Midwife-led care

Midwife and researcher Ellie Wernham and Prof Diana Sarfati discuss their work showing worse outcomes under midwife-led care, and the Ministry of Health's coordination with the College of Midwives in response to that work.



Government policy might not change, but you can update your practice.

The practice we followed a bit over a decade ago:

1. Find a midwife the second you think you're pregnant - or even earlier. Get one with proper training, not just the midwife certificate. You want a midwife who had rigorous nurse's training prior to going in for specialisation in midwifery. The ones who have training go very quickly. If you wait, you will be left with a midwife with weaker training. 
2. Pay for shared care with an obstetrician anyway. In 2008, we paid a fixed price of $2k; in 2010, it was $3k. At the time, it was about the same price as a decent flat-screen TV; we kept the old CRT around for a few more years instead. Having your obstetrician available on-call during delivery to provide a c-section if needed is worth it. 

Previously: The Midwives have a history

Drinking in Pregnancy: The NZ stats

The Science Media Centre points to some new statistics on drinking during pregnancy. Given the alarming figures they highlighted, I was surprised to see that the actual data looked pretty good.

Here goes.

First, the highlights from Science Media Centre:

The analysis indicated a high prevalence of drinking, including binge drinking, among mums to be. The prevalence of drinking alcohol ranged from 20% to 80% in Ireland, and from 40% to 80% in the UK, Australia, and New Zealand.
Across all countries, factors associated with alcohol use included smoking during pregnancy and Caucasian ethnicity.
“Our data suggest that alcohol use during pregnancy is prevalent and socially pervasive in the UK, Ireland, New Zealand and Australia”, conclude the authors.

Wow. Sounds pretty terrible. But here's the paper. Table 4 has the main results.

That's hard to read, and I'm sorry. What does it show? I've transcribed the NZ column into this chart; I hope I haven't introduced any transcription errors.

The y-axis has the number of women in each category. The number of women reporting non-drinking increases substantially from pre-pregnancy (the blue bar) to first trimester (orange) and again to second trimester (grey). They do not have separate data for third trimester. 

During first trimester, the main risk from heavy drinking is miscarriage. After that, heavy drinking can yield foetal alcohol syndrome. But there's no evidence that 1-2 per week does harm.

What do we see? In the first trimester, 35% of women consume more than 1-2 units per week. Those women are at increased risk of miscarriage. 12% drink over one unit per day on average.

In the second trimester, 220 of 2006 women, just over 10%, report consuming 1-2 drinks per week. There is no evidence of harms from that level of drinking. 7 women report consuming 3-7 drinks per week - which is still within the safe range. No women report drinking more than that on average and two of 2006 report ever having binged during the second trimester. 

Binging during the second trimester is a pretty bad idea. But it is 0.1% of those surveyed, or 0.35% if you want to include everybody reporting in the 3-7 per week range. 

Expect scary newspaper headlines tomorrow accompanied by pleading calls for action. But remember that the rate you should care most, if foetal alcohol syndrome is your main concern, about is 0.1%. About 35% of women are at increased risk of miscarriage. Both are well below the highlighted 40-80%. 

Read Emily Oster's summary on drinking and pregnancy.

I reviewed many, many studies, but I focused in on ones that compare women who drank lightly or occasionally during pregnancy to those who abstained. The best of these studies are ones that separate women into several groups—for example: no alcohol, a few drinks a week, one drink a day, more than one drink a day—and that limit the focus to women who say they never had a binge drinking episode. With these parameters, we can really hone in on the question of interest: What is the impact of having an occasional drink, assuming that you never overdo it?
I summarize two studies in detail in my book: one looking at alcohol consumption by pregnant women and behavior problems for the resulting children up to age 14 and one looking at alcohol in pregnancy and test performance at age 14.  Both show no difference between the children of women who abstain and those who drink up to a drink a day. I summarize two others in less detail: one looking at IQ scores at age 8 and a more recent one looking at IQ scores at age 5. These also demonstrate no impact of light drinking on test scores.
I argue that based on this data, many women may feel comfortable with an occasional glass of wine—even up to one a day—in later trimesters. (More caution in the first trimester—no more than two drinks a week—because of some evidence of miscarriage risk.)

Her book on pregnancy is excellent - if you want actual evidence rather than scaremongering.

Previously:

• Drinking and Pregnancy (referencing this study)
• Noble lies: Alcohol and pregnancy edition.
• No safe level?
• Expecting Better

IUDs and teen pregnancy

Better access to IUDs at subsidised family planning clinics reduces teen birth rates, says a new NBER working paper by Jason Lindo and Analisa Packham.

From their abstract:

Despite a near-continuous decline over the past 20 years, the teen birth rate in the United States continues to be higher than that of other developed countries. Given that over three-quarters of teen births are unintended at conception and that over a third of unplanned births are to women using contraception, many have advocated for promoting the use of long-acting reversible contraceptives (LARCs), which are more effective at preventing pregnancy than more commonly used contraceptives. In order to speak to the degree to which increasing access to LARCs can reduce teen birth rates, this paper analyzes the first large-scale policy intervention to promote and improve access to LARCs in the United States: Colorado's Family Planning Initiative. We estimate its effects using a difference-in-differences approach, comparing the changes in teen birth rates in Colorado counties with Title X clinics (which received funding) to the changes observed in other US counties with Title X clinics. The results of this analysis indicate that the $23 million program reduced the teen birth rate by approximately 5% in the four years following its implementation, providing support for the notion that increasing access to LARCs is a mechanism through which policy can reduce teenage childbearing.

I'd love to know whether the programme also had effects on STD rates. Where the price of unprotected sex goes down, you should get more of it - as Klick and Stratmann found. That's hardly a reason not to provide access, just something to consider as an offsetting cost potentially in the mix.

No Safe Level

Loyal readers here know the data on drinking and pregnancy. Binge drinking in early pregnancy increases the risk of miscarriage. Light drinking during pregnancy carries basically no risk, but moderate to heavy drinking in pregnancy, and especially heavy drinking, can result in foetal alcohol syndrome. That's bad and should be avoided.

Pregnant women, for way too long, have been told that there's no safe level of drinking in pregnancy. For some, that's just increased anxiety and made pregnancy a worse experience than it's needed to be.

Others took the message to heart and, fearing that they'd done something horrible by having had too much to drink before knowing they were pregnant, have sought abortions.

The main risk of drinking too heavily in the very very early stages of pregnancy is miscarriage: spontaneous abortion. Because the anti-alcohol establishment has convinced women that any amount of drinking is going to result in foetal alcohol syndrome, some women are seeking abortions in order to avoid the risk of miscarriage.

Via James Nicholls, I find this piece at The Guardian:

The day before I discovered I was pregnant with my son, I’d shared nearly two bottles of red wine with a good friend. It was more than three glasses or six units; I’d thus been binge drinking.

As the faint blue line of the white stick deepened in intensity, my mind raced back. Visions of midweek drinks followed by longer weekend sessions filtered through, and I was mortified. Weeks had gone by where I was ignorant of my pregnancy. Had I caused the foetus irrevocable harm? Luckily for me, I had friends who’d been in exactly my position. My worries were assuaged. I was told it would be fine; rather than fretting, I should enjoy this new reality.

Such guilt and anxiety is increasingly causing some women to abandon pregnancy altogether, in an unintended consequence of the amplified policing of pregnant women’s bodies. Britain’s largest provider of abortion services, the British Pregnancy Advisory Service (BPAS), warns that binge-drinking scare stories, hyped up by the media, are causing heightened levels of fear. The organisation reports that it is “regularly seeing women so concerned they have harmed their baby before they knew they were pregnant, they consider ending what would otherwise be a wanted pregnancy”.

I'd characterised doctors' advice on drinking and pregnancy as being the noble lie: that they know it's a lie, but they're scared of encouraging risky heavy drinking in later pregnancy by saying light drinking's ok. The lie isn't noble. It is doing harm. Please stop.

Expecting Better

My review of Emily Oster's excellent Expecting Better appeared in this weekend's Christchurch Press; it's copied below. I've added in a few relevant links.

I had a lot of questions for our midwife when we expected our first a few years ago. Questions like, "Which shared-care obstetrician has the best delivery outcomes adjusting for the risk of the patient base?" My wife later warned me that our excellent midwife seemed to think me some kind of pod-person for asking questions about the evidentiary base around the standard pregnancy recommendations. Had we then had a copy of Professor Emily Oster's new book, "Expecting Better", I wouldn't have needed to torture her. I should send her a copy now. And if you're expecting, or thinking about getting pregnant, you should pick up a copy too.

Emily Oster is a University of Chicago economist. When she and her husband, economist Jessie Shapiro, decided to start a family, she started into the data. The pregnancy books and doctors provide a lot of recommendations. Some of these benefit the foetus at next to no cost to the mother. Others provide only a small benefit to the foetus while imposing some cost on the mothers. And, sadly, some impose reasonable cost on the mother while doing nothing to help.

Oster provides us the story of her pregnancy, in an accessible and conversational style, while walking us through the research she conducted along the way. While trying to conceive, she worked out the conception probabilities at each date of the cycle. She also found that while obesity makes it harder to conceive, merely being overweight isn't much different from being normal weight. When the pregnancy test came back positive, she wanted to know, and quickly, whether she could stick with her standard caffeine addiction. She charted the probability of miscarriage at every week of pregnancy. All the “no, you can't eat that” rules? She shows us which of them make sense. Later in the book, she walks through the difficult cost-benefit analysis around amniocentesis - the exact same calculation we ran ourselves.

So what's an economist doing writing a book on pregnancy? Economists are good at framing tradeoffs between risks and benefits to help others decide what's right for them. Further, economists' statistical toolkits are built for solving the kinds of statistical inference problems that plague the population health literature. If a study finds mothers who drink more coffee during pregnancy have worse outcomes, is it because of the coffee, or is it because more nauseous women both have better outcomes and find coffee unappealing? Economists' training helps us sort out which studies have done a reasonable job and which ones really haven't. Oster concludes that a couple cups of coffee a day are just fine.

If costs to the mother never mattered, and if statistical inference were easy, then life would be simpler. But in most cases, we need to weigh how much real risk is imposed by, say, smoking a cigarette during pregnancy, and then decide whether the benefit to the mother could outweigh the cost to the foetus. Smoking during pregnancy is very risky and even light smoking is associated with worse outcomes, so the calculus for most mothers on that one should be easy. But what about drinking? Oster's review of the literature here coincided perfectly with what I found when I looked at the same studies: light drinking during pregnancy, on the order of a small glass of wine every other night or so, does absolutely no harm to the foetus. Heavy drinking is very very bad indeed. But the bulk of the well-designed studies show no risk, and in some cases some benefits, from light drinking. If a small glass of wine with dinner helps you relax and you've been abstaining because you're scared that one glass will do harm, you're making pregnancy less pleasant than it could be and achieving little for it.

Oster concluded, as I did, that most recommendations in this area seem motivated by the fear of encouraging binge and heavy drinkers to continue such very harmful practices during pregnancy. But is it really ethical to lie to pregnant women because we're scared they can't handle the truth?

Similarly, and at least in North America and the UK, there's no good reason to avoid sushi during pregnancy as the dangerous forms of salmonella there are very rare. Were we ever to contemplate a third child, I'd be investigating whether those strains are at all common around New Zealand. On the other side, gardening is riskier than I had expected because of toxiplasmosis gondi.

I worry that the standard full set of dos and don'ts make pregnancy sufficiently costly and nerve-wracking that some families are smaller than they otherwise would be. A lot of current recommendations seem to be public rituals designed to allow the mother to display how much she cares about the infant, and for others to display similar amounts of care for the infant by tut-tutting the mother-to-be. This does harm. We make pregnancy a worse experience, and too-often needlessly so, for the mothers who care and worry most about following all the rules. I worry further that by promoting rules that most people know make little sense, we encourage some mothers to discount even the rules that make a lot of sense. Oster provides a sound assessment of the actual risks to help families make their own decisions about the path through pregnancy that is right for them.

Related posts:

• Naming names
• Transfusions and operating room ethics
• Otago bioethics: Downs edition

Kid Sanity

Bryan Caplan tells us that because the return to parental input is low, we can all ease up on the parental production function. Parents agonise about whether they're doing enough; the ones who do so-agonise are usually doing far too much on any rational cost-benefit calculation. Conclusion? Spread the same amount of total effort over more kids. The reduction in average child quality really won't be that big and you'll be a lot happier in your old age.

But Bryan errs a bit. He neglects that we also could be putting too much effort into antenatal care. Sure sure, there's a big left tail that are screwing up horribly on that front. But that tail isn't reading economics blogs or parenting books written by economists. Instead, the folks who do read econ blogs are busily beating themselves up for having a bit of soft cheese or sneaking a sip of wine during pregnancy. If we are erring in making pregnancy far more costly for our wives than it really needs to be, then we're really screwing up: no matter how convinced we are about Bryan's arguments, if pregnancy is really unpleasant, that up-front cost can kill our future potential unrealised children.*

Emily Oster's forthcoming book then will be a beautiful complement to Bryan's work. Amazon should sell them as a bundle. Doctors, midwives, and right-thinking-tut-tutting-jerks give us all kinds of advice about what good people do. A lot of those really just seemed to be nonsense.

Take alcohol. When we were expecting, none of the advice on alcohol seemed to make sense. Sure, getting drunk seemed a really bad idea. But the dose always makes the poison. So I went and checked the literature and concluded that light drinking during pregnancy was effectively harmless. So Susan had the occasional glass of wine; we were also big fans of Harrington's SobeRing Thought - the low alcohol beer that local brewer Harrington's made for the Lord of the Rings.** And I blogged a bit on how the risks of alcohol during pregnancy seem overstated: if anything, public health folks' warnings that there's no safe level of drinking seem a noble lie intended to dissuade those pregnant women who'd otherwise drink a bottle of scotch in an evening.

If you can't have a glass of wine with dinner every other night during pregnancy, then pregnancy is less fun than it otherwise would be. And so the kind of people who listen to this kind of advice are having too few kids.

Oster seems to have been as annoyed as we were. But she's done something far more constructive about it - she's compiled the evidence for those of us who care about evidence. From the Amazon blurb:

When Oster was expecting her first child, she felt powerless to make the right decisions for her pregnancy. How doctors think and what patients need are two very different things. So Oster drew on her own experience and went in search of the real facts about pregnancy using an economist’s tools. Economics is not just a study of finance. It’s the science of determining value and making informed decisions. To make a good decision, you need to understand the information available to you and to know what it means to you as an individual.

Take alcohol. We all know that Americans are cautious about drinking during pregnancy. Official recommendations call for abstinence. But Oster argues that the medical research doesn’t support this; the vast majority of studies show no impact from an occasional drink. The few studies that do condemn light drinking are deeply flawed, including one in which the light drinkers were also heavy cocaine users.

Expecting Better overturns standard recommendations for alcohol, caffeine, sushi, bed rest, and induction while putting in context the blanket guidelines for fetal testing, weight gain, risks of pregnancy over the age of thirty-five, and nausea, among others.

The tut-tutters are doing real harm here. Lower decile groups hear the "drink nothing" warnings, dismiss them entirely as nonsense, and go on to drink way too much while pregnant, doing real harm. High decile groups hear the "drink nothing" warnings and, adding that to all the other advice they're given about all the other costly-and-useless rituals they must follow during pregnancy, rationally decide to have fewer kids. This is a bad equilibrium. Shame that Oster's book won't be out for another year - the current equilibrium is costly, and the faster we can start fixing it, the better.

* As clarification: there's some optimal number of kids that each couple will decide to have. If the actual cost of having one more kid is lower than the cost parents think they have to face, or the cost they mistakenly decide to impose upon themselves, then optimal family size is a bit larger than the deciding-couple thinks. The deadweight costs of kids who optimally would be born from the parents' perspective but aren't born because of parental cost misperceptions is the problem - I don't think I'm pushing into Parfit territory here. But the problem is my wording, now clarified. Thanks

** Yeastie Boys and Kelly Ryan brewed the beers in this year's Hobbit film.