Booties on the ground

In his excellent review of Annie Murphy Paul's new book, Origins: How the Nine Months Before Birth Shape the Rest of Our Lives in the New York Times Book Review on Sunday, physician/author Dr. Jerome Groopman wrote:

Of necessity, research on fetal development involves observing pregnant women in their daily lives; no one would purposefully have one group eat in a possibly risky way or be exposed to a potentially dangerous substance, and compare outcomes with an unperturbed control group. We have, at best, only correlations between a mother’s lifestyle and her child’s future health, not clear causation.

And, in "The Case Against Breast-Feeding," Hanna Rosin's 2009 article in The Atlantic, she wrote, "An ideal study would randomly divide a group of mothers, tell one half to breast-feed and the other not to, and then measure the outcomes. But researchers cannot ethically tell mothers what to feed their babies."

Really? Why not? Both Groopman and Rosin are writing about how vulnerable observational studies are to being tainted by hidden variables. Controlled trials are a better system for testing what works and what doesn't.

But if I am reading their statements correctly, Groopman and Rosin are saying that we cannot even think about practicing actual, rigorous science if babies and fetuses are involved.

Building up a body of "evidence-based medicine" around a segment of the population that is exempted from clinical trials — depending entirely on observational research, that is — seems unwise to me. We don't need to wonder what a worst-case scenario involving babies would look like;  we have the 50-year-old thalidomide catastrophe as a demonstration. Thousands of children around the world were born with deformed limbs after their mothers took the drug.

Subjecting drugs and behaviors that can affect unborn children to standard scientific trials that include pregnant women might save the population from potentially massive damage from those behaviors, and from the drugs once they are put on the market. This is especially true now that we suspect the experience in the womb has a huge influence on the course of an individual's life — the subject of Paul's book, Origins.

Now I understand why the medical ethicist Ruth Macklin, writing in The Lancet last winter, called for the inclusion of pregnant women in drug trials, and retaining women who get pregnant in such trials. Conventional wisdom seems to have rendered the concept so unthinkable that a call for change is necessary.

What do you think about including pregnant women in clinical trials? I would love to read your comments.

Putting motherhood on the clock

One of Hanna Rosin's grievances against breast-feeding in "The Case Against Breast-Feeding," her article last year in The Atlantic, is that it prevents women from doing work that would be more productive, or at least more lucrative.

"It is a serious time commitment that pretty much guarantees that you will not work in any meaningful way," she wrote.

Hello? This week alone, as the mother of a 12-year-old at the end of summer vacation, I have spent a morning at the beach, an entire day at a water park, and an afternoon turning Gatorade bottles into papier mache fish. Need I say that no one gave me one shiny dime for any of this activity?

To the extent that women do it themselves, motherhood is a career-wrecker. Six months or so of exclusive breast-feeding at the front end seems hardly worth mentioning.

I have not worked more than 30 hours a week (most years much less) since my older daughter, Nora, was born almost 23 years ago. It was my choice, but I paid a price in diminished salary and less prestigious assignments — in opportunities.

Even so, I would do it again if I got a do-over.

Why is that? Because I can't think of anything I would rather have than time and relationships with my husband and my children. That was true when the girls were little, and it's true now.

Nora has moved 2,000 miles away this summer. When she calls me, I drop everything to talk with her. And even though, if I added up our phone/Skype sessions, the total would probably look like a serious time commitment, I don't ever worry about how much valuable time I'm losing.

(For a twist on this perspective, see "Putting a Price on Motherhood" in today's New York Times.)

A skeptical look at breast-feeding

The anger and ridicule Gisele Bundchen attracted when she advocated a "worldwide law" requiring new mothers to breast-feed for six months mostly has to do, I would say, with the fact that mere mortals perceive she shares very few of the frustrations the rest of us deal with us on a daily basis.

But I think some of the rage comes from a certain rancor around the topic of breast-feeding, which has been presented in the last several years as the only acceptable choice for nourishing an infant, not only from a health standpoint, but also from a moral one. Not breast-feeding — for whatever reason, including such a worthy and often necessary one as a full-time job — has come to be regarded as thoughtless at best, abusive at worst.

But do women who reach for the formula deserve the sneers they get from breast-feeding partisans? Writing in The Atlantic last year, Hanna Rosin, journalist and mother of three, made "The Case Against Breast-Feeding," and an intriguing argument it is.

First, let it be said that Rosin did breast-feed her children. However, by No. 3, some of the negative aspects of breast-feeding — the huge investment of time it requires, and the toll Rosin believes it takes on the ideal of co-parenting with Dad, to name a couple — were making her wonder if the health benefits were really all they were cracked to be.

Rosin found evidence that they aren't. She writes:

Most of the claims about breast-feeding’s benefits lean on research conducted outside the lab: comparing one group of infants being breast-fed against another being breast-fed less, or not at all. Thousands of such studies have been published, linking breast-feeding with healthier, happier, smarter children. But they all share one glaring flaw.

The flaw is that the studies are observational, not randomized controlled trials, Rosin writes. Other variables than just breast-feeding might more easily affect the conclusions drawn from an observational study.

Exploring some of the studies that have given breast-feeding its good reputation, Rosin concludes that there are "clear indications" breast-feeding protects against gastrointestinal disease, at least in some cases, but only "murky correlations with a whole bunch of  long-term conditions." The evidence on enhanced intelligence in breast-fed individuals suggests "a small advantage," Rosin writes.

She writes:

So overall, yes, breast is probably best. But not so much better that formula deserves the label of “public health menace,” alongside smoking. Given what we know so far, it seems reasonable to put breast-feeding’s health benefits on the plus side of the ledger and other things—modesty, independence, career, sanity—on the minus side, and then tally them up and make a decision. But in this risk-averse age of parenting, that’s not how it’s done.