Our Bodies, Ourselves (83 page)

Women considered overweight or obese are at increased risk for certain complications, including gestational diabetes, high blood pressure, a larger-than-average baby, and cesarean sections. Of most concern is the sky-high rates of cesarean sections. Many providers work under the assumption that being fat interferes with a woman's ability to give birth vaginally and that cesareans are necessary when women are obese. But other providers and activists question whether the high rate is medically necessary and believe that it is caused in part by misguided assumptions about obesity and by unneeded interventions and protocols commonly used with big women.

Cesareans involve major abdominal surgery and thus pose risks for women of any size. They are even more risky for big women. Obese women who have surgical births have higher rates of anesthesia problems, severe bleeding, and infections than non-obese women who have surgical births.
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If you are considered overweight or obese, there are things you can do to lower your chances of having a cesarean section. These include being proactive about your health habits, choosing a provider who is size-friendly, avoiding routine medical interventions during labor unless clearly needed, and not intervening when a big baby is suspected. (The fear of big babies is one of the strongest factors driving the high rate of cesareans in heavy women; however, having a big baby is not in and of itself a valid medical reason for having a cesarean.) For more detailed information, see “Women of Size and Cesarean Sections: Tips for Avoiding Unnecessary Surgery” at the Our Bodies Ourselves website, ourbodiesourselves.org.

Some studies find that one in six women is battered during pregnancy. Unfortunately, this figure may be misleadingly low, because many women do not report abuse—or even recognize that they are being abused.

Many women experience abuse for the first time during pregnancy. The stress of a pregnancy and jealousy over the baby may trigger violent or controlling behavior in a partner who hasn't behaved violently in the past. Abuse can involve any type of physical violence (slapping, hitting, shoving, squeezing, choking), sexual violence (forcing you to have sex when you don't want to or making you have sex in ways that are painful or make you feel bad about yourself), or emotional abuse (keeping you away from friends or relatives or saying things that make you feel bad about yourself).

Many health care providers do not notice or recognize the signs of abuse (bruises, depression, drinking to cope) and therefore fail to address it. But if you tell your care provider about the abuse, she or he can direct you to community resources that can help. You can always get help by calling the National Domestic Violence Hotline (thehotline.org) at 1-800-799-7233. This free, confidential service is available twenty-four hours a day, and translators are available for those who don't speak English. Hotline advocates can provide crisis intervention, safety planning, and information on and referrals to local domestic violence agencies in all fifty states.

For more information about partner abuse and getting help, see “Intimate
Partner Violence.”

The effects of previous sexual abuse may resurface during pregnancy and labor and after the baby is born. For example, you may feel invaded or violated during prenatal checkups, feel extraordinarily vulnerable in the midst of labor, or have unsettling flashbacks while nursing or bathing your baby. Try to find a health care practitioner who listens carefully to you—and with whom you feel comfortable enough to tell at least part of your story. Find a family member or friend to talk with, or a therapist if possible. Though having a history of sexual abuse may be emotionally difficult, with good support, pregnancy, birth, and motherhood can be empowering and healing, both physically and emotionally.
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Women with physical, intellectual, or psychiatric disabilities have the right to the same choices as women without disabilities.

However, you may encounter inaccessible facilities, insensitive practitioners, ignorance, or discrimination when attempting to get care. There have been limited research, data, and training about disability and pregnancy. Be prepared to advocate for yourself and to educate your health practitioner, or to find someone who can help.

People may try to talk you out of having a baby, unable to imagine how you could cope. Don't let their ignorance affect your decision. Asking yourself questions beforehand can help clarify your thoughts and wishes: Will pregnancy and birth put my health at risk? If so, how? Are there ways to lessen the risk? If my disability is genetic, how do I feel about the possibility of passing my disability on to the baby? Contact organizations that deal with your specific concerns.

© Britt Fohrman

Being in the hospital and experiencing the intense physical changes of labor may trigger feelings of vulnerability or helplessness. Remember that you are the expert about your own needs. Trust yourself to handle difficult situations and people, and ask for help. Make sure someone accompanies you to act as your advocate. You may want to tour the hospital or birth center in advance. You also may want to write a brief statement about yourself and include a paragraph describing how you want to be treated (for example, “Don't talk to me through my attendant/interpreter; talk to me directly”). Hand out copies to everyone so that you won't have to answer the same questions over and over.

If you have a chronic illness, you may wonder both how the pregnancy will affect the illness and how the illness will affect the pregnancy. Some chronic illnesses are unaffected by pregnancy, some may be made worse, and others may actually improve. If possible, arrange for a preconception consultation with a maternal-fetal medicine specialist or a physician with expertise in your particular condition.

Carefully choose the people who know you and your needs best to help you decide where you want to have your baby and who you want to be with you during childbirth. If your health care insurance plan doesn't allow you to make these decisions, try to meet all of the members
of the health care team who might care for you.

I found a diabetes educator who listened to me and helped me assemble a health care team. She encouraged me to learn more and be more involved in my care. I was started on insulin and a diet and given blood sugar goals and supplies
.

It was not easy, but I did it all—testing eight times a day, insulin shots five times a day, and the diet. I didn't have a baby yet, but I lugged a large insulated diaper bag everywhere I went. It was filled with my needles, insulin, log, meter, snacks, ice, and other supplies
.

I became an active member of the team who had a good idea of what was going on and even offered suggestions. I am thankful my body responded favorably to my efforts and I was able to keep hitting my goals without complications. After my son was born, it was scary to no longer have such intense support, but the knowledge I gained will allow me to continue to care for myself in order to care for him
.

If you are struggling with addiction to tobacco, drugs, or alcohol, it's important to get help. Some of us find added motivation to quit in knowing that our babies will be affected by our use. Finding treatment may also be easier, as federal laws require that Medicaid and most private insurance plans cover smoking cessation counseling and drug therapy for pregnant women.

The following resources can help you find the care you need:

• To find a smoking cessation program, call 1-800-QUITNOW, or go to smokefree.gov or quitnet.com.

• The U.S. Department of Health and Human Services' Substance Abuse Treatment Facility Locator (findtreatment.samhsa.gov) provides detailed listings of treatment programs near you, including their particular focus and forms of payment accepted.

• To find help if you are abusing alcohol, visit Alcoholics Anonymous (aa.org), Narcotics Anonymous (na.org), or Women for Sobriety (womenforsobriety.org) to find local groups and meetings as well as online support. All are free and guarantee anonymity. Volunteers can answer questions and help you get connected with support people, meetings, treatment centers, and other help. Even if alcohol is not the drug you are using, AA can connect you with a counselor or support person in your area who is familiar with the drug you are using.

Many pregnant women are afraid to seek treatment for alcohol or drug addiction. You may not know whom to trust or if by telling someone about your use you could get into legal trouble. Women with addictions deserve support and access to safe, affordable treatments—not punishment.

Most women who have given birth by cesarean section in the past can safely give birth vaginally in a following pregnancy, thus avoiding the complications associated with cesarean surgery. These complications include infection, excess bleeding, and problems associated with blood clots. Vaginal birth is also associated with an easier and shorter recovery than cesarean surgery. The risks of pregnancy and likelihood of problems during cesarean section increase the more C-sections a woman has had, so women who intend to have future pregnancies can reduce
the chance of problems by planning vaginal birth.

However, about one out of every four women who plans a vaginal birth after cesarean (VBAC) will have a cesarean because of problems that arise during labor. Cesareans that take place during labor are somewhat riskier than cesareans occurring before labor. In addition, a small number of women who plan VBAC—about 1 in 200—will experience uterine rupture during labor. Uterine rupture—a tear through the complete thickness of the uterus, usually at the site of a previous C-section incision—requires immediate delivery of the baby and surgical repair of the uterus to control bleeding. Although most women and babies who experience uterine rupture recover fully, studies show that for every 100 uterine ruptures, about 6 babies will die and 25 women will have hysterectomies (removal of the uterus). Overall, death of the baby during labor or soon after birth is very rare but slightly more common with planned VBAC versus planned cesarean.

Not every woman faces the same chances of experiencing harms and benefits. For instance, if you have given birth vaginally in the past, you are more likely to give birth vaginally and less likely to have a uterine rupture than women who have not. If your cesarean section was for slow progress in labor, your chance of giving birth vaginally is lower than if your C-section was for a problem such as fetal distress. You need accurate, unbiased information about
your
likelihood of various outcomes to make an informed choice. In addition, you must consider the risks and benefits of different choices within the context of your own life and priorities.

I hated the idea of recovering from surgery with a toddler in the apartment and a new baby to take care of, especially since my partner could only take a few days off of work. I also wasn't sure we were done having kids, and I was afraid of some of the complications you hear about with third and fourth C-sections. I'm so glad I was able to have a VBAC
.

Unfortunately, in the United States today, most women are discouraged from planning VBAC. As of 2009, half of hospitals in the United States
required
women with prior cesareans to consent to cesarean surgery in order to give birth there, and a large proportion of maternity caregivers are unwilling to attend VBACs, a clear violation of the right of informed refusal.
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In 2010, the National Institutes of Health convened a Consensus Conference to review all of the scientific evidence on planned VBAC and planned repeat cesarean and affirmed that both options have important risks and benefits and that VBAC is a reasonable and safe choice for most women.
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Several months later, the American Congress of Obstetricians and Gynecologists (ACOG) released a practice guideline encouraging greater access to VBAC and reaffirming women's right to autonomy and choice.
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Based on strong evidence, the guidelines recommend that most women with one or two previous cesareans receive counseling and be offered the choice of VBAC. These developments have paved the way for consumer advocacy to improve access to the full range of safe birth options for women with prior cesareans.

For more information about the advantages and risks of both VBAC and repeat cesarean section and how to advocate for the best care for either choice, visit Childbirth Connection (childbirthconnection.org) or the International Cesarean Awareness Network (ican-online.org).

Despite the stereotype that all pregnant women are glowing, for some women pregnancy is a difficult
time. Symptoms of depression include loss of pleasure in activities that you used to enjoy; persistent feelings of worthlessness, sadness, or hopelessness; prolonged periods of appetite change or fatigue; uncharacteristic tearfulness; or suicidal thoughts. It is possible to be depressed without actually having feelings of sadness. Though depression can affect any pregnant woman, it is more common in women who have experienced depression in the past.