Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 9:12 Serial Cervical Lengths, MAHA, and More!
Howard Herrell and Antonia Roberts explore evidence-based practices in obstetrics and gynecology, examining both established protocols and emerging research with critical perspectives on medical misinformation.
• Serial cervical length monitoring after LEEP procedures lacks evidence for improving outcomes despite being common practice
• SMFM's 2016 recommendation explicitly advises against routine cervical length screening for patients with history of cervical procedures
• Retrospective studies on induction timing require careful interpretation due to inherent biases in methodology
• Understanding the difference between intent-to-treat and per-protocol analysis is crucial when evaluating medical research
• Pseudoscience and alternative medicine have gained mainstream acceptance over decades through celebrity endorsements and media platforms
• Reusable surgical instruments like stainless steel uterine manipulators offer both economic and environmental advantages over disposable options
• Plus, Learn the history of The Green Journal's distinctive color
Be sure to check out thinkingaboutobgyn.com for more information and follow us on Instagram. We'll be back in two weeks.
00:00:35 Monitoring Cervical Length After LEEP
00:10:30 Understanding Intent-to-Treat Analysis
00:28:54 MAHA Movement and Medical Misinformation
00:53:49 Carbon Footprint of Uterine Manipulators
00:57:30 History of the Green Journal
Follow us on Instagram @thinkingaboutobgyn.
Welcome to Thinking About OB-GYN. Today's episode features Howard Harrell and Antonia Roberts discussing serial cervical ultrasounds, maha and more.
Antonia:Howard.
Howard:Antonia.
Antonia:What are we thinking about on today's episode?
Howard:We're going to talk about a couple of new studies, maybe whether or not we should be giving the COVID vaccine to pregnant women. I heard the recommendation changed and even a history segment about the history of the Green Journal. But first, what's the thing we do without evidence?
Antonia:Well, how about routinely monitoring cervical lengths for pregnant patients with a history of a leap or a cold knife cone procedure?
Howard:Okay, sure, yeah, so patients who have had a leap or a cone excision are more likely to have spontaneous preterm birth in future pregnancies. In fact, it roughly doubles the risk of spontaneous preterm birth. This, of course, is one of the negatives of doing excessive cervical cancer screening, in that it leads perhaps to excisions that were not necessary, strictly necessary, and then that in turn could lead to an unnecessary rate of preterm birth or risk of preterm birth and then subsequent morbidity and mortality associated with preterm birth.
Antonia:Yeah, we know that not everyone benefits from a LEAP or a cone. I remember some of my attendings saying that with prior guidelines they would be doing PAPs on 16, 18-year-olds and be doing LEAPs on 18-year-olds back in the day. So thankfully we don't do that anymore, but there probably still is some excess that is done. But if we follow the current ASCCP guidelines or whatever your own respective national set of guidelines are, that's when we have the best chance of only doing leaps or cones on someone when it's going to benefit them. But even then, even within the guidelines, there are plenty of gray areas where we just have to end up doing some shared decision-making with the patients. And obviously, if we really are over-screening beyond what the guidelines are telling us, then at least one thing that we're causing is that we're not even giving the patient's body a chance to clear the abnormalities on their own. But you and Stuart had talked a lot more about cervical cancer on just the most recent episode, which was really fantastic, by the way.
Howard:Well, that was all, stuart.
Antonia:Well, I know, that's kind of what I'm saying. Maybe one day you'll be as good as Stuart too.
Howard:Okay, well, yeah, stuart's great.
Howard:Anyway, we do know that the risk of preterm birth seems to obviously increase with the size of the excision how big of a cone or whatever you did.
Howard:One study found that an excision under 10 millimeters is associated with a 7.5% risk of preterm birth, which is similar to having had just a punch biopsy, almost sort of baseline, and that increased all the way up to an 18% risk if you had an excision greater than 20 millimeters. Overall, though, there appears to be about a 2.59 relative risk of preterm birth with a cold knife cone and a 1.7 relative risk of preterm birth with a leap procedure. Along with that, there's an increased risk of preterm rupture of membranes and, obviously, things like low birth weight. There's also an increased risk of second trimester miscarriage, which again might be linked to cervical insufficiency, and, of course, an increased risk of infertility related to cervical stenosis from the cautery effect, but also labor dystocia related to cervical stenosis from the scarring and, ironically, then an increased rate of cesarean delivery because the cervix is not working as it should, perhaps, but the question is, does following the cervical link with ultrasound make a difference in any of this?
Antonia:Right. So we're not just talking here about checking the cervical length at the time of the anatomy ultrasound, as we already do as standard, and then using that information to inform, maybe, whether someone needs progesterone therapy or something else. What we're talking about is starting the serial measurements earlier, like 16 weeks perhaps.
Howard:Right and then continuing even later to 24 weeks. Some people might do further than that. I think what happens is a study's done that shows, of course, that a shortened cervix is associated with an increased risk of preterm birth, and that the shorter the cervix, the more likely the preterm birth. And then, therefore, it's just assumed that it would be useful information to know the length of the cervix and to follow that information and chart it out.
Antonia:And these ultrasounds are not free either.
Howard:You're so jaded, but, yes, maybe there's a financial motivator there too. You're high risk. We're going to do extra ultrasounds. We're going to follow your cervical length. The problem is we have to ask the question of how does it change the management? That's a problem with so many of these. We're seeing the emergence of biomarkers and things like that, or things you find in ultrasound, and we have information that can help us stratify risk, like how short your cervix is or whether you have a biomarker, but can we do anything with it?
Antonia:Yeah, and we already know then that the patients do have that increased risk. But knowing whether it's 18% or maybe 15% or 12% risk of preterm birth doesn't necessarily change anything for that individual patient, unless you're going to step in and have some intervention that can lower that risk.
Howard:Right. This gets back to a discussion that Maddie and I had a few episodes ago about how cervical links and other tests are used in labor triage. The problem is, at what cervical length does some specific intervention become indicated? Because it makes a difference in outcomes, and that's not just an issue with this issue. Here we don't have an intervention or a treatment beyond what we're already routinely offering in the mid-trimester when we check cervical links at the time of the anatomy ultrasound, meaning like vaginal progesterone, which has been shown to make a difference. So, absent a clinical trial that's looked to study some specific treatment that makes a difference in the rate of preterm birth, there's simply no reason to do the serial ultrasounds on a patient's cervix who's had one of these procedures performed in the past.
Antonia:I think the idea here is that, let's say, they check the cervical length at 16 weeks because somebody had a leap. If they see that it's short whatever let's say less than three centimeters long then they might possibly start the vaginal progesterone earlier, and if it's even shorter they might even suggest a cerclage earlier at the 16-week mark, instead of waiting till 20 weeks.
Howard:Right, and that's how we talk ourselves into things that make sense on the surface. But again, I'm the empiricist in OBGYN. I guess, again, you need a study that says that that actually makes a difference, rather than just the thought of we could do this or do that. And actually I'll say too that knowing this information leads to heightened anxiety for the patient who you're doing all this extra testing, because you've really reiterated the risk of preterm birth to her, so she's anxious throughout her pregnancy. But also it brings in interventions that may not work Right so well, I'm worried about how short your cervix is. I think you should probably be on bed rest. Someone has said that to a patient in the past. Because you have this information, she's anxious, she wants you to do something, and so the mind creates and fills the void and creates this idea, and then you deliver it full term. And wasn't it good that we had decreased activity or no intercourse or things like that?
Antonia:And there actually is an SMFM paper about this. So in 2016, the SMFM consult number 40 came out that specifically addresses the question of whether women with a history of treatment for cervical dysplasia should undergo routine cervical length screening, and they say that these patients should not have the screening performed.
Howard:Well, there you go. There's the answer. I didn't even need to say anything. Stuart would have just had that at the first line and gone on to another topic.
Howard:But they do go a little further, though it is interesting, and they suggest that the cervical length is not even the real variable I like this but rather that the degree of dysplasia, and that the dysplasia itself, rather than the procedure they had performed, may be the reason for the cervical dysfunction that leads to cervical insufficiency or preterm birth, and so I thought that was really interesting. Cervical insufficiency or preterm birth, and so I thought that was really interesting, and I'm not sure exactly how you prove that or how you conduct that study to understand that, but obviously women with more severe dysplasia, larger lesions, things like that, are likely to have more aggressive procedures, like a bigger cone. So it just it sort of looks like the same thing on one end of it, but perhaps it could be that the length of the excision is just a surrogate for the degree or size of dysplastic lesion that you had, which, again, is always a reminder not to create narrative fallacies and to consider alternative hypotheses.
Antonia:There was a study in JAMA in 2024 that compared excision versus observation for moderate dysplasia, which for moderate dysplasia that's still a reasonable option, not for severe dysplasia and they found the same preterm birth risk afterwards. So yeah, maybe that's one actual legitimate source of this theory. But yes, that SMFM consult paper also recommended against cervical length screening after cerclage placement and also for patients with multifetal gestations.
Howard:Right so, which means that there's a lot of patients who have undergone cervical links for that as well. So basically, there's not much of a role of cerebro-cervical length in obstetrics.
Antonia:Yeah. So it's for a very carefully selected population, as of what ACOG says right now. So the practice bulletin 234, which is prediction and prevention of spontaneous preterm birth, says I'll just read this little one line quote because of the relatively high detection rate and predictive value in individuals with prior preterm birth and because treatment is available, the serial endovaginal ultrasound measurement of cervical length beginning at 16 weeks zero days of gestation and repeated until 24 weeks zero days of gestation for individuals with singleton pregnancy and prior spontaneous preterm birth is recommended. So that's the group of people that only that group of people does ACOG say they should get their cervical length checked. I did find an abstract from the 2023 ACOG say they should get their cervical length checked.
Antonia:I did find an abstract from the 2023 ACOG annual meeting and in this study they scanned patients who had prior preterm births as early as 23 weeks but not before that, and they concluded that even for those people like, let's say, someone's pregnant and their last pregnancy delivered at 23 weeks, even they can just routinely get their cervical length checked at anatomy scan.
Antonia:So they didn't seem to find benefit in this study. So that makes me think that at least a prior late preterm birth like, let's say, 36 and six, probably doesn't need the screening before their anatomy scan. This one 2023 abstract is suggesting that even a prior 23 week delivery likely doesn't benefit a whole lot from getting their cervical length checked before their anatomy scan. I might still lean towards offering it anyway. That's what ACOG is still saying. And then, of course, if I had a patient, let's say, who had a spontaneous like they just had a baby pop out at like 17 weeks, painless, something like that I'd probably offer it to them as well. But again, all of this has nothing to do with having had a leap or cone or anything like that.
Howard:Yeah, I saw a patient. I've actually seen a couple of patients in the last few months who are in this gray area where we have a lack of understanding. So they both had lost a mid-trimester spontaneous preterm birth. But how do we define cervical insufficiency? They both had stories that were so vague that you can't just say that they had cervical insufficiency. So then did they benefit from cerclage, things like that, and I think that's where that carve out is. Are these people who might benefit from a cerclage? And if you see shortening at 16 weeks, that indicates that they're back on their way to a second loss and you were going to put a cerclage in them. You're way better off doing that at 16 weeks than at 19 weeks when they're three centimeters with bulging membranes. So I do think that that's that population, the people that have some suspicion of something on what we'll call the cervical insufficiency sort of spectrum. But they're never clear.
Howard:And actually one of the patients I saw had such a loss, had a cerclage, and now and this is she's not my patient, but in this one they're just using the progesterone. She's doing great right. Did the cerclage help her? I don't know. Did it hurt her Not? Yet Maybe the cerclage caused scarring. That changed the composition of her cervix and it did in fact help her in the second pregnancy, even though there may not be a need in the third. But her cervical links are doing fine. So I can see following cervical links on patients like that where there's this ambiguity and I think that's what's in the practice bulletin, but not just because five years ago they had a leap.
Antonia:Right.
Howard:Okay. Well, let's move on to something else. Did you see this article from BMC Open Access? It's making all the little OBGYN emails this month. That states that induction of labor at 40 weeks was associated with a 25% rate of cesarean, compared to induction of labor at 41 weeks was associated with a 33% rate of cesarean.
Antonia:Yeah, it's being positioned, I think, sort of to agree with the ARRIVE trial that inducing earlier is better and means a lower cesarean rate.
Howard:Yeah Well, I think sometimes the articles that we pick on here to talk about are meant to illustrate some teaching point about how to read articles in general, rather than the individual article being practice changing or super important, not writing the Nobel Committee. This one, though, is being I've seen it in a couple of the emails that you get by the aggregators for OB-GYN listservs and things like that and so that makes it important because people are highlighting it, but I think it demonstrates a bigger principle about how we interpret literature and why literature like this can sometimes be faulty.
Antonia:Okay, yeah, so analyze one article for a doctor and you prepare him for that one article. But teach a doctor how to analyze all articles and you prepare him for all articles.
Howard:So is that like the give a man a fish thing restated?
Antonia:I was kind of trying I was trying.
Howard:Stuart probably could have done that better.
Howard:Probably we need to get Stuart on here to interject the punchy points here.
Howard:Well, I appreciate the effort but, yes, this particular study is very characteristic of a type of study that's relatively easy to produce and get published but has, frankly, no real importance and no interpretable meaning, although it's in our email inboxes and that's because it's prone to being misinterpreted by those who read it.
Howard:So this was a retrospective cohort and they identified low risk women, some of whom were induced between 40 and 40 weeks and six days and some of whom were induced between 41 weeks and 41 weeks and six days. This was done in China, where I think it hasn't been as widely accepted to deliver everyone by 41 and zero. So they still have a large number of patients going beyond 41 weeks, large number of patients going beyond 41 weeks. And they actually cite the ARRIVE trial as sort of the inspiration for what they're looking at here, although again, it's a retrospective cohort. So they compare a whole lot of things that they could get out of the charts and compare and they think about the Bishop scores and all these other data points that they can come up with, but ultimately they end up with a conclusion that the women who were induced in the 40th week had a lower section rate than the women who were induced in the 41st week, of course, without any increased adverse outcomes.
Antonia:Well, you had me at retrospective. I appreciate knowing the Bishop scores at least, but I do have a lot of other questions about things that are maybe between the lines, like how do their labor induction practices and indications for cesarean compare to what we're used to Do? Their patients tend to have doulas. How often do they do intermittent monitoring or position changes and that kind of thing? Do they do pit breaks? Who do they do antenatal testing for? But setting aside any potential differences in those areas, let's even pretend they all do things exactly the same way we do in the US. It still was a retrospective study, not a prospective randomized trial.
Howard:Exactly right, and that's just a limitation of this type of study. And we have to be just so disciplined about what conclusions we glean from retrospective studies, because there's sort of this survivor bias in play. So if you think about the group of women who were still pregnant at 41 weeks who then needed to be induced in that post 41 week time period, well, that automatically excludes all the patients who already went into labor before 41 and 0. There's something inherently different about pregnancies which extend beyond 41 and 0 or all the way up to 42, really, and the ones who are delivering spontaneously before then. You could think of them, the patients that are still pregnant at 41 and 5, you could think of that as a pathologic abnormality, some problem perhaps with signaling the onset of labor, just as abnormal as preterm labor is really. And then all the women who didn't have whatever this poorly defined abnormality I'm describing is, well, they already went into spontaneous labor before they got a chance to be induced. So these populations are fundamentally different.
Antonia:Yeah, and, in contrast, within the group of women who got induced at 40 weeks, that might have included a lot of women who would have labored on their own just within the next few days, definitely before 41 weeks, and obviously it's also going to include some of the women who may have gone past 41 without intervention. We don't know the exact mix. We can possibly make an estimate based on published rates from the US which, according to the CDC, only about 6% of pregnancies reach 41 weeks. Less than 1% will extend past 42. I don't know what the rates would be if we never induced anyone and only made everyone go into natural labor. Would those numbers still be the same? But regardless, the 40-week group included more sort of quote, normal labor processes and pregnancies and then you can argue that the 41-week group really all were pathologic in the sense that their pregnancies have gone on longer than is optimal or healthy for the mother or baby and certainly past when the natural labor process should have started.
Howard:Right, yeah, exactly, the earlier induction group absolutely included some number of women who would have stayed pregnant had they been left alone, but the group that was induced at 41 to 42 weeks included no women who spontaneously labored before 41 weeks, and so you get that mismatch whatever the number is, 94 to 6 percent mismatch or whatever it is. So it's an apples to oranges comparison. There's just a whole bunch of patients who were not in the latter group because they didn't survive long enough, they didn't stay pregnant long enough to make it to 41 weeks to get induced, and so it shouldn't be surprising that the latter group of women have an abnormality that makes induction more difficult. Perhaps they're not as responsive to oxytocin, the prostaglandins, the cervical composition, like whatever it is, and therefore they have an increased risk of cesarean compared to a group of women who largely labored on their own.
Antonia:Yeah. So here we're getting into the difference between intent to treat analysis versus per protocol analysis. If these patients had been prospectively randomized and then analyzed by intent to treat, then there may have been a significant cohort of women who were put into the 41-week group but then just labored spontaneously and had a vaginal birth. All of that would still be included in that 41-week group's outcomes and vaginal birth rates. So If that were the situation, you might have actually found that from an intent-to-treat perspective, randomizing women to the 41-week labor group might give you a lower C-section rate than the 40-week group because you let more of the normal pregnancies just spontaneously labor rather than subjecting them to perhaps a prolonged induction before they had a favorable cervix.
Howard:Exactly, the denominator is wrong in the 41-week arm of this retrospective study. It's not comprehensive enough and so it ends up being undiluted, if you will. It ends up being effectively a per-protocol analysis and it doesn't include the correct mix and population of patients. It's an unfair comparison and, of course, the ARRIVE trial was prospective. It was randomized. This isn't a criticism of the ARRIVE trial. We've done that elsewhere but this study doesn't add credence to it, it doesn't take away from it, it doesn't have anything to do with it and, like you said, it could be that, had this been a randomized trial, that you actually found the opposite finding because of the way it's constructed.
Antonia:And this is how retrospective studies tend to report their outcomes, sometimes even prospective studies. So that is the thing to look for and understand was this intent to treat or per protocol? But certainly no one should be using this paper without seeing some kind of attempt at intent to treat, analysis of their numbers, to claim that inducing at 40 weeks would have any benefit, especially in terms of lowering cesarean delivery rate compared to inducing at 41 weeks.
Howard:Right. Imagine that someone does a study of a new. We're talking about progesterone and preterm birth earlier. So imagine someone does a study of a new progesterone formulation to prevent preterm birth. Then imagine that many of the patients are randomized to progesterone. This new formulation stopped the medication due to side effects or reactions or just maybe difficulty. Completing the regimen is difficult for some reason. Well, an intent to treat analysis might show a small or even non-significant effect of assigning a patient to progesterone because many of the patients assigned didn't go on to complete the therapy, while the per-protocol analysis might show a significant reduction in preterm birth among those who did complete therapy. So if that were true, you could counsel a patient that if she were able to complete the therapy as prescribed, she might expect to see some percentage reduction in her risk of preterm birth. That would be an argument in that case, in that narrow use case, for using the per-protocol analysis, even though on the whole, from an intent-to-treat perspective, they didn't find a difference or benefit, let's say, in the progesterone therapy.
Antonia:Yeah. So that's one situation where using per-protocol is helpful compared to using intent-to-treat for interpreting a study. But another counter argument for where we should still use intent to treat might be, let's say, for a study of birth control methods, and we can just use real data in this example. So from a per protocol perspective, the Nexplanon is the most effective form of birth control. But from an intent to treat perspective, the hormonal IUDs are more effective. And that's because the Nexplanon has that pesky side effect of irregular bleeding and it ends up having a significantly higher discontinuation rate than IUDs do because of those side effects. And sometimes there's other side effects also cited, but I think most commonly it's the bleeding.
Antonia:And so then when patients discontinue the Nexplanon, oftentimes they're not very likely to switch to an IUD, because maybe they didn't want one in the first place. That's why they picked Nexplanon, and now they feel that they've already been let down by one implantable birth control device. They don't want another one. So in real world implementation, if you give a thousand patients an IUD and then at the same time you give another thousand patients an explanon, there's going to be more pregnancies in an explanon group within two years than the IUD group. But in a theoretical world, if nobody discontinued their explanon and all thousand patients kept it, there would be fewer pregnancies in the Nexplanon group. So in the people who actually continue using it it's more effective. But in the real world not as many people continue using it. So for that you would want to use intent to treat.
Howard:When you're counseling the patient or making public health decisions or whatever.
Howard:So yeah, so in that situation, the intent to treat analysis is definitely more meaningful to the patient sitting in front of you than the per protocol analysis, whereas in the progesterone for preterm labor prevention that I just made up a minute ago, you'd be better off using the per protocol, because there's one, there's not an alternative to choose from.
Howard:Protocol. Because there's one, there's not an alternative to choose from. And two, you might actually encourage the patient to use it when she realizes how important the use is. You can give her a real life example of reducing her risk by using it correctly versus not. But the more people you can convince to use this imaginary progesterone, the fewer the preterm births, and that data actually helps you do that. But if you have a trial of two different progesterone formulations, say, you have this really messy cream, and then you've got again making all this up an oral tablet or something, a patch maybe, or something that was much better tolerated, and you found that patients were more likely to use the pills than the cream and continue using this less messy formulation, even though it was slightly less effective at preventing preterm birth, you might conclude that, on the whole, we're better off using the pill rather than the cream for the average patient sitting in front of you, because she's more likely to use it effectively and consistently.
Antonia:Yeah. So the key is you have to think about the differences in what it means when you interpret the data in these two different ways real world versus controlled experimental conditions. So for many studies of this nature, the authors really should provide both types of analyses and discuss the pros and cons of the results if they end up being different results.
Howard:Yeah, in most cases it's intent to treat that matters, and the trickery usually involves the more limited and manipulative per protocol analysis. Where, to go a step further, you design the protocol to take out all the tricky wickets that led to failure of treatment. And so all of a sudden, your per protocol looks amazing, but in real life you don't see this. Another birth control example of that might be just the sort of perfect use rate versus actual use rate of failure rates of birth control pills. Which one's actually more applicable to your patient? Your per protocol looks really good 99 point something percent but the protocol is so stringent and throws out so many patients that it really doesn't apply to any patient that you meet.
Antonia:So yeah that that's not really even a matter of motivation, because sometimes people literally just forget one morning to take a pill. Yeah Well, I'm going to switch gears now. So have you been keeping up with the Maha movement?
Howard:Oh my.
Antonia:Yeah, make America healthy again. I thought I might just need to check in with you about this and make sure you're doing okay.
Howard:Yeah Well, I think we're living in interesting times, but I will say that none of what we're seeing is really anything new. The anti-vaccine movement has definitely accelerated in recent years, especially with COVID, and there's just huge amounts of money to be made in false dietary advice and fear mongering and all those kinds of things that drive people to seek alternative treatments and alternative models of medicine or whatever you want to call it. But that's not new. That stuff goes way back Doctors. For as long as there's been doctors, they've lent their names to false medical claims, especially if there was some bucks to be made off of it.
Howard:So we have normalized for decades what I would call alternative medical advice, or maybe we should say non-scientific medical advice. Even in saying the word alternative medicine, appreciate there's really just science-based medicine and non-science-based medicine, and so we don't benefit by using the term alternative medicine or complementary medicine. There's science-based and non-science-based Science. Doesn't care whether the medicine in question was used by the ancient Chinese, or whether it comes from a tree or an herb, or whether it's made in a factory. Whatever, it either works with an acceptable side effect profile or it doesn't, and that's therefore science-based, or there's non-cience based but, and that carries terms like alternative and complimentary and functional and all sorts of labeling today that that, just that, has normalized this sort of stuff. And I think OBGYNs have seen this in our field and maybe this isn't true We'll get angry letters from internists or something, but I do feel like we've seen this stuff in our field more than other physicians have seen in their fields.
Howard:We've had to deal with all this false information about hormones both from within our profession and outside our profession, not just since the Women's Health Initiative in 2002 or whatever, but going back decades to books like we've talked about before Feminine 2002 or whatever, but going back decades to books like we've talked about before Feminine Forever or whatever, that written by the companies to sell this stuff. And we've had to deal with vaccine hesitant and, just frankly, anti-vaccine patients, along with our pediatric colleagues I mean definitely they're in the mix here for a much longer time than I think other specialties where all of a sudden during COVID they're like what people don't take vaccines and we've had to deal with this sort of false information and pet alternative theories about pregnancy. I mean think about all of the.
Howard:I don't think we've ever really done, but we could do a whole episode about all the old wives tales, and some of them are minor and playful, like the coiling of the umbilical cord is related to how many times the baby spins around in the first trimester, Okay, but we're filled with this sort of stuff about birth in particular, because it's so present. Everybody lives with it and everybody has experience with it and everybody has ideas about it. We deal with that on a daily basis.
Antonia:Yeah, I'd say I'm sure we definitely get our fair share, but I'm sure I can think of plenty of examples of other specialties having these struggles as well, who just didn't understand why are we employing any kind of delicacy or kind of persuasive effort with vaccines? They'd be like wait, what do you mean?
Howard:You just give it to them right, but if you're an orthopedic surgeon, the femur is broken.
Antonia:Yeah, yeah, I could see that. Yeah, okay, well, so they did just change the COVID recommendation for pregnant patients, so are you going to stop recommending it now that the CDC changed up their tune?
Howard:the science hasn't changed right, so the recommendation didn't change because of any new information that's come about. In fact, the science is stronger than ever and if we look at we discussed sometime this year the mortality data, maternal mortality data from the last two or three years and the spike in maternal deaths related to COVID that's now we're on the back end of, is alone is proof of how much the COVID vaccine has benefited pregnant women. We spend so much time talking about maternal mortality and we're ultimately talking about for the whole year, the whole big number. We're talking about 800, 900 deaths, and then we spiked up three or four or 500 more during the COVID pandemic. And what's hard for people to realize is that the COVID vaccine has saved hundreds and hundreds of pregnant women's lives. It's always hard to prove if people don't follow science, a metric to prove what didn't happen. The same thing happened with flu. We had the peak in maternal mortality after the Spanish flu pandemic in 1918. And so I think most people, even OJOMs, don't really appreciate how many pregnant women's lives are saved every year by the flu vaccine, because we don't deal with it, we don't see it that often, but the science hasn't changed. So, yes, we'll still be giving the COVID vaccine to pregnant women and recommending that.
Howard:I'm actually very optimistic about what we're living through, about this leading to people sort of opening their eyes up a little bit about how science and health data and information in general is manipulated by powerful organizations and powerful people for their own special interests. And yes, that could be medical societies who are influenced by large pharmaceutical companies, who spend their advertising dollars at their conventions and at their meetings or through educational grants. Absolutely, we're no strangers to that discussion. It certainly includes researchers who are influenced by the companies that fund their research and give them grants. And, again, a listener to this podcast will know with what skeptical sense we treat every company funded study.
Howard:But it's also politics, and politics are ultimately people who are appointed to organizations like the CDC or the NIH or any other government agency around the world. Well, these are just political appointees and politics to some degree will bias their decisions, and this is across the political spectrum. People are just now all of a sudden way more aware of it, and I'm not saying there's not more of it, but I welcome that people are all of a sudden aware of how important the political process is in the implementation of scientific data, but so we should always be skeptical of bias when we look at any scientific data. Data never speaks for itself. It always has to be contextualized by someone, and if we allow a drug company to do that, you're going to get a different set of results than if you allow someone else to do that, et cetera. Like it always questioned the bias, and try to look beyond that and see what the actual data says.
Antonia:Well, supposedly we were also promised that soon I think September of this year we're going to know the cause of autism right, and all of our health problems will go away after we remove a few food colorings out from our food and remove fluoride from the water and just finally get rid of those silly vaccines.
Howard:Yeah, Wow, and that's of course what happens when you put non-scientists and, frankly, disgraced scientists in charge of important institutions, we finally have a surgeon general who's never practiced medicine and didn't even complete a residency. Has gotten to this point of such disrespect for science is interesting and it's something I've thought about for a long time. I'd love to write about but there's so many fish to fry that I haven't pursued it. But I do believe what you're seeing now politically is not a cause but a result of decades of broader acceptance, mainstream acceptance of pseudoscience, so long before we had Maha. Well, I've often talked about Oprah Winfrey as an example of how middle America adopted health pseudoscience on a large scale. So after we've talked about this, I think, way back in the third episode ever of the podcast about the Women's Health Initiative study, oprah gave on her television program, suzanne Somers, a very powerful and large platform to advocate for so-called bioidentical hormone replacement therapy and alternative cancer treatments, as well as promote false claims about anti-aging and other nutritional supplements and things like that. Oprah gave a platform to Jenny McCarthy While she was openly claiming that vaccines cause autism and advocating for chelation therapy as a treatment for autism. Of course, jeannie McCarthy went to the Playboy School of Medicine. She made Dr Oz a household name. I think he's involved in the administration as well and launched and produced his television program. We have scientific paper that concluded that at least half of everything Dr Oz said in his program was frankly a lie. She promoted Dr Christiane Northrup in OBGYN, made her a best selling author and the sort of go-to person on the internet and the search engines and in the interviews and the magazines. While Northrup promotes lies about hormones and anti-aging treatments, she's an avowed anti-vaxxer. She questions the existence of the germ theory. Like this person is not even in the realm of legitimate medicine, and Oprah made her a household name. She made Dr Phil a household name with a questionable psychological and psychiatric advice, but also promoted I think, worse his wife, robin McGaugh, who again became a bestselling author due to Oprah because of books that were full of scientifically untrue lifestyle and wellness advice. And there are countless other examples of books that became bestsellers or people who were platformed to spread misinformation due to Oprah. And that poisonous tree has sprouted a lot of fruit, and it's not the only tree. I just know a lot about this one because of the hormone angle and the influence about vaccines.
Howard:But Dr Phil and his son, propped up by Oprah's production company, started the television show the Doctors back in 2008. And that show platformed the pediatrician Jim Sears, whose brother, bob, lost his license in California, at least for a while, I think. He got it back for giving out fake vaccine exemptions, and the brothers promote vaccine hesitancy with their alternative vaccine schedule. One of the producers of that show was a man named Dale Bigtree, who was also a producer of the Dr of that show was a man named del big tree, who was also a producer of the dr phil show, and he's the leading anti-vaxxer in the united states. He's the one that produced the vaxxed film that undoubtedly will lead to the deaths of countless children it already has, if you think about what's happening in texas and promoting lies. He also, by the way, was a communications director for Robert F Kennedy's presidential campaign. So we're reaping the fruit that's been sown for decades, and I guess I'm intolerant of pseudoscience.
Antonia:It's so unfortunate because there were so many good sides about Oprah too. I'm pretty sure my mom used to watch it and I'd kind of see it in the background and it just seemed like such a fun, positive show. In general, I think she has very broad appeal and I think that's why all of these people you mentioned and their theories unfortunately, got so much limelight. And I wonder I'm not really sure, did she actually believe all of this stuff or maybe thought like, well, they've got an interesting story, maybe we should just hear what they have to say? Or did she just really think this audience is going to eat it up I'm going to make a lot of money, we're all going to benefit from this and not really think about the consequences? I know at least because I've kind of read more into autism, since we have an autistic kid, and I know at least in that community there was a lot of very appropriate and well-deserved frustration against the medical community.
Antonia:Psychiatrists for the longest time were often practicing some pretty harmful treatments that would include things like shock therapy or other punishments or just over sedating them with medications, basically institutionalizing these kids for life, and some even came out and said these are soulless shells of human beings. They're not even real people. Basically, even in this generation there's been doctors saying that. Basically Even in this generation there's been doctors saying that. And while there has been more humane and actually helpful approaches, even since Asperger's time, a lot of that wasn't necessarily mainstream, even within the medical community. So there were a lot of desperate and angry patients over the last few decades and I think overlapping into Oprah's time who really wanted to be more proactive and latch on to something better than what they were being offered and just something that they thought that they could possibly do on their own for their autistic kids.
Howard:Yeah, I think that's a general pattern. Replace autism with other difficult-to-deal-with conditions that we don't have a lot of knowledge about chronic pain or all sorts of things, or cancers that we seemingly haven't made a lot of progress on, although we have, but it's just so minor. Why haven't we cured cancer, those sorts of things? Replace it with anything that's difficult, a bit ambiguous, not well studied, or maybe it's well studied, but the studies haven't produced much of consequence in terms of making people's lives better, and you get an open door to this sort of approach where people will seek out these alternative sort of ideas. Sort of ideas. And my only point about Oprah and I could have done this about somebody other than Oprah, for sure but my only point about Oprah and folks like this is that a lot of people have become very wealthy and spent the last, in her case, 30 years or so promoting this kind of misinformation. That's gotten us to the point where we're living in now, and maybe, as you said, part of it was due to the failings of licensed physicians, who weren't and it's still true today right, I mean, licensed physicians participate in so many of the scammy things that we talk about, and, of course, it's not just these people, but you know, lots of people have influenced the thinking of tens of millions of people who are now willing to accept pseudoscience in some degree in their daily lives. And I see it in our profession. I see folks in our profession who are doing all the things I listed because they do make money.
Howard:And does Oprah believe it or not? I don't know and I don't care. I don't know if anybody ever believes it I think she probably is interested in. She has said that she believes in some things that are new, age-ish is how I think people would describe them. That she believes in some things that are definitely not mainstream. I don't think she's ever said I think vaccines cause autism. But she's given people like Jenny McCarthy hours of prime television time to tell her viewers that.
Howard:And I think that people like that, or Joe Rogan or other people who have a big audience, have a higher responsibility than others about thinking who they platform. We've been having this past year. We've been having and hope to continue having other guests hosts on to try to grow the experiences and expertise of people we have on the show. But you and I put a lot of thought into who are we getting and what are they going to say? And do we platform somebody on this podcast that represents our thoughts about things and what we're doing? Do we expose to our audience people who promote nonsense? And so far we've been good at not doing that.
Antonia:Yeah, yeah, fingers crossed. I think we've got just really excellent guests so far. And I do think for every big name sort of pseudoscience influer, like every Jenny McCarthy or Phil McGraw or Dr Oz, there's at least 100 people out there who are amplifying that message with their own little social media channels and followings and maybe subscriptions and money-making schemes. So they're just really kind of it's not like Jenny McCarthy is just shouting into a void like people are eating it up and they're promoting it themselves. So physicians have to raise their standards about evidence-based practice of medicine and we have to reject marginalized ideas that are not proven by science. Or then we're just part of the problem and it's a slippery slope. If physicians are doing things in their practice that are not based in good science, they're contributing to the sorts of mindsets that eventually will accept vaccines as a cause of autism, for example.
Howard:Yeah, there's this concept called creeping normality Another one of the things I'd write about if I didn't have a job and false scientific beliefs exist on a spectrum, a very broad spectrum. Most people wouldn't give the time of day to a person who believes that the earth is flat, and 40 years ago most people wouldn't have given any heed at all to folks who claim that vaccines were a cause, a negative thing, a cause of ill health of any sort, or that they were bad. But we've had this creeping normality where people with such wholly fabricated and non-scientific beliefs have become mainstream. And that's my point about Oprah and any other influencer or mainstream person that you can think of. Folks may not realize that we get requests on this podcast for people to come onto the podcast promoting something that we would consider to be well beyond the margin of science. Some of them are paid offers Come on or we'll exchange audiences and this sort of stuff change audiences and this sort of stuff. Podcasters do this all the time and they're OB-GYN specific and in that OB-GYN podcast space many of them you'll see them out there and they're on other shows that are good shows with regular frequency, and we've also gotten email asking to be on and again, we have a responsibility about that.
Howard:I think that the consumer of information has to be careful about where they get their info. So most episodes of the Oprah show, like you said, were wholesome and positive and uplifting and they were innocuous. They may even be helpful to a degree, but a percentage of them have caused horrible damage to public health and erosion of trust that Americans have in science and in physicians. I see that in a lot of platforms that deliver health information to physicians whether it's some of those email aggregators like we talked about earlier or certain podcasts that have some of these folks on them on a fairly regular basis. As consumers, we have to have a low tolerance for people who platform pseudoscience and misinformation. And in the OBGYN space, that might be anti-vaccine or vaccine hesitant or alternate schedules, things like that, or vaginal CO2 lasers or bioidentical hormone pellets or vitamins and supplements or whatever it is that seems rather innocuous and people are doing to make money, I think. Still, I don't think any of it's new, though I guess that's what I was saying. There's always been, will always be, bad physicians who've sold varieties of snake oil to people, and the truth is we're way better off today than we were 50 or 100 years ago, but it's a constant battle to fight misinformation and to police our own discipline.
Howard:Science has worked. We have longer life expectancies than ever, particularly if you subtract out the recent COVID bump in mortality and the opioid abuse pandemic. We're living longer, healthier lives than ever, but from a worldwide perspective, people have just never lived so long. But that then comes with an increasing burden of chronic disease. We've replaced dysentery as a cause of death with things like cancer and heart disease as causes of death, which were primarily due to a consequence of getting older and aging, a problem people didn't have as often 100 years ago. We also live in a time of rampant overdiagnosis, as people make money off of labeling patients with diseases and over-testing again something we talk about on this show.
Howard:The science has also worked with maternal and perinatal and infant mortality. We've reduced both maternal and perinatal mortality by 99% in the last 150 years and we continue to make progress. But we see insurgencies or resurrections of practices in this space which are associated with worse maternal mortality or worse neonatal outcomes. But on the whole, these practices they come and they go and they'll be washed away over time, and we've replaced obstructed labor and infection and hemorrhage as causes of death for mothers, with more complex causes of death like mental health disorders and substance abuse, which existed 150 years ago but were small in comparison to the obvious and frequent causes of maternal death like hemorrhage and obstructed labor and infection.
Howard:That we tackled first and the science has defeated not defeated entirely, but 99% reduction. We've always had cancer, we've always had heart disease, we've always had suicide, we've always had substance abuse, we've always had autoimmune diseases, we've always had autism, but many of these conditions in previous generations were marginalized by the more immediate threats which were killing people at age 38. And that was the more upfront thing that you wanted to tackle. And now we've done that. We've taken female life expectancy in the United States in 1850 from 38 to like 79 or whatever it is. Now we're taking on harder, more challenging, more complicated issues that affect people at later parts of the lifespan, because we've won so many battles and the complexity of all that breeds lots of unknowns. There is no one neat trick to any of them, which is what sells on social media and in 144 character tweets I know they expanded it no emails please.
Howard:And we have so many unknowns that come out every day with really immature fields of large data analysis that science is. It's hard to keep pace in a temperate, you know judicious way that science normally progresses. Things are moving so fast it feels like that it's hard to keep pace and satisfy people's concerns. And then we have people who stand to make money off of that uncertainty and those voids of knowledge and make money off of novelty and media platforms that are good at capturing eyeballs. Using fear mongering and bold claims and making so many people afraid all the time promotes an erosion of trust in science and in the health care system. And then something like Maha comes along that says that the whole system is so broken that it needs to be replaced, and then they can sell nonsense in the void. So wouldn't it be nice if all of our health problems were just due to seed oils or food additives, rather than very complex problems that require large scale, science based, robust systems to address?
Antonia:science-based, robust systems to address. So you think people will see that this campaign is not making America healthy and this whole Maha movement will eventually pass over.
Howard:Well, the journey is its own reward, right? I think we've seen these sentiments before and that life is largely self-correcting, even though this might seem like it's worse than it's been in the past. And read newspapers from 1910, they were all sponsored by snake oil salesmen. But the burden is on us to fight the good fight for sure.
Antonia:Okay, well, I didn't mean to open up a whole 30-minute long can of worms for you. I was just kind of checking in it's called a rant, yeah, okay. Well, I'm glad you got that off your chest, and I guess we're largely preaching to the choir anyway with this podcast, so maybe we can just switch it up for a second and talk about an article that I think will make you happy.
Howard:Okay, yeah.
Antonia:Okay, this'll be quick. I think this one's from the Green Journal. It's the Comparative Carbon Footprint and Cost Analysis of Uterine Manipulators for Hysterectomy.
Howard:Now I just feel like you're trolling me.
Antonia:I think this will make you happy, though. So essentially, they found that reusable stainless steel manipulators had the lowest carbon footprint and overall environmental impact compared to disposable single-use manipulators. Compared to disposable single-use manipulators, they found that over time, the hospitals saved substantial money by investing in the reusable manipulators up to $43,000 per 300 cases. So they were arguing against using the V-Care or the Avinkula delineator or that hybrid roomie, in favor of using this reusable Pelosi. So now your job is to find some joy in this.
Howard:Yeah Well, these devices are still very expensive Over 300 uses. The hybrid roomie costs $43,000 more than the reusable device, including the cost of maintenance and cleaning, I guess for this reusable Pelosi. In fact, the price of the Pelosi ended up being only about $18 per surgery amateurized out, compared to $162 per surgery for the Rumi again over 300 cases. So it would be the most cost-effective option as well as the most environmentally friendly option because it doesn't have a bunch of plastic on it that you're buying every case of the choices that you listed anyway. But I suspect that most surgeons doing laparoscopic hysterectomies, if they've ever even heard of the Pelosi device, they don't want to use it because it conducts electricity. One, and it doesn't seal off the vagina to preserve insufflation when you make her colpotomies.
Antonia:two, so it sounds like none of them are a great option. If you care about the environment, or if you care about not burning, I got you now.
Howard:This is where I find my joy. Yes, correct. So the low cost and environmentally conscious uterine manipulator is to use no uterine manipulator and either do a vaginal hysterectomy or, if you're doing other laparoscopic procedures, to simply use a reusable or a hume-type manipulator, I guess, and still do your colpotomy from below, so that you don't need to use one of these fancy manipulators. That's what you wanted me to say.
Antonia:And that's what I thought you were going to say. Well, I'll make the argument for the laparoscopic hysterectomy. Perhaps the next best one should still be the V-care, because it has plastic on it which does not conduct electricity and burn the vagina when you're cutting on it. So in this study that was the least expensive of the disposable the non-Pelosi options at $72 per case and so it is the cheapest thing. That gets you some kind of non-conductive cervical compotomizer cup with still having good uterine manipulation and having the ability to have an air occluder in the vagina. And that makes me happy because that's what I was trained up on for laparoscopic hysterectomies and I still use it today. It's really the only one we even have available in my hospital, so I'd say that has the lowest carbon footprint of the non-Pelosi options.
Howard:All right. Well, environmentally conscious Looky there Fair enough.
Antonia:Yeah, so we're both happy with that article. Yeah, so, if we still have time, you were going to tell us about the history of the Green Journal.
Howard:Yeah, okay, so you may not know this, but next year is the 75th anniversary of the American College of Obstetricians and Gynecologists. Year is the 75th anniversary of the American College of Obstetricians and Gynecologists, so the original incorporation date was 1951. And the first secretary of the ACOG was a man named Ralph Reese. Reese had wanted to start a second journal, a second major OB journal, to the American Journal, what we call the Gray Journal today, the American Journal of Obstetricians and Gynecology, and he'd wanted to do this for many years. He'd even approached the American Medical Association about starting a journal and they said no.
Howard:But within the first few months of the foundations of ACOG, ralph had suggested again to the board that we needed a second journal and the board agreed. And so they submitted bid requests to different publishers and a publisher named Paul Hober, who worked for Harper Brothers, won the bid. And then he commissioned his art department to make 200 different covers, different color schemes, different typefaces, that sort of thing. And then he at one point had all these mock-ups and he brought them to Ralph Reese's home where they laid them out across his living room floor in four rows of 50 each. I don't man had a big living room.
Howard:I'm guessing, I don't know, I don't think I can do that in my living room, but anyway, another fellow was there named Herbert Schmitz and Ralph had been chosen as the first editor and Schmitz was going to be on the editorial board, was on the editorial board, so they were there looking at these. Okay, now the other thing you need to know about Ralph Reese was he was known for using green pens that he carried with him to edit articles or write things or make notes or anything like that. So he was known for his green pens. So when they spread these across the floor, schmitz noticed that one of the covers was green and he mentions to Ralph hey, you've got to pick this deep green cover because it's the color of your ink. And so he did Like they were done. And then, of course, quickly, it became known as the Green Journal and ACOG adopted that same color for its branding.
Antonia:And that branding is going to be changing up a little bit right and that branding is going to be changing up a little bit.
Howard:Right, it is indeed. There's going to be a new color scheme. There's going to be some green in there, don't worry, and a new seal will be rolled out next year as part of the 75th anniversary of the Green Journal was dedicated to Ralph Reese and featured several articles that he had written in the past as the first few articles of it. You can read all these, by the way, in the Green Journal through your ACOG account you can go back to any year you want of the Green Journal and take a look. Of those in that edition honoring him. My favorite was entitled Reducing Hazards to the Newborn During Caesarean Section. He also wrote one of the first books on the management of diabetes during pregnancy.
Howard:Now, the very first article ever published in the Green Journal was called Hormone Producing Ovarian Tumors by the great Emil Novak. The first edition was published January of 1953, and that paper had been read at the very first clinical annual scientific meeting of ACOG in December of 52. Dr Novak was born in Baltimore in 1884 and spent almost his whole career at Johns Hopkins. He made incredibly important contributions to the field of gynecologic pathology as the assistant to Thomas Cullen, who was the chief of the Department of Gynecology gynecologic pathology, I should say at Hopkins. The other interesting connection is that Dr Novak, along with Nicholas Eastman, who was the Hopkins professor of obstetrics, they were the ones that created, in 1946, the Obstetrical and Gynecologic Survey, which has always been one of my favorite journals, still an important journal in the field. Nicholas Eastman, by the way, was also the editor of the 10th through the 13th editions of Williams' obstetrics.
Antonia:Didn't he also invent one of the vacuum aspirators for performing an endometrial curatage?
Howard:Novak yeah, Novak did. He made a lot of very important discoveries relating to uterine pathology and ovarian hormonal function, but he developed a thin metal pipette that was hooked up to wall suction. That allowed him to take endometrial samples, and we still use that in a way today, but the little pipettes have their own internal suction. It's essentially what you use to do endometrial biopsies, but also led to the principles of aspiration DNC.
Antonia:Well, so what's the new logo and color going to look like?
Howard:You'll find out in less than a year.
Antonia:No spoilers, I guess. Well, I think you have to tell us quickly about the Gray Journal's history now.
Howard:Yeah, well, originally it was founded in 1869 and it was called originally the American Journal of Obstetrics and Diseases of Women and Children. It was called that actually until 1920. The founding editors were Emil Nagaroff and BF Dawson. Dawson specialized in uterine pathology, but Nagaroff was a professor of obstetrics and diseases of women and children in New York.
Howard:He was born in Germany, as the name might suggest, and at that time back in the latter part of the 19th century, pediatrics was really sort of a branch of OBGYN, as much as OBGYN was even its own specialty and the term diseases of women was more often used for gynecology. So you saw a lot of diseases of women and children books and diseases of women and children kind of publications. The doctors who delivered the babies were typically the ones who were interested in newborn care and really the first year of life they were calling on the mothers who were breastfeeding and who were taking care of the newborn. So they developed this interest in the infancy time period and pediatrics eventually grew out of that. The regular general doctors took care of everybody a year and up. By the turn of the century pediatrics really did grow into its own discipline that separated and spanned longer than just, obviously the first year of life in the whole lifespan of young people. So eventually the journal's name was changed to just the American Journal of Obstetrics and Gynecology in 1920.
Antonia:So when did that become the Gray Journal?
Howard:gynecology in 1920. So when did that become the gray journal? I'm not actually sure, and maybe a listener knows that. My impression, though, is it became the gray journal after the green journal became the green journal. In the 1930s, the journal of pediatrics was actually called the gray journal because it had a gray cover, and certainly after the green journal came out, pediatrics changed. The cover was different, and I think that it was just natural that, once we had a Green Journal as a short way of saying obstetrics and gynecology, we had a Gray Journal as a way of saying the even longer name of the Gray Journal.
Antonia:Okay, well, and in case you didn't know, urology is called the Gold Journal.
Howard:Those guys geek out about that yeah they do yeah, okay, well, good, well, we will be back in July.
Antonia:Oh yeah, that's right.
Howard:Well, we have one more episode to go and we're going to have a guest again, and then you'll be back in the first bit of July.
Antonia:That's right.
Announcer:We'll see everybody then. Thanks for listening. We'll see everybody then. Thanks for listening. Be sure to check out thinkingaboutobgyncom for more information and be sure to follow us on Instagram. We'll be back in two weeks.