Saving Babies’ Lives

Repeating a scare — no matter how often or how loudly — won’t make it true. Once again, fat women are being meanly frightened by news their bodies could cause their babies harm.

In the news, a new government report is said to have found that rising levels of obesity could be contributing to rates of stillbirths in the UK. The same source used by the news last year to claim obesity contributed to mothers dying in childbirth is now being used to scare them about their babies’ safety. It wasn’t true last year and it isn’t today. But the misperceptions are the same, so let’s start by looking back at what we learned about the women in the report last year.

The Confidential Enquiry into Maternal and Child Health (CEMACH) just issued its report, Perinatal Mortality 2005: England, Wales & Northern Ireland. This report examines the perinatal outcomes in 2005 among women in Britain, just as the CEMACH had done for its Saving Mothers’ Lives report, examining maternal deaths. As you’ll remember, the most striking things in this report were its heartbreaking examinations of the hardships and suffering among the most disadvantaged women in our society. It had found that the most significant underlying factors for women with high-risk pregnancies and who died in childbirth were social and economic deprivations.

Extremely higher rates of maternal deaths were seen among immigrants and refugees, who were often in poorer health and suffering from medical conditions, such as HIV and TB; among minorities, with Black African women, including asylum seekers and newly arrived refugees, suffering mortality rates nearly six times those of White women; women living in poverty and those receiving less or late prenatal care had more than 7 times the risks of dying, with 5-fold higher rates of death and high-risk pregnancies seen among women living in deprived areas of the country; and higher deaths among victims of domestic abuse denied access to prenatal care. A total of 1.5% of maternal deaths, alone, were due to women who had had genital mutilations that hadn’t been recognized and repaired prior to delivery.

And among all of the direct causes for maternal deaths, the report found that 64% were among women who had received substandard care, especially seen among the heaviest women.

This report had found no substantiation for blaming obesity. Nor did its own data show obesity was a growing problem among women in the UK. In 2005, 21.9% of women of childbearing age had BMIs>30. This compared to 23.5% in 2001 and 21.2% in 1998. [Data also used in this new report.] Despite the fact that focusing on obesity, for which no known effective intervention exists anyway, would do nothing towards helping to lessen and prevent the needless suffering and deaths for these women and their babies, the CEMACH “selected obesity in pregnancy as its principal [sic] project with a maternal health focus for 2008-2011.”

The new perinatal report

This new report on 2005 perinatal outcomes also pulled from the same CEMACH database compiled from notification forms and surveillance activities on women and babies in Britain.

Before needlessly worrying mothers-to-be, it’s important to keep this report in perspective. As Professor Ian Greer, Chairman of the CEMACH National Advisory Committee wrote in the Preface, while the loss of a baby is a devastating event for any parent, “the perinatal mortality rate remains low.” From 1954 to the mid 1990s, stillbirth and neonatal death rates in England and Wales fell steadily. Since then, neonatal mortality has continued to drop slightly, while stillbirths have largely remained unchanged, according to the report. The stillbirth rate was 0.56% in 2000-2004 and was 0.55% in 2005. The neonatal mortality rate was 0.35% in 2005 compared to 0.37% in 2000-2004. Late fetal losses dropped dramatically from 2,764 in 2003 to 1,102 in 2004.**

The actual findings, unlike the media spin, found no support for blaming obesity. In fact, the report notes that the rates of stillbirths among women of various BMIs are similar in proportions to their representation in the population of women of childbearing age, but records didn't allow for more definitive conclusions. Most late fetal losses, stillbirths and neonatal deaths occur among women who make up the bulk of the bell curve (BMIs 18.5 – 24.9).

Instead, the exact same social and economic deprivations were described and found to be most related to poorer outcomes for the babies, just like for their mothers.

Social deprivation accounted for over one-third of all stillbirths and neonatal deaths in this report. The most deprived women had about twice the rate of stillbirths (0.62%) and neonatal deaths (0.38%) as the least deprived women (0.35% and 0.17%, respectively).

Minority women in England had significantly higher rates of stillbirths and neonatal deaths — among all Black women stillbirths totaled 4.23% of total births — 9 times those of White women at 0.48%; stillbirth rate among Pakistani women was 1.2%; and among Indian women was 0.96%.

Most of the deaths among the babies were to those born premature or weighing less than 1500 grams, and higher rates were also seen in mothers who were teens or over 40 years of age. While the causes for most stillbirths are never found, among the most commonly recognized are birth defects and chromosomal abnormalities, which account for up to 20% of stillbirths. Placental problems are believed to cause another 10-20%, the most common being placental abruption. Other factors are poor fetal growth (intrauterine growth restriction), infections (such as listeriosis or paraovirus), umbilical cord accidents (as many as 15% of stillbirths, alone), street drugs, trauma and accidents, and about 10% are related to poorly managed medical conditions such as preeclampsia and kidney disease.

When the disparities of stillbirths among more than 10 million births in the U.S. were examined, using the CDC National Center for Health Statistics data, lack of prenatal care was found to be the most significant factor, in both non-risk and high-risk pregnancies. “Lack of prenatal care increased the (adjusted) relative risk for fetal death 2.9-fold in blacks and 3.4-fold in whites. Blacks were 3.3 times more likely to have no prenatal care compared with whites,” the study concluded.

While it appears currently popular to blame obesity for just about everything, if the health of women and their babies were really the primary concerns, then we’d be looking at things we can do that might make a real difference. And those aren’t always the easiest or most comfortable issues to confront, such as socio-economic disparities and access to early and quality prenatal care. Professor Jason Gardosi, director of the Perinatal Institute, for example, recently presented the results of a ten-year study of stillbirths in Britain and estimated as many as 1,000 a year might have been avoided had the early danger signals been recognized and the women received appropriate medical care. He and professor Sabaratnam Arulkumaran, the incoming president of the Royal College of Obstetricians and Gynaecologists, were part of a story noting a need for better trained prenatal and delivery care personnel, adequate staffing levels, and more resources directed towards prenatal care to help improve outcomes. Not for blaming mothers for their figures.

So, even if the most socially disadvantaged women in certain population studies may also happen to be fatter, that correlation does not make fat the cause. Blaming their fat is unwarranted and needless. As was recently seen, in more than 19,000 pregnancies from 2000 to 2004 seen at Kaiser Permanente Northwest healthplan, there was no difference in stillbirths related to obesity. The most “extremely obese” women had the very same stillbirth rate (0.6%) as the “normal” weight and “overweight” women.

The news

Reading the media reports is almost a moot point, but now you may read it more critically and see a very different story than you might have without the facts:

Obesity linked to high stillbirth rates

Rising levels of obesity could be contributing to the rates of stillbirths in the UK, a new study has warned today. [The study actually urged caution in making conclusions about obesity.]

The Confidential Enquiry into Maternal and Child Health (CEMACH) found that the stillbirth rate in England, Wales and Northern Ireland is not decreasing, with 5.3 babies out of every 1,000 births being stillborn in 2006. Women who had a stillbirth were found to be more likely to be aged below 20 or above 40; from deprived circumstances; or from an ethnic minority. Over a quarter (26 per cent) of the mothers who had a stillbirth and 22 per cent of mothers who had a neonatal death were obese... [By mentioning these facts together, we are to assume that obesity was shown to be related to the stillbirth rates, when no such correlation was demonstrated.]

Jane Brewin, chief executive of the baby charity Tommy's, said the CEMACH study shows more research is "desperately needed" into finding the causes of stillbirth. "Obesity in pregnancy is a significant problem in this country and has massive implications for both mother and baby," she explained. "It carries an increased risk of major pregnancy complications including miscarriage, preterm birth and stillbirth."... [Repeating statements without evidence won’t make them true.]

All mothers-to-be need and deserve good prenatal care for the sake of their health and safety and that of their babies. Sadly, the continued war on obesity could distract us from real healthcare priorities and that would come at the most tragic cost of all.

© 2008 Sandy Szwarc

**Some caution is warranted whenever we look at neonatal data from other countries, of course, as it’s also variable depending in the definitions. Since 2004, babies who die before completing 24 weeks gestation don’t have to be registered as stillbirths in the UK, according to the Royal College of Obstetricians and Gynaecologists. But they might be, or they could be reported as “late fetal losses,” or reported as a neonatal death if they lived a period in the NICU. In the U.S., stillbirths are any deaths after 20 weeks, and definitions in other countries vary from 16 to 28 weeks. The point being, be careful when comparing data between countries or from year to year, but the overall figures for Britain continue a downward trend.