Pre-pregnancy or preconception healthcare is a decades old concept in United States healthcare. The idea is to treat all women* (that’s what they say, though they mean people with wombs) between 15 and 45 as in a state of pre-pregnancy; that is, any treatment or behavior that might be deleterious to fetal development is avoided. The Centers for Disease Control (CDC) just released updated guidelines recommended all women in this age cohort who are not on birth control abstain from drinking, even when not pregnant. While the goals are noble enough – preventing painful disabilities in newborns – this single-minded focus is not best policy.
For thirty years of our lives, our healthcare is framed not by our own needs, but by the possible needs of a hypothetical fetus. Women, et al complaining of disabling pain from periods and endometriosis are regularly refused the hysterectomies they seek. Cancer patients are counseled to favor less aggressive treatments that may preserve fertility, instead of getting to choose how much import to give that when picking life-saving treatments. In extreme cases, patients taking certain medications deemed unsafe for fetuses are required to submit monthly pregnancy tests to continue getting their prescription.
Often, things that will best ensure potential fetal health are also things good for the primary patient’s health to begin with. Abstaining from street drugs and cigarettes, not drinking to excess or with excessive frequency, and eating a healthy diet are generally good for people, regardless of gender or reproductive organs or fertility. They’re also not equally available. Cigarette users, for example, are overly represented in mental illness and homeless populations. Cigarettes are also an appetite suppressant and people with food insecurity smoke at higher rates.
Addressing smoking systemically would mean ensuring everyone has access to enough good food, and that mental illnesses are being treated and medicated so that the patient no longer needs cigarettes. Instead of being viewed as a symptom of socio-economic exclusion, smoking is seen as a personal vice and bad decision, possibly indicative of an inferior moral character. State-sponsored smoking cessation programs will send out a box of nicotine gum to people wanting help quitting, but appropriate mental health health care, adequate housing, and plenty of food won’t come in the package. And no consideration will be given to the fact that nicotine replacement methods of quitting have been shown to not work as well with women. A pregnant (or pre-pregnant) woman who smokes cigarettes will be judged harshly, while little attention will be paid to the lack of available help quitting.
Fetal alcohol syndrome is a disability caused by fetal exposure to alcohol. While guidelines from the CDC recommend complete abstinence from alcohol during – and before, whether planning to conceive or not – pregnancy, FAS is not a universal risk for all pregnant people who drink small amounts of alcohol. FAS is highly linked to smoking during pregnancy, poverty, and a specific pattern of binge drinking (6 or more drinks in an episode) rather than more frequent but more moderate drinking.
For instance, a woman who has one drink a day every day and a woman who binges once a week, consuming six or more drinks at once, both average seven drinks a week. Yet each of these drinking patterns represents potentially very different levels of alcohol exposure for the woman and her fetus. Since peak blood alcohol levels (BALs) reached per drinking episode are a crucial factor in FAS (Abel, 1999), the ‘average drinks’ measure distorts the relationship between alcohol and teratogenesis and muddies our perceptions of risky drinking.
– Fetal Alcohol Syndrome: The Origins of A Moral Panic (link)
Furthermore, studies since the early 1990s have shown evidence that “male” alcoholism could alter sperm in such a way as to impact fetal development.
Wives of men exposed to vinyl chloride and waste water treatment chemicals have more miscarriages. Welders who breathe toxic metal fumes develop abnormal sperm, even after exposure stops for three weeks. Firemen who are exposed to toxic smoke have an increased risk of producing children with heart defects. Several studies have found that fathers who take two or more alcoholic drinks a day have smaller than average infants.
– “Research on Birth Defects Shifts to Flaws in Sperm”, New York Times, 1991
Fetal health is treated as being the sole responsibility of women* and as being largely under their control. As I wrote about recently, visibly pregnant women are often socially sanctioned from doing anything perceived to cause fetal harm. But in the United States, particularly for poor women of color, chemical endangerment and fetal homicide laws are being used to criminalize pregnancy outcomes. This is combined with limited access to birth control, and even more limited access to abortion. Treating all women (etc) as probable incubators, rather than humans with rights and medical needs, plays into this.
This country is not fetus-centered, except as a means of telling women what to do. We don’t generally ask (cis) men to think of their future fetuses when they head to the bar for a guys’ night, and we certainly don’t criminalize their poor physical health in the same way. We don’t ensure nail salons are properly ventilated to reduce the high rates of miscarriages among the mostly poor, often immigrant women working there. We don’t keep lead out of water supplies, from Flint to New Orleans and beyond, and we don’t keep uranium poisoning from impacting Navajo pregnancies. We don’t end poverty, which causes the greatest number of negative health impacts (and their financial costs to the rest of society, if that’s all you care about).
The CDC’s line of reasoning for telling all non-pregnant women to behave as if they were pregnant is that half of US pregnancies each year are unplanned. To me, that data point screams out for better access to birth control and freedom from sexual coercion. It does not say “women shouldn’t drink if they can’t access birth control – which we won’t help with – even if they don’t want to get pregnant.” Everyone should have access to healthcare that focuses on them and their needs, whether those needs include treatment for drug addiction, smoking cessation, access to birth control, or help getting or staying pregnant. Preconception healthcare takes the focus off the real patient right in front of doctors, and moves it to a figment of the imagination. There’s no way that’s the best plan.