Spanner in the Works

I’ve just started maternity leave. I’ve been planning to update this blog for a while, but work has been consuming so much of my brain and time and baby stuff the rest that it’s been squeezed out.

But today when I was just starting to adjust to the new normal, I got an unpleasant surprise. The official email states:

Dear CMP Client

Due to unforeseen staffing circumstances, the Community Midwifery Program regrets that if you are planning a hospital birth (Domino), or if you are planning a homebirth and are required to transfer into hospital during your labour, your Community Midwife will be unable to remain with you and will hand over your care to the hospital staff.  When you are discharged from hospital, your Community Midwife will continue your care at home.

This arrangement will continue until further notice.

If you have any questions or would like to discuss this further please contact <name and number redacted>

Yours faithfully

Community Midwifery Program

I also got an email from my midwife who I subsequently phoned about it. I’ve been planning a Domino birth (as suggested by my midwife incidentally) and one of the main reasons I chose the CMP was because of the continuity of care. I’m very keen to be able to birth with someone I know, and this pretty much negates that. Coming a month out from my due date, it’s a big unpleasant shock.

I haven’t had a chance to meet the midwifery teams at the hospital I’m planning to attend (why would I when I have a midwife?) and my experiences with the obstetricians have left me less than impressed. They have been for the most part impersonal, uninterested and poor on the details. The last one didn’t even take my blood pressure and tested my protein levels only when I asked about it.

My biggest fear comes down to the BMI issue. I’ve been eating fairly normally throughout my pregnancy and putting on more weight in my third trimester (most of which is going to the baby who is now ~3kg). Despite being otherwise healthy, I’m getting close to those scary cutoffs and that’s when I weigh myself at home first thing in the morning. The scales at the hospital are less discriminating, especially later in the day and wearing clothes. I’m really afraid that I’m going to be packed off to King Edward hospital for delivery sans midwife and lose any autonomy over my birth because I happen to be a kilo over the cutoff if they insist on weighing me.

Tomorrow I have an appointment with the backup CMP midwife and then another appointment at the hospital. I’m going to discuss my concerns with the midwife (especially in light of my anxiety issues around the BMI issue) and see if there’s anything they can do. I understand that they’ve had staff leave, but I’d like to hope they feel some sense of responsibility for people who are already in the system. At the hospital, I plan to decline to be weighed. I’m mostly going in to find out if spudlet is still breech and to get an anti-D injection so I’m hoping they don’t push the issue.

If we aren’t happy after the conversation with the midwife, I might contact the CMP manager and discuss it with her. I’m half tempted to see if I can switch to a homebirth even though it wouldn’t be my first choice as I’d feel safer with that than at KEMH. It’s distressing to have to consider these sorts of things when I thought it was all sorted. In the meantime, I’ll be eating salad so I can try to fit within the stupid BMI restrictions. I can’t help feeling sad and angry that the system is letting me down like this.

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Too fat to give birth here

I’ve been sitting on this post for a fair while now to give myself time to settle down. I think it represents the most stressful thing in my pregnancy so far even including the high risk result. It still upsets and angers me a great deal to think about. When I found out I was pregnant, even before we got back from holiday, I started researching birthing options. The Department of Health site on this topic came up very quickly. After a bit of reading, the KEMH Family Birth Centre started looking like a really good option. It’s a midwife led centre which provides a comfortable and low intervention place to give birth but is also right beside the best maternity hospital in WA. When we got back and started planning visits to check out some options, it was at the top of my list.

It wasn’t until just before we went on a tour that I found out about their body mass index (BMI) limit. We did the tour anyway, it was an amazing place with lovely suites and a huge bath you can give birth in. It looked practically perfect from our point of view. We hung around afterwards to talk to the midwife and ask about the limit. Sure enough, she confirmed that the centre doesn’t take women with a BMI over 35. Furthermore, if their BMI goes over that limit at any point during their pregnancy , they will be bounced from giving birth there! At this point in my pregnancy I was about 12 weeks along and hadn’t gained any significant weight (+/- 1kg). I was just under the 35 cutoff. She told me that if I wanted to give birth at the KEMH birth centre I would need to not put on any weight during my pregnancy. She thought this was doable despite it being essentially a pretty steep weight loss diet.

At birth, the combined weight of the baby, placenta, amniotic fluid, extra maternal blood, breast tissue and other fluids is somewhere around 14kg. This is the amount of weight I would have to not gain while still getting enough nourishment to keep me and the fetus healthy. It didn’t sound feasible to me and I was concerned about the effect of watching my weight so strictly on my anxiety which was already beginning to get knocked around by the stresses of pregnancy.

So after quite a bit of anger and tears and consulting with my doctor, I decided to explore the option of the Community Midwifery Program (CMP). We decided after some more research and consultation to sign up with the program and give birth at Armadale Hospital via the Domino program. This means that our midwife will accompany us to Armadale hospital and provide continuity of care throughout and after the pregnancy. Ironically, despite being effectively turned away from the KEMH birth centre, I am eligible for a home birth if I want one because the BMI cutoff for the CMP is a measure of maternal weight prior to pregnancy.

The BMI issue has raised its head a few times since then. At one point, my midwife advised me that I was over the cutoff to have a water birth. This surprised Craig and I since we’d looked up the relevant policies (or thought we had) and it didn’t look like it would be a problem. I’m keen to have the option of a water birth and Armadale hospital has inflatable pools available for this purpose. That caused another emotional scene over stupid bureaucracy. We asked our midwife to double check the policy and fortunately it turned out she’d been looking at one which had been superseded and I can have a water birth if I want to.

I’m still extremely angry about BMI being used as a sole method of weight based risk stratification in pregnancy. I’m not going to go into the science of BMI here because there’s lots of information about it all over the internet (see here, here, here and here for some examples with varying degree of scientific rigour and readability). BMI can be a useful tool when used across populations, and a lot of dieticians and clinicians like it because it’s easy to calculate. When applied to individuals however, it can be extremely misleading. When using it as the basis of risk stratification (e.g. among pregnant women), it may fail to consider that some women are overweight and obese as a result of being unwell. This can skew both statistics and clinical experience of obesity.

I am obese according to medical definitions. I am also relatively healthy. My blood pressure and blood sugar are low, I’m reasonably fit (I walk an average of ~5km/day even in my 6th month of pregnancy). All of the risks that are supposed to be attendant on obese pregnant women have failed to materialise for me. I don’t have prenatal diabetes, it seems very unlikely that I will develop pre-eclampsia going by my blood pressure results. Also, my ultrasounds have shown spudlet to be in the 52nd percentile of growth for his gestational age meaning he’s bang on normal size. I see my pregnancy as low risk and don’t think my BMI changes that.

So why is BMI used in pregnancy? Especially when you’d be expecting women to gain weight as part of a normal pregnancy? It appears to be part of the increasing medicalisation of pregnancy which is predominantly coming from, surprise surprise, the United States (where medical care is big business). Caesarian section rates in the US and Australia have exceeded 30% of live births as more people see doctors for the birth of their children. Doctors/obstetricians view patients through the lens of pathology. Pregnancy and childbirth isn’t a disease, it’s a normal human process which like many processes can vary from person to person. Doctors however are trained to look for and treat anomalies. This can lead to a pathway of increasing intervention which more often than not results in a C section.

Don’t get me wrong, if anything goes awry with my pregnancy I intend to seek medical attention (and have done so to date). If something goes wrong during the birthing process, I’m not going to eschew medical treatment (including a caesarian if it comes to that). However I prefer not to borrow trouble. It concerns me sometimes that I’m being sent for so many extra tests based on my BMI (when by other measures I’m healthy) and I’m mindful that I don’t want any of this to snowball into unnecessary intervention just because a doctor who doesn’t know me or my medical history just wants to be extra careful.

I’m a person, not a number. I’m not stupid and I am capable of making decisions about my own health and that of spudlet. I am very glad that modern medicine exists, but I strongly prefer that medical decisions be made based on up to date evidence based research rather than out of date practices with little to no science to back them up. This is why I am, and will continue to be critical of the BMI as a individual measure of wellness.