A correspondent asked for my opinion of a new book by journalist Jennifer Margulis that is apparently getting a lot of attention in some circles: The Business of Baby: What Doctors Don’t Tell You, What Corporations Try to Sell You, and How to Put Your Pregnancy, Childbirth, and Baby Before Their Bottom Line. I got a copy from the library and read it. It was a painful experience. One of the customer reviews on the Amazon website accurately sums up my own reaction:
There is a great need for an incisive look at all sides of modern maternity care in the United States, because — let’s face it — we all know it’s not perfect. This, however, is not that book.
The author is a strong advocate of home birth, water birth, midwives, “embracing the pain to make you stronger,” “parents know better than doctors,” natural = good, and very early potty training. She thinks bathing a newborn is harmful. She questions the need for well baby checkups: she thinks they are mainly a gimmick to sell vaccines. She questions the (science-based) practice of giving newborns vitamin K and prophylactic eye drops. She is against the use of chemicals in general. She reports that Johnson’s Baby Wash contains “a host of unpronounceable chemicals, some of which are known toxins…and carcinogens.” She doesn’t seem to have grasped the basic principle of toxicology that the poison is in the dose. She is against formula, which she says is killing babies, and against disposable diapers because they contain chemicals and petroleum and because they can cause your child to become infertile. Her only evidence for “infertility” is one study showing that disposable diapers raise scrotal temperatures. Indeed, plastic underpants are probably warm.
She chooses anecdotes and words intended to bias the reader. For instance, a description of a C-section says electrocautery produced an “odor of burning meat” so awful that it caused two nurses to “step away and turn their heads in disgust,” and when the obstetrician exteriorizes the uterus to facilitate repairing the incision, she characterizes it as leaving the patient’s guts inside out on the operating table.
Margulis says we do way too many ultrasounds. She’s right about that. A New England Journal of Medicine study found that routine prenatal ultrasound screening in low-risk women does not improve perinatal outcomes. There are legitimate reasons for doing ultrasounds in high-risk pregnancies or when a specific problem is suspected, but not as a routine for every pregnant woman.
In an article I wrote a couple of years ago, I reviewed the arguments for and against ultrasounds. There is no actual evidence of harm, but since adverse effects might not be immediately obvious and since there is no way to entirely rule out any possibility of harm, the precautionary principle argues for restraint. Non-medical use is particularly objectionable, especially for long-exposure keepsake videos done just “for fun” and for sex-prediction ultrasounds done with the intention of aborting female fetuses.
She recommends that ultrasounds be done as infrequently as possible and as quickly as possible. So do most doctors. The American Academy of Radiology and the American Congress of Obstetricians and Gynecologists jointly published guidelines in 2007:
Fetal ultrasound should be performed only when there is a valid medical reason, and the lowest possible ultrasonic exposure settings should be used to gain the necessary diagnostic information.
Margulis strongly implies that ultrasounds cause autism, but she doesn’t have any actual supporting evidence. She herself reminds us that correlation is not causation. Yet the “evidence” she gives us against ultrasounds is a mishmash of correlations, hypotheticals, emotion-laced anecdotes, and speculations:
- She gives a lot of credence to speculations based on rat studies and the untested hypotheses of a handful of researchers.
- She says “High-risk women who receive multiple ultrasounds are at higher risk of having autistic children.” High-risk women are already at higher risk of having autistic children, whether they have ultrasounds or not. High-risk women will naturally get more ultrasounds for legitimate reasons because they are at high risk.
- She claims that countries where ultrasounds are commonly done have higher rates of autism. Countries where ultrasounds are more available are countries where diagnosis of autism is also more available, so the reported rates might be higher even if the actual rates were the same.
- “People who do not use ultrasound, like the Amish, are at lower risk for autism.” This is doubly wrong. Amish women don’t reject ultrasounds and the idea that the Amish don’t get autism has been shown to be a myth.
- Someone who observed a long-exposure sonogram procedure thought the baby looked like it was in pain because it “flipped transverse and buried its face in the placenta and covered its ears with its hands.” But newborns are not capable of covering their ears with their hands in response to anything. They have poor control of their arms and don’t know what ears are or where they are located.
- A patient was “bullied” by a doctor when she said she didn’t want ultrasounds. Admittedly his bedside manner was insensitive, but it sounds like he was only trying to persuade her to get a test that he thought was medically necessary and that was in her and her baby’s best interests.
- She points out that x-rays were done on pregnant women before the link between cancer and x-ray exposure was recognized. True, but irrelevant.
- She suggests that doctors’ decisions to order ultrasounds are often profit-motivated, but offers no supporting evidence. Do doctors who are on a fixed salary order fewer ultrasounds? Do doctors who bought their own machines order more tests to re-coup the purchase cost? Maybe, but I couldn’t find any studies.
- She omits any mention of the evidence against the ultrasound/autism hypothesis. She cherry-picked only the studies that supported her opinion. I easily found this study showing there was no correlation between ultrasounds and autism. And this one. And this one.
There are many valid arguments against infant circumcision, but Margulis’ chapter on circumcision is a biased diatribe, full of distortions, exaggerations, and inflammatory verbiage. She describes some of the published studies about medical risks and benefits, but she refuses to accept them, preferring to rely on anecdotal evidence. She tells horror stories of botched circumcisions. She thinks there is a high incidence of unreported complications and deaths. She says hospitals encourage circumcisions because they make a profit from selling the foreskins.
She thinks babies suffer terribly during and after the procedure. When a doctor reported that his newborn son went right to sleep after the procedure, she refused to believe the baby could be comfortable: she argued that falling into a deep sleep is a coping mechanism babies use to deal with extreme pain. And then on the same page she tells us that newborns react to pain by screaming. You can’t have it both ways. As a family physician caring for newborns, I have personally observed hundreds of newborns in pain; every one of them cried, and not a single one went into a deep sleep. I have heard hundreds of babies cry vigorously, but it wouldn’t have occurred to me to describe their vocalizations as “screaming.”
The chapter on vaccines is by far the worst. She admits that vaccines save lives, but then she recites all the tired old anti-vaccine myths that have been repeatedly debunked. She defies the scientific consensus by insisting that “we know vaccines cause autism in some children.” She misinterprets the meaning of the Hannah Poling case and misrepresents the story of the removal of thimerosal from US vaccines. She believes Barbara Loe Fisher of the anti-vaccine NVIC and she misquotes what vaccine expert Paul Offit says about infants’ ability to handle multiple antigens. She claims that the US vaccine schedule is a result of profit motives and collusion between Big Pharma and the government. She says the chickenpox vaccine is more dangerous than the disease (clearly false, since the death rate from chickenpox dropped 97% after the introduction of the vaccine and no deaths have been reported from the vaccine). She claims that even the doctors who most vocally support the CDC’s current vaccine schedule are choosing an alternative route for their own children, delaying the schedule or refusing individual or all vaccines. She doesn’t offer a single reference to support that claim, and I don’t believe it for a minute.
It goes on and on, and gets worse. She digs herself deeper and deeper into the anti-vaccine party line, with no attempt at balance or acknowledgement that there are facts and arguments on the other side. It’s really pathetic.
A Condemnation of doctors
She mentions a lot of things doctors have done in the past that were later found to be harmful, such as x-rays, Twilight Sleep, and routine episiotomy. She describes episiotomy — an incision to enlarge the vaginal opening during labor — as “sexual assault”! And she says it has unnecessarily harmed millions of women, in “many” cases making lovemaking unbearably painful or even impossible. That can’t be true. I might be persuaded to believe “rare cases” but not “many” cases. Just think about how many women have gotten pregnant again through lovemaking after having an episiotomy. The number of children per woman peaked in the US during the years when episiotomy was routine.
Margulis sees past errors as a reason not to trust doctors. I see them as illustrating the value of the scientific process as it constantly asks better questions, accepts new evidence, and changes practices accordingly.
Things that need fixing
Common practices tend to lag behind published evidence. We should make sure obstetric practice is following the best available evidence:
- Delayed cord clamping.
- No routine episiotomy.
- Allowing ambulation during labor.
- Choice of positions during labor and delivery.
- Having a birth attendant remain with the patient throughout labor and delivery.
- Reducing the rate of C-sections.
- No exorbitant overcharging on bills (hospitals have been known to charge the patient $41.85 for 8 Tylenol pills that only cost them 8 cents each; that’s abusive.)
- Less use of continuous fetal monitoring.
- Accommodating personal preferences during the birth process whenever possible.
- Allowing women to eat during labor.
- Not only strongly encouraging breast-feeding, but actively providing practical support to help women breast-feed successfully.
- Allowing newborns to stay with Mom instead of in the nursery.
- Not handing out free samples of formula (because it tends to undermine breast feeding).
- Not doing routine ultrasounds on low-risk patients.
- Recruiting nurse practitioners to do well-baby exams and provide practical advice to parents, thus freeing up pediatricians to spend more time on the more specialized tasks they were trained to do.
It really boils down to two things: following the evidence, and improving personal interactions with patients.
Legitimate problems, poor solutions
That which is broken in the medical system is fixable, but opting out of it doesn’t fix anything. She tells about a mother who worried about exposing her baby to sick children in the pediatrician’s waiting room and thought it didn’t make sense to follow the advice of a doctor who only saw her child for 10 minutes. Her solution? She switched from a pediatrician to a chiropractor trained in nutrition and homeopathy! If that isn’t the epitome of idiocy, I don’t know what is.
This is a dreadful book. It is inaccurate, biased, and inflammatory. It could do a lot of harm.
It is a polemical screed that promotes unscientific beliefs while masquerading as science journalism. As Amy Tuteur, the Skeptical OB wrote in her review, this book has nothing to do with science, and nothing to do with journalism.
Too bad. The baby business in the US is far from perfect. A responsible journalist could have produced a science-based analysis of its deficiencies, with useful suggestions for improvement. Instead, Margulis chose to produce a deplorable travesty.