Monday, February 19, 2007

Pre-Pregnancy, Again

An interesting post on Eschaton asks the following question:

Picking up on something from the comments, I'm curious if the medical establishment's obsessive concern with potential fetuses is a relatively new thing or not. I gather that when obtaining just about any prescription or medical treatment which could impact fetal health in any tiny way, women have to convince doctors that not only are they not pregnant, but that they couldn't possibly be. This of course requires having abstained or abstaining from intercourse for a nontrivial amount of time.

Ladies, is this new? be clear, I'm not talking about inquiring about whether it's been a bit long since your last period or other evidence that you genuinely "might be" pregnant, I'm talking about a somewhat lower standard here, that you "could be."

In any case, this is not really what the "pre-pregnancy" concept for women refers to. Women have always been asked questions about whether they are pregnant before dental x-rays or before getting prescribed certain medications. No, the new "pre-pregnancy" is something much longer term, like from twelve to fifty years of age for women, pretty much whether the woman ever plans to get pregnant or not. This is the walking-womb version, in my mind.

Here is how it came about: In the late 1980's or early 1990's a report about birth defects came out. It reviewed available evidence on any that were known to be preventable, and most of these focused on what the woman should do. Not the pregnant woman, but the woman before pregnancy, because certain birth defects happen very early in pregnancy. The recommendation for increasing folic acid consumption came from this study as lack of folic acid has been shown to be a cause of birth defects.

Now, I had a little trouble with the part of the report which said that it is actually impossible to get sufficient amounts of folic acid from just food so that women should take supplements, because this sounds very odd to me. As if the birth defects are "natural" in some ways, or as if the research might have been wrong.

But that wasn't what angered me about this early report. It was the part where the writers argued that as roughly one half of all pregnancies are unplanned, the prevention of birth defects requires that we must treat all women as potentially pregnant. They might be, given that unplanned bit. The only safe thing is to make all women between menarche and menopause take folic acid supplements and whatever else the medical establishment decides might prevent birth defects. ALL WOMEN. Nuns, those with hysterectomies and so on. All women.

Not perhaps such an unprecedented conclusion if your objective is to reduce birth defects. It's very much like saying that if my objective was to reduce rapes a good way of doing that would be to put all men under house-arrest. It would work. And we can't tell, FROM OUTSIDE, which men might be rapists, so why not just lock them all up. And yes, I know that this is an extreme comparison, but it brings out the fact that the recommendations for women put zero value on what she might want to do with her life, and the rape example shows why such a recommendation wouldn't be made if we put value on the other people's rights and freedoms.

I had a lot of trouble with the values that this recommendation showed, especially as it might turn out one day that what is good for the potential pregnancy some day in a woman's future might be bad for her health right now and then a similar rule might be applied. Hence the walking wombs fears.

This was over ten years ago. The newest version has dressed the very same recommendations in empowering clothes. Now the health care for women is supposed to have pre-pregnancy care as a routine part, because it empowers the woman! Yeah. Except that I know the backstory. And except that we are likely to be in the state of pre-pregnancy or pre-conception for decades.

I'm going to get flack for this. To see what kind, I'm going to reproduce a few comments from that Eschaton thread (hope it's kosher to do)

Could part of it be a reaction to the gnarly, birth defect producing shit
the F.D.A. allows to be sold these days?

Women who are deficient in Folic Acid can cause some horrendous genetic birth defects.
Women who are deficient in Folic Acid can cause some horrendous genetic birth defects.


Jesus H. Christ people.

Not saying that at all, and Folic Acid deficiency could lead to your child being born without a brain. It's a vitamin for god sakes.

Note how women "cause" birth defects? And how it isn't too much to ask for you to take a vitamin so that no child, anywhere, will be born without a brain? But what if the next recommendation is to avoid certain jobs, just in case you might be pregnant? Or not to run for the president of the United States, what with all the stresses of that job which might harm the fetus? Where do we draw the line between fetal concerns and the rights of women to be full human beings?

Some other comments in that discussion thread also seemed interesting. First this one:

I design radiation therapy treatment plans for cancer patients and we make sure none of our patients is pregnant before they begin treatment. A whole body dose of just a few Gy is enough to kill a large adult and we routinely deliver 50-74 Gy to small treatment areas. There's not a threapist, dosimetrist (me), physicist, or doctor who is going to treat a pregnant woman. The risk of damaging/killing the fetus and/or getting sued are just too high. I supposed xrt for cancer qualifies as non-trivial and may not obtain to this discussion.

Note that a woman with cancer is not given this treatment. But there is hair loss treatment for men with dire warnings on the package, warnings, which are aimed not at him but at any woman who might happen to touch the product:

Well, what's with all the advertising for men's erectile or follicle dysfunction that warn that women should not handle said medications if "they might become pregnant"?

i dunno the chemo-stuff about pregnancy, but stuff that gets a guy's hair to grow mightn't be conducive to prenatal health...

So we might ban cancer treatment for pregnant women but allow hair growth products for men? Or this comment:

i was denied palliative pain treatment for endometriosis in the ER until they determined I wasn't pregnant. Several hours and just excruciating.

I see a difference here in how responsibility is viewed and in who gets freedoms to have better hair and who gets to have pain instead.