Fourth Estate 2012
Ben Goldacre is well known for his trenchant views on the importance of science and using it properly. In this book he is not writing about childbirth, he doesn't mention maternity and barely mentions obstetrics. What he offers is a very detailed exposé of the global pharmaceutical industry, a $600 billion business 'rife with corruption and greed' : he describes how drug companies distort the research into effectiveness of drugs; how government regulators fail to regulate and withhold information; how diseases are invented for profit; and, vitally and shockingly, how much of medical education is now managed by the drugs industry. His conclusion is the stark one that 'medicine is broken'.
So why should AIMS members get hold of this book? It seems to me that this is important knowledge not just for us but for our children: there are some frightening passages about the lack of research on the effects of drugs on small bodies, sometimes alongside massive marketing for use with children. But I also feel that all of this is relevant to childbirth. One example that springs to mind concerns the most common intervention in childbirth globally; that is the use of the artificial hormone, Oxytocin, now given routinely in developed countries probably to a majority of women in labour, followed by prophylactic Oxytocin immediately after birth to almost every woman. This intervention is not evidence based and a recent study concluded that, 'Oxytocin during labour appears to be an independent factor for severe PPH', the most common form of morbidity for women in childbirth.1
Goldacre doesn't use this example himself but shows how such a thing can arise and continue.
The relevance to childbirth, however, is more than just an awareness of how research into new drugs is distorted by the pharmaceutical industry: it is much broader than that. We need to understand how health professionals can't get objective information about drugs; how they are under enormous pressure to conduct research themselves and publish frequently; and how sometimes the temptation to fabricate is too strong. Goldacre, in one of his few references to maternity, quotes the example of Malcolm Pearce, a British obstetric surgeon who published a case report claiming that he had reimplanted an ectopic pregnancy resulting in the successful birth of a healthy baby; an anaesthetist and a theatre technician in his hospital thought this was unlikely as they'd have heard of it so they searched the records and found nothing. In the same issue of the same journal Pearce had also published a paper reporting a trial of 200 women with polycystic ovary syndrome who he treated for recurrent miscarriage; the trial never happened and not only had Pearce invented the patients and the results, he had even concocted a fictitious name for the sponsoring drug company, (Wells F. 2008, cited in Goldacre, pg 174). But plain fraud like this is usually not the problem; it is far more likely that findings are wrong not because of avarice, but because of ambition, excitement at discovery, ignorance of statistical analysis and sometimes chance.
The danger is that flawed, wrong or fraudulent research results are used and give rise to a 'spurious overcertainty' within the relationship between women and obstetricians. This leads Goldacre to discuss the role of the doctor in a way that, I think, will appeal to AIMS readers: he uses the concept of doctor as 'personal shopper', that is someone who knows how to find evidence, can communicate risk clearly but who can also understand in discussion with women their interests and priorities. AIMS has long argued for this kind of role. Another serious side effect of the distortions caused by the vested interests of the drugs manufacturers is that people studying social factors, or lifestyle changes, are edged out in favour of academics working in more commercial areas, and that is very detrimental to our understanding of what is important in maternity.
I recommend this book as a detailed and thorough account of how medical knowledge is developed and what can be done to improve it.
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