Putting the fear of God into people is bad medicine

Emily Oster has a book coming out entitled Take Back Your Pregnancy. In preparation for the book launch, as most authors do, she wrote a nice piece in the Wall Street Journal about decision-making, risks, and how some of what OB/GYNs recommend during pregnancy isn’t always evidence based.

In particular, she mentions listeria, a bacteria that is a food borne illness with potentially devastating outcomes during pregnancy. Osher quotes the risk of about 1/8,000 and felt that she should cut out queso fresco, but was still ok with eating deli meats.

In response, the New York Times’ Motherlode blog featured a beautifully written post by KJ Dell’antonia that picked up on the listeria risk that Osher quoted at about 1 in 8,000. Ms. Dell’antonia was the one.

This led me to give thought to what is a valid discussion of information and risk and what is fear mongering? Listeria is actually a great subject matter for the discussion.

Listeria monocytogenes is a bacteria that is food borne. It is killed by pasteurization. In the United States listeria is typically acquired from eating unpasteurized foods or deli meat (studies of what grows in the deli counter are pretty gross, and as an aside I never buy deli meats, but that’s me).

Listeria is not a benign infection. The case-fatality ratio is 21%, although most people who get very sick or die from listeria are over 65 or have a weakened immune system.

Listeriosis (infection with Listeria) is 18 times more common during pregnancy. Since listeria can cause miscarriage, stillbirth, and serious illness for the mother and newborn and since it is significantly more common in pregnancy it is a valid topic for an OB/GYN to discuss during pregnancy. In fact, if you developed listeriosis in pregnancy and had a bad outcome and your doctor never mentioned listeria you could probably sue your doctor. In medicine an 18-fold increased risk is a lot.

But what does an 18-fold increased risk really mean? Can we translate that into more useful numbers? There are about 4 million births a year and the CDC reports about 114 cases of listeria a year during pregnancy. By my incredibly non scientific method the risk of having listeria that will be identified during pregnancy is about 1 in every 40,000 births. Turns out I’m not too far off as a recent review article quotes 1.2/10,000 during pregnancy, basically the 1/8,000 quoted by Osher.

Risk means different things to different people. When I was pregnant with triplets I knew based on statistics that the average gestational age is 32 weeks and the odds that I would take 3 babies home from the hospital was 87%. If I had a selective reduction the average gestational age for my now twins would have been 36 weeks and the odds that I would take both home from the hospital was 88%. Difficult stats. High stakes situation. I chose not to reduce and of course I was in the 13% who loses a baby and was on the wrong end of the gestational bell curve delivering my surviving sons at 26 weeks. However, I don’t regret my decision one bit because I made an informed decision.

When I discuss risk I focus on major complications and I typically use an air travel analogy. If the risk of a major complication with a procedure is 5%, I tell people to think about it like air travel. Would you get on an airplane if the risk of crashing were 1 in 20? It might depend on the reason for traveling and other factors. If you have cancer and the odds the surgery is going to save your life are 40% and your risk of dying without the surgery is 100%, then a 5% risk doesn’t look bad at all.

However, if you have chronic pain and the surgery is to remove adhesions which we know will not help your chronic pain and the surgery has a 5% risk of a major complication then that 5% means something else. That 5% may also mean something more to you if you have a family member who died from a surgical complication or if you yourself had a complication from a previous surgery. Life experiences matter when deciding what risk you can tolerate.

So what about listeria? The facts are:

  • The risk of getting listeria is 18 times higher in pregnancy
  • If you get that infection during pregnancy there is a significantly increased risk of a bad outcome
  • Most pregnant women in America will not get listeria, but every year 120 or so will
  • There are some foods that increase the risk of listeria, unpasteurized cheese being the most common source in the United States but deli meats and other foods can be sources as well.
  • Nothing bad will happen if you avoid the most common sources of listeria for 9 months

How you assemble those facts will be different for different people. And an OB/GYN who has seen a case or two of listeria will probably present those facts differently than an OB/GYN who has never seen the infection.

Let’s put it another way. Knowing the risk of listeria is 18 times higher during pregnancy, albeit the absolute risk is low, do you think it would be appropriate for your doctor not to mention the increased risk?

Putting the fear of God into people is bad medicine and if your doctor makes you feel like you are a bad person for eating soft cheese during pregnancy, then you should probably get another doctor. However, it is good medicine to explain the risks of listeria and what can be done to avoid it. An informed patient listens to that information and then makes a decision.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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  • Anon

    I dont see how “putting fear of God” relates to your entire article.

    • Tran

      It is just one of those American idioms, it is really nothing to do with Christianity or God these days (though it almost certainly started out that way). I don’t think it’s meant to be taken literally. There is a Thai equivalent, “ทำให้ หวาดกลัว มาก”, you are causing someone to have a lot of dread.

  • meyati

    Remember the listeria outbreak from cantaloupes the other summer? It killed a few people. I think that absolutely everything can cause harm to someone. I think that a person should be able to choose their lifestyles-food and med decisions and the attending medical staff should respect it. There should be information, but not nagging caused by disrespect.

    • rbthe4th2

      “There should be information, but not nagging caused by disrespect.”
      This is EXACTLY why my former doc and I parted ways. Any question on other options was interpreted as challenging their authority and not trusting them. I was nagged so badly that to this day, I won’t even take certain tests because of the “PTSD” I got. I mean sometimes I almost said ‘would you shut up already’?
      It was not respected and I was told that ‘if you don’t do as I say, I’ll put it in your record, other docs will see it, and wonder why’. What does that say about our docs?

  • GT

    Fruit and vegetables can also pass on Listeria (see the 2011 cantaloupe mass-poisoning). To be perfectly “safe”, pregnant women would be advised to subsist solely on medically-guaranteed aseptic formula or somesuch. Which of course is ridiculous.

    Scaring pregnant women to death, causing them to live in a state of abject fear for 9 months, is probably not good for their developing babies either.

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