"pre-pregnant"

[cellio]

The Washington Post reported yesterday that 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. amergina posted a link to the 30-page report from the CDC, which I haven't gotten to load yet but I'm caching the link for future reference.

Recognizing that this is (currently) a limited recommendation, I am still fearful of where this could go. It's a small step from "recommend" to "require"; even if the government doesn't formally require, will doctors follow the recommendation to stay on the right side of malpractice claims and future federal action? Will many (or most) pharmacists refuse to fill prescriptions for drugs to treat actual ailments for fear of harming a hypothetical fetus (even if the woman says "if impregnated I will not carry to term")? Will restaurants and bars start refusing to serve alcohol to women? Will employers keep women out of jobs with environmental hazards? No, not immediately, but we shouldn't ignore it any more than we should ignore other dangerous trends oozing from Washington (and Washington's handlers).

Women are not incubators. It is hubris for anyone not directly involved to expect women to restrict ourselves for the sake of children we're not necessarily even planning to have. If, heaven forbid, I come down with some serious illness, I want the best treatment available -- regardless of what it could do were I to become pregnant. [1] I will listen to my doctor's advice about things like alcohol, diet, and exercise for my own sake (that's part of what I pay him for), but acting on it is my decision alone, morally speaking, and it's insulting to say "think of the baby!" rather than "think of your own health!". ('Cause, I suppose, we aren't smart enough to want to take care of ourselves, but we're programmed to love babies. Bzzt.)

By all means -- make patients aware of the effects of their choices and treatment options on hypothetical future children if they care about this. That's being a good doctor. So long as we stay in the space of recommendations from doctors to patients, we're fine. But I fear the slope before us -- that it will not stay between doctors and patients, and that it will not stay as mere recommendations. And I don't know what the best way to prevent a slide down that slope is.

[1] Ok, I am not personally capable of becoming pregnant, but that is irrelevant to my point.

Comments

[ichur72.livejournal.com]

The silliest part about this, IMHO, is that it treats all women as interchangeable units. The chance of pregnancy is not equal for all women. There are those who can't get pregnant b/c they have had their tubes tied. There are those with prohibitive biological conditions such as Meyer-Rokitansky syndrome. There are those with fertility problems who would dearly love to get pregnant but can't. There are those with conditions such as endometriosis that get treated via chemically induced menopause. Ad infinitum, ad nauseam. And then there's the fact that birth defects are more likely in pregnancies that begin when the mother is a teen-ager or over 40 -- i.e., these pregnancies stand a better chance of presenting problems no matter what the mother does or doesn't take beforehand.

Behaving as if the risk is equal for all women is just silly. Moreover, I also think it is poor medical practice as it encourages doctors and other providers not to go to the trouble of making a careful assessment of an individual woman's situation and making decisions accordingly; instead, just follow the pre-pregnant protocol and turn your brain off.

This strikes me as something that was written up by trial lawyers or written wih trial lawyers in mind.

[cellio]

The guidelines do at least say "women capable of conceiving" rather than "women of child-bearing age", so women known to be infertile should be free of some hassle from their doctors, though it won't help with others.

Excellent point about unequal risk. Even if a woman is both capable of having a child and interested in doing so, sometimes you have to look at the odds. 1% chance of pregnancy versus 50% chance of death if the most-effective drug isn't used? No contest. 50% chance of pregnancy and 1% chance of unpleasant side effects from the best drug? The woman might call that one differently.

While this specific issue won't cause me problems with my doctor, if I ever learn that my doctor is making decisions for me instead of presenting me with the alternatives and his recommendation, he will quickly correct the error or become my ex-doctor. 99% of the time I'm going to do what my doctor says because he's the expert and that's what I pay him for, but he is my advisor, not my guardian.

[ichur72.livejournal.com]

>> 99% of the time I'm going to do what my doctor says because he's the expert and that's what I pay him for, but he is my advisor, not my guardian

Yes, absolutely. I can't tell you how many times I've seen people complaining in parenting forums about how unsupportive their pediatricians are about this or that technique/philosophy/whatever. The usual response is something along the lines of "oh you poor suffering martyr for the cause, that doctor should be reported and then sent to a re-education facility". (In other words, "there ought to be a law ...") I always wonder why these people don't A) find a different doctor or B) stop behaving as if the doctor has the power to tell them what to do and then enforce it. For example, my son's pediatrician said even tiny babies should be taking vitamin supplements. I listened, nodded, then went home and did my own research and opted not to give any.

Disclaimer: This is not to say there aren't bad doctors out there who need to brush up on some basics. There are, and I've been to one or two. But I think there are also some consumers of medical care that could stand to educate themselves.

[cellio]

Yup. I'm surprised at how many people don't seem to get that they're consumers, not sheep. This sometimes becomes obvious from people's reactions when I tell the following story:

Some years ago, after a camping trip, I saw symptoms consistent with Lyme Disease, most significantly the distinctive rash. I saw my doctor two days later, by which time the rash had faded. I told him about my symptoms and the camping trip, and he was convinced that it was not Lyme. (All symptoms other than the rash are consistent with the flu, though I should note that it was August.) I insisted that he do the blood test, and he grudginging agreed.

It took about a week for the results to come back (he warned me of that). I got a phone call from a surprised-sounding doctor saying "you have Lyme". I said ok, what are we going to do about it? He named a drug and a dosage, and I named the other drug commonly prescribed for Lyme and asked him to compare them. I also asked if the dosage wasn't a bit low. I did all of this politely and respectfully; I'm sure doctors have to put up with a lot of pompous smart-asses and I was not trying to go down that path. Anyway, it was almost as if I heard the "pop" of the lightbulb going off; he gave me a fairly thorough explanation of the trade-offs between the two, how dosages are computed, and how we would evaluate the treatment, and after that he never, ever gave me the "there there dear, it's ok" treatment again. He is still my doctor.

(This all happened pre-web, but in that week between test and diagnosis, and aided by a friend in the health-care industry, I did some research.)

[estherchaya.livejournal.com]

Despite my obvious inability to get pregnant, at least without intervention, my doctor allowed me to take Depakote for migraine prevention, only on the condition that I took frequent pregnancy tests. Obviously, once I began seeking fertility treatment, I ceased taking Depakote all together. But actively seeking to conceive (either the normal way or though fertility treatment) SHOULD count as "pre-pregnancy" whereas a woman just wandering around minding her own business should not be forced to identify herself that way.

[cellio]

But actively seeking to conceive (either the normal way or though fertility treatment) SHOULD count as "pre-pregnancy" whereas a woman just wandering around minding her own business should not be forced to identify herself that way.

Completely agreed. If you're trying, you should assume you could succeed at any time and your doctor should behave accordingly.