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, by Jennifer Margulis

7/28/2019 THE BUSINESS OF BABY: What Doctors Don't Tell You, What Corporations Try to Sell You, and How to Put Your Preg

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Tis publication contains the opinions and ideas o its author. It is intended to provide helpul

and inormative material on the subjects addressed in the publication. It is sold with the under-

standing that the author and publisher are not engaged in rendering medical, health, or any

other kind o personal proessional services in the book. Te reader should consult his or her

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Te author and publisher specically disclaim all responsibility or any liability, loss, or risk,

personal or otherwise, which is incurred as a consequence, directly or indirectly, o the use and

application o any o the contents in this book.

Some o the material in chapters 4, 8, and 9 was previously published in a dierent orm in

Motheringmagazine.

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Contents

Introduction ix

Authors Note xix

c h a p t e r 1 GESTATION MATTERS: The Problem with PrenatalCare 1

c h a p t e r 2 SONIC BOOM: The Downside o Ultrasound 24

c h a p t e r 3 EMERGING EXPENSES: The Real Cost oChildbirth 45

c h a p t e r 4

CUTTING COSTS: The Business o CesareanBirth 75

c h a p t e r 5 PERINATAL PRICES: Proft-Mongering Ater the BabyIs Born 96

c h a p t e r 6 FORESKINS FOR SALE: The Business o

Circumcision 118

c h a p t e r 7 BOTTLED PROFITS: How Formula ManuacturersManipulate Moms 137

c h a p t e r 8 DIAPER DEALS: How Corporate Profts Shape the WayWe Potty 166

c h a p t e r 9 BOOST YOUR BOTTOM LINE: Vaccinating or Healthor Proft? 191


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CONTENTSviii

c h a p t e r 1 0 SICK IS THE NEW WELL: The Business o Well-BabyCare 226

c h a p t e r 1 1 So Where Do We Go rom Here? 246

Abbreviations 253

Glossary o Terms 254

Appendix 261

Resources 261

Recommended Reading 263

Vaccine Schedules in Norway and America 264

Photo Credits 265

Notes 266

Acknowledgments 329

Index 333


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c h a p t e r 1

GESTATION MATTERS:

The Problem with Prenatal Care


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Like many middle-class American women, Elizabeth Goodman-Logelin,at thirty, had put childbearing on hold to establish a career. In hertwenties she used her smarts, drive, and organizational skills to become a

high-powered management consultant. When she and her husband, Matt,decided it was time to get pregnant, the couple rom Minnesota elt as i

they had it all: a spacious new home in L.A., a happy marriage, and a baby

on the way.But pregnancy was harder than Liz expected. A petite woman, Liz

struggled to gain weight. As Matt details in his memoir, wo Kisses or

Maddy, Liz had debilitating morning sickness and vomited requently. Just

to be sae, when she was about twenty-eight weeks along, her obstetrician

reerred her to a high-risk specialist in Pasadena, Greggory DeVore, M.D.

DeVoreperormed an ultrasound and announced that Lizs amniotic fuidlevels were low, the baby was small or gestational age, and the cord was

wrapped around her neck.Ten he prescribed three weeks o bed rest.

When a subsequent ultrasound indicated no improvement, DeVoreinsistedthough the babys due date was still nine weeks awaythat

Liz spend the rest o her pregnancy in the hospital. erried rst-time

parents, Liz and her husband did not question this advice.

Aer two weeks in the hospital, the doctors told her and Matt that it

was time or the baby to come out, believing she would be saer outside the

womb. Madeline Logelin was born seven weeks premature via C-sectionon March 24, 2008. She was rushed to the neonatal intensive care unit

(NICU), placed in a plastic incubator, and given supplemental oxygen

as a precaution although her ather was told she was breathing just neon her own. It turned out that Maddy was a perectly healthy baby. At 3

pounds 13.5 ounces and 17.25 inches long, she was in the normal weight

and height range or her gestational age.Her only issue was that she wastoo young to swallowan iatrogenic problem caused by early delivery.

wenty-seven hours later, getting ready to nally hold her daughteror the rst time, Liz mumbled that she elt light-headed, ell backward

into the wheelchair waiting to take her to the NICU, and then slumped

orward onto the foor.

She was dead.


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GESTATION MATTERS: The Problem with Prenatal Care 3

Te doctors told Matt that Liz most likely died o a pulmonary

embolisma blood clot or other blockage that impedes blood fow to thelungs. Matt believed shitty luck killed the woman who had been the love

o his lie.Expectant parents such as Matt and Liz are rarely told that putting

a patient on bed rest dramatically increases the risk o pulmonary

embolism (one study showed that embolism is almost twenty times more

likely or pregnant women on bed rest). I was put on strict bed rest at

three dierent hospitals and never told there was a risk, says one mother

o our rom Pennsylvania.Most expectant parents are also unaware thatseveral studies have shown that it is dicult to access the amount o

amniotic fuid in utero accurately. When researchers at the University oMississippi Medical Center analyzed three techniques used or testing

amniotic fuid level, all three were ound to be moderately accurate,giving correct estimates only between 59 and 67 percent o the time.

In other words, at least one third o a doctors diagnoses rom ultrasound

that a womans body is generating too much or too little amniotic fuid

are wrong. Tese misdiagnoses lead to more pregnancy interventions,

including C-sections.As Sarah Buckley, an Australian amily physician

and obstetrician, birth advocate, mother o our, and author o GentleBirth, Gentle Mothering: A Doctors Guide to Natural Childbirth and Gentle

Early Parenting Choices, explains, using ultrasound to detect low amniotic

fuid levels has been shown to lead to overdiagnosis o problems resulting

in high rates o induction or healthy babies.Te science on this subjectis abundant: One double-blind randomized study o more than een

hundred pregnant women concluded that measuring amniotic fuid

levels or women who were at orty weeks gestation was not signicantlycorrelated with better etal outcomes. It was, however, a predictor or more

unnecessary intervention. Te study concludes: Routine use [o amniotic

fuid index, that is, an approximate estimate o amniotic fuid levels rom

ultrasound] is likely to lead to increased obstetric intervention without

improvement in perinatal outcomes.

According to her husbands account, the doctor spent only a ew minutes

looking at an ultrasound beore prescribing Liz bed rest. Yet more than

hal a dozen studies have determined that bed rest is either o no proven

benet or that there is simply not enough available evidence to support or

reute that it works.While there is not sucient evidence showing bed restis o benet, there is evidence that it causes harm. Researchers have ound

that it not only dramatically increases the likelihood o getting blood clots,but it can also lead to signicant bone loss in pregnant women.


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THE BUSINESS OF BABY4

I dont put pregnant women on bed rest anymore, asserts Reynir

mas Geirsson, M.D., the chair o the Department o Obstetrics andGynecology at the Landsptali University Hospital in Reykjavik, Iceland.

Reynir has been practicing obstetrics or thirty-six years and has attendedmore than three thousand deliveries. I sometimes ask women at risk or

preterm laborand occasionally those with high blood pressureto stop

work, to rest at home, or occasionally in the hospital, and I direct them

on what exertion to avoid, and when and how during the day to take rest

periods. But enorced strict bed rest has never been proven o use.

Since Baby Maddy turned out to be o normal height and weight or her

gestational age, its possible that nothingwas wrong with Lizs pregnancy

in the rst place. Lizs tragic story begs the question: Would this youngmom be alive today i the doctors had done less testing, paid attention to

the existing scientic literature instead o prescribing a course o action

that is o no proven benet, and taken into consideration that she was a

petite woman likely to have a smaller-than-average baby?

TESTING 1, 2, 3Te twenty-rst century has skewed every aspect o modern lie, argues

Michael Klaper, who has orty years o experience practicing medicine, and

has done postgraduate training in obstetrics at the University o CaliorniaSan Francisco. Dr. Klaper and I talk or more than an hour via Skypeteleconerence. Weve made pregnancywhich is normally this joyous,

wonderul processbecome a perilous and oen tragedy-lled event.

ake, or example, the astonishing number o routine prenatal tests that

almost every pregnant woman is subjected to in the United States today.

Tis dizzying array o testing can make prenatal care an unpleasant,

uncomortable, time-consuming, and expensive experience or women

and their partners. You go in and its like, Lets see what horrible new

problem you have today that youve never heard o beore, says one dad

rom Bualo, New York, who accompanied his wie to every appointment.Between the alse negatives and the alse positives, and the endless stream

o tests, when are you ever going to eel reassured?

As a mother o our, I know rsthand how stressul it can be to have

prenatal testing (or to reuse it and incur the wrath o a provider), but I

wanted to hear an obstetricians point o view. Which is how I nd mysel

on a bitterly cold December evening walking past a bicycle wrapped in

Christmas lights on the ront lawn o a home in Arlington, Massachusetts.


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Stephanie Koontz, an obstetrician at Mount Auburn Hospital in

Cambridge, grew up with me about eight miles rom here, in NewtonCentre. Tough we havent been in touch in years, she has graciously

agreed to gather colleagues to talk about prenatal care.Teres apple cider warming on the stove as Mary Baker, a certied

nurse midwie with a ready laugh and a thick Boston accent, tells me she

eels her practice overwhelms patients by having to oer so much testing

when they come in or a rst prenatal visit: serial sequential testing, AFP4,

CVS, nuchal translucency screening, glucose tolerance test, eighteen-

week ultrasound, amniocentesis, cystic brosis testing regardless o

genetic risk. Stephanie says she eels like she needs to give her patients a

crash course in statistics and risk assessment to help them understand thatmost o this early prenatal testing gives you only a percentage o risk, and

that a higher risk estimate on a test helps guide patients in considering

the option or urther (and usually more invasive) testing, not proo that

anything is wrong.

Te two obstetricians and two hospital midwives Im interviewing

dont hesitate to admit that we are overtesting moms. Teyre as rustrated

by it as some o their patients, but they also eel their hands are tied.

Hospital doctors and midwives are required to ollow state guidelines,answer to their colleagues, and be hypervigilant that they have oeredand perormed every test required in order to satisy both health and

malpractice insurance providers in the event o a bad outcome.

Mary and the other certied nurse midwie, Phyllis Gorman, both

agree they would rather spend their time talking, really talking, to

expectant moms: asking them what theyve been eating, how they are

eeling about having a baby, how they are preparing to welcome that baby

into the world, how they can work together to be a provider-parent team

and make shared decisions.

Stephanies colleague Brian Price, M.D., associate clinical directoro Harvard Vanguard Medical Associates, interrupts to interject that in

the current model o obstetric care in the United States, when youve got

dozens o items to cover and very little time per appointment, those kinds

o conversations are impossible.

Brian practiced or our years in Brooklyn, New York, in the late 1980s

and early 1990s at the Brooklyn Hospital Center, where there was virtually

no prenatal testing available. Tey did not do alpha-eto-protein testing,

routine etal surveys, or ultrasound scans to check etal growth. And yet

now that we are doing more prenatal testing, he points out, the outcomeshave not improved.


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Brian is articulate, opinionated, and incisive. Bald and broad-eatured,

he sits up straighter to emphasize his point: We have not decreasedmorbidity or mortality, he says, talking loudly to be heard over his

colleagues, who are clamoring to agree. All weve done is increase thecost o care, and increase the anxiety.

GLUCOSE TOLERANCE TESTING

As any pregnant woman who has had it can attest: One o the most

unpleasant prenatal tests is the screening or diabetes. According to the

American Diabetes Association, about 7 percent o pregnancies becomecomplicated by gestational diabetes.Gestational diabetes arises when toomuch sugar builds up in the bloodstream, either because the body is not

producing enough insulin (the hormone that clears sugar rom the blood

and takes it into the cells to use as energy) or pregnancy hormones block

the eects o insulin. Many women have gestational diabetes that is not a

cause or concern. It is usually a mild condition that develops in the third

trimester, causes no symptoms, and clears up aer the pregnancy is over.

But pregnant women with elevated blood sugars can have larger-than-normal babies and be at more risk or high blood pressure. For this reason,care providers order a diagnostic gestational diabetes screening test. A

woman is told to drink an unnaturally sweet and horrible-tasting syrupy

beverage that has a high glucose content. One brand, GLUOLE, has 75

grams o glucose. Its ingredients: glucose syrup, maltodextrin (a creamy-

white slightly sweet starch derived rom processing corn or wheat),

puried water, acidity control compound E330 (a pH control agent),

preservative E211 (also called sodium benzoate, used as an antiungal

and antibacterial; one study ound that when paired with articial ood

additives it causes hyperactivity), cola aroma, oodstu color E150 (acaramel coloring made rom sucrose), and carbonic acid (a weak acid

with a tart taste ound in many sodas and also in champagne).

Te beverage made Angela Decker o San Mateo, Caliornia, when

she was thirty-our years old and pregnant or the rst time, so sick that

she vomited it up in the waiting room. But the real problem with thistestin addition to having an already queasy pregnant woman drink anunappealing nonood beverage laden with articial colors, preservatives,

and additivesis that there are no international standards or the amount

o glucose in the test or pregnant women (50 grams, 75 grams, or 100


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grams) and there is no clear consensus on what glucose response is

elevated enough to be cause or concern.A positive result leads to urtherscreening and, oen, aggressive intervention, including the use o insulin

during pregnancy, a scheduled early induction, or even C-section becauseo a ear the baby will grow too big.

I you are having a healthy pregnancy, your baby is measuring normally,

and you have no risk actors or diabetes, should you even have this test?

Although the American College o Obstetricians and Gynecologists

(ACOG) recommends that every woman be screened or gestational

diabetes regardless o risk actors,the U.S. Preventive Services ask Force,which does systematic reviews o all the available scientic evidence, has

concluded that the evidence is insucient to recommend or or againstroutine screening or gestational diabetes, and the American DiabetesAssociation concludes that low-risk status requires no glucose testing.

AvOIdING GESTATIONAL dIABETESTHROUGH LIFESTYLE CHANGES

Kristen Boyle o Denver, Colorado, was surprised to be diagnosed withgestational diabetes during her rst pregnancy seven years ago. Tirty

years old, slender, and t, Kristen had no diabetes in her personal or

amily history and she thought she ate well. But her diabetes got so badthat she had to take insulin during the last trimester. At every visit she

had etal monitoring and an ultrasound. At thirty-eight weeks her blood

pressure was high.

Your amniotic fuid is low, she was told aer an ultrasound. We need

to induce you today. She was given a Pitocin drip and then an epidural.

Hoping or a natural childbirth, Kristen ended up birthing her seven-

pound daughter Soa via C-section aer thirty hours o unproductive

labor.

My body wasnt ready to have her, Kristen remembers sadly when wetalk. Baby wasnt ready to come out.

For her second pregnancy, Kristen decided to do things dierently. She

went to a midwie instead o a doctor and she and her midwie devised

a proactive diet to keep her rom developing diabetes in the rst place.

It was then that she realized that what she had been eating during her

rst pregnancy had not been healthy. Instead o being advised to avoid

processed oods and eat whole resh vegetables and ruits, high-quality


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protein and ats, and whole grains, Kristen had been told to eat granola

bars and take glucose tablets when her blood sugar was too low. Tis timeKristen added high-quality protein to her diet, eating hemp seeds, eggs,

chicken, and the occasional steak. She cut out all rened sugar (thoughshe still ate oods sweetened with agave or maple syrup). She made sure

to eat a lot o ber. Like in her rst pregnancy, she practiced yoga, took

prenatal swimming classes, and walked two and a hal miles around

Sloans Lake almost every day. Kristen monitored her own blood sugar

levels by pricking her nger. She had no problems and gave birth at home,

vaginally, to a healthy nine-pound baby boy.

In one survey rom August 2012, 62 percent o women who were

expectant or had given birth reported that their providers did not talk tothem about how to care or their health during pregnancy.Doctors oendont tell women that eating oods that are low in nutritional content but

high in sugar and starchlike white bread and bagels, white pasta, icecream, cake, candy, and so drinkscan induce or worsen gestational

diabetes. Tese oods also add to excessive weight gain during pregnancy,

which can lead to high blood pressure. Te best way or a pregnant

woman to avoid developing gestational diabetes is to eat a healthy diet that

contains high-quality protein and no added sugars and no rened grains.I elevated blood sugar becomes a problem, pregnant women can start

removing naturally occurring sugars rom their diet, like ripe bananas

and other ruits.

But even women who continue to eat a high-sugar diet can help theirbodies process the sugar by exercising. Tis is why most homebirth

midwives have women keep a ood log over three or our days to record

what they eat and spend a good deal o time during prenatal visits

strategizing about how to improve their diets and how to nd time to

walk, swim, run, bike, take yoga classes, or do other daily exercise.

When youre under the hospital model theyre just looking at numbers,

not the whole picture, Kristen says. She now suspects the anomalous high

blood pressure reading that led to an induction and then a C-section in her

rst pregnancy was because she was excited about having her rst baby.I my blood pressure had been high at thirty-eight weeks, my homebirth

midwie would have said, drink some water, relax, meditate, go or an easy

walk, and well check you again. First-time moms are very suggestible.

We look at doctors as being the experts. When they say something, we

say okay. I never questioned it. In hindsight, when they said induction, I

should have asked, Can I come back and you can monitor me? Do I really

need this? Is it really a medical emergency?


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NUTRITIONALLY dEFICIENTdOCTORING

What do you eat? What do you have or breakast, lunch, and dinner?When doctors start asking those questions o pregnant women, then well

see a change in prenatal care, says Dr. Klaper, who looks younger than his

sixty-our years and directs the nonprot Institute o Nutrition Education

and Research in Manhattan Beach, Caliornia. In the early days and

weeks o pregnancy, just aer conception, when a woman doesnt even

know shes pregnant, the embryo is the most vulnerablejust a cluster

o a ew cells. Tis is the time the mothers diet is key. Klaper, talking

rapidly and convincingly, continues, So she goes to a ast-ood restaurantor lunch, and shes ingesting a witches brew o chemicals, favorings,colorants, and stabilizers. All these molecules are inusing the baby in this

very vulnerable time. Who knows what this does to the etus?

When I ask Klaper why obstetricians dont emphasize the importance

o nutrition during pregnancy, he chuckles. No one tells us its important!

he exclaims, shaking his head. We go to medical school to learn how to

work in the body repair shopwhich is what hospitals are. I you break

your body, go to the hospital. Teyll x it. But then get out o there. Noone is going to mention nutrition to you beore, during, or aer, because

no one mentions it to us.Doctors actually denigrate nutrition, believing it is irrelevant and

unimportant, Klaper says. Tere is an inherent contempt or nutrition

built into Western medicine. Nutrition is a sissy sport among physicians.

One look in a doctors own rerigerator will show you that he is eating the

same junk ood that most Americans eat, Klaper points out. I think o a

riends husband, a doctor who eats vanilla cupcakes or breakast, and apediatrician I know who has been trying to eat more healthy ood but who

still eeds the amily sugar-laden processed cereals, bread ull o additives

like calcium peroxide (a bleaching agent), white pasta, granola bars, and

conventional milk (because organic is too expensive). Real doctors workin the operating room. Real doctors deliver babies, Klaper says. Te sad

irony is then they go back to their oces and see a waiting room ull o at,

unhealthy women who are sick because o what theyre eating.


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dO PRENATAL vITAMINS MAkEPREGNANT WOMEN SICk?

At rst Jenna Nichols thought she was so sick because she was pregnantduring a heat wave in Philadelphia. A petite woman with air skin and

hazel eyes, Jenna, twenty-our, looked and elt green. But reaching the rst

trimester milestone, when morning sickness is supposed to abate, didnt

help. Every day, shortly aer Jenna took a one-a-day prenatal vitamin, her

hands would sweat, she would eel clammy all over, and get so nauseous

she could barely breathe. She lay as still as she could on the couch, air-

conditioning at ull blast, eeling more motion sick than she had on the

dragon ride at the carnival when she was six years old.One night about halway through her pregnancy, Jenna unscrewed the

cap on her vitamins to check i she needed more. Te smell triggered a resh

wave o nausea and Jenna realized it might be the vitamins themselves that

were making her sick. Because she was vegan beore she got pregnant,

Jenna was worried her baby might be malnourished. She kept a detailed

ood log o everything she ate and started trying dierent vitamin brands:

arget, rader Joes, Whole Foods. Nothing changed. Her symptoms only

went away when she stopped taking vitamins.Sarah Jane Nelson Millan, a mother o two in Los Angeles, broke out

into mouth sores every time she took her conventional prenatal vitamin.Every time Katherine Womack, a Las Vegasbased mom o a two-year-

old, took her vitamins she threw up twenty minutes later.Another youngwoman experienced unpleasant nausea in ve pregnancies. Because she

had undergone cancer treatment and been told by the doctors she would

stop menstruating, she did not know she was pregnant or the sixth time

until the second trimester. She took no prenatal vitamin and or the rsttime in six pregnancies had no morning sickness.

Tough some pregnant women are not aware o experiencing any

adverse reactions to prenatal vitamins, others report painul constipation,horrible stomach pains, and dizziness. Since bad reactions to prenatalvitamins are not unlike pregnancy symptoms, most women dont realize

when their body is reacting badly to the vitamins.

During pregnancy a womans body undergoes enormous changes: rst

the ertilized egg implants into the lining o the uterus and then, beore

a woman even knows she is pregnant, the egg (called a blastocyst) starts

separating into cells that will become the placenta and cells that will

become the baby. Just two weeks aer ertilization, the layers o the embryo

itsel actually start to dierentiate into specialized parts. Te outer layer


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will become the hair, skin, eyes, and nervous system; the middle layer will

become the heart, reproductive organs, bones, muscles, and kidneys; andthe inner layer the babys liver, lungs, and digestive system. As a pregnant

womans body grows an entirely new organ (the placenta) to sustain thebaby, her blood increases in volume and her heart enlarges. Because o

the demands o pregnancy, it is thought that women need more o certain

nutrients, especially iron, calcium, and olic acid. Women are told that

prenatal vitaminsbe they over-the-counter or prescriptionwill help

ensure they are getting what they need nutritionally to grow a healthy

baby. Tey are also told that olic acid around conception and in the rst

trimester is especially important. Tis has been the recommendation since

1999 aer a large study o pregnant women and inants in China oundthat taking 400 g o olic acid a day reduced the likelihood o neural

tube deects, which occur in early gestation when openings in the spinal

cord or the brain do not properly close.Prenatal vitamins are considereda nutritional insurance policyto protect a growing etus.

But what most pregnant women and their partners (and even doctors)

dont realize is that many prenatal vitamins contain extra nonvitamin

ingredients that are known to be harmul. Tere are no standard

guidelines or any clear consensus on what amount o which vitaminsshould be included in prenatal vitamins. For example, some doctors now

believe that to have a positive eect pregnant women need more than

twice as much olic acidas much as 1,000 gan amount available only

by prescription.

Women also dont realize that just because they are taking vitamins itdoes not mean the body is able to absorb and use them. In their promotion

o prenatal vitamins, the medical community overlooks this problem, as

well as that the studies o the importance o olic acid supplementation

have never included a group o pregnant women who receive olic acid

rom whole-ood sources (lentils, kidney beans, broccoli, spinach, kale,

and citrus ruits are high in olic acid).

Despite its name, there is nothing natural about Sundown Naturals, an

inexpensive over-the-counter prenatal vitamin. In addition to synthetic

vitamins, Sundown Naturals contain vegetable cellulose, vegetablestearic acid, calcium silicate (anticaking agent), vegetable magnesium

stearate, titanium dioxide color, FD&C Yellow No. 6 Aluminum Lake,

FD&C Red No. 40 Lake (CI 16035), FD&C Blue No. 1 Lake (CI 42090).Other brands, some o which are much higher in price, have identical

ingredients.

Tis natural vitamin contains our articial colorants. Tere is no


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good reason or any articial colors to be added to prenatal vitamins,

but there are ample reasons to avoid them. itanium dioxide, also oundin paint and sunscreen, has been shown to cause neurological damage,

cell injury, mutation, and ultimately respiratory tract cancer in rodentexperiments, and is now believed to be carcinogenic in some ormsto humans. It has also been shown to harm marine animals and hasbeen linked to autoimmune disorders.Yellow 6, Red 40, and Blue 1 arepetroleum-based dyes that in industry-sponsored animal studies have

all been ound to provoke allergic reactions as well as nerve-cell damage

(Blue 1) and possibly tumors (Red 40 and Yellow 6). Red 40 and Yellow 6

have also been ound to be contaminated with carcinogens.

Stuart Prenatal Multivitamin/Multimineral supplement tablets cost$29.99,more thanour times as much as Sundown Naturals.Yet the list ounpronounceable ingredients you would never eed directly to an inant

and probably wouldnt want in contact with a developing embryois twiceas long. It includes sodium aluminosilicate, mixed glycerides, sodiumbenzoate, polysorbate 80, polyethylene glycol, as well as cornstarch and

sugar, to name just a ew.How can we assume that it is sae or benecialor a pregnant women to swallow a pill loaded with nonood substances

our bodies have not evolved to ingest?When Jenna nally realized her prenatal vitamins were making her

sick, she was told to switch to Flintstones childrens chewables. Tis is

common advice: Doctors and midwives tell women who cannot stomach

the prenatal vitamins to take a childrens multi. But it le Jenna perplexed.

She did not want to eat a sugary product (the children she used to nanny

thought their vitamins were candy), and she knew the amounts in vitaminsdesigned or children were not comparable with those or pregnant adults.

Indeed, it is impossible to know i the amounts listed on the label

o any vitamins are actually whats inside the vitamin. In 2004, testing

by ConsumerLab.com, a White Plains, New Yorkbased company that

independently evaluates health and nutrition products, revealed that one

prenatal brand tested could not ully disintegrate, suggesting it would not

deliver its nutrients to the body. It also contained twice the amount o olic

acid listed on the label. Tat same report ound that a childrens gummy

vitamin was contaminated with high amounts o lead.More recent testingo multivitamins showed thirteen out o thirty-eight brands did not

contain the amount o nutrients as listed in the ingredients.

Since 1994, when the Dietary Supplement Health and Education

Act was signed into law by President Bill Clinton, dietary supplements,


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including prenatal vitamins, all under a new regulatory ramework.

While the government plays a strong role in ensuring ood saety, it is thecompany that makes the vitamins that is responsible or determining i

they are sae. Manuacturers take ull responsibility that the representationsor claims made about vitamins are substantiated by adequate evidence

that is not alse or misleading. Prenatal vitamins do not need approval

rom the FDA beore they are marketed, their contents do not have to

be tested by the FDA, and the claims made about their health benets

are not independently veried. Te manuacturer does not even have to

provide the FDA with the evidence it relies on to substantiate saety or

eectiveness beore or aer it markets its products.

We nd problems all the time, says od Cooperman, M.D., presidento ConsumerLab.com. We have ound problems with prenatal vitamins in

the past. It wouldnt surprise me to nd a prenatal that was contaminated,

didnt disintegrate, or didnt have all its ingredients. I have three kids.

When my wie was pregnant, we only used products we had tested. Just to

cover our bases, I had her switch each day between two dierent products.

According to Consumer Reports, American consumers spent $26.7

billion on supplements in 2009.Te average prenatal vitamin costs about

30 cents a pill.I the more than our million pregnant women each yearin the United States take a prenatal vitamin every day or at least nine

months, they collectively spend at least $336 million a year. With so much

money at stake it is no wonder that pharmaceutical salesmen peddle

their brands directly to American obstetricians and amily practitioners,

bringing treats to their oces (like doughnuts or catered lunches) and

giving ree samples to the sta. When doctors distribute these samples totheir pregnant patients, they are openly endorsing the brand. Endorsement

by a trusted physician is an extremely eective marketing strategy. We get

salespeople in here all the time trying to promote their vitamins and saying

why they are better, says Dr. Lester Voutsos, section chie o obstetrics

at Providence Hospital in Novi, Michigan. I hear their presentation and

they give us ree samples, which I give out. But I dont prescribe them.

Voutsos doesnt think pregnant women should waste their money on

expensive prenatal vitamins when they can buy less expensive over-the-

counter or generic brands. Pregnancy is a proound experience, Voutsossays. When they are pregnant, women are so ocused on the pregnancy

they are willing to spend $30 or $40 a month on vitamins. Frankly, I dont

think its worth it.


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FOOd RULES

When she was six months pregnant, a young woman walked into a bagel

shop and asked i they had bagels made with whole wheat four. Te youngclerk behind the counter looked perplexed.

No, she said in a low, almost conspiratorial tone, none o our

products are made with wheat.

Te clerk was mistaken. Tough there were no whole-grain bagels on

hand, all o the products in that bakery, even the pumpernickel (which

also contained rye four), were made with wheat four. Like the bagel clerk,

most Americans dont know the dierence between processed wheat and

whole wheat.A wheat kernel is made up o three components: the bran, the germ,

and the endosperm. Te bran, which contains most o the plants ber,

and the germ, which contains most o the nutrients, are both removed

in the process o converting whole four into white four. What is le is

the starchy endosperm. I your eyes are already glazing over, heres what

you need to know: Because so many vital nutrients are taken out during

processing, most ood companies add chemical nutrients back into white

four, which is why the four is called enriched. However, so manynutrients are lost in the rening process that enriched four, though it

sounds healthy, can never be as nutritious as whole-grain four.Most o the nutrients that were there to begin with are never

reinstated, Larry Lindner, ormer executive editor o the ufs University

Health & Nutrition Letterand an expert on nutrition, explained to me.

Tese include vitamin E, vitamin B6, pantothenic acid, magnesium,

manganese, zinc, potassium, and copper.

Phytochemicals are another vital component o the grain lost duringprocessing. Phytochemicals are substances ound in plants that are notvitamins or minerals but that play a part in promoting good health.

Unlike vitamins and minerals, phytochemicals are not put into prenatal

supplements, Linder explains, but they are in whole grains. In act,researchers are just beginning to isolate and identiy these compounds

there are literally thousands o them.

Whole grains (like brown rice, unpearled barley, whole millet, and

oats) are high in ber, which can help alleviate constipation. Since whole

grains take longer to digest, pregnant women suering rom low blood

sugar report ewer symptoms when they eat whole grains. Whole grains

metabolize more slowly in your body, explains a ormer obstetric nurse

rom Brattleboro Memorial Hospital in Vermont and an expert on


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but emphatic way, Qualtere-Burcher explains that there is an enormousnancial imperative or obstetricians to see as many women as possible,

which is leading to an inadequate level o care. In order to pay or xed

overhead costs (including oce sta and medical liability insurance),obstetricians in private practice squeeze as many prenatal appointments

into a day as possible, keeping women waiting and then racing through

the visits.

Qualtere-Burcher recently chose to take a $150,000-a-year pay cut to

move rom a practice in Eugene, Oregon, to a medical school in Albany,

New York. In his new position he is doing more teaching and supervising.He tells me he can talk more honestly now because he doesnt have to

worry about jeopardizing his job or oending his colleagues. He patientlyruns through the numbers and the dierent work models, using words

like median productivity (the national standard across the country o

how many patients an obstetrician sees on average) and Relative Value

Units (RVUsthe more patients you see, the more income you generate).

Ten Qualtere-Burcher cuts to the chase: Whether in private practice

or employed with a steady salary by a health group or HMO, the more

women an obstetrician sees in a day, the more money he makes.

Human behavior responds to incentives, and the incentive or OBs isto spend less time with people, Qualtere-Burcher explains. Whether you

spend ve minutes or een, the ee is essentially the same. Te nancial

incentive is to run them through quickly. Tere is no nancial incentive

to take your time.

At Qualtere-Burchers last job or a nonprot medical group, moreincentives came quarterly. I you delivered enough women over medianproductivity, you could make as much as $48,000 more a year beyond

your base salary.

For OBs in private practice the nancial incentives are even more

pronounced: Once youve paid xed expenses, everything else you make

is yours. Even doctors who dont go into obstetrics or the money nd that

earning more becomes an irresistible motivator. Once youve covered

your expenses, its all gravy, Qualtere-Burcher says. Why take home

$200,000 when you can increase your patient volume and make $500,000

instead?o boost his bottom line even more, one o Qualtere-Burchers

colleagues reused to provide care or medically complicated pregnancies.

I a pregnant woman had any kind o problem, he sent her to another doctor.

Te doctor bragged to his colleagues that only seeing straightorward

pregnancies meant he could see more than orty women a day. Tat was


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his moneymaking conveyer belt, Qualtere-Burcher says, though he is

quick to add that this colleague was not typical. Most OBs like doing allaspects o their specialty, and do enjoy taking care o complicated patients.

It reminds us that we have some skills.But Dr. Edward Linn, chair o obstetrics and gynecology or the Cook

County Health and Hospitals System in Chicago, Illinois, who has made

time to talk to me in between seeing gynecology patients, says that he has

spent many years watching doctors punt complicated pregnancies and

cherry-pick their clients because they do not get higher reimbursement

or high-risk women who take up more time. We sit in his spacious h-

foor oce, which has a wide bankers desk piled with academic journals,

papers, and les. While many doctors reuse to give any care to women onpublic assistance, other doctors prey on them,Linn says, maximizing theirprots by ollowing a woman during pregnancy and collecting per-visit

reimbursement rom the state with no concern about the outcome. Tesedoctors see pregnant patients and carry them along with no intention

o ever delivering them, Linn tells me. Tey tell them that once they go

into labor, they should show up in the emergency room o the hospital o

their choice. Tese doctors increase their income margin by cramming

in as many oce visits as possible, collecting a per-visit ee or each visit,but reusing to be present during labor and at the birth (which takes time

away rom the oce). We see these patients coming into our emergency

room, Linn continues. People accept that. Tey dont understand why,

but they trust their doctor. Doctors who are practicing like that lackproessional integrity. Teyre looking or the billable opportunity.

Tis kind o unethical behavior leads to ragmented care and poor

outcomes, Linn says, especially or socioeconomically disadvantaged

women who have among the worst outcomes and who most need

ollow-up and continuity o care. Sharon Rising, a certied nurse

midwie with more than thirty years o experience, ormer aculty

member at Yale Universitys School o Nursing, and ounder and CEO

o a womans health care advocacy nonprot, agrees that the kind o

prenatal care we are delivering in America is not working, especiallyor Americas poor.

We have terrible premature birth rates, which i anything are getting

worse. We still have a high percentage o pregnant women who are

coming late to prenatal care, lots o women who arent breasteeding, and

the overuse o triage and emergency rooms. Tese outcomes are really

less than desirable, Rising says. Whats really happening? What kind

o a system do we have? We have a care system designed to support the


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hospital and the clinicians, and is tailored to their convenience. When the

outcomes arent great you need to change the system.Tis is only xable at a systems level, agrees Qualtere-Burcher. You

want to say this is physician bad behavior, but it really isnt. . . . Nothing isgoing to change until you take the prot out o medicine. Te economics

o medicine keep distorting medical decision-making and the doctor-

patient relationship, even the relationships between physicians and

midwives, because you view a colleague as a potential competitor. It just

distorts everything. Until you remove that it is going to be impossible to

make substantive changes.

MIdWIFERY: PROACTIvE vERSUS REACTIvE CARE

When Alice Domurat Dreger, Ph.D., a proessor o clinical medical

humanities and bioethics at Northwestern University Feinberg School o

Medicine, asks her medical school students to describe the kind o woman

who would give birth with a midwie rather than an obstetrician, they

imagine someone who wears long hippie skirts, eats vegetarian ood, and

drives a VW minibus. Her students are always shocked to learn that whenDreger, a pants-wearing omnivore and sel-described science geekandher partneralso an academicbecame pregnant in 2000 they chose to

have their prenatal care and delivery overseen by midwives.Why? Dreger scoured the scientic literature to learn everything

she could about the saest way to have a baby. Her reading revealed she

should walk a lot during pregnancy, Dreger explains in an article in the

Atlantic; get regular checkups o her weight, urine, blood pressure, and

belly growth; and avoid vaginal exams. She also ound out that she should

not agree to any prenatal sonograms in her low-risk pregnancy because

doing so would be extremely unlikely to improve the babys health, but

could result in urther testing and intervention that increased risk to her

and her baby with no benet.But her obstetrician and his team were uncomortable with such an

old-ashioned approach. So Dreger and her partner quit the practice,

instead engaging a midwie who, she says, was committed to being much

more modern.

Te modern midwies approach is to be proactive during pregnancy

and childbirth. Instead o aggressively treating gestational problems with

the latest medications and the most advanced technologyaferthey arise,

good midwives (like the one who helped Kristen avoid gestational diabetes


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by changing her diet) work closely with their pregnant clients to ward o

problems beore they start.Te medical model o obstetrics is reactive, explains Stuart Fischbein,

an obstetrician who has spent much o his thirty-year career workingclosely with midwives, when I interview him via Skype teleconerencing at

his home in southern Caliornia aer hes spent a long day seeing patients.

When a woman develops diabetes, theyll x it. When a woman develops

preeclampsia theyll treat it. When a woman develops anemia, theyll deal

with it. Te midwiery model is preventive. Tey help build a womans

hemoglobin so she wont become anemic. Tey educate her about not

eating sugar and doing exercise so she doesnt get gestational diabetes. en

minutes o every hour visit is spent talking about nutrition so a womanwont develop preeclampsia.

Tough many hospital midwiery practices run their groups much

like obstetricians, racing through appointments and reacting only aer

problems arise, midwives usually oer a higher level o individualized

prenatal care than obstetricians. Qualtere-Burcher thinks one reason or

this is that midwives dont ace as many nancial pressures as doctors.

Tey make less money, pay a much lower rate o malpractice insurance,

and usually dont graduate rom school with the kind o education debtthat physicians do. When Qualtere-Burcher worked at Olean GeneralHospital in an academic position or SUNYBualo rom 1995 to 2002, his

medical malpractice insurance cost about $65,000 a year. Te midwives,

who supervised just as many pregnancies and delivered just as many

babies, paid only $3,500 a year. I the midwives run into a problem they

are not usually sued. I they have a patient who gets into trouble, they are

going to consult an ob-gyn, so an ob-gyn will be involved and available to

be sued, Qualtere-Burcher explains. So they will always drop the lower-

level proessional. Im told thats pretty typical.

It is partly this constant ear o being sued that leads most obstetriciansto see themselves as managing the pregnancy, dictating to pregnant

women what they should eat, how much weight they should gain, and

how many weeks they will allow gestation to continue beore medically

inducing labor. Tey react strongly and swily at the rst sign that

something might be wrong, whether the issue is a high blood pressure

reading or the suspicion o a larger-than-average baby.

O course obstetricians have a laudable reason or wanting to

monitor their clients behavior: Tey want their patients to have healthy

pregnancies and healthy babies. But they also have nancial incentivesand proessional concerns that have little to do with a pregnant womans


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health. No pregnant woman should have to sit or an hour in the waiting

room because a doctor has overbooked clients in order to maximize prots.It is wrong or care providers to hand out samples o expensive prenatal

vitamins, or to undermine a womans condence about breasteedingbeore shes even had a baby by giving her ormula samples and coupons.

Tis is why pharmaceutical salesmen are not allowed into the doctors

oces, and women who receive prenatal care rom Harvard Vanguard

Medical Associates, where Brian and Stephanie practice, are not given ree

samples o branded products.

We have never allowed ree pharmaceutical samples to be given to

patients because nothing is ever ree, Brian explains in a ollow-up

email. We also do not give out new baby bags with ormula samples orallow any product placement in our patient handouts. Several studies have

clearly shown that clinicians are very clearly swayed by all o these subtle

orms o advertisement and promotion. I have gone so ar as to orbid

drug lunches and pen distribution.

It is also wrong or doctors to prescribe radical medical intervention

beore trying less invasive ways to x a potential problem. reating

gestation as an illness or an accident waiting to happen not only takes

the joy out o pregnancy, it also creates the opportunity to interveneunnecessarily and potentially do harm. Expectant moms and dads whoquestion their providers, seek a second opinion, or ask or gentler or less

invasive care are oen met with scolding, bullying, or genuine surprise

(Why wouldnt you want that test? No other patient has ever reused it!).

During my our pregnancies, I discovered I didnt need stressul prenatal

testing and intervention; I needed wholesome ood, time to exercise,

sunlight, quality sleep, eective ways to destress, and riends and amily

to listen patiently to my hopes and ears and give me hugs when I cried

(pregnancy is an emotional time). Te best prenatal care happens when

health care providers take the time to really listen to their clients, examinethem gently, oer evidence-based advice, and support gestation as a

natural, healthy, awe-inspiring, lie-changing event.

Dr. Qualtere-Burcher believes that healthy women having normal

pregnancies should go to midwives, be they certied nurse midwives who

work in a hospital or proessional midwives who deliver babies at home. He

points out that in European countries such as Ireland and Norway, where

the maternal and etal mortality rates are much lower than in the United

States, midwives, not doctors, provide prenatal care. Like Dreger and her

partner, Qualtere-Burcher and his wie chose not to see obstetricians. Tebirths o his own three children were supervised by midwives.


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Midwives do a much better job caring or pregnant women than

Im able to, Qualtere-Burcher conesses. I wish all OBs would work intandem with midwives. We can always be there or backup i something

goes wrong.

American College o Obstetricians and Gynecologists gross receipts or the

20092010 scal year: $80 million

Average salary o a high-risk obstetrician: $446,886/year

Average salary o a hospital midwie: $100,000

otal cost o prenatal visits with a doctor: $3,940

otal cost o prenatal visits with a homebirth midwie: $1,300

Cost per minute to have pregnancy supervised by a doctor: $15.00

Cost per minute to have pregnancy supervised by a homebirth midwie: $1.67

Ingredients in GLUCOLE (gestational diabetes test): glucose syrup, maltodextrin,

puried water, acidity control compound E330, preservative E211, cola aroma, oodstu

color E150, and carbonic acid

Money spent on prenatal vitamins per year: more than $336 million

Nine-month supply o brand-name prenatals: $1,169.55

Nine-month supply o generic prenatals: $134.91

Cost to eat organic kale: $1.99 a bunch

Jennifer Penick: My Midwife Knew Me Better After One Hour

Than My OB After Four BabiesJennier Penick, thirty-two, a mom o fve rom La Vista, Nebraska, liked herobstetrician. He was always personable during prenatal appointments. It was truethat she oten had to wait as long as an hour, and that once she had to reschedulean appointment because he was running behind, but she just assumed that washow things worked. Then she ound another option.

I grew up military so when I got out o that lie an ha to pic my own octors,I i it pretty ranomly. My husban an I int now better. I was twenty-two

when I got pregnant or the rst time. When our OB nally came into the room,he woul get through eerything as ast as possible, listen to the babys heartbeat,reassure us that eerything was oay, an rush to the next appointment. I honestlyint thin there were any alternaties. I int thin miwies still existe in theUnite States.

My rst birth int go ery well. The OB tol us that he wante to inuce me


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because he was concerne about the size o the baby. I was thirty-seen wees.He tol us it woul be better i we inuce because the smaller the baby the easierit comes out, an theres less chance o neeing a C-section. We int want to be

inuce. I ha hear rom enough people dont get inuce, because it hurts wayworse. But when he tol us, Youll hae a better chance o a aginal birth! weagree to the inuction. At thirty-eight wees, one ay I was inuce with Pitocin,an then the obstetrician broe my water. I ha an epiural, but it only wore onone sie an I was in excruciating pain. Ater an hour an a hal o pushing, theoctor trie to get the baby out with orceps. When that int wor he wheeleme in or a C-section.

My son, A.J., weighe 7 pouns 3 ounces. I was completely ope up onpain meication an exhauste. I only hae one picture o my son an me ater

he was born an it always maes me cry. The worst part is I ont hae anymemory about the birth. The only thing I remember is saying to the octor, Hewas suppose to be bigger, thats why we went through all this. The octor intsay anything. He int apologize.

I got pregnant again when A.J. was just nine months ol an we went bacto the same OB because we werent sure where else to go. He was supportie ous haing a vBAC [aginal birth ater Cesarean]. Im only e-three. I hae notorso, an I only gain lie twenty pouns in my pregnancies. Theres nowhere orthe baby to go but out, which is why I loo so big. The octor gure it out this

time an wrote LARGE FOR GESTATIONAL AGE on the outsie o my chart. Iorgae him. I tae some responsibility or not oing my own research an maingmy own ecision. He was ery nice to us no matter how much in a hurry he was.I neer remember him being gru or upset or lie I was a bother. But he enitelyint tae his time or get to now us. I I saw him at the grocery store he woulnthae a clue who I was, een though hes eliere our o my is.

My ourth birth in the hospital was pretty awul. The octor barely mae itan the nurses ept saying, dont push! dont push! Wait or him to get here!The resient who ene up eliering the baby int now what he was oing.

So when a miwie opene a birthing center, The Miwies Place, in our area lastdecember, I ecie to elier there. She too time to tal about my past meicalhistory an births. My miwie new me better ater one hour than my OB iater our babies. It elt lie she care. She hant booe e people or that hour.She mae time to sit an tal to me. She explaine there are tests but that I coulopt out o them i I wante to an she woul sign the paperwor. I always hatebringing my is to the obstetricians oce because I elt lie I ha to tell them toeep still an be quiet. At the birthing center there are toys or my is to play

with. My three-year-ol was so excite because she coul go on the rocing horse.

It was so much less clinical. I int eel lie I was waling into this scary placewhere eeryone was resse in scrubs an white coats waiting or something togo wrong. Eery time a baby is born at the birth center the miwies a thebabys ootprint to the wall outsie the birth rooms. Instea o fimsy paper gownsan pin paper rape oer your thighs, you wear a fuy plush white robe anytime you hae a proceure. I chece my own weight an bloo pressure. When


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I neee a Pap smear, the miwie warme up the speculum so it woul be morecomortable. Its o to tal about a nice Pap smear! But they just care about yourcomort. I wish we hant waite so long to mae the switch.

But when I was thirty wees pregnant, I oun out that the birth center woul notlet me hae my baby there, because o my one prior C-section. I was heartbroen.My husban an I toure the hospital that bacs up the birth center; Ie ha rienselier there who ha goo experiences an I thought I coul mae peace with it.But I coulnt. At thirty-two wees I tol my husban I wante a homebirth. Thatsnot easy in Nebrasa. Certie nurse miwies are not legally allowe to attenhomebirths in our state. But I ha a rien who is a homebirth miwie who agreeto assist us, een though it was last minute an she was ue two wees ater me.

Three o my our babies ha been inuce with Pitocin an I ha epiurals

or all our births. This time we let the baby ecie when she was reay to come. Iwas pretty miserable the last month. I thought I woul be pregnant oreer. I got apeicure, ha acupuncture twice, an trie herbs but I was still pregnant. At orty

wees e ays, on August 29, 2012, I woe up eeling lie my bac was a wall opain. I pae aroun the house unable to get comortable. This was it! We lleup a birthing tub in our liing room an when the pain got really intense, Aamcame in the water with me. He isse my hea an tol me I coul o it, that Ione it our other times beore, een though I sai I coulnt an I wante to leae.

Our aughter, Unity dale Penic, shot across the pool at 6:36 a.m. She

weighe 8 pouns 11 ounces an was 20.5 inches long. Our biggest baby yet! Ionly ha one tiny tear that int nee stitching. My miwie staye or a ew hoursto be sure eerything was oay. Ater she an my oula an the photographer alllet, there was no parae o nurses, octors, an other sta interrupting us eeryew minutes to chec me an the baby or to tae the baby away to the nursery. It

was just us, learning how to be a amily o seen.

Documents

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, by Jennifer Margulis