The New York Times Health and Dining sections seem to be in a bit of a scuffle over prenatal care. On one hand, there was a Health piece on Tuesday, rehashing the Centers for Disease Control and Prevention advice that reproductive-age women treat themselves as perpetually "pre-pregnant," which we covered with some consternation back in the spring. On the other, we have the Dining section story today, which regards the prohibition on pregnant women's drinking alcohol and avoiding certain foods with some skepticism. The first seems to advise long-term hypervigilance toward anything that could harm a fetus (even an imagined, distant-future fetus), while the second shrugs its shoulders and weighs the (possibly overblown) risks against the pleasures of daily living. Hey, Gray Lady, what's it gonna be?
Frustrating though they are, the mixed messages make sense for a bunch of reasons. First and foremost, the Dining piece notes that "because of ethical considerations, virtually no clinical trials can be performed on pregnant women." No one's going to suggest getting 100 pregnant women to drink wine to see if it gives their kids fetal alcohol syndrome, so the medical community can't assess the risks with certainty. Most studies rely on mothers' own accounts of how much they drank during pregnancy, which may not be accurate. And while many physicians privately say that moderate beer and wine consumption in the second and third trimesters of pregnancy probably won't hurt, a 2004 Times piece noted that if having a single drink lowers an expectant mom's inhibitions and increases the chances of her ordering additional drinks, the danger to the fetus may be much greater. This week's Dining section story acknowledges the ongoing dispute between clinicians and mothers over the alcohol issue. The trouble is that some studies suggest that even limited prenatal alcohol exposure may impair brain development and overall growth, but the fact remains that some fetuses seem to escape unscathed, even when their mothers drink heavily -- and no one really knows why.
Then there's the issue of paternalism and public health. Our government isn't shy about promoting habits that contribute to good health (exercise, wearing sunscreen) and ditching those that don't (smoking, eating trans fats). And government health recommendations often weigh medical findings against likely behavior; the FDA recommends that consumers not exceed the maximum doses of over-the-counter medications, though it's generally accepted that occasionally taking a slightly higher dose won't kill you. There may be some paternalism in this approach, but the government's interest is in producing the best health effects in the widest number of people possible. Most of the CDC's advice for prospective mothers is consistent with what it considers healthy habits for people generally. And given that about half of all pregnancies are unplanned, it seems legit to look out for potential fetal health as well -- especially since, as the recent Times Health piece notes, "preparing for a healthy pregnancy can require behavioral changes that may take months." After all, it's not like women benefit from having babies with fetal alcohol syndrome or other health problems.
Still, it's understandable that many women would find the whole pre-pregnancy thing uncomfortable. Historically, women's interests and autonomy have often been treated as subordinate to the interests of their (born or unborn) children. And it's not just historically; as the Dining section piece observes, pregnant women's "responsibility for minimizing risk through perfect behavior feels vast" -- and "the public seems to seriously doubt whether pregnant women can be trusted to make responsible decisions on their own." In this context, it can be hard to hear that nonpregnant women should avoid alcohol just in case they become pregnant, or that pregnant women should avoid alcohol entirely even though science isn't settled on what effects limited alcohol consumption have on a fetus. The advice itself may be sensible, and naturally parenting involves personal sacrifice. But maternal sacrifice is such a loaded concept that even well-meaning government recommendations can sound heavy-handed.
Especially at the moment. The Bush administration's policies on contraception and abortion seem designed to promote women's being perpetually pregnant, never mind pre-pregnant. With a Messianic right-winger in office, it's tough to assess what's at the heart of pre-pregnancy guidelines -- is it public health, or the hope that young women who have practiced pre-conception care will be more interested in conceiving and less likely to have abortions? That supposition may sound paranoid, but when you look at who the administration just selected to head family-planning efforts these days, it doesn't seem so far-fetched. Plus, the Health piece notes that most health plans, including Medicaid, don't cover pre-conception care. Let's hope that the CDC guidelines result in more coverage for all of us pre-pregnant American women, but at the moment these recommendations seem to be giving women advice without giving them the means to follow it.
So for now, we'll be happy if the CDC's recommendation prompt more reproductive-age women to exercise, quit smoking and otherwise look out for their own health. If they take some prenatal vitamins, too, then so much the better. But we'll hold off on judging pregnant women who have the occasional glass of wine (or "pre-pregnant" women who consume alcohol moderately). Maternity, and pre-maternity, are tough enough as it is.
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