Wednesday, May 17, 2006

Trust Your Mechanic

There's been a lot of noise in Left Blogistan lately about this scary Washington Post article on this CDC report titled "Recommendations to Improve Preconception Health and Health Care." The report itself is fairly innocuous on its face, although some of the rhetoric in it is disturbing at best. To get this out of the way briefly, I have no problems whatsoever with preventative medicine, prenatal care, regular assessments and reassessments with one's doctor about one's overall health, and/or being asked if one's birth control or lack thereof is working out well. However, I have two main objections to this report. The first, which I'm going to look at in not too much length, is the discourse used by the report, since it's also important as a lead-in to the second point. The second objection I have is to the scope and consequenses of these guidelines.

First of all, the line from the original report that jumps out at me is "all women of childbearing age in the United States [should] receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health." ("Childbearing age," defined more precisely, is between the onset of menstruation and menopause.) The recommendation in itself isn't so bad, although it's inartfully and inaccurately worded. If it said something like "all women of childbearing age in the United States should have access to preconception care decrease the likelihood of adverse pregnancy outcomes if and when they become pregnant," that would be quite different. In fact, it's a completely different statement.

We don't know the intent of the CDC authors, but just in that one line we have the implication that "preconception care" must be given to all women who may be capable of becoming pregnant, regardless of whether they're single, partnered, straight, gay, celibate, or sexually active. Notice too that there is no "out" here for those women who, for whatever reason, don't want to or can't get pregnant. All women are assumed to "enter pregnancy," whatever that means -- the key there is the phrase from the above quotation "will enable," which probably more accurately should have read "would enable." See the difference? One is presuming that all women will become pregnant, the other is assuming that all women may become pregnant. Neatness counts. (According to the CDC report itself, only 85% of American women are ever pregnant, so careful writers would use the subjunctive anyhow.)

I notice that they do refer to Canada's preconception care guidelines, with which I am not overly familiar. My experience with Canadian government documents (extensive) leads me to believe they're likely clearly written and parsed better than an argument in a room full of hungry lawyers. My practical experience with Canada's preconception care guidelines so far has been to be asked "Are you happy with your birth control?" and so on, since my medical professionals already know I'm not intending on having children. One of the last times I was in to see my doctor, she asked me if I had considered having a tubal ligation. Those sorts of guidelines may be what they are going after in this document, but this is not clear from the rhetoric, which seems to imply a pregnancy-centred model of addressing women's health. They specifically and distinctly (twice, I think) separate this initiative from what they call "well-woman" programmes, which suggests to me that it is more pregnancy-focused, rather than a component of an overall programme to encourage women to be healthier.

Bolstering this point further down, we have the usage of "the interconception period," suggesting that the focus of these guidelines is to view women's health entirely through the lens of their reproductive status. (To digress a moment, a commenter on Eschaton claiming to be a CDC employee opined that, "our field is working on improving the health of women in the pre-conceptional and inter-conceptional stages of their life," to which someone replied, "I for one do not think of my life in terms of pre-conceptional, inter-conceptional, post-conceptional or any other 'conceptional' stages.") The report itself mentions that the "Guidelines for Perinatal Care, jointly issued by AAP and ACOG, has recommended that all health encounters during a woman's reproductive years, particularly those that are a part of preconception care, should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes," which seems pretty unambiguous in a certain sense. Again, this may be a case of inartful and inexact wording -- do they really mean all "health encounters" (one would assume they mean medical interventions of one form or another) need to be reframed in the context of "optimiz[ing] pregnancy outcomes"? The implication here is less like, "If you're already healthy, you have a better chance of having a healthy baby," than "Be healthy because it's good for your future baby."

Incidentally, the frequent uses of the word "consumer" (twelve times) where a similar document from another country might use "patient" disturbs me slightly. While I realise this usage is a reflection of the organisation of the US healthcare system (if it can be accurately described as a "system"), it seems to me to be reflective of the apparent schism here between practical advice and sound practice.

Make no mistake, there is plenty of practical advice in this report. In general, it's a coherent, targeted strategy addressed at a pernicious problem in the US. I think, however, that it is pursuing that practical advice in completely the wrong fashion. The ends don't justify the means.

Why is this framing a problem? First of all, to get an idea of why these framings are problematic, check out the Washington Post article. The spin presented there may or may not be accurate, but that meme has definitely been injected into the noosphere now, like it or not.

I don't like it. Here's why:

The problem here is not advocating a healthier diet and exercise and the rest of the bland advice in most of the report, but rather if this "pre-pregnant" framing -- which does not appear in the CDC report, by the way -- gets into the public and/or medical community mindset, as a result of this recommendation or not, it's likely to have adverse effects on what doctors will and will not prescribe to women, on the grounds that they might become pregnant while on those drugs. The guidelines themselves, federal and applying to all public health initiatives in the US, may contribute to the mindset as well.

(The precedent for this move from rhetoric to reality might be the whole manufactured controversy about "partial-birth abortion," which is a loaded, misleading, and manufactured term used to push outlawing "dilation and extraction," a procedure performed infrequently in the later stages of pregnancy and only if the woman's life is in danger or the fetus has died, or has severe, fatal health problems.)

There is already a drug, Accutane, where the US prescribing guidelines require women have monthly pregnancy tests and be on two forms of birth control while on it, out of fear of birth defects in potential fetuses. Someone on LJ relates her problems with catastrophic weight loss (-50lbs) and ineffective seizure control due to the drugs she's on for epilepsy, but her neurologist won't prescribe better, more effective drugs with less harmful side effects. The reason? "'You're a newlywed. You'll want a baby'," and the more effective drugs cause birth defects. (Never mind that she's a nonpregnant newlywed with an eleven-year-old daughter, epilepsy, a 98-pound body, and no desire to conceive again.)

Relatedly, due to generalised and non-targeted fears of potential abuse (as opposed to an assumed generalised, non-targeted risk of unintended pregnancy), many US doctors already no longer prescribe Oxycontin, and some US pharmacies won't stock it. Former legitimate Oxycontin patients are usually put on other drugs that often are not as effective and may have worse side effects. (Full disclosure: I used to date an American who was forcibly taken off Oxycontin for precisely this reason. He was put on transdermal and oral morphine, and oral fentanyl in a sugar matrix, with devastating -- and seriously addicting -- consequenses.)

There are more than enough examples of doctors treating patients paternalistically, without having the media spin and a set of guidelines which, read the right (or wrong) way could certainly encourage the mindset.

Add in "conscience clauses," the active war on birth control and abortion by the US religious right, stir in a bit of the usual moral panic, and lo and behold, it's a recipe for disaster -- and anxiety. Need anti-anxiety drugs? Sorry, we can't prescribe those because you might get addicted to them, and your future baby could be harmed by them or your withdrawl. Need painkillers? Sorry, you'll just have to tough it out, because you might be pregnant and not know it. By the way, we require you to have a negative pregnancy test before starting any drug or any form of birth control. (This is not far-fetched; I was informed by one doctor that he wouldn't put me on Depo-Provera until I had a negative pregnancy test, never mind that I wasn't sexually active at the time.)

That's the real trouble with this recommendation -- in effect, treating all women as if they are "preconceptive" (I, OTOH, will cop to being post-pissed-off) restricts women's ability to make their own decisions about their health care, by treating them as adjuncts to their hypothetical fetuses. If there are liability reasons to make sure that a woman does not become pregnant while on a medication, brief her on the dangers and options, and have her sign a waiver. Isn't that the way American culture usually handles risk?

What the question boils down to, is, do you trust women to make their own decisions about their health care? If not, why not? And why would anyone put the health of a potential, unconceived fetus ahead of the health of an actual, living woman? (That's a rhetorical question.) In short, the CDC either needs to change its discourse habits, or agitate actively for a better healthcare system (single-payer?), which would reduce or eliminate many of the class and race disparities (not all, but a significant percentage) that are driving up the US' maternal and infant mortality rate, if indeed this "for your own good" stuff is actually a reaction to the infant mortality rate at all.


Blogger Anne Johnson said...

I got myself spayed some years ago without telling my husband until the day of the procedure. He was furious with me. Excuse me, sir? Whose body is it anyway? I'm 40 years old and sexually active with two kids to support already! And note I didn't ask HIM to take the easy step on his end. (I guess he's still in his conceptual years and will be until he's dead.)

Needless to say, now that he sees gray-haired, doddering dads at the Middle School play, he's come around. But it never was any of his business. Ergo, it's none of the doctor's business either.

A doctor prescribing a new medication should have a woman of childbearing years sign a form that she has been TOLD that the medication could cause birth defects. Put that statement in her records and give her the damned drug she needs!

And oh please, I just thought of this! Does this mean that women between menstruation and menopause can't drink alcohol or smoke cigarettes? HAHAHA HAHAHA!

How about this? Women between menstruation and menopause can't operate motor vehicles, because injury in an accident might prevent their becoming pregnant!

Women between menstruation and menopause can't attend sporting events because they might incur an injury while sitting in the stands.

Okay, I needed a laugh, but this isn't the first writing I've seen on that report today, and it's disturbing that all women will be looked on as walking wombs.

Then again, makes us all feel like a wife of Henry VIII, eh?

3:32 PM  
Blogger Thers said...

Great post...

I suspect that an account of how the report came to be writen, and the internal politics of the CDC, would make for fascinating, if unsettling, reading.

4:41 PM  
Anonymous Anonymous said...

It does seem like yet another manifestation of the whole "non-procreative for-pleasure sex is wrong" culture that the current US government is forcing on its citizens. Dan Savage mentions this in his latest column (scroll down to "straight rights update"):
Savage Love May 17, 2006

Let's hope the Kewpie doll in charge up here doesn't try to push for the same things. (With a minority government, not likely, but..)

10:40 AM  
Blogger Interrobang said...

Thers, I think you can get a whiff of that at times from reading Effect Measure. I think I'd be first in line to buy a copy of that account, though. I like gruesome, lurid confessional literature at times. :)

10:18 PM  
Blogger rrp said...

I followed you over here from Bitch PhD. Great, thoughtful post with more depth on the implications.

4:06 PM  
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