“Naturopathic obstetrics”? Be afraid. Be very afraid.

Despite having found my niche long ago in the medical blogosphere as a skeptic and supporter of science-based medicine, not to mention a scourge of quacks and anti-vaccine activists (no little ego mine!), I rarely, if ever, write about obstetrics. It’s always been one area of medicine that I’ve felt least comfortable with. True, there are some areas of O.B. woo, such as home birth ideology that directly contributes to the deaths of babies, and perhaps I should mention such incidence more often. They are, after all, just as egregious an example of ideology triumphing over science and harming innocents as any cancer quackery.

All of this just serves as an introduction to one of the scariest concepts I’ve ever come across. I saw it earlier this week on the website of the American Association of Naturopathic Physicians (AANP). It is, in essence, naturopathic obstetrics, or at least naturopathic prenatal care. OK, it’s actually naturopathic pre-conception care, but the very title of the post on the AANP blog brought to mind images of naturopaths advising women on prenatal care. At least, that’s what I thought when I read Pre-Conception Testing: A Naturopathic Perspective. It’s by a naturopath named Sara Thyr, ND, who describes herself as a a naturopathic midwife, who is also president of the American College of Naturopathic Obstetrics and founding member of the American Association of Naturopathic Midwives. Now, there‘s a scary concept, a naturopathic midwife and naturopathic obstetrics.

So what do naturopaths recommend for pre-conception care? A lot, it turns out. But first, let’s see what real doctors (as opposed to fake doctors) recommend for pre-conception care. Science-based recommendations weren’t too hard to find on the CDC website and elsewhere, including pamphlets from the American College of Obstetrics and Gynecology. Science-based guidelines emphasize identifying risk factors for bad outcomes such as alcohol abuse and smoking (which should be eliminated if at all possible), anti-epileptic drugs, diabetes, the use of Accutane, the presence of HIV/AIDS (where anti-retroviral therapy can decrease the risk of maternal-fetal transmission). Other interventions include folic acid supplementation, reducing obesity, vaccinating for hepatitis B, testing for maternal phenylketonuria, testing for immunity to varicella and immunizing if the woman is not immune, and adjusting dosages of thyroid hormone replacement in women who require it. Basically, in healthy women, not a lot needs to be done, and in women with certain defined risk factors what needs to be done to reduce the risk of pregnancy loss are fairly straightforward and targeted. This is how Dr. Thyr characterizes these “boring” interventions:

Standard medical testing might include some look at hormones for ovarian function, particularly for women trying to have babies later in their childbearing years. Most will check to see if the woman has antibodies to Rubella and vaccinate her before pregnancy if these levels are low. They might also look at thyroid function, as malfunction of this endocrine gland makes it more difficult to get pregnant and maintain a healthy pregnancy. They may even look at a woman’s vitamin D levels, and perhaps if they are very progressive check her folic acid, B12 and complete blood count. Most do not look any deeper, unless a woman is having some difficulty getting pregnant. Even then, they are not looking at all of the factors that go into having babies who are not only healthy at birth, but healthy throughout their lives.

Ah, yes. How often do we hear naturopaths complain that real doctors don’t look at “all the factors” or that they don’t see everything that naturopaths see. Of course, the reason that real doctors don’t see everything naturopaths see is because a lot of what naturopaths see is not based on science. A lot of it is, in fact, pure woo. You’ll see what I mean very quickly just by looking at the first thing that Dr. Thyr thinks she has to look at in women looking to become pregnant. In describing it, she manages to betray ignorance of immunology and many other areas of medicine:

What will a naturopathic doctor look at?

Food allergies
Food allergies are a very misunderstood topic, in my opinion. If I ruled the medical world, this test would be as common as a complete blood count (CBC) or thyroid testing. When people have delayed hypersensitivity reactions, they may have some random symptoms, but don’t usually know that there is an association between them and the foods they are commonly eating. Undiscovered food allergies are the most common cause of unexplained infertility. And if a woman does end up getting pregnant, she will pass all of these antibodies on to her child. The mother’s antibodies are passed on to her children, so if she does not eliminate them as much as possible during pregnancy and breast-feeding, she passes her sensitivities on to her children.

About the only thing that Thyr gets right is that food allergies are indeed a very misunderstood topic. Unfortunately, she’s one who’s contributing to the misunderstanding by saying that almost everyone should be tested for them. Funny how the committee that produced the CDC recommendations five years ago by poring over the existing medical literature at the time missed food allergies. In fact, the word “allergy,” much less food allergy, isn’t mentioned even once in the CDC report or in other more recent synthesized recommendations. It couldn’t be because there’s no evidence that food allergies are a major problem that results in infertility or pregnancy loss, which makes Thyr’s blanket assertion that “undiscovered food allergies are the most common cause of unexplained infertility” utterly unsupportable. Does she present any evidence to back up this assertion? Of course not. She’s a naturopath. Or, I remind myself, not just a naturopath, but a naturopathic obstetrician/midwife. Apparently, she don’t need no steeenkin’ science-based guidelines.

It also never ceases to amaze me how naturopaths so frequently criticize physicians who practice SBM for supposedly doing too many tests and using too many interventions, rather than “natural” remedies and diagnosis that doesn’t rely on technology. Yet, here we have a naturopath recommending going far beyond normal tests recommended by those nasty, reductionistic physicians. Thyr recommends elimination diets in order to identify foods to which a woman is allegedly allergic, IgG antibody testing, and a variety of other tests. One thing I couldn’t help but notice is that she seems to misunderstand how mothers pass antibodies on to their babies. It’s true. They do pass antibodies through the placenta to their babies. However, maternal antibodies aren’t forever, as Thyr seems to think they are, nor do they result in food sensitivities being passed on from mother to child. Maternal antibodies pass through the placenta and provide protection to the baby for as long as they last, which is usually a few months to as long as a year. In addition, an even bigger misunderstanding on Thyr’s part though is this: The only kind of antibody that passes through the placenta to the developing fetus is IgG. Allergies are mediated through IgE. Maternal antibodies can’t mediate allergic responses in newborns because they’re the wrong kind of antibodies! I mean, seriously, where did this woman learn basic immunology?

Oh, wait. She learned her immunology at a school of naturopathy. Never mind. That explains her ignorance.

There’s one thing that’s missing from Thyr’s initial advice, though. It’s something that all naturopaths love and recommend constantly to their patients. Don’t worry, however. it’s coming, and here it is:

Environmental Toxins
We are all exposed to many environmental toxins every day. Toxins–from pollution while driving or walking down the street, to pesticides and chemicals on our foods, to the plastic liner of the coffee we buy on the way to work, to the perfumes and parabens that are in our body and hair products–are all around us. Some people believe that if they are not working in an oil refinery or carpet factory that they are not exposed to toxins that can be harmful to developing fetuses. Toxic exposure is one area where epigenetics have given us a great deal of information about how we can improve the health of our newborns as well as our entire population. Bisphenol A (BPA) exposure in utero has been linked to men having prostate disease later in life. Phthalates can cause decreased testicular size. Octyphenol is linked to decreased FSH in women and decreased testicular size and function in men. PAH from cigarette smoke exposure while in utero is linked to decreased behavioral scores, ADD and asthma in children.

Ugh. While there are certain exposures that have been linked to problems in pregnancy, as naturopaths are wont to do, Thyr plays the “toxin gambit.” Everything is due to toxins, and you have to “detoxify.” She also does something that every crank from anti-vaccine loons to homeopaths to naturopaths likes to do; she abuses epigenetics. In real science, epigenetics is the study of gene regulation and heritable changes in gene expression or cell phenotype that are due to mechanisms other than changes in genomic DNA. Such mechanisms can include methylation of DNA or remodeling of chromatin, among other mechanisms. These are the sorts of mechanisms that real scientists mean when they refer to epigenetics. When, for example, a naturopath, homeopath or anti-vaccine activist speaks of epigenetics, she seems to mean magic. Sometimes this magic of which she speaks comes from confusing epigenetics with other forms of gene regulation. Sometimes, this misunderstanding and abuse of epigenetics take on outright Lamarckian overtones, wherein bad lifestyle leads to phenotypic changes in parents that can somehow be passed on to offspring. Indeed, there’s more than a little hint of that in sort of magical thinking in Thyr’s invocation of food allergies. Either that, or it’s just a complete misunderstanding of antibodies and allergies. I’m still not sure which it is.

Finally, Thyr recommends adrenal testing at, in essence, the drop of the hat. If a woman is stressed out or reports insomnia, test her adrenal hormones! While there’s no doubt that adrenal dysfunction can cause infertility and pregnancy loss, Thyr seems to see “more subtle” adrenal problems everywhere and in everyone, much as Mojo Nixon sees Elvis everywhere. (The difference, of course, is that Elvis is everywhere, but adrenal problems are not.) It’s hard not to suspect that she probably tests almost everyone’s adrenal hormones. I did a little Googling about “naturopathic obstetrics” and found a lot that disturbed me. Although Thyr doesn’t describe her recommendations this way in her relatively brief post for the AANP blog, what she proposes for a naturopathic preconception work-up certainly resembles what I found at the website of another “naturopathic midwife.”I realize that the following information didn’t come from Thyr’s website. I post it to demonstrate the sorts of things “naturopathic midwives” recommend as “preconception” testing and care. The naturopath in question, Thauna Abrin, recommends “preconception detoxification” for three to six months before attempting to get pregnant. Her “four phase program” includes “environmental and hormonal evaluation” (which sounds a lot like what Thyr described), “nutritional counseling” (which, knowing naturopaths, invariably is only related to science-based nutrition by coincidence), “detoxification” (of course), and “hormone balancing. For “environmental evaluation,” Thauna proposes saliva testing for hormones (not standard of care and not validated) and “toxins” (ditto). Her “detoxification” phase is described thusly:

The detoxification program consists of herbal medicines, homeopathic Biotherapeutic Drainage, colonics and/or saunas. These natural medicines gently but effectively remove harmful chemicals and metals from the body’s tissues and organs. The detoxification phase will last 2-9 months, depending on the individual.

She also recommends craniosacral therapy for mothers and infants.

When I deal with naturopathy, I tend to stress areas of medicine with which I’m familiar, hence my broadsides at “naturopathic oncology.” Every so often, however, I’m reminded that naturopathy has infested every medical specialty, including obstetrics.