Thursday, May 26, 2011

OB/GYNs vs obesity. Blatant discrimination or professional honesty?

In case you haven't heard the story, apparently there's a group of OB/GYNs in Florida who are actively refusing to follow pregnant women who are obese.

The rationale they've presented is that they're too complicated, and for their patients' safety they're electing not to see them. Instead they're suggesting their patients with obesity get referred to specialized high risk obstetricians.

Now it's certainly a fair point to state that pregnancies in patients with obesity do carry more risk, both to moms and to babies, but the question that leaps to my mind is whether or not the OB/GYNs are telling the truth? Would the care they would be capable of providing these patients truly be substandard, or are they just avoiding taking on more complicated patients?

Put another way, are these OBs blatantly discriminating against people with obesity, or are they trying to protect them from their own professional inadequacies?

Now I'm not an OB, so for the sake of this discussion, I called up my friend Dr. Glenn Posner who's an OB here in Ottawa. Glenn broke it down practically. He confirmed that managing labor in women with obesity is more challenging. He told me that it's significantly more difficult to monitor the baby, and if things go sour, it takes more people to help in the OR and the skin-to-baby time for a crash C-section is much longer.

He also stated quite emphatically that just because there's a greater degree of difficulty didn't in his mind justify refusing to care for a significant, and growing, percentage of patients, and that indeed, any OB/GYN out there should be sufficiently trained to handle them.

Our discussion then turned to why these docs, who certainly are capable of caring for patients with obesity, have chosen not to.

We came up with a few options.

1. Overt and ugly bias.
2. Laziness - not wanting to have to deal with more complicated cases
3. Inadequate facilities - equipment does matter and depending on weight, may not be readily available.
4. Fear of litigation - with a much higher rate of complications, it may well stand to follow that there's a much higher risk of lawsuit.

Any way you slice it, it ain't pretty.

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  1. I think that fear of litigation is the #1 reason.

  2. Anonymous10:13 am

    What if a woman had another factor increasing risk factors - some disease or disability or injury ... would an OB then refer the patient to someone who could offer specialized care?

    Would that be considered discrimination?

    There is something else going on here - the refusal to admit that obesity actually causes health problems.

    Ideally, every place where babies are born would be able to handle every single complication. Even if doctors had no disincentives from handling complicated cases (eg potential lawsuits) it would be impractical to have every possible intervention available at every birthing location.

    From what your OB friend said, it seems obesity is a danger not just to the woman''s health, but possibly to her baby, as well.

    I was obese when I had my 2 kids. I happened to be near a regional hospital which did handle all complicated cases, and as it turned out I didn't need any special care anyway - but in retrospect, my obesity could have been bad for my babies. If I had been in a small isolated community with fewer resources and my doctor suggested I go to a specialized care hospital (just like someone with other risk factors), I would have gone without complaining about "discrimination"

  3. Anonymous2:18 pm

    As an obese woman, who has faced discrimination by way of many doctors, I would say that no, this is not a case of discrimination.

    The US is very much a "suing" country and fear of litigation if something goes wrong would likley be the #1 reason these doctors are refusing to treat obese pregnant women. If something goes wrong, they'll likely blame the medical team, not their own obesity.

    I think the doctors have every right to refer them to a specialist who can do a better job in the event of an emergency or complication.

  4. Anonymous1:43 am

    I'm not sure I believe the equipment line, since the weight limit they set is 200lbs.

    I'm fat, had all my three kids fat. My first was a c/s due to a failed induction, my next two were born at home. Sample size = 1.

    What concerns me, if this becomes more of a trend in medical practices, is what I saw happen in the VBAC world over the years. As it became harder to find an OB who would "allow" a woman to VBAC more and more of us stayed at home. At first, most of us opted to have skilled midwives with us (though my son decided not to wait for mine), and listened to our care providers when they risked someone out. Then over the years I watched as more and more woman totally opted out of the system, and UBAC (unassisted birth after c/s) became acceptable. Some had prenatal care. Some didn't. I've heard of UBAC with twins. Woman started ignoring "risk outs" and deciding they'd just stay home. The limits were pushed, much further than I personally was comfortable with, and I pretty much severed most of my ties with the community.

    The thing is.... when the option of a respectful VBAC in hospital became difficult, woman found another way, and that way became more and more, imo, dangerous. If it becomes difficult for a fat woman, no matter her health status, to find a normal OB, will she opt for the high risk OB or will she decide to opt out of the model entirely? Of those who opt out, some will be fine, and will have healthy pregnancies and easy births. Some will not.

  5. The reason for the policy is legal liability. Florida Ob-gyns pay well over $100,000 a year (US dollars) for malpractice insurance. Not to mention the huge time drain of fighting the legal battle.


  6. Anonymous11:49 am

    I would be shocked if this were to happen in Canada. We don't have the crippling fear of legislation like in the States (not that it's non-existent...but I think you'd be more likely to be sued for Human Rights violations and discrimination).

    Also, aren't OB/GYNs there for high-risk patients? I'm low-risk and I went with a midwife. Some of my low-risk friends opted to go with General Practitioners/Family Doctors. But if you're high-risk, you go to an OB.

    I think if an OB doesn't want to deal with high-risk patients, then they maybe shouldn't be an OB. Obesity is just one form of risk --> they could also be dealing with pre-eclampsia, placenta previa, placental abruption, eclampsia, etc. It's not exactly a risk-free area of practice...

  7. Anonymous3:16 pm

    I'd like to second what Dr. Parker said - Florida has the most ridiculous tort/malpractice laws in the US. This has resulted in numerous physicians leaving the state. If I was practicing Obs/Gyne in the state, I too would restrict my practice only to the youngest, healthiest subjects possible, for fear of bankruptcy. I think this has less to do with physicians than legal issues.

    Need further evidence Florida is nuts? A physician can be sued for asking patients if they are armed.

  8. What if a woman had another factor increasing risk factors - some disease or disability or injury ... would an OB then refer the patient to someone who could offer specialized care?

    Would that be considered discrimination?

    Anon, I was expecting you to go in a completely different direction.

    Are these doctors refusing to see any women over 40 or under 18? Women who have twins or other multiples? Women who have had previous cesarean sections? Women who've had gestational diabetes or preeclampsia but are under their weight cutoff? Do they have ANY other categories that they refuse to even see because of increased risk of complications? If not, then it's not really about the complications.

  9. Anonymous6:17 am

    I think it is fine for OBGYNs to choose their caseload and structure. Taking on patients who are high risk from the outset is more time consuming and stressful. It may reduce the number of patients you can manage without much financial compensation - it may limit your holidays (perhaps other OBGYNs won't accept your patients when you are away). I am a vet and doing surgery in obese animals is far more stressful, time consuming, difficult and laden with complications - from increased anaesthetic risk, to wound healing problems and everything in between. I think we are failing to look at OBGYNs as people - and in my view, they have a right to choose just as much as the woman had a right to choose to be pregnant.