Women & Childbirth in the Twentieth Century: A History of the National Birthday Trust Fund 1928–93

Book reviews

Cocaine-Exposed Infants: Social, Legal and Public Health Issues. By J.A. Inciardi,H.L. Surratt and C.A. Saum. Thousand Oaks, CA: Sage, 1997, pp. 116, £14.95.

Looking for a brief, solid, up-to-date starting place to learn about cocaine-exposed

infants? This may be the book. Inciardi, Surratt, and Saum have written a short but

surprisingly informative account of the chief social, legal and public health issues

re cocaine, cocaine abuse by mothers and cocaine exposure in children.

Four chapters of clear and neat expository prose address the main topics.

Chapter 1 includes a history of cocaine (from the businesses of Mariani and

Pemberton through the optimism and pessimism of Freud to the social

organisation and hellish euphoria of crack houses) and a discussion of the

psychology and health consequences of cocaine abuse among women (in the

context of gender difference in drug use).

Chapter 2 undermines `myths and misconceptions' about cocaine-exposed

children. Early research promoted untenable generalisations about the untoward

effects of cocaine exposure on child development: exposure to cocaine in utero was

supposed to cause complications during pregnancy (stillbirth, prematurity),

adverse effects on the fetus (size, microcephaly, malformations), postnatal compli-

cations (SIDS, neurological problems) and compromises to cognitive (attention,

memory, learning) and social (hyperactivity, unpredictability) development. The

authors document how compromised all of these effects were themselves by poor

methodology and measurement (assessment strategies, sampling), confounding

(failure to disentangle the effects of cocaine exposure from exposure to other drugs

and other biological and environmental factors), and ineptitude (studies reporting

adverse effects of cocaine were more likely to be presented at the Society for

Pediatric Research, so most presentations demonstrated that cocaine use was

unduly harmful to mother and fetus despite the fact that rejected studies that

reported no differences had better methodologies). In fact, research appears to

have led to no clear effects of cocaine (`scientific proof of a cause and effect

relationship between cocaine use and adverse prenatal and postnatal conse-

quences has been difficult to establish') ... but is this possible. Probably not. Crack

is probably àssociated' with child abuse, neglect, abandonment and adverse

development the way cigarette smoking was àssociated' with lung cancer.

Despite these sound warnings about `myths and misconceptions', the authors

proceed to discuss `the effects of prenatal exposure to cocaine' on pregnancy and

the developing fetus, infant and child in Chapter 3. But then, if cocaine had no

Paediatric and Perinatal Epidemiology 1998, 12, 355±360

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effects there would be nothing to write a book about. There may be sleeper effects

or effects may be complex, ephemeral, idiosyncratic or reversible; existing

measures may be insufficiently sensitive for the task of detection; or, like the

proverbial drunk in search of his lost keys, we may just be looking only where the

light is. Although this volume reaches sensible contemporary conclusions

mirroring our collective ignorance of cocaine effects, Chapters 2 and 3 provide

valuable summaries and leads for future research.

Chapter 4 includes a review of criminal and civil actions against pregnant drug

abusers and the consequence of these actions for public policy and maternal drug

use. In fact, however, there are relatively few individual cases. As is true of this

legal discussion, this book is limited in scope to circumstances and statistics from

the United States.

There are excellent homilies herein about Pygmalion effects in the schools and

the media, about the continuing chaotic living arrangements and life circum-

stances and about the focus of remedial attention away from the child, which

cocaine-exposed children continue to face and overcome.

MARC H. BORNSTEIN

Women & Childbirth in the Twentieth Century: A History of the National

Birthday Trust Fund 1928±93. By A. Susan Williams. Thrupp, Glos: Sutton

Publishing, 1997, pp. 331, £19.99.

In 1928, approximately 1 in 200 women per year were dying in childbirth in

Britain. The National Birthday Trust Fund (NBTF) was founded as a charity by

women at the highest level of British society, with the aim of attempting to

improve the appalling mortality and morbidity associated with childbirth.

Historians have a curiously delicate job to do, especially if they mix history

with science. It is relatively easy to investigate the past; the retrospectroscope

is a very useful too of the trade and hindsight is a wonderful thing! The delicacy

of the job comes with placing the information in its historical context, both

socially and politically, and then to set about achieving the balance of fair and

constructive criticism.

With her history of the National Birthday Trust Fund, A. Susan Williams has

made a brave attempt to achieve this balance, although one detects a certain bias

toward the NBFT in the reporting of its achievements. The bibliography reveals

extensive and, one would imagine, exhaustive research into the subject, and I feel that

the end result does not perhaps do full justice to the intensive research undertaken.

This work is not a dry, dusty reporting of facts and heavily crunched numbers;

indeed, it is full of anecdotal evidence and oral history, which gives it the warmth

of real history, real people relating real human experience and, in the context of

social history, it has value. In the context of science, however, I suspect the

356 Book reviews

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academic purists will consider it to be lightweight. Although the reporting of the

key findings of the major birth cohort studies is basic, this work does provide a

good signposting for students just starting to study this particular field of human

experience. The reference section alone will serve as a guide for students

wondering where on earth to start.

In conclusion, although this work does add to our knowledge of the history of

maternal experience and its place in society in general, it also confirms what

everyone ± scientists, historians, social commentators, mothers, fathers ± must

already know: poverty was the major disease threatening mothers and infants at

the beginning of this century and poverty remains the biggest disease facing

mothers and infants as we come to the end of it.

JULIE SMITH

Modern Regression Methods. By T. Ryan. New York: John Wiley & Sons, 1997,

pp. 515, £50.

This is a comprehensive review of regression method that covers standard

concepts as well as some more recent developments from the literature.

Techniques are introduced using illustrative examples from several disciplines,

with many results derived algebraically and potential problems and pitfalls given

due consideration. Each chapter ends with a useful list of references and a series of

exercises for the reader. The author begins with a description of simple least-

squares regression and the checking of assumptions before introducing multiple

regression, graphical techniques and transformations. The selection of covariates

using stepwise procedures is then discussed, along with the use of polynomial and

trigonometric terms. Other topics covered include logistic, non-parametric, robust,

ridge and non-linear regression. Finally, some of the techniques and problems

introduced in the book are explored in the analysis of five real data sets.

The author suggests his book for use in an undergraduate course after an

introductory course in basic statistics, and it is certainly essential to have an

understanding of basic statistical concepts before embarking on the text. Although

much of the material covers reasonably basic regression methodology, the

extensive use of algebra means that the reader who is unfamiliar with the

techniques might have difficulty grasping the concepts on a first reading. In fact, I

would hesitate to recommend this book to someone who is not entirely com-

fortable with algebra as its use is sometimes rather uncompromising. In addition,

the book is designed as a text to cover a wide range of disciplines including

business, engineering and the physical sciences, which means that some of the ex-

amples used and issues raised are not immediately relevant to the medical reader.

It is encouraging to see a suitable emphasis placed on the checking of

assumptions, with an entire chapter devoted to the subject. There is also further

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information on possible alternative techniques for use when assumptions are not

valid although this exposition may be rather too detailed for the casual reader. In

addition, there is refreshing discussion throughout of the possible limitations of

the methods, which is not always found in other texts.

This book will be of more interest to the theoretician than the applied

researcher as its emphasis is towards the mathematics rather than the practical

application of regression techniques. For example, the selection of covariates is

described entirely in terms of automated stepwise procedures with no discussion

of a more intuitive choice of exposures. The book attempts to cover a very wide

range of disciplines with the result that it is not an ideal text for the medical

researcher, particularly in view of the wide range of alternatives that are available.

ELISE WHITLEY

Congenital limb reduction defects: clues from developmental biology,

teratology and epidemiology, By Nigel Brown, Judith Lumley, Cheryll Tickle andJanet Keene. London: The Stationery Office, 1996, pp.177, £19.99. (Available

through the Inter-net from http://www.the-stationery-office.co.uk/publicat/

catalogs/medhlth/medhlth.htm). ISBN: 0 11 321992 X

This compact and inexpensive monograph was written, according to the

foreword, as a `response to continuing concern about the origin of limb defects,

particularly from parent support groups...'. An advisory group to the UK

Department of Health recommended a systematic review. The authors were

assigned a monumental task. The bibliography spans one-third of the monograph.

The list includes publications such as the book by Czeizel, Evans, Kodaj and Lenz

(Congenital Limb Deficiencies in Hungary, 1994), which covered broader ground,

including historical information about limb defects. One apparent exclusion from

the bibliography is the encyclopaedic monograph of Temtamy and McKusick (TheGenetics of Hand Malformations, 1978), which is still particularly useful for

epidemiologists interested in classification systems.

For reference purposes, epidemiologists may find the third and longest section, a

review of human studies of limb deficiency, the most useful. Earlier sections on

embryology and animal teratology are also very relevant and well cross-referenced

in the epidemiological discussion, but readers with little experience in these areas

may be dazed by the frequent jargon ± a glossary would have been useful.

Nevertheless, researchers will find a variety of references to reinforce the biological

plausibility of epidemiological associations, such as potential mechanisms for

retinoid or chorionic villus sampling teratogenesis. The authors sometimes courage-

ously conclude, on the basis of available experimental and epidemiological evidence,

that certain exposures are likely (or not) to be teratogenic. Some of these conclusions

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are undoubtedly unpalatable to some constituencies. For example, they conclude

that maternal use of Bendectin is not likely to be related to limb defects, that maternal

use of folic acid possibly protects against limb deficiencies and that there is good

evidence that chorionic villus sampling can have a teratogenic effect. Recently

reported clusters of limb deficiencies along coastal areas received significant media

attention. The media events were important factors leading to this monograph, but

the authors definitively challenge the idea that such clusters even exist.

The review is very timely and overall quite complete. As a trade-off for these

attributes, there are some mildly distracting stylistic problems and typographical

errors. Although many monographs lack an index, this tool would have made the

work more useful as a bookshelf reference; the table of contents is comprehensive, but

it does not quite substitute for a complex index. At least six references are erroneously

cited or have missing information. Tables and figures are at times distant from the

corresponding text or titles. Tables are reprinted from journal articles; one table, out of

context, is lacking an important element in the title (the exposure in question). The text

concludes abruptly after a discussion of traumatic exposures, requiring the reader to

flip back to the executive summary in front to abstract important conclusions.

However, none of these minor problems seriously detracts from the usefulness of the

monograph and they are perhaps to be expected for this type of publication.

Academic epidemiologists and public health officials not directly involved with

birth defects research will find some important teaching and political messages in

this work. In reviewing published descriptive studies and coding methods, the

authors note that both the overall limb deficiency rates and the distribution of

deficiency subtypes vary greatly with the classification system or method used.

This problem illustrates the danger of comprising so-called `background' rates of

limb defects or many other reproductive outcomes in studies of clusters or

outcomes of medical interventions during pregnancy. The obvious nature of limb

deficiencies, the tremendous hardships they create for families, and the historical

precedent of thalidomide all ensure that concern about the occurrence of these birth

defects should remain in the public consciousness for years to come.

RICHARD S. OLNEY

Methods for Statistical Data Analysis of Multivariate Observations, Second

Edition. By R. Gnanadesikan. New York: John Wiley and Sons, 1997, pp. 353, £55.

Gnanadesikan has presented a book that will be of great value to applied

statisticians in any field. It covers many aspects of multivariate analysis in a

concise and thoughtful way. The author provides a refreshingly unconventional

approach to this topic. The emphasis of this work is upon data analysis in a

pragmatic and sensible manner. There is little written here on formal inferential

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procedures and statistical distribution theory. This book goes beyond the well-

known and usual techniques of the applied statistician's tool-box to do justice to

the full spectrum of varied and useful methodologies that constitute the

heterogeneous field of multivariate analyses.

I would not recommend this book, however, to anyone without a good

mathematical grounding, particularly in linear algebra. The analytical ideas are

expressed mathematically throughout; there is a paucity of plain language

descriptions and explanations, which makes this book unsuitable for the

untrained. This is the cost of a thorough and detailed exposition of an area that

does not always translate well from the abstract.

The second edition of this book has not changed greatly from the first of 1977.

A few new sections have been added to the body of the text and a new appendix

appears providing information on routines currently available through some

standard statistical software. The layout remains unchanged. It is well structured,

with chapters organised in a sensible fashion influenced by the emphasis on

multivariate data analysis rather than multivariate statistical models.

The first chapter is a brief introduction to the book outlining some of the

difficulties associated with the analysis of multivariate data and stating the general

orientation of the book. The second chapter deals with the reduction of

dimensionality and presents principal components analysis, factor analyses and

multidimensional scaling. A good and thoughtful discussion is provided of non-

linear and generalised techniques. The third chapter is concerned with multivariate

dependencies. This includes some interesting graphical techniques and canonical

correlation analysis. Multidimensional classification is covered in the fourth

chapter. This deals with discriminant analyses and clustering techniques. Attention

is focused on hierarchial clustering but there is some mention of non-hierarchical

techniques. Formal multivariate statistical models are not met until chapter 5.

Multivariate hypothesis tests are considered in brief and in general terms.

Attention is given to assessing distributional properties of data, data transforma-

tions and robust methods. The final chapter is entitled `Summarization and

Exposure'. This is an interesting chapter presenting techniques of èxposure',

defined as ``...the presentation of analyses [for] the detection not only of the

anticipated but also unexpected characteristics of the data.'' This includes graphical

methods in the investigation of unstructured multivariate data samples and the

identification of outlying observations. A good selection of references is provided

covering critical historical developments of the subjects covered. Many examples

are provided which usefully illustrate and expand ideas discussed in the main text.

In summary, this is a well-organised, detailed book covering many aspects of

multivariate data analysis. I would recommend it to applied statisticians but

would not suggest it as a textbook for general researchers.

LEE SHEPSTONE

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Women & Childbirth in the Twentieth Century: A History of the National Birthday Trust Fund 1928–93