“Pre-Pregnancy”

Many in the feminist blogosphere have commented about this WaPo article, “Forever Pregnant”:

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,” said Samuel Posner, co-author of the guidelines and associate director for science in the division of reproductive health at the Centers for Disease Control and Prevention (CDC), which issued the report.

Other groups involved include the American College of Obstetricians and Gynecologists, the March of Dimes, Dartmouth Hitchcock Medical Center, the National Center for Chronic Disease Prevention’s Division of Reproductive Health and the National Center on Birth Defects and Developmental Disabilities.

The idea of preconception care has been discussed for nearly 20 years, experts said, but it has drawn more attention recently. Progress toward further reducing the rate of unhealthy pregnancy results, including premature birth, low birthweight and infant mortality, has slowed in the United States since 1996 “in part because of inconsistent delivery and implementation of interventions before pregnancy to detect, treat and help women modify behaviors, health conditions and risk factors that contribute to adverse maternal and infant outcomes,” according to the report.

Nearly 28,000 U.S. infants died in 2003, according to the National Center for Health Statistics (NCHS). The infant mortality rate increased in 2002 for the first time in more than 40 years to seven deaths per 1,000 live births, but it did not change significantly in 2003. Birth defects, low birthweight and sudden infant death syndrome (SIDS) were the leading causes of infant death in 2003, according to NCHS.

The U.S. infant mortality rate is higher than those of most other industrialized nations — it’s three times that of Japan and 2.5 times those of Norway, Finland and Iceland, according to a report released last week by Save the Children, an advocacy group.

Preconception care should be delivered by any doctor a patient sees — from her primary care physician to her gynecologist. It involves developing a “reproductive health plan” that details if and when children are planned, said Janis Biermann, a report co-author and vice president for education and health promotion at the March of Dimes.

“The recommendations say we need to be opportunistic,” or deliver care and counseling when opportunities arise, said Merry-K. Moos, a professor in the University of North Carolina’s maternal fetal medicine division who sat on the CDC advisory panel. “Healthier women have healthier pregnancies.”

Women should also make sure all vaccinations are up-to-date and avoid contact with lead-based paints and cat feces, Biermann said.

The report recommends that women stop smoking and discuss with their doctor the danger alcohol poses to a developing fetus.

Research shows that “during the first few weeks (before 52 days’ gestation) of pregnancy” — during which a woman may not yet realize she’s pregnant — “exposure to alcohol, tobacco and other drugs; lack of essential vitamins (e.g., folic acid); and workplace hazards can adversely affect fetal development and result in pregnancy complications and poor outcomes for both the mother and the infant,” the report states.

The CDC report also discusses disparities in care, noting that approximately 17 million women lack health insurance and are likely to postpone or forgo care. These disparities are more prominent among minority groups and those of lower socioeconomic status, the report states.

The NCHS data also reflect these disparities. Babies born to black mothers, for example, had the highest rate of infant death — 13.5 per 1,000 live births. Infants born to white women had a death rate of 5.7 per 1,000.

Obstacles to preconception care include getting insurance companies to pay for visits and putting the concept into regular use by doctors and patients. Experts acknowledge that women with no plans to get pregnant in the near future may resist preconception care.

“We know that women — unless you’re actively planning [a pregnancy], . . . she doesn’t want to talk about it,” Biermann said. So clinicians must find a “way to do this and not scare women,” by promoting preconception care as part of standard women’s health care, she said.

Some medical facilities have already found a way to weave preconception care in with regular visits. At Montefiore Medical Center in Bronx, N.Y., a form that’s filled out when checking a patient’s height, weight and blood pressure prompts nurses to ask women, “Do you smoke, and do you plan to become pregnant in the next year? And if not, what birth control are you using?”

“It’s a simple way of getting primary care providers to think about preconception care,” said Peter Bernstein, a maternal fetal medicine specialist who sat on the advisory committee that helped produce the report. “It’s simple and [it] costs nothing.”

Here are the CDC guidlelines the article references. Reactions to the piece can be found at Bitch, Ph.D. (see also her update), Shakespeare’s Sister, Pandagon, Broadsheet, Feministing, Pen-Elayne, and, most movingly, at Scheherazade in Blue Jeans, where blogger Shadesong wrote:

…I have been unable to obtain adequate medical care for my epilepsy because I am what they’d call pre-pregnant. As my neurologist puts it, I am a woman of child-bearing age. As such, they flat-out refuse to try me on any medicines other than the ones proven least likely to affect a fetus (read: the ones that are paying off my neurologist). Despite the fact that I have declared my belly a no-fetus zone.

My neurologist does not trust me to not get pregnant. My neurologist puts a potential fetus’s potential health over my health.

And now the government wants to officially sanction that.

Oh HELL no.

I should not have to get my fucking tubes tied in order to not have seizures and/or get medication that at least doesn’t have me dropping weight. (90.5 on the Craftsman’s bathroom scale; even taking into account that it’s a different scale from my doctor’s, it’s a significant enough difference that I have to look at it. I’m 89 on my scale right now. Which slips, but – still.) To get off a medication that’s caused what’s essentially a whole-body crash.

Pre-pregnant? Hell no. I am post-pregnant by 11 years. Pregnancy and me do not belong in the same sentence.

Screw that noise.

EDIT: When I first posted this, I was writing just for myself and my friendslist, so I didn’t put in a whole lot of background. Now this post has been linked all over LJ and in DailyKos. So. Background for people who have not been reading me since the dawn of time, quick-and-dirty version: I was diagnosed with epilepsy in October 2003. My first neurologist put me on Lamictal, which caused some pretty untenable side effects, including the first 2/3 of what became a catastrophic weight loss – 50 pounds in total, to a low of 85 pounds.

She tried me on Keppra, which was worse – then gave up for the sake of the potential fetus. I switched neurologists and medications, trying Topomax and Trileptal, the latter of which (plus Zonegran) I’m still on. The weight loss continued. Uncontrollably.

There are medications that have, as their side effects, weight gain. I have begged for these medications, but been refused. Direct quote from my neurologist: “You’re a newlywed. You’ll want a baby.” I’m a newlywed with an 11-year-old daughter and a body that’s falling apart. Trust me. I do not want a baby. But my stated desires are irrelevant – I cannot get prescribed a medication that will keep me from losing weight and may control my seizures better than the one I’m on now, due entirely to increased risk of birth defects.

While most women are familiar with the issue of employment-related pregnancy discrimination, the concept of treating women as “potentially pregnant” has surfaced too, most prominently in United Auto Workers v. Johnson Controls, Inc. (1991). In that case, the Supreme Court held that a battery manufacturer could not bar potentially fertile women from jobs involving exposure to lead, despite the possibility that fetuses could be harmed by lead poisoning. The Court justified its holding in part by pointing to “evidence about the debilitating effect of lead exposure on the male reproductive system.” Male behavior can effect a fetus too. If men are socially constructed as “pre-inseminators,” there is no reason not to apply the CDC recommendations to them as well. I breathlessly await the govermental campaign about the dangers posed by drunken, nicotine-addled sperm to healthy, wholesome fallopian tube-surfing ova.

In fairness to the CDC, here are the stated goals of its recommendations:

These recommendations are a strategic plan to improve preconception health through clinical care, individual behavior change, community-based public health programs, and social marketing campaigns to change consumer knowledge and attitudes and practices. In addition, they are designed to increase research knowledge related to preconception health and care and to improve reproductive health outcomes for all women and couples. Policy changes at the local, state, and federal levels will be necessary to support several of these recommendations. These policies will address changes in access, payment, and types of services available. Four goals were established for achieving these recommendations: 1) improve the knowledge and attitudes and behaviors of men and women related to preconception health; 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; 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; and 4) reduce the disparities in adverse pregnancy outcomes.

Getting accurate medical information out to people, lobbying for improved access to healthcare for women, and attempting to “reduce disparities in adverse pregnancy outcomes” are all positive things, and at a macro level the articulated goals are worthy ones. It’s just something about the framing, which seems to suggest the most important thing about improving women’s health is optimizing their effectiveness as fetus incubators, that really rankles.

Care needs to be taken in articulating objections to the CDC recommendations, because this is the sort of issue that can make feminism look like a movement of the privileged and affluent. I doubt that many feminists would object if the report lead to better and more accessible medical care for poor women; quite the contrary. So I think it’s important to note that to the extent the CDC is working to push other government actors to engage in actions that improve women’s health, it should be supported.

–Ann Bartow