When I got pregnant I weighed 53 kilos at
170cm (118 pounds, 5’8); I gained 13 kilos or 28 pounds over my pregnancy. My
daughter was born at just 2.6 kilos (5 pounds 11 ounces). By British or
US criteria my gain was fine, and indeed I found myself wondering
if I should have gained a bit more, judging by my baby’s rather modest size. Yet
by Japanese standards I had gained an excessive amount. Welcome to the insane
world of the incredible shrinking Japanese pregnancy.
Official guidelines in Japan recommend that
women gain 7-12 kilos if they are normal weight, and 9-12 kilos if they are
underweight—significantly lower than the guidelines of the UK and US. However,
these figures mask the reality that is going on in clinics and hospitals where
doctors routinely pressure women to gain even less than the official limits. “My
doctor told me I should stop eating all fruit and carbohydrates,” complains one mum
(whose weight gain was picture perfect according to the US guidelines). “I was
scolded by the nurses every time I went in; they said I wouldn’t be able to
push the baby out,” says another. Others reveal stories of doctors telling them
they should be losing rather than gaining weight during pregnancy, or informing
them that they would get a “fat vagina” unless they drastically restricted their calorie intake. No, I don’t know what a fat vagina looks like either.
What are the trends in newborn weight?
Perhaps part of the anxiety about gaining
too much weight comes from the widespread misconception in Japan
that average the average newborn is getting heavier. In fact, birthweights did
rise through the 1960s and 1970s in Japan, but from about 1980 the trend went into reverse, with birth weights falling by 125g in the
past 25 years. It seems that previous decades' anxieties about “babies getting too big”
may have lingered on into the present, distorting doctors’ and the public’s
perceptions.
To a certain extent it is understandable
that Japanese medical authorities became worried by fact that babies and
mothers were growing a bit heavier during the 1960s and 1970s. If a woman
genuinely does gain too much during pregnancy, it does indeed increase the risk
of difficult births, and this may be particularly true for Asian women. Asian
women who gain too much are significantly more likely to develop gestational diabetes than other ethnicities. Big babies may be more likely to wreak havoc
on an Asian mother’s body, as there is also some evidence that women of Asian
ethnicity are more likely to sustain serious perineal tears in childbirth. Nobody is quite sure why—perhaps it is because Asian babies are proportionally
larger compared to their relatively small mothers. In most developed/middle
income Asian countries, this problem is increasingly being circumvented through
very high cesarean rates (40-50% in countries like China and Vietnam). But the
Japanese remain emotionally and culturally committed to the idea of natural childbirth;
not surprisingly, a “Keep ’em small at all costs” mentality has tended to
develop.
I suppose there is a sort of “sunk-cost
fallacy” in such matters—if you have spent the last decade or two telling
women to severely restrict their weight, the possibility that this advice may have been harming babies may be too painful to
confront. Easier to keep telling yourself that your advice is correct and
always has been. It’s not like Japanese healthcare providers are exactly great at accepting
questioning at the best of time.
Oh, and it’s very, very hard to get an
epidural in Japan, due to a critical shortage of anesthesiologists and the cultural belief that mothers are “supposed” to suffer in childbirth,
and this has probably also encouraged doctors and midwives (all of whom will have watched women suffering
in long, hard labors) to encourage mothers to keep their bellies and babies
small. In fact, a small baby does not always equal an easy birth--I know women
who’ve torn badly pushing out five-pounders--but when you are staring down the
barrel of a completely unmedicated labor with absolutely no way out of it, you
are naturally going to clutch at whatever straws are available to you
which might, maybe, just make things a bit easier. Add in standards of beauty
which demand insect-like thinness in women even before pregnancy, and you have a perfect storm for
extreme weight restriction in pregnant women.
Slowly, however, awareness is
growing in Japan about the risks of too little weight gain in pregnancy. Japanese midwives are still heard to express enthusiasm about the idea of keeping fetuses small and then feeding them up after delivery, but as the doctor quoted in the Bloomberg article puts it, “Being born small and growing big is the worst possible scenario for risk of disease." Babies undernourished in the womb and born small may be at elevated risk of problems such as obesity and hypertension later in life, possibly because such undernourishment sends out signals that cause the fetus's body to prepare for famine conditions in the outside world (an extreme form of this was seen in the babies born after the Dutch Hunger Winter of 1944-45, who have proven to be more prone to problems such as cardiovascular disease as adults).
It’s not that we need a complete
free-for-all either. Most women I know who gave birth in the UK report that
they were never weighed or given any advice on weight gain, a fact which
is almost certainly connected with the fact that the percentage of deliveries
assisted by forceps has doubled over the last 10 years as mothers start their
pregnancies heavier, gain more and have bigger babies. It’s completely
reasonable for healthcare providers to be honest with patients about the fact
that excessive weight gain increases the risk of difficult births, not to mention the fact that (in my own experience) women who gain huge amounts are more likely to feel uncomfortable during pregnancy and have an difficult psychological transition to motherhood afterwards.
Nevertheless, there is
mounting evidence that excessively strict weight guidelines in Japan are
putting the health of babies at risk, and making pregnancy--which is supposed to be one of the happiest times in a mother's life--into a period of unnecessary anxiety, guilt and embarrassment for women. While a certain amount of caution regarding weight gain is probably advisable for Japanese women in particular, given ethnic factors relating to gestational diabetes and the problem of perineal trauma, the advice to restrict weight in pregnancy seems to have become unnecessarily extreme and to have taken on a life of its own. For mothers' and babies' sake, it's time for Japanese healthcare providers to swallow their pride and review their policies on gestational weight gain.
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