Prior Family Planning Experiences of Obese Women Seeking Abortion Care

Sizing Up General Practice Environments for Big-Bodied Patients: An Environmental Assessment of Three Facilities in Aotearoa New Zealand

OBJECTIVES

This research describes the physical environments of and equipment in Aotearoa New Zealand (NZ) general practices in relation to available standards for big-bodied people (BBP) seeking healthcare.

BACKGROUND

The prevalence of BBP both in NZ and globally has increased over the last 30 years and is expected to increase further. As the first and most utilized point of contact for patients in NZ and many countries, it is essential that general practices provide suitable environments to cater for and meet the needs of big-bodied patients seeking healthcare.

METHODS

An exploratory study utilizing an environmental investigation was undertaken in three diverse general practices. Data collection consisted of direct observation and physical measurements of practice layout and equipment. Findings were compared to the existing guidelines or standards for the healthcare of BBP.

RESULTS

The analysis identified most environmental facets and equipment in all three general practices did not meet published guidelines for the care of BBP.

CONCLUSIONS

In the global context of increasing and sustained prevalence of BBP, this exploratory study highlights it is crucial that general practices and similar community-based facilities review their physical environments and equipment and consider modifications to improve accessibility, inclusivity, and comfort for BBP.

An analysis of misoprostol effectiveness in second trimester pregnancy terminations

Background/Aim: Misoprostol is frequently used as a single agent in pregnancy terminations. However, it increases the risk of uterine rupture in patients who have had previous uterine surgery and terminations due to stillbirths. Therefore, it is used with concern by clinicians. The aim of this study was to evaluate the clinical features of the groups that responded and did not respond to termination treatment with misoprostol in a tertiary center and to investigate its efficacy and safety. Methods: The study design was comprised of a retrospective cohort study. A total of 114 second trimester pregnancies (between 13-24 weeks gestational age) were included in the study. These pregnancies were indicated for termination based on the prenatal diagnosis unit for fetal or maternal causes. According to the International Federation of Gynecology and Obstetrics (FIGO) directions, misoprostol was applied in the following dosages: for 13-17 weeks gestational ages, one tablet per 6 hours; for 18-26 gestational ages, ½ tablet per 6 hours; and for other indications 2 tablets per 3 hours were administered. If the patient had had a previous cesarean operation, all doses were halved. After the first 24 hours, the percentage and demographics results, such as age, body mass index (BMI), gravida, number of cesareans, number of curettages, cervical lengths, BISHOP scores, gestational age, amniotic fluid index, and fetal cardiac beat of the patients with miscarriage, were recorded. Results: The number of cases resulting in miscarriage within 24 hours were 84 (73.7%) and within 48 hours were 14 (12.2%). The total of misoprostol doses used were 8 tablets of 200 mg, mean time until the complete abortion was 17 hours. Sixteen patients required additional treatment, of whom four required Foley catheterization, five required D&E, seven required resting, and no one required a hysterectomy. Uterine rupture occurred in two patients who needed laparotomic surgery. The maternal age (P=0.340), BMI (P=0.790), gravida (P=0.270), previous cesarean history (P=0.390), previous curettage number (P=0.520), cervical length (P=0.380), Bishop score (P=0.190), gestational age (P=0.072), amniotic fluid index (P=0.470) and presence of fetal cardiac beat (P=0.350) were similar between groups Conclusion: Our results indicated that misoprostol is a safe, useful, and effective treatment option for second trimester medical terminations. Caution should be exercised in its use in patients with a history of uterine surgery.

A cross-sectional study exploring obesity and pregnancy planning among women attending an antenatal clinic in Suva, Fiji

BACKGROUND

Pregnancy planning enables maternal health optimisation which is particularly important for women who have obesity and are at increased risk of adverse perinatal outcomes.

AIMS

The prevalence of pregnancy planning and its relationship to body mass index (BMI) was investigated in a cohort of women attending antenatal clinics in the main referral hospital in Suva, Fiji.

MATERIALS AND METHODS

The questionnaire captured health and socio-demographic data, anthropometry and asked about pregnancy planning.

RESULTS

Two thousand, two hundred and three pregnant women presenting for their first booking at the antenatal clinic were enrolled; 721 (37.4%) out of 1926 women with complete data reported they did not plan their pregnancy. A third of women (n = 633, 32.8%) had overweight and 805 (41.7%) had obesity. In multivariable analyses parity, employment status, marital status, and BMI were significantly associated with pregnancy planning. Compared to women of a healthy weight or underweight, women who have obesity were less likely to plan their pregnancy (adjusted odds ratio 0.742; 95% CI 0.569-0.967).

CONCLUSION

Tackling the cycle of obesity will require attention to preconception care and optimising weight before pregnancy.

Risk of complication during surgical abortion in obese women

BACKGROUND

Surgical abortion is a generally safe procedure. Obesity is a known risk factor for complications in other surgical procedures, but insufficient information exists to determine the effects of increasing body mass index on the risk of surgical abortions.

OBJECTIVE

The purpose of this study was to determine whether obesity is a risk factor for major complications in surgical abortions.

METHODS

A quality control database from a single outpatient center was analyzed to determine rates of major complications during surgical abortions in relation to obesity class. Complications included hemorrhage, need for repeat evacuation, uterine perforation, cervical laceration, medication reaction, unexpected surgery, or unplanned admission to the hospital. Chi-squared and analysis of variance were used for analysis.

RESULTS

We included 2468 procedures: 1475 procedures (59.8%) in the first trimester and 993 procedures (40.2%) in the second trimester. The overall complications rate was 2.2%. Second-trimester procedures were more likely than those in the first trimester to have complications (3.1% vs 1.6%; P=.009). Overall, 39.6% of the women were obese, and 9.6% of them met criteria for class 3 obesity (body mass index, >40 kg/m²). Women who underwent second-trimester abortions with class 3 obesity had a rate of complication of 8.7%, which was significantly more than normal weight women (odds ratio, 5.90; 95% confidence interval, 1.93-8.07; P<.001).

COMMENT

Surgical abortions are overall safe procedures, but class 3 obesity increases the rate of complication in second-trimester procedures.

Pregnancy Intention and Contraceptive Use among Women by Class of Obesity: Results from the 2006-2010 and 2011-2013 National Survey of Family Growth

OBJECTIVE

Conflicting research findings on the association of obesity and pregnancy intention may be due to their collective definition of obesity at a body mass index of 30 kg/m² or greater. However, obese women with a BMI of 40 kg/m² or greater may be both behaviorally and clinically different from obese women with a lower BMI. This study reexamines this relationship, stratifying by class of obesity; the study also explores variations in contraceptive use by class of obesity given their potential contribution to the incidence of unintended or unwanted pregnancy.

METHODS

This study combined data from the 2006 through 2010 and 2011 through 2013 US National Survey of Family Growth. Pregnancy intention (intended, mistimed, unwanted) and current contraceptive use (no method, barrier, pill/patch/ring/injection, long-acting reversible contraceptive, sterilization) were compared across body mass index categories: normal (18.5-24.9 kg/m kg/m²), overweight (25.0-29.9), obese class 1 (30.0-34.9 kg/m²), class 2 (35.0-39.9 kg/m²), and class 3 (≥40 kg/m², severe obesity). Weighted multinomial logistic regressions were refined to determine independent associations of body mass index class and pregnancy intention, as well as contraceptive method, controlling for demographic, socioeconomic, and reproductive factors.

RESULTS

Body mass index data were available for 9,848 nonpregnant, sexually active women who reported not wanting to become pregnant. Women with class 3 obesity had significantly greater odds of mistimed (adjusted odd ratio [aOR], 1.67; 95% confidence interval [CI], 1.02-2.75) or unwanted (aOR, 1.96; 95% CI, 1.15-3.32) pregnancy compared with normal weight women. Women with class 2 or 3 obesity were more likely to not be using contraception (aOR, 1.53-1.62; 95% CI, 1.04-2.29). Although women with class 2 obesity were more likely to be using long-acting reversible contraceptive methods and sterilization over short-acting hormonal methods (aOR, 1.67; 95% CI, 1.08-2.57; aOR, 2.05; 95% CI,1.44-2.91), this association was not observed among women with class 3 obesity.

CONCLUSIONS

Women with class 3 obesity are at greater risk of unintended pregnancy and are less likely to be using contraception than normal weight women. Whether these findings are related to patient and/or provider barriers that are not as visible among women with class 1 and class 2 obesity warrants further investigation.

Weight management during pregnancy: a qualitative study of women's and care providers' experiences and perspectives

Background

Obesity during pregnancy is a serious health problem for women and their children. Despite the high prevalence of high body mass index (BMI) among women of reproductive age in high-income countries, there is insufficient evidence to inform practice and policy about weight management for women with high BMI who are pregnant. The aim of this project was to describe women’s and midwives’ experiences and perspectives of care for weight management during pregnancy in Melbourne, Australia.

Methods

A qualitative study. Semi-structured interviews were conducted with pregnant women and midwives. Transcripts were analysed thematically.

Results

A total of 17 women and 2 midwives were interviewed. Five themes were identified: 1. Reluctance to and difficulties discussing weight and its implications; 2. Barriers to providing appropriate pregnancy care for women with high BMI; 3. Inconsistent weighing practices; 4. Beliefs about the causes of obesity; and 5. Opportunities to assist women to manage their weight. Although most women were satisfied with the pregnancy care they had received, both women and midwives expressed concerns about effective weight management during pregnancy. These included constraints on discussing weight, difficulties accessing appropriate resources and additional support from other health care providers, and inconsistent weighing practices.

Conclusions

The findings suggest that women with high BMI would benefit from additional information and support about weight management prior to conception, during pregnancy, and postnatally.

Safety of Outpatient Surgical Abortion for Obese Patients in the First and Second Trimesters

OBJECTIVE

To evaluate the relationship between obesity and surgical abortion complications in the outpatient setting.

METHODS

We conducted a retrospective cohort study of 4,968 women undergoing surgical abortion at a large outpatient clinic network from September 2012 to July 2014. We used log-binomial regression to evaluate body mass index (BMI) as an independent risk factor for first- and second-trimester abortion complications. Body mass index was analyzed as both a continuous and categorical predictor. We assessed complications including need for uterine reaspiration (including same-day reaspiration), uterine perforation, cervical laceration, infection, emergency department visit or hospitalization, and excessive blood loss defined as estimated blood loss greater than or equal to 100 mL.

RESULTS

The majority (77%) of procedures was performed in the first trimester. Forty-seven percent of women were normal weight or underweight, 28% were overweight, and 25% were obese, including 4% with BMI greater than or equal to 40. The overall complication rate was 1.7%; the most common complications were need for uterine reaspiration (1.0%) and excessive blood loss (0.6%). Obesity was not associated with increased risk of surgical complications, including when adjusting for age, gestational age, and history of prior cesarean delivery.

CONCLUSION

In a high-volume outpatient abortion clinic with experienced health care providers, abortion is very safe. Obesity does not appear to be an independent predictor for abortion complications and should not be used in isolation to refer women to hospital-based facilities for abortion care in the first or second trimester.

Stigma in Practice: Barriers to Health for Fat Women

In this paper, we explore barriers to health for fat people. By shifting the focus from what fat people do or do not do, neoliberal principles are replaced by a focus instead on structural and institutional policies, attitudes, and practices. This includes the impact of stigma on the health treatment and health-seeking behavior of fat people. For example, we consider the role that provider anti-fat attitudes and confirmation bias play in the failure to provide evidenced-based healthcare to fat patients. This is an autoethnographic paper, which provides the opportunity to read research from the perspective of fat scholars, framed by questions such as: can fat people have health? Is health itself a state of being, a set of behaviors, a commodity, a performance; perhaps the new social contract? As a co-written autoethnographic paper, one aspect of the evidence provided is the recorded experiences of the two fat authors. This includes writing from notes, journals, compiled and repeated experiences with medical professionals, family, and the community. Framed by feminist standpoint and supported by literature drawn from Fat Studies, Public Health, Obesity Research, and other interdisciplinary fields, this is a valuable opportunity to present an extended account of fat discrimination and the impact of the stigma fat people face through the medical profession and other sectors of the community, written by fat individuals. The paper concludes by considering the health pathways available to fat people. Special attention is paid to whether Bacon and Aphramor's Health at Every Size paradigm provides a path to health for fat individuals.

Obesity as a Risk Factor for Complications After Second-Trimester Abortion by Dilation and Evacuation

OBJECTIVE

To evaluate the association between obesity (body mass index [BMI] 30 or higher) and dilation and evacuation (D&E) complications.

METHODS

We conducted a retrospective cohort study of women who underwent D&E abortion from February 2009 to April 2013 at a hospital-based abortion practice in California. We evaluated the association between obesity and risk of complication after D&E using logistic regression. We defined complications a priori as cervical laceration, hemorrhage, uterine atony, anesthesia complications, uterine perforation, disseminated intravascular coagulation, and retained products of conception. We defined major complications as those requiring hospitalization, transfusion, or further surgical intervention.

RESULTS

Complications occurred in 442 of 4,520 D&Es (9.8%), with equal proportions in obese and nonobese women (9.8%). Major complications occurred in 78 (1.7%) patients. After adjustment for age, ethnicity, prior vaginal delivery, prior cesarean delivery, and gestational duration, there was no association between BMI and D&E complications. Any individual complication was associated with each additional week of gestation (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.3-1.4), prior vaginal delivery (OR 1.5, 95% CI 1.2-1.9) and prior cesarean delivery (OR 1.8, 95% CI 1.4-2.3). Major complications were associated with each additional week of gestation (OR 1.3, 95% CI 1.1-1.4) and cesarean delivery (OR 1.8, 95% CI 1.1-3.1).

CONCLUSION

We found no association between obesity and D&E complications. Our findings are consistent with previous studies demonstrating that later gestational duration is associated with an increased risk of complications. Obesity may not warrant referral to a high-risk abortion center, particularly because referral-associated delay might increase the risk of complications.

LEVEL OF EVIDENCE

II.