Book Review: "Managing Morning Sickness" by Miriam Erick

"Managing Morning Sickness"
Miriam Erick
2004, 412 pages

After reading this book, I felt.... confused. Yes, definitely confused. And also irritated.

I liked the book better upon rereading it. It definitely has good information. So I guess that my review is mixed!

I want to start off with three big complaints.

First - This is not a book about hyperemesis. This is a book about morning sickness - ALL morning sickness - from the slightest queasiness to the severest case of HG. I am not sure that the choice to lump all forms of MS/HG together was a wise choice. What works for one will not work for the other, and what applies to one will not apply to the other. I found it confusing to wade through oodles of advice, only some of which applied to me.

Of course, I realize the quandary. Hyperemesis is not a well-defined condition, just because morning sickness is a spectrum/continuum condition. It progresses from mild to life-threatening, and the exact dividing point between garden-variety MS and HG is not well-defined - or rather, it is an artificial division that doesn't really exist! So it would be hard to separate the conditions for separate books! Still, it was confusing.

Which brings me to my second complaint - Miriam's definition of HG. First of all, she gives several different definitions of HG:

"The technical name for moderate-to-severe nausea and vomiting during pregnancy is hyperemesis gravidarum (HG)." p. 5

Although she admits that "Currently, there is no set of criteria that can delinate this spectrum," (p. 5) she later states that "On occasion a hospital stay to correct dehydration is necessary. If this happens, morning sickness becomes known as hyperemesis gravidarum." (p. 245)

She seems to stick with this definition, for the most part - she repeats it several times throughout the book. So, if you end up in the hospital, you had hyperemesis; if you don't, you didn't.

Speaking from a somewhat scientifically-trained background, this is the WORST possible way to define a condition - to define it based on the clinical action taken. Frankly, I don't know how she could even contemplate this methodology! Let's take some analogous situations to see how ludicrous this appears:

- "You only have pneumonia if you go to see a doctor. Otherwise it's just a bad cold."
- "You only have cancer once the doctors decide to do chemotherapy. Otherwise it's just your imagination."
- "You only have a broken bone if the doctor gives you a cast. Otherwise it's a strain."
- "You only have a bad cut if you get stitches. Otherwise it's just a scratch."

Conditions need to be defined symptomatically; not by end-results.

My own case is a good example. I know, by personal experience and symptom-matching, that I had a (mild) case of HG. If I had known then what I knew now, I would have gone to the hospital (and thus I would have "had HG"). However, we did not have insurance and I believed (falsely) that there was no medication to give to pregnant mamas for fear of harming the baby. Thus, we stayed home even though I was dehydrated and wanting to die. But if we had gone in, like we should have, then I would (by Miriam's estimate) have had HG! Since I didn't, I obviously didn't!!

A couple more examples....

- What about the woman in a third world country who doesn't have access to medical care? Well, obviously she doesn't have HG because she wasn't hospitalized!
- What about women who check themselves into a hospital unnecessarily? I once heard a doula describe an unbalanced, hysterical-type client of hers who constantly checked herself into the hospital for imaginary or minor complaints (including nausea and vomiting, which didn't exist). Well, obviously she had HG - because she was hospitalized!
- What about the woman who isn't hospitalized because her doctor is ignorant or insensitive and refuses to hospitalize her even though she needs it? Well, obviously she didn't have HG!

Forgive the sarcasm - but her definition did make me angry. You simply cannot classify a disease condition by what the medical community decides to do about it. It must be symptom-based.

My third complaint:

I realized about two-thirds of the way through the book that this book didn't have the same "feel" as other HG books I have read. It took me a minute to realize what it was, and then I realized that this book (as far as I could tell) was not written from personal experience. Miriam has not been through HG herself. How do I conclude that? #1 - She has no "my story" part of the book, something that will never be missing from an HG-mama's writings. #2 - She has a statement in the beginning of the book that pretty much clinches it (more on that later).

Hyperemesis is what I can only describe as a "path of darkness." It is an experience with the deepest physical agony and mental suffering - an encounter with deep, deep darkness. A friend of mine described it as "sliding into the Pit," and I highly concur. Writings of HG women (such as McCall and Schmitt) deeply reflect this experience with darkness. This book had no such reflection - it was mostly bright and cheerful. I found myself thinking, "Gosh, I was making a fuss over nothing! This is just a normal condition that can be treated sensibly like anything else."

This statement made me laugh, and it made me a bit mad at the same time. Here it is:

"Believe me I know exactly what you are going through - because I take care of women just like you every day of the year." (p. xxiv, italics in original)

Oh, my goodness! Miriam, don't write things like that! If you have not been through HG, you do NOT know what HG-mothers are going through. You may know about the condition, how to treat it, have empathy with HG-mamas - but until you've been there you will not know anything about "what you are going through" - and it is presumptuous to say that you do. If you have had HG, you need to state it. If you have not had HG, then I suggest the following rewording: "Believe me, I have a lot of experience working with severe morning sickness - because I take care of women just like you every day of the year."

Let's take an example: Imagine a male obstetrician leaning over a woman in transition (the hardest part of labor) and saying, "Believe me I know exactly what you are going through - because I take care of women just like you every day of the year." What would we do? We'd laugh him out to the parking lot!!!

For major life changes, disease conditions, suffering and crises, not one of us can say that "I know just what you're going through" until he/she has been there. I cannot truly know the hurt of infertility, the hurt of deepest grief, the hurt of losing a child (much as I may sympathize) because I have not been down those paths in my own life.

There's no reason why people shouldn't study or write about conditions that they haven't experienced. Counselors and pastors counsel people all the time who are going through disasters that the counselors themselves haven't experienced. Men can make great obstetricians. And I'm sure Miriam is a great dietition helping out HG mothers. But she should not say that she "knows exactly what we're going through."

Enough complaints (for the moment).... Let's move on to a survey of this book.

The first chapter deals with the question "what is morning sickness?" There are so many facets to this condition that it is actually a pretty hard question! Miriam lists some of the different facets of morning sickness:

- Nausea, vomiting, retching
- Aversion to odors
- Aversion to bright lights
- Aversion to noises
- Aversion to tight-fitting clothes
- Low-level claustrophobia
- Sensitivity to visual motion from computer screens/televisions

I personally experienced the first two, and I have no idea about the rest - I was too sick to notice!!

She then goes on to give some of the differences between MS and HG (which, again, is hard to do). She mentions some of the other facets of morning sickness - that it's not generally "morning" sickness, that it doesn't always (or even usually) dissipate by the end of the first trimester, and that it is a condition unfortunately prone to relapse.

Miriam then writes a chapter about how morning sickness affects women's careers and families/relationships. Very important! I know that with my experience, social relationships suffered greatly (from neglect). If I had had a career, it would have been over, and if I had had a less than perfectly-patient DH, my marital relationship would have suffered as well. I got off easy - but many women don't, especially when they have careers or small children.

Chapter three is really interesting - it presents the different theories as to WHY women get morning sickness. Oddly enough, no one really knows for sure!! Here are some of the theories:

- Lowered blood sodium
- Adjustment of the brain's chemical sensors
- Metabolism of pregnancy hormones
- Slower emptying of the stomach
- Rising hormone levels
- Left vs. right ovary theory (women, for some reason, have more MS when the egg is released from the right ovary)
- Protection from sexual activity (which might conceivably harm the baby)
- Placental enzymes and low blood sugar
- Protection from food toxins
- Heightened stress
- Your diet 1 year before pregnancy (diets higher in saturated fats result in more morning sickness)
- Baby girls (has been pretty much disproven)
- Altered ratio of t-helper cells
- Lowered levels of B vitamins

When it all comes down to it, no one really knows! But it's a great education to read about it.

Chapter 4 is a study of "morning sickness through history" - it describes, in some detail, the remedies for morning sickness used throughout history and in other cultures. When I first read this chapter, I was really annoyed - because this is a chapter that is utterly useless to me as an HG mother. However, upon rereading I realized that this book is a book about morning sickness - and thus, any information known about morning sickness should be included in order to form an exhaustive text. Anyone doing research on morning sickness from an academic perspective will find this chapter very interesting - it's just not useful to here-and-now morning sickness sufferers.

After a chapter on odors (where they are, how to avoid them, etc.), Miriam writes about the technique of dealing with morning sickness "triggers." In other words, for MS/HG women, various things (noises, sights, odors, tastes) set off vomiting. Miriam writes that one should practice extreme vigilance to notice what triggers nausea and strictly avoid that. She also writes that one should think deeply about what one wants at a given moment (ice cream? soup?) and pursue that. She gives a chart which women can use daily to chart their nausea level, food preferences, climate (which can cause shifts in nausea levels) and various environmental stimuli so that they are able to track patterns and make shifts accordingly.

This all sounds great in theory. In practice? Well, she claims it works. But when I think back to my own experience, it doesn't sound very practical. I was too sick to be charting anything, all food sounded repulsive, and the least bit of solid food would cause uncontrollable vomiting. There is no way on earth I would have been able to sit there and say, "Okay, it's ten o'clock and I'm craving pickles. I see by the weather that the storm front caused an increase in nausea, so I'll wait to take my prenatal." No way!!

But I'm willing to give it a try. Hey, I'd stand on my head for an hour a day if it would work! So I'm definitely willing to give this a try.

And I should say that this book got great reviews on Amazon, with five HG mothers saying that Erick's techniques helped them greatly. So despite my skepticism, I'm not writing off this advice - it just sounds impossible from the outside.

Miriam's next chapter is on morning sickness and emotions. This covers a myriad of topics, most of which are helpful. However, there was one section in here which was so funny (unintentionally, I'm afraid) that I have to mention it. It is called "boredom and morning sickness" - a list of things to do when one is kept at home by morning sickness - things such as "make beaded barrettes or belts with a kit," "writing a child's storybook for the baby's third or fourth birthday, complete with pictures," "Knitting or embroidering," "Organizing a photo album," etc. What on earth??? If, like I was, you are in bed with morning sickness, you are in NO condition to even think about activities! That is just about as practical as giving a list of "things to do when you're home with severe food poisoning." When I was at home in bed, I was either throwing up or sleeping. Period. Origami never crossed my mind. If you're feeling well enough to do these things, I don't think you need to be in bed!! Of course, every case could be different. Who knows? I only have my experience from which to judge.

The next part is the part I find the most puzzling. As a nutritionist (registered dietitian), Erick's main focus is on "helping morning sickness with food." She (as mentioned above) asks mothers to think, for example, "Would something salty reduce or aggravate the queasy feelings at this very minute? What food or drink comes to mind at this very moment?" (p. 171) and "What food or beverage would ease your nausea? Something salty, sour, bitter, tart, sweet, crunchy/lumpy, soft/smooth, mushy, hard, fruity, wet, dry, bland, spicy, aromatic, earthy, hot, cold, thin or thick?" She then gives lists of foods for each category and asks mothers to focus on finding what they really want to eat or drink and to pursue that thing.

I can't but be puzzled by this. Erick claims to have helped cure hundreds of women with hyperemesis with this method... But even with my own mild HG, I can't imagine this helping! When all food sounds horrible beyond belief and you're retching at the first bite of solid food (and some of my severe-HG friends have been unable to even tolerate liquids), I can't really think that satisfying cravings (which I didn't have) would be the least bit helpful.

She then gives "sick day meal plans" according to the various flavors mentioned above (crunchy, salty, etc.). Again, I am puzzled. Let's look at this one, from p. 204

Sick-day meal plan (bland)
7 am - 4 unsalted oyster crackers
8 am - 1/2 egg matzo cracker
9 am - 1/2 cup instant cream of wheat
10 am - 1/2 ripe banana blended with 1/2 cup milk to make a milkshake
etc.

How does that help when you're throwing up so hard you can't even leave the bathroom? How does that help when you're so sick you can't even handle food? I remember being annoyed with my poor mother when she suggested making milkshakes, because getting out to the kitchen and getting out food and equipment to make a milkshake was simply impossible due to exhaustion and food aversions. In a later chapter, Erick gives recipes as well. They look great, but again, how is a woman with HG (whose hubbie is generally at work) going to get out to the kitchen to start cooking? I couldn't even manage to make the cheesecake for my friend's baby shower, let alone get out into the kitchen to cook for myself!!! The average hubbie is not going to be spending his entire evening cooking up various from-scratch recipes (not to mention that even if he did, that wouldn't help day-time cravings). Especially since HG-hubbies generally have a TON to do in the evenings with childcare, basic meal prep, shopping and housework - they don't have time to be whipping up various recipes.

Erick then gives a very helpful chapter on hospitalization, with all the procedures and policies to expect. This is not as indepth as McCall's treatment, but still very good.

She writes sections also on pharmaceuticals for HG, and also a bit about alternative treatments - her main focus is on acupuncture, with a wee bit on herbs and homeopathy. Her sections on herbs/homeopathy need a bit of formatting help for clarity, as she just incorporates the remedies into the text rather than putting them in bold or bullet-format - they're very hard to locate.

She closes with a chapter on the rarer complications of HG, and then gives a list of resources for HG women. Very, very helpful.

Side note: I do not like Erick's treatment of the subject of abortion. She is remarkably complacent and blase about the fact that many HG pregnancies end in abortion. It was kind of like, "So-and-so couldn't handle the nausea, so she aborted. Okay! Moving on to our next subject..." There is sympathy, but that's it.

Abortion is an inextricable part of HG. It's kind of inevitable in a country where abortion is available on demand. When you're in the midst of unbearable suffering and relief is either nine months away (basically an eternity) or one short doctor's appointment away, many women choose abortion. While I don't condemn these women, as I know what they went through, I am still 100% pro-life and believe that any abortion is a tragedy and a deep violation of human rights on the part of the unborn baby who was denied life. Any book on HG needs to contain in-depth material on abortion - at the very least, encouragement for abortion-minded women, telling them strongly that HG WILL PASS and that their beautiful baby will be in their arms. When HG is over, it is over. But when an abortion is over - the HG is gone, but the baby is dead. And most post-abortive HG women feel compelled to try again for a baby - meaning that their journey through HG will be considerably longer than if they didn't abort in the first place.

Ashli McCall's book "Beyond Morning Sickness" covers this in depth. McCall suffered severe HG four times, the first time ending in a second-trimester abortion which left her deeply scarred and grieving for life. She devotes a large part of her book to dealing with abortion and encouraging HG mothers to stick it out. There is no such encouragement in this book, and it is a big hole that needs to be filled.

On the whole? Well, I recommend this book for the information. There's a lot of information here. Even if the nutritional stuff doesn't help, there's a lot of helpful information. For myself, as a post-HG mother contemplating another pregnancy, I want to know everything about morning sickness and HG before going into another pregnancy. In the middle of HG is NOT the time to be flipping through reference books! I want to know all facets of morning sickness, drugs, alternative therapies, hospital procedures, coping strategies, nutrition, complications - knowledge is power, and I want as much of it as possible before facing another pregnancy.

In terms of the nutritional coping strategies Erick outlines, I do not possibly see how they could be helpful (although for any morning sickness short of HG, I am sure they would be GREAT - don't get me wrong). However, this woman has years and years of experience with treating HG mothers, so I'm not going to write her off. I'll give her methods a try. And I'll let you know if any of it works!

So.... Buy this book. Read it, and let me know what you think of it. If you use or have used any of her techniques in the past, let me know about it and I'll post it here. I'm quite willing to eat crow if they work!

Signing off,
Diana