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What to Expect When You’re Expecting

A correspondent asked me to review the book What to Expect When You’re Expecting by Heidi Murkoff and Sharon Mazel. She wrote “I’m very worried about this book.”

She had just seen an NPR article about the book and was alarmed because it provided an excerpt from the book recommending that patients with morning sickness “Try Sea-Bands” and “Go CAM Crazy.” She knew from reading SBM and other science blogs that “going CAM crazy” is not a good idea. She was savvy enough to search Google Books with the title and “CAM” and found more alarming advice

The book is billed as the #1 bestselling pregnancy book and is now in its 4th edition. It has been widely praised by the media and by doctors. In Amazon’s sales rankings it’s number 1 in its category and number 57 overall. It even has its own article on Wikipedia that tells us

Originally published in 1984, the book consistently tops the New York Times bestseller list in the paperback advice category, is one of USA Today’s “25 Most Influential Books” of the past 25 years and has been described as “the bible of American pregnancy.” As of 2008, over 14.5 million copies were in print. According to USA Today, 93 percent of all expectant mothers who read a pregnancy guide read What to Expect When You’re Expecting.

So it’s certainly worthwhile to look at this book to get an idea of what American women are learning about pregnancy.

It’s an impressive tome (616 pages) that does a good job of explaining everything an expectant mother might want to know as well as some things she mightn’t (critics have called it too alarmist because it covers scary complications).  It covers fetal development, diet and lifestyle recommendations for a healthy pregnancy, common symptoms, labor and delivery, the postpartum period, and much more. It is well-organized and easy to read. It has question and answer sections to cover pretty much every question a pregnant woman has ever asked, even rather silly ones (“All my pregnant friends seem to have problems with constipation. I don’t — in fact, I’ve remained very regular. Is my system working right?”) and it has separate chapters on every month of pregnancy.

Most of the book is so good I wish I could recommend it. But it has a disturbing flaw: misinformation about CAM. Here are some examples from its section on CAM:

The Place of CAM

CAM is more and more likely to find a place in your life…[Its practitioners examine and integrate] the nutritional, emotional, and spiritual influences, as well as the physical ones. CAM also emphasizes the body’s ability to heal itself, with a little help from some natural friends, including herbs, physical manipulation, the spirit, and the mind.

Acupuncture

The Chinese have known for thousands of years that acupuncture can be used to relieve a number of pregnancy symptoms… Scientific studies now back up the ancient wisdom. [No they don’t, and it’s not ancient wisdom.]

It recommends acupuncture for pain, nausea, speeding progress in labor, and treating infertility. It warns against stimulating certain acupressure points in the ankle before term because it can cause uterine contractions. If only! Wouldn’t overdue women and frustrated obstetricians love it if they could bring on labor that easily!

Chiropractic

This therapy uses physical manipulation of the spine and other joints to enable nerve impulses to move freely through an aligned body, encouraging the body’s natural ability to heal. Chiropractic medicine can help pregnant women battle nausea; back, neck, or joint pain; and sciatica (plus other types of pain), as well as help relieve postpartum pain.

Reflexology

Similar to acupressure, reflexology is a therapy in which pressure is applied to specific areas of the feet, hands, and ears to relieve a variety of aches and pains, as well as to stimulate labor and reduce the pain of contractions.

As with acupressure, the book warns against stimulating contractions before term.

Moxibustion

…combines acupuncture with heat (in the form of smoldering mugwort, an herb) to gradually help turn a breech baby.

Aromatherapy

Scented oils are used to heal body, mind, and spirit and are utilized by some practitioners during pregnancy; however, most experts advise caution, since certain aromas …may pose a risk to pregnant women.

Herbal Remedies

At last, a voice of reason: it points out that “natural” is not synonymous with “safe.”

Most experts do not recommend herbal remedies for pregnant women because adequate studies on safety have not yet been done.

But even here it quickly degenerates as it continues,

Even the most traditional ob-gyns are realizing that [CAM] is a force to be reckoned with, and one to begin incorporating into ob-business as usual.

Homeopathy

Homeopathy is inappropriately included under herbal remedies and there is no explanation of what it is or whether it is effective. They only say the safety of the remedies has not been established by any regulatory system so they recommend that it be avoided unless it has been specifically prescribed by a traditional practitioner who is knowledgeable in CAM and who knows you’re pregnant.

The section concludes

CAM can still be strong medicine. Depending on how it’s used, this potency can be therapeutic or it can be hazardous.

Advice for Specific Problems

CAM misinformation pops up in several other sections of the book.

  • For labor pain: acupuncture, hypnosis, hydrotherapy, and reflexology.
  • For symphysis pubis pain: acupuncture or chiropractic.
  • For carpal tunnel syndrome: acupuncture.
  • For indigestion: meditation, visualization, biofeedback, or hypnosis.
  • And for morning sickness:
    • Try Sea-Bands to put pressure on acupressure points or use a battery-operated ReliefBand that uses electrical stimulation.
    • “Go CAM crazy. There are a wide variety of complementary medical approaches, such as acupuncture, acupressure, biofeedback, or hypnosis, that can help minimize the symptoms of morning sickness — and they’re all worth a try.”

Conclusion

There is no credible scientific evidence to support any of these recommendations. It could be argued that this is all feel-good, “keep-the-patient entertained” advice with little chance of direct harm. But it is deceptive and dishonest to represent these modalities as effective treatments based on science, especially in a book that is otherwise scientifically reliable. It would be interesting to find out whether the coverage of CAM has changed from earlier editions. It could be much worse: at least there is no hint of anti-vaccine propaganda.

It’s an “almost very good” book that I can’t recommend. There is no way for the average reader to separate the accurate science-based information from the misinformation about CAM.  It’s unfortunate that so many women are reading and presumably trusting everything it says.

 

 

 

 

Posted in: Book & movie reviews, Obstetrics & gynecology

Leave a Comment (70) ↓

70 thoughts on “What to Expect When You’re Expecting

  1. Tell it like it is says:

    @ Harriet hall Hi Dr Hall

    As I see it, the author has attempted to write a helpful publication that appeases all camps. Perhaps this is done to maximise sales.

    You obviously feel very strongly about some of the contents of this publication – in terms of the merits of the advice proffered, and the safety and/or effectiveness of some of the suggestions.

    It is one thing to publish fact-based fiction so as to entertain – it is quite another to publish contentious fiction-based ‘facts’ that serve as both advice and panacea to the many millions of expectant women – ‘facts’ which fail to serve the need.

    May I suggest that, using your influence, you contact both the author and the publisher – the former to enquire the provenance of the recommendations; and the latter for endorsing litigious practices by publishing the book in the first place.

    It might prompt a new edition.

  2. highnumber says:

    My wife consulted this book throughout both her/our pregnancies. I’ve read chapters here & there. I had no idea this CAM stuff was in there, but I’m not surprised. Most of the published materials I’ve seen for pregnant women eventually come around to some woo-iness. The middle road between (to skip ahead to the birth) “lie on your back and let the good doctors take care of this natural process for you” and “I’m a doula and a Wicca and we’re going to do this in the comfort of your home” can feel like a narrow road at times. (it isn’t that narrow really – we used a midwife practice with a doctor on staff that had a very comfortable birthing center at a hospital for the second birth, but between the authoritarian ob-gyn we had for our first and the horror stories I’ve heard about some home births…)

  3. AllieP says:

    That’s just the tip of the iceberg when it comes to the nonsense included in the most recent editions of this book. Once, I think it was helpful. Now the editors/contributors have fallen down the crackpot celebrity new age rabbit hole and it’s just alarmist. It includes every half baked idea about “what might endanger” your pregnancy to the point that it scares pregnant women about using small amounts of herbs to season their cooking, drinking from water bottles, using lipstick or mascara, and eating even pasteurized cheese. The part about planning your birth gives equal weight to every crackpot dangerous “natural birthing method” there is as well as including inaccurate and alarmist descriptions of “interventions.”

    My doctor recommended the far less political and crackpot-filled YOUR PREGNANCY AND BIRTH, which is an ACOG publication.

  4. VentureFree says:

    “It might prompt a new edition.”

    Followed by a massive outcry about Big Pharma’s attempt to harm our most vulnerable members of society by censoring valuable information about healing that hasn’t been filtered through their own PR division first.

    No, even if they know it’s BS (and I rather think that they do), they’ll almost certainly never update the book to say so. Their reputation would be irreparably, if entirely unfairly, tarnished.

  5. Intraneural says:

    My wife and I just had our first baby nine months ago and I remember this book. My wife read parts of this book but I do not recall discussing anything about CAM from this book. I will have to go back and take a look. Both of us are in healthcare and we could not stop getting advice from many of her friends about acupuncture, herbs, chiropractic, blah, blah… The worst were some of her friends recommending either all natural or attempting a home birth. In particular we were recommended a movie with Ricki Lake about her journey to a home birth. We watched knowing that it was a propaganda piece for nonsense. I strongly recommend if you want to be horrified. My wife still occasionally gets heat from some of her friends for having had an epidural! My point is- CAM has infiltrated this field very well. It is scary how popular this nonsense is with pregnant women.

  6. DW says:

    “What to Expect” is moderate, I’m afraid, on the spectrum of popular childbirth advice. I’m sorry to hear that woo-woo has infiltrated … but it’s still basically a meanstream advice manual, compared to some of the lunacy coming from the folks who advocate unassisted childbirth, “extended” breastfeeding (i.e., for many years), eating the placenta, etc.

    There’s a rich vein here waiting to be tapped for this blog …

  7. The “go CAM crazy” line sounds like the usual, ditzy advice that pervades women’s magazines. We’ve seen this before in places where it shouldn’t be found. Let’s hope that this infantilization of women (if you’ll excuse the context), insulting as it is to their intelligence, will eventually be noticed sufficiently to make it no longer a pragmatic editorial decision.

  8. David Gorski says:

    Interesting. It’s been nine years since I last looked at that book. I don’t recall the CAM stuff being there, but I also wasn’t nearly as attuned to the issues of CAM and its infiltration into medicine back then. In any case, it doesn’t surprise me. This sot of stuff is rife in “mother” self-help and medical books directed at lay people, for instance in Mothering.

  9. Amy says:

    Oh, so glad you did this Dr. Hall! I have a 6-yr old copy (given to my SIL by her OB), which is pretty good, but still has CAM (although not as heavily). The other problem I had with the book is its strong encouragement to go without the epidural, only use it as a backup, with no real reason why they promoted this. The funny thing is, many people promoting natural childbirth and alternative medicine in pregnancy and childbirth HATE this book; one blogger encouraged her readers to hide copies in the bookstores! although, as said before, this is mild compared to some others, I was very disturbed and upset by our bodies ourselves: pregnancy and childbirth edition. Mayo clinic was good as far as science went, but not too entertaining to read, and it still had CAM stuff, with the disclaimer that most have little to no evidence. My OB’s office made their own booklet for patients, and I understand why!

  10. Amy says:

    @ DW

    they already tried that, the skeptical OB blogged here for awhile, then left, but still currently blogs at her own site. Dr. Hall does a nice job of covering women’s issues when it’s in the news or requested.

  11. Gregory Goldmacher says:

    Have you guys seen the Dara O’Briain standup bit about the pseudoscience bull$#!t surrounding childbirth, and the stuff taught in childbirth classes?

    If you have not, check it out, it is absolutely hilarious.

    http://www.youtube.com/watch?v=khfJ-HB12Z0

  12. torgoguy says:

    I think Harriet Hall is being too generous to the book. She’s write that there is a lot of good information in there, but it is interspersed with crap. And that makes it unreliable. However, it’s not just the CAM stuff as she discussed, but all sorts of things in nearly every section of the book. See AllieP’s comment above for more examples.

    Here’s another problem–in many areas it’s not written in a way that communicates effectively with its target audience. For example, sometimes the book tries to present a survey of study findings (both positive and negative) to back up its answers. However, it in such a wishy-washy way, and presents it in a fashion that an average person is not equipped to parse. This makes the book less concise (the publisher seems to think more-pages=better-book), and less clear/helpful.

    One side effect–here you’ve got a bunch expectant parents reading this thing, nervous about what to expect. Because it brings up so many potential concerns you might not have even had until seeing them in the book, and then fails to answer some of them with clarity, you (as an expectant mother) actually end up with new things to worry about–things that the book *should* be telling you clearly not to worry about (or at least don’t worry about it except in this or that special circumstance).

    An example: there is a question in there about whether it is safe to use a microwave when you’re pregnant. This should be a reasonably straightforward question to answer, taking somewhere between a word and a paragraph to answer, depending on how nuanced you want the response to be and if you want to give some reasons for the answer. Well, this book takes about a page of text to give its answer. I gave that 1-page blurb to 7 pregnant women and asked them to summarize its take-home message. I can summarize their responses as being “yeah, it’s safe, well, er, probably safe, and, uh, well, it sounds like its saying wouldn’t be a bad thing for you to avoid it, right?” The book failed to do it’s job here.

    I consulted the same topic on a couple of other pregnancy and they were much more clear and unambiguous. “Pregnancy for Dummies,” for example, included microwave use as a simple bullet point on a list of things that some people wonder about, but we don’t have good reason to believe they’re unsafe.

    If you present me with a plate full of mixed, cooked mushrooms (which I love), and 75% are safe-to-eat mushroom varieties, while 25% are not, then I’m going to have to pass on eating any of them. It’s the same with this book, as the above blog post points out, even if most of the information is good, when it is interspersed with so much woo, you gotta give it a pass.

    Note: my comments are based on my recollections from reading (a good chunk) of whatever edition was current 4 years ago, which may or may not be the current edition. Given Harriet Hall’s review above, I don’t think the book has gotten better.

  13. DW says:

    “the stuff taught in childbirth classes?”

    The irony is, “childbirth classes” per se are mainstream on the spectrum of looney childbirth advice. The real woo-advocates don’t want you to go to a childbirth class at all!! You might get ideas about, say, pain relief, vaccination, cesarean section etc.

  14. Rina says:

    Gregory, I shared the Dara O’Brien video on my facebook and got extremely vitriolic comments from my cousin and aunt, who are homeopaths. My aunt subsequently blocked me on facebook, after calling me judgemental and narrowminded. She didn’t even want to discuss the issue with me.

  15. Harriet Hall says:

    DW,

    “a rich vein to be tapped.”
    I’m tapping it. For your convenience, here are links to several posts I’ve written on these subjects:
    Prenatal vitamins: http://www.sciencebasedmedicine.org/index.php/13303/
    Eating placentas: http://www.sciencebasedmedicine.org/index.php/eating-placentas-cannibalism-recycling-or-health-food/
    Epidurals: http://www.sciencebasedmedicine.org/index.php/childbirth-without-pain-are-epidurals-the-answer/
    Home births: http://www.sciencebasedmedicine.org/index.php/home-birth-safety/
    Alcohol and pregnancy: http://www.sciencebasedmedicine.org/index.php/alcohol-and-pregnancy/
    Breastfeeding: http://www.sciencebasedmedicine.org/index.php/breastfeeding-is-good-but-maybe-not-that-good/
    Birth Day (a book review) http://www.sciencebasedmedicine.org/index.php/birth-day/
    Sterile water injections for relief of labor pain: http://www.sciencebasedmedicine.org/index.php/sterile-water-injections-for-pain-relief/
    The movie The Business of Being Born: http://www.sciencebasedmedicine.org/index.php/the-business-of-being-born/
    And then there’s the one (probably best forgotten) that I wrote on circumcision where I tried to look at the science dispassionately only to be accused of being a mutilator of babies.

    This is an area I’m interested in because I’ve experienced childbirth from both sides, as patient and doctor. Suggestions for future topics are always welcome.

  16. RQbrain says:

    Thanks for the review Dr. Hall.

    My partner and I are trying to have a baby and read the book What to Expect *Before* you’re Expecting, and were planning to get this one too and try to ignore the CAM advice. However, given that it’s difficult to pick out, combined with the worst-case scenarios, I think I’ll pass on this one.

    The one thing we’ve decided on is “as much painkillers as possible” (Within reason of course).

  17. DW says:

    Dr. Hall, so you have! Thanks for all the links, I guess I haven’t read widely enough here!

  18. DW says:

    “I wrote on circumcision where I tried to look at the science dispassionately only to be accused of being a mutilator of babies. ”

    No good deed goes unpunished.

  19. Scott says:

    I find this rather troubling since my wife and I just picked it up recently, though I’ve not looked at it myself. It really does have a reputation as “The Book,” which is a bad thing if it’s not really reliable.

    I think I’m better equipped than most to pick out the BS (largely based on reading here), but still. The heads-up is appreciated.

  20. sowellfan says:

    @Harriet (re: circumcision) – I think that ‘mutilator of babies’ should be replaced everywhere with “wang-mangler”. That just rolls off the tongue so much more nicely ;-)

  21. Jann Bellamy says:

    One thing the authors should consider is the unfortunate, even dangerous, chain of events this advice can set off. Once in the chiropractor’s office, what’s to prohibit the DC from selling the parents on the “Webster technique” for breech position, or on the idea that they need to bring their neonate in asap after birth so his/her “subluxations” can be “corrected.” How about a lifetime of “maintenance care” or some anti-vax propaganda? Or selling them on the idea of “pediatric chiropractic” as opposed to a real pediatrician?
    Thanks for taking the authors to task on this, Dr. Hall.

  22. Thanks for the review HH, I guess I’ll take that book off my baby shower gift list.

    I didn’t do the pregnancy thing, but I can say that if you suspect infertility issues and you want to build a family, you should be saving your money for infertility treatments or adoption expenses, both paths that have documented success rates, not throwing it away on acupuncture, which has no documented success.

    I’m not surprised that WTEWYE features alarmist stories, it seems so much of the parenting literature is the same. There seems to be an assumption that to be a good parent one must live with an extremely high level of paranoia, this is alternated with advice to enjoy your child while they’re little because it will go by so fast, (and they will end up with an emotional disorder if you don’t pay enough attention to them. :) )

    As someone with anxiety issues, I found the alarmist tone unhealthy. So now I try to stick to doctor sites like familydoctor.org, our pediatricians’ info site for information that has to do with kids health issues but doesn’t warrant a doctor’s visit.

  23. Jimmylegs says:

    It truely pains me to see such information that is misleading or false in the mainstream. Not only does unproven (even disproven) methods persist in “help” or “advice” books but 3rd world wackado stuff still thrives.

    For example, my girlfriend’s sister-in-law was pregnant not too long ago. My gf’s parents (and grandparents) wanted to know if it will be a boy or girl, so they had two chairs will pillows on it. One chair had a fork the other not, depending on which she sat on would determine if it was a boy or girl… WHAT THE!

    I know this isn’t a place to rant and rave, but I thank you for reviewing a very popular book and pointing out such misinformation that could be harmful in some manner.

    Again I thank you and all of SBM for reviewing medicine to bring it at a level where it has to be, science-based.

  24. pmoran says:

    And for morning sickness: Try Sea-Bands to put pressure on acupressure points or use a battery-operated ReliefBand that uses electrical stimulation.
    “Go CAM crazy. There are a wide variety of complementary medical approaches, such as acupuncture, acupressure, biofeedback, or hypnosis, that can help minimize the symptoms of morning sickness — and they’re all worth a try.”

    Some of these will help, through distraction, counterirritation, relaxation and expectancy.

    Do we have anyth,ing better to offer these often seriously distressed women?

  25. pmoran – crazy bands or Daily Show – Colbert Report On Hulu?

    Many of my girl friends swore by eating small snacks like soda cracker often.

    I just don’t like to think of my friends, who can’t afford it, spending a bunch of money on acupuncture and the like, just for distraction, etc. If they know that’s it only distraction, fine. But, if they’re being told there’s more to it, that’s not cool.

    Not everyone has a bunch of money set aside* to “try” expensive therapies that have no benefit beyond the criteria you listed.

    *Gee I probably have less money set aside than when I started this email… gotta love those 401Ks.

  26. Harriet Hall says:

    @pmoran,

    “Some of these will help”

    Is that just your personal belief, or can you back it up with any evidence? This Cochrane review showed that acupuncture, acupressure, ginger, and other interventions were not supported by evidence. It concluded “Given the high prevalence of nausea and vomiting in early pregnancy, health professionals need to provide clear guidance to women, based on systematically reviewed evidence. There is a lack of high-quality evidence to support that advice.”

    http://www.ncbi.nlm.nih.gov/pubmed/20824863

  27. Lytrigian says:

    While homeopathy ought not be lumped in with herbal medicine in principle, it’s probably a good idea to do so for the purposes of warning about possible safety problems. I’ve noticed recently a number of supposedly “homeopathic” remedies with very low potencies — even as low as 1X — which therefore contain significant amounts of the listed ingredient.

    I suspect this is done for labeling purposes, so they can make claims about its effects without the “Miranda warning”. As long as the thing is listed in the HPUS and it’s prepared according to homeopathic procedures, I would guess that even one dilution is sufficient for the “homeopathic” label.

  28. Jimmylegs says:

    @pmoran
    “Do we have anyth,ing[sic] better to offer these often seriously distressed women?”

    I honestly don’t know of anything helpful to them off hand, but we should never seek treatments that does not have proven effectiveness (such as acupuncture).

    @micheleinmichigan
    I agree 100% that such treatments if used and told to be a distraction, fine that’s their business. However the person recommened such treatments and stated it MAY or WILL help with symptoms or the cause I would disagree with that advice.

    Not to veer off topic, I also agree with the cost part. I would say (with out evidence now) that, these “alt” treatments are expensive, not covered by insurance, and take multiple treatments (which add up in cost very fast).

    One should never try any treament unless it has been shown to be effective (excluding clinical trails but that’s not what is being discussed).

  29. pmoran says:

    Is that just your personal belief, or can you back it up with any evidence? This Cochrane review showed that acupuncture, acupressure, ginger, and other interventions were not supported by evidence.

    What they showed was that if you eliminate all the influences I listed as plausibly being helpful, there is no convincing effect. That is a quite different question i.e. these were sham-controlled trials.

    I have been discconeted from O+G for some decades. What do you do for severe nausea?

  30. pmoran says:

    Please forgive my recurring spelling mistakes. I mean no disrespect. Just getting old.

  31. AlexisT says:

    I hate WTE. It’s needlessly alarmist in places (is that Best Odds Pregnancy Diet still in there? Treat yourself to a bran muffin!) and in others, talks about every possible complication but in such a way as to make them meaningless. Everything’s just one of a laundry list. It’s hated by “natural” and “medical” alike, IME. The “natural” tell you to read Ina May Gaskin (please don’t–as a preeclampsia patient, this book makes me very, very angry) and the “medical” recommend the Mayo Clinic book (haven’t read it). The ACOG book is okay. It’s very bland and written-by-committee, but is fairly balanced.

    WTE is pretty much badly written on every front.

    BTW, the “natural” types do want you to take childbirth classes. It’s the hospital ones they dislike, which they claim are just geared towards producing compliant patients who accept hospital policy and don’t encourage non-medical methods of pain management–a claim buttressed by some hospital CBEs.

  32. Harriet Hall says:

    @pmoran,

    “all the influences I listed as plausibly being helpful”

    You’re backing down and qualifying your original claim that “some of these will help.” Is “plausibly being helpful” enough to justify recommending them?

    What do I do for nausea? I laughed when I read your question because I’m retired and not currently advising patients about morning sickness; but when I read false health claims and pseudoscientific nonsense, it makes me want to throw up. My self-prescription for my own nausea is to write a blog post. Writing is therapeutic for me; it helps relieve my discomfort. :-)

  33. @ Alexis T: Eight years later and I’m still traumatized by the Best Odds diet. Hopefully the authors have added some reasonable dose-response language so heavily pregnant women don’t agonize over every particle of refined flour or drop of caffeine that wafts past their lips.

    Something wrong with the baby? It’s the half of a white-flour bagel you ate before you knew you were pregnant. Mind-numbingly exhausted after childbirth and days without sleep while you breastfeed around the clock? It’s the epidural you had when you “gave in.” It’s like The Secret in that it implicitly blames the moms when something out of their control goes awry. Which lays the groundwork for following the CAM business.

  34. LMA says:

    Being of perimenopausal age and happily child-free, I have nothing to offer on pregnancy per se other than that my personal bugaboo myth is the assertion that there is something known as a “biological clock” that inexorably ticks in all females and if deferred or denied will result miserable regret — a horrible, horrible fairy tale that results in the real world fact of lots of women being panicked and pressured into having kids — a pretty irrevocable thing once you’ve gone and done it.

    But to the nausea question I have a “it works for me — but is there *scientific* evidence either way?” addendum: a general practitioner/family doctor once told me the best treatment for nausea was cola syrup, which you could buy at the pharmacy counter, or make youself by pouring a glass of Coke/Pepsi and then pouring it back into another glass a few times in succession (now that I type that, it sounds kinda like homeopathy without the dilution!) until it’s defizzed, and then sip it. Was he advising me to try a genuinely harmless old wives’s tale kind of thing that works because of the placebo effect or have there in fact been studies to determine there’s something to it? Since it’s “worked for me” on more than one occasion, maybe I *shouldn’t* be disabused of the belief ’cause having severe IBS and GERD nausea is something I experience far too often. But “inquiring minds” want to know!

  35. Snookums says:

    I have noticed that it is incredibly difficult to find a pregnancy book that sticks to good, scientific information. I liked Expecting 411, written by two doctors, but even they recommended sea bands and acupuncture for morning sickness.

    (I experienced debilitating morning sickness in the first trimester of my current pregnancy and sea bands did absolutely nothing for me, but at least they only set me back about $3, and the drug store was willing to give me full refund. I shudder to think what I might have spent with a homeopath or acupuncturist.)

    I returned another popular book, The Mother of All Baby Books, after flipping through the birth section and reading, “your baby knows when to be born” (if my baby is smarter than my ob, I’m in a heck of a lot of trouble) in a small section about inductions, which strongly implied they were done largely for the doctor’s convenience, and which did not mention any of the benefits of induction or why one may be necessary.

    Really, the best one I’ve found so far is The Pregnancy Care Book by Dr. Michèle Farrugia. It’s very factual, even-handed, and easy to understand. But it took me a very, very, very long time to find it, and I don’t think it sells well outside Canada.

  36. Intraneural says:

    Just a funny anecdote- back in residency I was doing a history and physical for a new pt on labor and delivery. I was consenting all the anesthetic options and the patient stopped me to refuse any needle in her back. She stated “you won’t do an ‘epidermal’ on me cus I had one last time and ever since I have had an inverted nipple”. So for all of you out there the worst feared complication of an epidural- inverted nipples! :)

  37. Intraneural says:

    By the way- name that logical fallacy from above.

  38. WilliamLawrenceUtridge says:

    Post-hoc ergo propter hoc.

  39. WLU Post-hoc ergo propter hoc.

    From this day forward to be known as the inverted nipple fallacy. (Maybe not, but it would make life more entertaining).

    Anyone ever wondered if, like the catholic church, the skeptic should consider dropping the Latin? :)

  40. WilliamLawrenceUtridge says:

    But Latin has such a nice mouthfeel…

    I see the advantage of brevity and conceptual separation. Post hoc ergo propter hoc is a distinct “thing” which we have a definition for. The English translation is something like “after this therefore because of this” though a reasonable equivalent would probably be time proximity attribution.

    Though “inverted nipple fallacy” would probably work as well really, and it’s got punch :)

  41. Intraneural says:

    I was going for post hoc ergo propter hoc but I think the inverted nipple fallacy is more appropriate! I love it.

  42. elburto says:

    Amy- by ‘the skeptical OB’ are you referring to Amy Tuteur aka wikigrrl aka a complete fantasist troll bloke?

    Google about a bit and you’ll see that ‘Dr Amy’ (along with the total bollocks spouted on her blog) is, in fact, made up out of whole cloth by some delusional idiot whose entire schtick seems to be “women are idiots”.

    Back on topic – WRT the book being discussed, surely there’s someone out there who can write a book about pregnancy (or any health matter) that’s purely factual? I’ve never been pregnant, I have no desire to be, but I’ve thrown many books across the room in a rage after reading that herb X can cure my endometriosis or that essential oil Z ‘promotes healing’ of lesions caused by ulcerative colitis.

  43. WTE is a book that any human with anxiety issues should stringently avoid.

    Also, I am totally going to use “inverted nipple fallacy” in place of post hoc from now on. :D

  44. ZDoggMD says:

    We just had our second child, and the only books I used for researching care of the newborn were comic books: http://zdoggmd.com/2011/08/neonate-dogg/

    My wife had the “Expecting” book laying around. It’s now laying around in the trash. Thanks!

  45. Harriet Hall says:

    @elburto,

    “Amy Tuteur aka wikigrrl aka a complete fantasist troll bloke?”

    This is your unsupported opinion and really doesn’t say anything. Tuteur is a skeptical OB/Gyn and IMHO her blog is a good source of information.

    If you have something to say about her, please offer concrete criticism supported by evidence from her blog. Just spouting insults isn’t enough to make any readers of SBM accept your opinion: in fact, it makes you sound like a troll.

  46. Scott says:

    Google about a bit and you’ll see that ‘Dr Amy’ (along with the total bollocks spouted on her blog) is, in fact, made up out of whole cloth by some delusional idiot whose entire schtick seems to be “women are idiots”.

    A good bit of Googling doesn’t turn up any indication of that at all that I see. Got any actual evidence for your accusation?

  47. pmoran says:

    Harriet: @pmoran,

    “all the influences I listed as plausibly being helpful”

    You’re backing down and qualifying your original claim that “some of these will help.” Is “plausibly being helpful” enough to justify recommending them?

    Ah, well caught! I did phrase things differently.

    The issue remains, as I know you all know, whether there is a sufficiently precise demarcation between what is helpful in clinical practice and what isn’t to warrant us being so precious about methods that we don’t like on grounds that are irrelevant to the patient’s immediate welfare, and fears that are somewhat theoretical, anyway.

    You ask for evidence, but I am also sure you also know everything I know. We can predict from very extensive experience that patients would report better overall results with these measures than if no concrete suggestions were made regarding treatment. Otherwise why do we need the sham-controlled studies?

    If you want more direct evidence, nausea is one of the symptoms that Hrobjartsson and Goetchke acknowledged as producing modest placebo responses in their comparisons of placebo and “untreated” groups, when in the context of the placebo-controlled clinical trial, which may be itself a special case.

    So it is not an accurate reflection of the solidity of the science to say that these measures cannot help anyone, even without considering what the other influences I mentioned may be contributing. All we can say is that they don’t work in mysterious or mystical ways.

    I laughed when I read your question because I’m retired and not currently advising patients about morning sickness —

    Heh, heh. Again, clumsy expression from me. I did not mean to accuse you of closet child-bearing :-).

    “What do you do — ” was of course meant to mean “what do ‘you’ do — ” as in “what does an evidence-based doctor advise for morning sickness these days”. I still want to know.

  48. Intraneural says:

    @pmoran I don’t do obstetrics but my wife was pregnant last year and experiences pretty significant nausea. She is an insomniac anyway and frequently takes doxylamine (unisom). The ob told her that they prescribe that for morning sickness. She also was prescribed zofran (ondansetron) for prn dosing for the daytime hours. Both seemed to help? I do not know the literature however and until my Internet gets set up in my new place I do not have easy access to pubmed. I know zofran works well for perioperative and chemo induced nausea that is documented in the literature.

  49. pmoran says:

    thanks, Intraneural. I expected more caution in drug use, at least in early pregnancy.

  50. Harriet Hall says:

    @pmoran

    “to warrant us being so precious about methods that we don’t like”

    Straw man.
    No one is being precious. No one is judging methods by whether we like them. We are only trying not to mislead patients by implying something has been proven to work when it hasn’t.

    “Plausibly being helpful” Is that sufficient justification for recommending something without proper testing?

    ” it is not an accurate reflection of the solidity of the science to say that these measures cannot help anyone”

    Straw man. No one has said they “cannot” help anyone, especially if you think using placebos “helps” people.

    Current recommendations start with simple measures that can be tried at home, like eating smaller meals or saltines. The safety of doxylamine/B6 is pretty well established. The safety of odansetron and other drugs is less well established, but it’s a trade-off between possible risks and definite effectiveness in a condition that can threaten the lives of mother and baby.

  51. AllieP says:

    I had SEVERE morning sickness during my pregnancy. Sea Bands did not work — they just made my wrists sore and bruised. Ginger did not work (though I wasn’t able to stomach it for months because I vomited up so much of it). Sucking on sour candies or nibbling constantly on crackers (so much for “best odds diets” — I survived for months on saltines and lemon balls) worked for a little while (maybe weeks 9-10) but around about week 13, when days went by where I couldn’t keep anything down but gatorade and was vomiting literally a dozen or more times a day, I broke down and went on zofran.

    BEST. DECISION. EVER.

    It changed my pregnancy entirely. It changed me entirely. I could eat. I could function. I could work. And my baby is fine. I deeply regret not going on it earlier and if I ever have another baby, I’m going to start it before things get to the point where I’m endangering my health or my baby’s due to malnutrition.

    It even came in convenient “melt in your mouth” form since I couldn’t even swallow pills. I used it until I was in my third trimester. I threw up once more during my pregnancy.

    Zofran has been used for something like 20 years on pregnant women, so its safety has been pretty well-documented. and my doctor told me that she herself had three babies on zofran. My baby is perfectly healthy.

  52. pmoran says:

    to warrant us being so precious about methods that we don’t like

    Straw man.
    No one is being precious. No one is judging methods by whether we like them. We are only trying not to mislead patients by implying something has been proven to work when it hasn’t.

    I know, but this is not only about my pig-headedness.

    The public cannot understand why we are not be more tolerant of them trying methods that merely “may” help, even ones that have a low likelihood of success if the distress is severe.

    It just does not make sense to them to do otherwise, and that is the source of some of the alienation and loss of trust that exists between us and sizeable elements of the public.

    I can see the negatives, but my advice to patients would be drawing a firm line against the use of CAM alone for any serious illness, and include evrything I know about safety issues and frank fraud. At that line the evidence is more solid and easier to argue through, if needed.

    Can you not see the positives?

  53. AlexisT says:

    Doxylamine (Unisom Sleeptabs–not the gels, which are dipenhydramine) + B6 is validated for nausea in pregnancy. It was sold as Bendectin in the US until it was withdrawn after what turned out to be spurious lawsuits. Still sold as Diclectin in Canada. Downsides: Yeah, it makes you sleepy. Still, it’s available OTC, and if your nausea/vomiting isn’t severe, it’s probably worth a go.

    After that, docs generally go to Zofran–popular and safe. Any risk of the drug (not yet demonstrated AFAIK) has to be weighed against the known risks of not eating or drinking, which is dangerous for mother and baby. Women are not incubators! (Pet peeve. You wouldn’t believe the flak I’ve gotten for daring to take meds in pregnancy.)

    If Zofran doesn’t work, or you’re at the point of dehydration, you need an OB/MFM who is experienced in the treatment of hyperemesis gravidarum. There are other things they can try, and in the worst cases, they will use IV therapy (I know 2 women who wound up on TPN for their entire pregnancies).

    Also, it should go without saying (but some people don’t realize this) that mild nausea and vomiting is a totally different beast from HG, which is a serious problem requiring medical management. If someone can’t keep anything down, recommending ginger, cola, etc is not going to help them. The home remedies are great for mild cases and really, if sipping Coke and munching on saltines settles your stomach, that’s good enough for you. Judging purely on anecdote, the mild cases seem to be very individual in terms of what settles and what doesn’t. Just don’t suggest it to your friend who’s already lost 10 lbs from constant vomiting!

  54. Plenty of anecdotal advice.

    For it to be valid, you must declare whether you have MD after your name.

    Sad how ppl slip right back into the normal mode of clinical decision-making.

    If Zofran or Unisom work, someone needs to post a reference indicating a study where 30 women with ‘morning sickness’ in 1st trimester and took the tab and, some portion felt “significantly better” “I could eat” upon treatment, plus a control group of 30 women taking placebo to control for the natural variability in remission of morning sickness.

    Sadly, I don’t have any anecdotes. With one pregnancy, nothing but time worked for my wife. I was very willing to run to the drugstore for any suggestion that seemed safe enough (the wristband, ginger, peppermint, etc.).

    It is puzzling that the presence and intensity of morning sickness differs for the same woman in different pregnancies.

    Sure, the morning sickness might deter a woman from eating, and so reduces possible dietary harms. but if that is the physiological purpose, then wouldn’t we expect it with every pregnancy?

  55. AlexisT says:

    Since Unisom+B6 HAS been approved for nausea of pregnancy in Canada (as Diclectin), I’m sure someone with better search skills than I could find the studies backing it. Here’s what the manufacturer says: http://diclectin.com/ra_psg.html

    It isn’t really that “puzzling” at all. Morning sickness is caused by rising levels of hCG and progesterone. So not only is the effect going to vary depending on a woman’s personal sensitivity to that rise, but by how rapidly they go up–this is why molar and multiple pregnancies are known for worse nausea and exhaustion.

  56. Harriet Hall says:

    @pmoran,

    “Can you not see the positives?”

    I can imagine the positives, but I can’t confirm that they are correct or are ultimately in the patient’s best interests.

    I can see that you are so motivated to “do something” that you are willing to abandon scientific rigor and try anything that “might” make a patient feel better. I have qualms about that approach because it substitutes experience and speculation for evidence and it smacks of paternalism. And of a double standard where prescription drugs are treated differently from other treatments.

  57. Calli Arcale says:

    elburto:

    Back on topic – WRT the book being discussed, surely there’s someone out there who can write a book about pregnancy (or any health matter) that’s purely factual?

    I found “The Girlfriends Guide to Pregnancy” reassuring, but it wasn’t really written for providing medical advice; it’s more of a “hey, yeah, this is a crazy wild roller coaster you’re on, but others have been on it too and they survived — you probably will too”. I also liked that it tried to counter the general “if you don’t do your pregnancy and labor right, your child will be screwed up for life and it will be YOUR FAULT”.

    But for actual, serious information, the best thing I got was this spiral-bound book provided with my hospital and clinic’s program. (It’s a fairly large non-profit health care corporation, so the clinic and the hospital are actually operated by the same company. For Minnesotans out there, it’s Allina Medical.) It came with the prenatal class, and if you didn’t already have it, they’d also give it to you in the childbirth class or, failing that, while you were recovering from the birth. It was EXCELLENT. It was definitely written like a user’s manual, but it really did a good job of neutrally covering options for various things, and also what one can expect at different phases of the process. Best part of all? Unlike all the other childbirth books I found, it wasn’t just about pregnancy and recovery. It also contained excellent advice about caring for a newborn — when to be concerned about a fever, how to tell if they’re growing adequately, suggestions for feeding positions (both breast and bottle), how to bond with daddy (actually, it also had a whole chapter for daddy), and so on. It helped enormously. OTOH, I’m a nerd, and enjoy that sort of textbook-style presentation of the material.

    pmoran:

    thanks, Intraneural. I expected more caution in drug use, at least in early pregnancy.

    The trouble is that for some women, the nausea isn’t a mere inconvenience or a punchline to a pregnancy joke. For some women, it’s life-threatening. As with asthma medications and such, the risk of *not* taking the drugs is far greater than the risk of taking them. Malnourished women are far more likely to deliver underweight, premature babies — or miscarry altogether.

    MedsVsTherapy:

    It is puzzling that the presence and intensity of morning sickness differs for the same woman in different pregnancies.

    Sure, the morning sickness might deter a woman from eating, and so reduces possible dietary harms. but if that is the physiological purpose, then wouldn’t we expect it with every pregnancy?

    It has no physiological purpose, per se. It’s a side effect of the hormone shifts. The physiological purpose of the hormones is to sustain the pregnancy; this is so important to the survival of our species that evidently nausea is an acceptable price to pay. Once you realize the hormones are directed largely (though not entirely) by the placenta, which is biologically part of the baby, not the mother, it’s perhaps not too surprising that the effects can vary from pregnancy to pregnancy.

  58. pmoran says:

    I can see that you are so motivated to “do something” that you are willing to abandon scientific rigor and try anything that “might” make a patient feel better.

    I clearly was not recommending “try anything”.

    And “– abandon scientific rigor–”?.

    I am aghast that this is how you see my comments, but it may well be my clumsy prose that is at fault.

    It was precisely because of the science that I started to examine skeptical positions more critically.

    I have no brief for CAM, and never ever considered that we should be less intolerant of it (in some settings) until the science of medical interactions, along with a realistic appraisal of present mainstream medical capabilities, suggested that this could be considered without the sky falling in.

    Another factor: I have talked to a great many CAM users and enthusiats , and I believe I have a better understanding of what makes the folk medical and CAM world tick than have most skeptics.

    1. Harriet Hall says:

      @pmoran,

      Waiting until the science is in – OK.
      Being tolerant of untested treatments that are probably not dangerous – OK.
      Trying to understand what make the folk and CAM world tick – OK.
      Recommending untested treatments – not OK

  59. Tell it like it is says:

    @ VentureFree

    Hi there

    “Even if they know it’s BS (and I rather think that they do), they’ll almost certainly never update the book to say so. Their reputation would be irreparably, if entirely unfairly, tarnished”

    I must strongly disagree with you. This is the equivalent of saying Dr Crippen was a good doctor.

    http://en.wikipedia.org/wiki/Hawley_Harvey_Crippen

    Any well-respected publisher worth their salt would be delighted to hear from a respected authority that informs the said publisher that they are endorsing litigious practices – without making a public hoo-ha about it – so that the publisher could take action that they deemed appropriate and necessary to rectify the concerns and better enlighten the uninformed or misguided.

    In a world of global communication, if such action included ‘do nothing’ then both authors and publishers leave themselves exposed and wide open to public shame and ridicule. Their reputation would be irreparably tarnished and this would greatly impact upon their future – a point I feel Dr Hall – who had the good grace to read the publication and point out its weaknesses to this community – would also endorse should she or others be morally driven to write to the publisher and/or authors of the said work.

    Whilst I appreciate that it might be unreasonable to seek or expect an apology, I believe that it would be ‘just’ to simply remove all of the contentious information and release a new edition – job done!

    In these times of recession, destitution, gang-crime, global warming, atrocious and pointless wars, preventable disease and avertable famine – as a holy man once said – “Blessed are the ‘meek’ – for they shall inherit the Earth”.

  60. elmer the fake nutritionist emailer not says:

    I’ve recently become curious about hypnosis, mainly for pain, and the reviews I’ve looked at (I’ll admit I haven’t looked at primary sources) give the impression that there’s a quite a bit of good evidence that it is effective for pain. Relevant to this post, there is a section on “Obstetrics” in this review (and some studies discussed in other sections might also be relevant): http://www.papelesdelpsicologo.es/english/1699.pdf
    This particular review doesn’t really talk much about quality, but presumably you have access to the papers and can say what you think?

    Also, biofeedback isn’t CAM, right? Seems to be worth mentioning.

  61. elmer the fake nutritionist emailer not says:

    It occurs to me that it would be useful to copy and paste the (directly) relevant text from the above link”

    Obstetrics

    Hypnosis has also been used in obstetrics to facilitate delivery. According to Pinnel and Covino’s review (2000), studies on this subject claim that patients treated with hypnosis had greater satisfaction with birth experience (Freeman, MacCauley, Eve, & Chamberlain, 1986); shorter labor (Brann & Guzvica, 1987; Jenkins & Pritchard, 1993); and they used significantly less analgesic medications than control patients (Jenkins & Pritchard, 1993).

    A subsequent review carried out by Cyna, McAuliffe, and Andrew (2004) found several studies in which mothers who used hypnosis needed less analgesia and less pain medication. The authors conclude that, in view of the possible benefits of including hypnosis in obstetrics, continued well-designed research is needed to confirm these effects during labor.

    There is also evidence that hypnosis facilitates pregnancy in women who are undergoing in vitro fertilization interventions (Levitas et al., 2006).

    More recently, Brown and Hammond (2007) reviewed the benefits and effectiveness of hypnosis in obstetrics and labor and delivery. In the studies they examined, it was found that hypnosis helps reduce labor and delivery pain significantly and the need for medication during and after labor and delivery. Moreover, hypnosis proved to be an effective adjunct to the medical treatment of preterm labor in a case of quadruplets. The authors suggest a multicenter randomized, clinical trial regarding the use of hypnosis for further research in order to evaluate the efficacy of hypnosis in this area (Brown & Hammond, 2007).

  62. elmer the fake nutritionist emailer not says:

    …again, hypnosis in obstetrics is a pretty narrow area of research, but there seems to be quite a bit of evidence for pain and general (I’ve got more links, if anybody wants).

  63. Harriet Hall says:

    I’m skeptical of hypnosis. Robert Baker wrote a book “They Call It Hypnosis” that questions whether it even exists. I was taught that it was not some kind of trance but merely a state of selective attention/inattention. The Skeptic’s Dictionary also questions it. See http://www.skepdic.com/hypnosis.html In experiments, people who were asked to pretend they were hypnotized were indistinguishable from those who were hypnotized by a hypnotist. Suggestion is known to influence pain perception, but there’s nothing qualitatively unique about suggestion “under hypnosis.” Non-hypnotic suggestion is probably just as effective.

    I’ve been “hypnotized” but when I had my babies I got effective pain relief with an epidural and with a paracervical/pudendal block. I’ll take real anesthesia over suggestion any day.

  64. elmer the fake nutritionist emailer not says:

    You don’t actually have to choose one or the other, though. That’s true of pain treatments in general.

    I’ll just provide a couple of my other links, rather than continue copying and pasting:

    Scientific American article on hypnosis:
    http://www.scientificamerican.com/article.cfm?id=the-truth-and-the-hype-of

    Responses to the suggestion that hypnosis isn’t real are on pages 2-3. I believe I read that the idea that hypnosis wasn’t real was most popular in the 80s. I might come back when I find that.

    A Systematic Meta-Review Of Hypnosis As An Empirically Supported Treatment For Pain:
    http://www.ingentaconnect.com/content/arn/pr/2001/00000008/00000002/art00001

  65. elmer the fake nutritionist emailer not says:

    Correction, obviously for some treatments shouldn’t be combined…see, I’m as capable of overgeneralizing as a skeptic!

  66. Harriet Hall says:

    Was it hypnosis that was empirically supported, or were they actually testing simple suggestion?
    Do you have any evidence that hypnosis creates some kind of unique state?

  67. elmer the fake nutritionist emailer not says:

    Not sure what kind of evidence would satisfy you. They’ve got evidence that people who are hypnotized, or “hypnotized,” if you prefer, behave differently from fakers when they believe they’re not being watched.

    They’ve got evidence that hypnotic suggestion works better for pain than relaxation with or without hypnosis. They’ve got some standardized tests for susceptibility. They’ve got the inevitable brain-imaging studies that distinguish hypnosis from various other mental activities.

    The idea that suggestion that it would be as effective without bothering with hypnosis is a novel idea. I haven’t seen anyone make that comparison. I suppose it might be worth doing.

  68. Harriet Hall says:

    Suggestion without hypnosis has been shown effective in reducing pain. Here are a just a couple of examples: http://www.ncbi.nlm.nih.gov/pubmed/21205609 http://www.ncbi.nlm.nih.gov/pubmed/21884868

    I thought I had seen one study comparing hypnosis to non-hypnotic suggestion, showing them equally effective, but I couldn’t find it again.

    I don’t think the brain imaging studies prove anything one way or the other: they may just be showing what happens when people react to suggestion and selective attention/inattention. If people who are hypnotized behave differently from fakers when they believe they’re not being watched, that doesn’t really prove anything either. Maybe they stick to the role-playing more consistently because they believe they should act that way.

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