Bioethics, healthcare policy, and related issues.
Much has been made of the government’s recent decree that all fertile women are to conduct themselves, and be treated medically, as “pre-pregnant” at all times:
New federal guidelines ask all females capable of conceiving a baby to treat themselves — and to be treated by the health care system — as pre-pregnant, regardless of whether they plan to get pregnant anytime soon.
Among other things, this means all women between first menstrual period and menopause should take folic acid supplements, refrain from smoking, maintain a healthy weight and keep chronic conditions such as asthma and diabetes under control.
While most of these recommendations are well known to women who are pregnant or seeking to get pregnant, experts say it’s important that women follow this advice throughout their reproductive lives, because about half of pregnancies are unplanned and so much damage can be done to a fetus between conception and the time the pregnancy is confirmed.
The recommendations aim to “increase public awareness of the importance of preconception health” and emphasize the “importance of managing risk factors prior to pregnancy” . . . .
However, part of the discussion has been over whether the Washington Post (quoted above) misread the CDC report on the issue, and made the whole thing sound more ominous than it should. The reliable and insightful Amanda at Pandagon thinks they not merely misread it, but re-wrote it to incorporate an anti-woman spin. As for the original report, the similarly admirable Ezra Klein thinks that “While the phrasing of treating women as ‘pre-conception’ was deeply discomfiting, the actual medical advice and data offered was all sound.”
I largely agree with both Amanda and Ezra, and so stayed out of the issue when it first arose. But I do have a few things to say about it, and so, prompted by a flattering request from Cara at Reproductive Rights Blog, I’ll add my two cents below the jump.
As Ezra notes, the recommendations are based on the most-current science, and generally make sense. The report begins by noting that 85% of US women have a live birth by the age of 44 (the CDC’s defined cutoff for “fertility”); half of those pregnancies are unplanned; the large majority of pregnant women see a primary care provider in the year before becoming pregnant; and, there is evidence that much of the US’s fetal mortality and birth-defect rates (higher than those of other industrialized countries) is related to maternal health conditions existing before pregnancy, or poor health behaviors during pregnancy. Taking that all together, using primary-care contacts as a focus point for encouraging women to improve their health status prior to a pregnancy certainly sounds like a reasonable way to reduce fetal morbidity and mortality, and that that is something most women would want. Raising the subject with women who do not immediately plan to become pregnant is also helpful, because many of them will conceive unplanned pregnancies, and half of those will choose to carry them to term. One major recommendation is that all fertile women, and all couples, develop a “reproductive life plan” encompassing their plans for pregnancy and the health steps best suited to carrying them out. That also sounds like a good idea, whether or not you intend to have children soon, or at all. The report also specifically notes and targets disparities in access to reproductive care across income levels, and the recommendations strongly emphasize increased Medicaid or insurance coverage for reproductive healthcare – these are important and highly progressive policy proposals. Another stated goal of the program is to increase the rate of planned, as opposed to unplanned, pregnancies – which is more or less Planned Parenthood’s entire program in a nutshell.
In other words, the basic thrust of the program is all to the good. And, notably, the report nowhere claims that women must live their entire reproductive lives as if they were about to become pregnant, or that pregnancy is the overriding health issue in women’s lives. The actual formal goals and recommendations of the program are not terribly controversial on their face:
Ten recommendations were developed for improving preconception health through changes in consumer knowledge, clinical practice, public health programs, health-care financing, and data and research activities. . . . The recommendations are aimed at achieving four goals, based on personal health outcomes.
Goal 1. Improve the knowledge and attitudes and behaviors of men and women related to preconception health.
Goal 2. Assure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health.
Goal 3. Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children.
Goal 4. Reduce the disparities in adverse pregnancy outcomes.
The recommendations are a strategic plan for improving the health of women, their children, and their families and are based on existing knowledge and evidence-based practice. Improving preconception health among the estimated 62 million women of childbearing age will require a multistrategy, action-oriented initiative.
Recommendations [Explanatory text ommitted.]
Recommendation 1. Individual Responsibility Across the Lifespan. Each woman, man, and couple should be encouraged to have a reproductive life plan.
Recommendation 2. Consumer Awareness. Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts.
Recommendation 3. Preventive Visits. As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes.
Recommendation 4. Interventions for Identified Risks. Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high priority interventions (i.e., those with evidence of effectiveness and greatest potential impact).
Recommendation 5. Interconception Care. Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects, low birthweight, or preterm birth).
Recommendation 6. Prepregnancy Checkup. Offer, as a component of maternity care, one prepregnancy visit for couples and persons planning pregnancy.
Recommendation 7. Health Insurance Coverage for Women with Low Incomes. Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care.
Recommendation 8. Public Health Programs and Strategies. Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes.
Recommendation 9. Research. Increase the evidence base and promote the use of the evidence to improve preconception health.
Recommendation 10. Monitoring Improvements. Maximize public health surveillance and related research mechanisms to monitor preconception health.
So far, there’s a lot here to like. And it seems clear that WaPo offered the most alarmist reading possible of these recommendations. Ezra and Amanda are perfectly right on both those points. However, no matter how well-intentioned these recommendations may be, there are some – perhaps unintended – nuances that cause concern.
First, there’s the practical problem of implementation – the implications of which are mostly what has everyone a-twitter about this report, from WaPo on down. The report does not explicitly say all women have to bear themselves ready for The Annunciation and Glorious Oven-Bunning at every moment, but it does say that its “pre-conception” regime should be followed by anyone who becomes pregnant – half of whom, it notes, have no warning beforehand that they will do so. How can you possible follow a pre-pregnancy health regimen if you have no idea you will be pregnant? – only by following it all the time, of course, just in case. And this is what WaPo was getting at when it said that women were expected to follow certain health practices “throughout their reproductive lives”.
Now, there is a defense to this interpretation. It seems perfectly compatible with the recommendations for “pre-pregnancy” health, and for having a “reproductive life plan”, for your plan to involve not having any children. And the unofficial goal (stated in the report) of reducing unplanned pregnancies requires effective contraception, which can be part of the reproductive life plan. The impetus for extending the recommendations to all women is that almost all of them have children at some point, and many don’t plan them – so a state of constant vigilance will produce health benefits that many women will value even if they didn’t expect to need them. And many of the recommendations – stopping smoking, reducing obesity – are healthful even for non-pregnant women. So the policy is not too onerous even for those women who do not become pregnant right away. That’s hardly equivalent to treating all women as mere breeding machines, even though it does envision many women essentially preparing for pregnancy years before they actually become pregnant.
However, the bottom line is that the policy can only work if all women follow it all the time (at least, all who are not absolutely certain they cannot or almost certainly cannot become pregnant, and will not carry a child to term if they do). And, while some of the health recommendations are valuable for all women, some (like cutting off all alcohol, or taking folic acid) are applicable almost exclusively to women about to become pregnant. (In fact, in the face of the known health benefits of moderate alcohol intake, this recommendation is counterproductive for women who do not become pregnant.) So the policy certainly does recommend a pervasive, and somewhat burdensome, health regimen on all women, for an unbroken 30-year stretch of their lives, that comprehends benefits only to some of them. It also prioritizes fetal health over the women’s own health (as in the case of a 30-year alcohol ban), and certainly over their personal lifestyle preferences.
Second, there’s the language: “pre-conception” and “inter-conception” healthcare. For women who are actively planning to have children, these terms make perfect sense. But, given the recommendation that women follow the guidelines even if they aren’t planning to have children, these terms do wind up being implicitly attached to all fertile women – and that is indeed creepy even if it’s understood that that is not the sum and content of the government’s vision of women overall.
Finally, there are a couple of other problems that arise implicitly – not precisely from the recommendations themselves, but from the general healthcare climate they exist in.
For one thing, consider the goal of reducing unplanned pregnancies. It goes without saying that can’t be a recommendation for expanded abortion access, in today’s political climate, which means it’s a healthcare goal that deliberately cripples its own implementation, as far as I’m can see. It just strikes me as strange that the report can note that one half of all live births were unplanned without also noting that many of those unplanned pregnancies are also unwanted. (Many women do choose to go through with unplanned pregnancies, but many are forced to by pressure, the press of circumstances, or the systematic barriers that exist to access to abortion.) The report implicitly puts forth recommendations for increasing the health of the expected hundreds of thousands of unwanted babies per year, without saying a word about providing means for those pregnant women to avoid having unwanted babies. The fact that the health-related recommendation is for those women to live their entire reproductive lives always ready to have an unwanted baby is especially creepy. So, notwithstanding that the policy does not actually recommend forced childbirth, its standards are not only applicable to, but intended to be applicable to, the many women who undergo forced childbirth each year, and the policy offers no recognition of that problem, never mind making provisions for ameliorating it. That is misogynist, even if it is a secondary effect of the policy.
Further, recalling that the entire rationale for applying the “pre-conception” guidelines to all women was that so many pregnancies occur without pre-planning, imagine now that, somehow, this policy succeeds and the rate of unplanned pregnancies drops dramatically (presumably because all women are now making “reproductive life plans” with their doctors’ help, and following them carefully and effectively). We would then have a situation in which the large majority of women still give birth (though likely many more of them would choose to remain childless if they were effectively immune to unplanned pregnancies), but almost all of them do so after carefully following a pre-conception health regimen designed to maximize maternal and fetal health. There would then be no need to recommend pre-conception care to women who were not actively planning a pregnancy. The crux question is: would they then drop the recommendation for application to all women? Doing so would be in keeping with the idea that the goal of the plan is only to maximize the chance of a healthy baby for those women who choose to have children; not doing so would demonstrate that all women are presumed imminent breeders regardless of their own choices. I honestly have no prediction to make on this point, which is another way of saying that, although I may believe this policy was not deliberately intended to promote forced childbirth, I am not confident enough in the government that promoted it to think they would not use it in that fashion even if it were unjustified on the medical merits themselves.
So, in the end, I don’t think it can be said that the policy is entirely benign. It may have been intended in such a manner, and it may be the case that the report’s fetal-centric aspects are the natural product of its consulting contributors – including the March of Dimes (MOD), the Maternity Center Association (MCA), the National Birth Defects Prevention Network (NBDPN), the National Healthy Mothers, Healthy Babies Coalition, and so on – who can be excused for seeing everything through the lens of preventing birth defects. But the policy distinctly imposes an all-encompassing fetal-health regimen on all fertile women without respect to whether they intend to get pregnant. It justifies this by noting that many of them will get pregnant unexpectedly and will go on to carry those pregnancies to term, but it does not note that many of those unintended pregnancies will also be unwanted pregnancies. While recommending a reduction in unplanned pregnancies by way of better pre-conception planning, it says nothing about increased access to contraception – the necessary component of such planning, nor about access to abortion as a means of preventing unwanted pregnancies and forced childbirth. The policy also does not acknowledge that some of its recommendations for “pre-conception” health are detrimental in women who do not then become pregnant, or offer any way of ameliorating this problem (which, again, would require access to safe and effective contraception and abortion).
As a final comment, the political climate in which this policy arises also cannot be overlooked. This recommendation comes on the heels of the recent flap over HHS’s weirdly heavy-handed warnings about failure to breast-feed, and of course in the generally misogynist context in which women’s health issues are discussed. This report clearly embodies some of the same strains and insinuations.
So it’s not easy to overlook things like the use of the term “pre-conception” to describe every fertile woman’s entire life from 15 – 44 years of age, or the prioritizing of the health of non-existent fetuses over that of every fertile woman throughout their entire life from 15 – 44 years of age, or the use of the fact of unplanned and unwanted pregnancies to justify policies aimed at the betterment of childbirth in the unplanned-but-wanted pregnancies, while completely ignoring any means of dealing with the unwanted pregnancies. At every step, and in every way – even the well-intentioned and helpful ones – women’s health becomes a weapon for carving out pieces of women’s lives and diminishing those women’s control over them. In this case, that piece is every fertile woman’s entire life from 15 – 44 years of age, which is no small thing.
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