Last week my book, Expecting Better, was published. It’s a data-driven look at pregnancy in which I take my training, in economics, to look at many of the decisions and rules that come up while pregnant. With a few exceptions (don’t smoke!) the book doesn’t make any real recommendations. What it does do is outline the data and decision process women could use to make decisions for themselves.
In the week or so since my book has come out, one of the most common pieces of criticism I’ve gotten—though, surprisingly, usually not from doctors themselves—is that doctors know best. Pregnant women, and patients in general, should just do what their doctor says, the refrain goes. He or she is the expert.
Unfortunately, this attitude misses the point. There is often significant disagreement among doctor—not to mention between individual doctors and national or governmental recommendations. The simple rule of just doing want the doctor says will lead to quite different behavior depending on who that doctor is.
In pregnancy, in particular, this disagreement can be extensive. Consider just a few examples:
Bed Rest. A 2003 bulletin on the prevention of preterm birth from the American Congress of Obstetricians and Gynecologists (ACOG) states: “Bed rest…should not be routinely recommended.” However, in a 2009 survey, 71% of obstetricians said they would recommend bed rest for women at risk of preterm labor. In fact, more than a quarter of doctors surveyed disagreed with the ACOG view that bed rest has few benefits. Another 43% agreed that there are limited benefits, but said they would prescribe it anyway. Only 29% would simply go along with the ACOG recommendation.
Prenatal Testing. Historically, invasive prenatal testing (amniocentesis or CVS) was suggested only for women over 35. In 2007, ACOG changed their recommendation to suggest that all women, regardless of age, be counseled on the same options. Despite this, a 2009 survey of obstetricians found that while 92% of them offered amniocentesis to patients over 35, only 15% offered it to patients under 35. Again, there is disagreement among doctors and between at least some doctors and the national organization.
Alcohol. ACOG makes a clear statement that no amount of alcohol has been proven safe in pregnancy and suggests that women abstain while trying to conceive as well as during pregnancy. In a 2010 survey, when asked about the safety of drinking in pregnancy, 40% of obstetricians reported that—in their opinion—women could “consume some alcohol during pregnancy without risk of adverse pregnancy outcomes.” In a 1999 survey of female doctors (not all of them obstetricians), 44% of them reported drinking alcohol in their own pregnancies.
My OB fell in this 40%, and told me it was fine to have a couple of drinks a week in later trimesters. What was missing for me from that advice was any understanding of why she thought that. What was the underlying information she had read differently from ACOG? It didn’t take long to then realize that recommendations—hers and theirs—were based on studies. The disagreement, therefore, stemmed at least in part from different readings of these studies.
What this disagreement suggests is not that women shouldn’t trust their doctors. But we should recognize that, in many cases, recommendations are coming from their doctor’s interpretation of research data. That data is often incomplete (this is certainly true in both the bed rest and alcohol cases above) and individual doctors and national organizations are left to make the best recommendations they can. Those recommendations are valuable, but they’re also subjective.
In the best case scenario, one which I know plays out in many doctors’ offices, the uncertainty around these recommendations is made clear, and doctors and patients can work through the reasoning behind the advice together. But when there is not time for this, and when the decision really matters to the patient, the only way to settle the question may be to go to the source.
Pregnant women shouldn’t be afraid to think for themselves. And doctors shouldn’t be afraid to help them sort through the complexities of the data.