treating autism, Yale researchers report that they can now identify kids at risk for autism right after birth — instead of waiting until they’re diagnosed at age 3 or 4 — by examining their mother’s placenta.

Harvey Kliman, M.D., a research scientist in the Department of Obstetrics, Gynecology & Reproductive Sciences at the Yale School of Medicine, says he is able to make such a determination by looking for abnormal folding in the newborn’s placenta – the organ that feeds the baby during pregnancy. Kliman’s study, based on examining 217 placenta samples, is out today in the journal Biological Psychiatry.

By finding these children early, the hope is that they can begin aggressive therapy that will compensate for any behavioral, social or communications difficulties they would otherwise have had.

“Now we have something that can flag children at birth,” says Kliman, a placenta expert and lead author of the study.

A Child With Faulty Folding

Chris Mann Sullivan is a believer.

Sullivan, a longtime autism behavioral therapist, sent her newborn daughter Dania’s placenta to Kliman three years ago because she thought she might recommend the analysis to her clients and wanted to try it herself.

Kayla and Dania Sullivan (Photo: Chris Mann Sullivan)

Dania Sullivan, at right, was flagged at birth for being at risk for autism. Her older sister Kayla does not have the condition. (Photo: Chris Mann Sullivan)

To her shock and horror, Kliman saw evidence of this faulty folding in Dania’s placenta.

Once she recovered from her surprise, Sullivan began to try the therapies she knew so well on her own child, adapting them for Dania’s young age. Sullivan, of Norman, NC, describes her approach as intensive, “really, really good parenting.” Instead of letting tiny problems resolve themselves, she addressed them aggressively.

As a baby, when Dania, would only look and roll in one direction, Sullivan started encouraging her to use the other arm.
When the child didn’t intuitively understand facial expressions, Sullivan spent hours showing her pictures of familiar people smiling. And when Dania, who had asthma, began getting sick a lot and couldn’t seem to bounce back, Sullivan started giving her preventive nebulizer treatments every time she came in from playing outside.

Last summer, when Dania, now 3, didn’t want to stay in a wet bathing suit, her mother quickly changed it – and then regretted it when Dania’s reaction escalated into a fear of anything wet.

“You would have thought the world would have ended the first time we did not put on a dry bathing suit,” said Sullivan. But now Dania is over her aversion. “We pushed through it. Pushing through it with little kids is a lot different than pushing through with an older child.”

And that’s why it’s so important for parents to know that their child may need extra help at the very beginning of life, rather than waiting for counterproductive patterns to get established, Continue reading

Mass. Teen Birth Rate Hits Record Low; Black Infant Mortality Tops Whites

WBUR’s Martha Bebinger reports on new data released by the state Department of Public Health:

Seventeen out of 1000 teenagers in Massachusetts had a baby in 2010. That’s half the national average. Patricia Quinn, director of the Massachusetts Alliance on Teen Pregnancy, says teenagers today do a better job with contraception than did their parents.

 (kristaguenin/flickr)

(kristaguenin/flickr)

“That’s not a message that adults wrap their heads around on a regular basis that young people could be doing more right than we did when we were teens and that is definitely the case when it comes to teen pregnancy and sexual behavior,” Quinn said.

Quinn says state figures out today also shows that teen abortion rates have declined 68% since a peak in 1989. And teen births rates are at a record low.

Black babies continue to a have much greater chance of dying before their first birthday in Massachusetts as compared to white infants….

The Public Health report says the black infant mortality rate is almost two and half times that of white infants. The gap has been higher, but health leaders say the numbers are still unacceptable. Department of Public Health interim commissioner Lauren Smith.

“This just remains a call to us to focus even more intensely on the health of women of childbearing age before they even become pregnant,” Smith said.

Pregnancy Dilemma: Premature Delivery Or Risk Of Stillbirth?

This is like a card game with the highest stakes in the world, I thought as I read Boston-based science writer Eugenie Reich’s harrowing story of the choice she faced when she was carrying a fetus whose growth was badly lagging. It’s on Slate: “When is it right to let your unborn baby die?”

Pregnancy can be full of dilemmas that require you to weigh the odds. Do you have an invasive genetic test even if there’s a small chance it will cause a miscarriage? If labor is progressing poorly, do you have a Cesarean section?

But I had never before heard of the either-or that confronted Eugenie: She could choose to deliver early, very early, and her child would face all the likely complications and disabilities of extreme prematurity. Or she could continue to carry the fetus, thus risking a high probability of stillbirth.

eugenie reich

Boston-based science writer Eugenie Reich

I wince at the very thought of it: Every day you keep the fetus in, you increase the child’s chances for a less-disabled life, but you also risk losing the pregnancy altogether. It’s quality of life vs. risk of loss. Every day is a roll of the dice, or maybe poker is the better metaphor: Do you hold or do you fold?

I don’t think it gives away too much to say that Eugenie chose to remain pregnant, and embarked on an exploration of the world of other women who made similar decisions — but who don’t usually talk or write about it except in anonymous online exchanges. Continue reading

Globe: C-Section Rates Reflect Hospital Subcultures

A doctor wonders how to stop the relentless rise in c-sections


Dr. Adam Wolfberg, an obstetrician at Tufts Medical Center, has an insider’s insight into the factors that make a hospital’s Cesarean-section rate high or low.

He does a wonderful weaving job in the latest Boston Globe magazine: from his own patient in a tricky delivery situation; to Cambridge Hospital, where the C-section rates are among the lowest in the state; to Holy Family Hospital in Methuen, where the rates are high. Some of the cultural and logistical factors that influence the rates may surprise you. What surprised me even more was this striking scene from a conference, given how much hand-wringing we tend to hear about C-section rates:

At a recent Las Vegas conference on obstetrical safety, some 125 members of the audience were asked to raise their hand to indicate their personal C-section rate. “Less than 15 percent?” the speaker asked. Two hands in the large auditorium went up. “Fifteen to 30 percent?” Half the hands were up. “More than 30 percent?” The rest. Then the speaker asked the room, “How many of you care?” No one raised a hand, and the room broke out in laughter.

 

 

First Live Birth Inside An MRI

I figure anything that makes me say “Ullp” out loud is worth posting…Fortunately, the video of the world’s first live birth inside an MRI scanner is really quite tasteful — and I’ve rarely seen such a good illustration of just how much of the mother’s body the baby takes up. This from cnet.com, and the full report is here:

Props to the woman in Germany who this morning became the first ever to give birth inside a magnetic-resonance imaging scanner.
Yes, the prototype scanner was built specifically for labor, and MRIs have been deemed quite safe. But the woman still had to give birth inside one, not to mention wear earmuffs to block out the high-frequency noise. (To protect the newborn’s hearing, the scanner was switched off as soon as the amniotic sac surrounding it opened.)
Woman and baby are both fine, according to gynecologist Ernst Beinder at Berlin’s Charité Hospital, who tells the Daily Mail that the birth was normal and the scanner captured all movements and processes throughout labor: “‘We can now see all the details we previously could only study with probes,” he says.