"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

[amergina.livejournal.com]

The main thing that struck me about the report was that it targets women's preconception health not because the gov'ment thinks that all women are baby-making machines, but because 85% of women in the US will bear a child by the time they are 44. That is... it focuses on improving all woman's pre conception health because the majority of woman will bear a child.

It's not that woman are baby making machines, it's that women tend, overwhelmingly, to make babies. Therefore some recommendations for women to make healthier babies isn't a bad idea.

I think the knowledge is a good thing for women to have. I don't think it should be pushed on people, any more than I think things like the food pyramid should be pushed on people... it's good to know what you should eat, but don't strap me down and feed me.

Or sex ed... giving a kid sex ed doesn't mean that he has to go out and have sex... but it's good info in the event that he wants to have sex.

I think the WP article is kinda written to set hackles up, though. Which is why I posted the link to the report.

[jhayman.livejournal.com]

Pre-Conception Health has been around for about 15 years. My health unit has had an active preconception program for that long. It's important because about 50% of all pregnancies are unplanned. That includes people actively attempting to prevent a pregnancy (the field use effectiveness of birth control is much less than the theoretical, and none of them are 100% effective).

The vast majority of birth defects occur during the time BEFORE a woman knows she is pregnant. Ergo, those unplanned pregnancies often occur in a woman who is smoking or drinking. Or taking recreational drugs, binge drinking, making poor lifestyle decisions. IF the offspring is affected, the child, the woman/family, and society all take a hit.

OTOH, Folic acid use prevents neural tube defects. Period end of story, the research is in. But it needs to be taken a minimum of 3 months prior to conception. That's why it's in your cereal products. Few people are really B Vitamin deficient, but that's added to your cereal products too. Or Vitamin A and D in your dairy products.

Given all the above, the obvious conclusion is that women who are of child-bearing age AND SEXUALLY ACTIVE, need to acknowledge they COULD become pregnant and make decisions based on that. If you cannot abide the notion of a aborting a pregnancy, then you take the consequences of your lifestyle or you change it. The recommendations suggest changing the lifestyle factors known to impinge on fetal health or cause birth defects.

There have been health recommendations from the CDC and every other health agency for years, including the ones you object to. They are ignored. How many people really follow the exercise and diet recommendations? This one will be ignored too. Very few of them have become law (only immunization and there's an out for that as well), so I do believe that your reasoning is specious.

[magid.livejournal.com]

There's a post in shadesong's journal about how she's already been denied medication changes because she's 'pre-pregnant'. It scares me.

[cellio]

Thanks for the information. I agree that knowledge is good; if this stays as advice then that's fine. My fear is that in the current political climate in the US, it might not stay there. :-(

[cellio]

I think it is perfectly reasonable, nay, meritorious, for doctors to say "if you would carry a pregnancy to term, even if you aren't planning one actively, I have some advice for you". Doctors are supposed to advise patients on their health in general and on factors they haven't thought of.

My fear is that, in the current political climate in this country, the zealots will attempt to compel rather than advise. See magid's comment below about someone already denied care because of fertility. Is that a fluke, or the leading edge of a trend? Too soon to tell, but I am concerned. I would be thrilled for this to turn out to be needless concern.

[cellio]

Thanks for the pointer.

[sue-n-julia.livejournal.com]

One of the first anti-inflammatories I was on required a pregnancy test before beginning it. The dr. decided that all she really needed to do was ask -- I would be pretty likely to know if I had a risk of pregnancy (unless, of course, Julia's been hiding something ;> ). It did require that you abort if you got pregnant.

S

[beckyfeld.livejournal.com]

There are a few drugs on the market that are so teratogenic (cause birth defects) or abortafecient (cause abortions) that people who cannot definitively say that they are not pregnant should be tested for pregnancy before starting on them and monthly while they are taking these medications. These include things such as Acutaine, Cytotec, Thalidomide, etc. We in the medical field have been making these recommendations for YEARS. I remember learning about them when I was in pharmacy school. The same thing is true for the routine use of folic acid. The basis for this is that many of these things can affect the fetus BEFORE THE WOMAN EVEN KNOWS SHE IS PREGNANT (that is, within the first few weeks after conception).

In your case, I suspect the drug your doctor wanted to use contained Cytotec (misoprostol), which is sometimes used to protect the stomach against ulcers and is given in combination with an anti-inflamitory which can cause them. Arthrotec is an example of such a drug.

[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.

[dagonell.livejournal.com]

"(unless, of course, Julia's been hiding something ;>)"

Pregnancy also depends on *where* you're letting her hide it. :D
-- Dagonell

[paquerette.livejournal.com]

Cytotec

Really? Interesting that they're still using it to induce labor. O.O (But I'm guessing, being in the medical field, you know about that controversy)

[paquerette.livejournal.com]

Another issue with this whole bruhaha is that they're trying to blame-shift here. A report recently came out about the US infant mortality rate being one of the lowest in the developed world. The natural birth community kind of collectively went, duh, the US model of care is geared towards keeping doctors from getting sued (sparing you the details, they have a habit of doing things which are statistically more likely to cause problems, but it makes it look like they're "doing something" and has evolved to look better in their favor when legal action occurs) whereas more enlightened places (ie, scandinavia) actually follow evidence-based care.

So I think one element of this is to try to keep people from scrutinizing medicine. 'Have a damaged baby? Did you ever smoke a cigarette, drink a glass of wine, or miss your vitamins a single day since puberty? ALL YOUR FAULT!'

But I also agree that this is a convenient way to set up for harsher control.

[jducoeur]

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?

Hmm; interesting point. Combine this with the American tendency towards litigation, and the corporate phobia about it, and the mix becomes explosive.

Consider: what happens when a woman receives a drug that *does* harm her baby, which she received because she didn't know that she was pregnant? The fact of these recommendations adds a fair possibility that she could sue the pharmacy and win -- the argument being that the pharmacist *should* have treated her as if she was pregnant (since those federal recommendations now exist), and didn't.

As soon as that happens, it's all over. It doesn't require intrusive laws: the chilling effect of such a verdict would shut many doors to women, from companies simply protecting their own asses...

[ladymondegreen.livejournal.com]

I am very afraid of the day when women have to walk up to a bar and say "I'm sterile" before they're served.

[cellio]

It doesn't require intrusive laws: the chilling effect of such a verdict would shut many doors to women, from companies simply protecting their own asses...

Yes, exactly. Some of the far righteous will also attempt legislation, and that's a problem, but even absent that, on something that pulls at some people's core values this strongly, there will be problems. Many women would, I'm sure, happily sign waivers of liability in order to get their epilepsy prescriptions filled, but the corporate lawyers will rightly ask their employers: "do you really want the responsibility of tracking all that, and the risk of making a mistake, whe you could just play it safe?". There'll be businesses that take the moral high ground, and those who see sound business reasons to offer services their competitors won't, but in what proportions, it's too difficult to predict.

I'm not as worried about Boston and Pittsburgh as I am about South Dakota and the bible belt. "Just move to a saner place" isn't always an option for people, especially if you didn't anticipate getting cancer or epilepsy or migraines (and who does?) when you chose where to live. And one should never, ever grow so complacent as to say "it can't happen here", no matter what the "it" is. Eternal vigilance...

[cellio]

I'm afraid of the day when saying it won't be good enough. Will doctor-issued special IDs be needed, certifying that you pose absolutely no threat to the business owner?

[sue-n-julia.livejournal.com]

I agree. I was just amused because my doctor figured a lesbian was quite likely to know the risk of being pregnant. But, I got her to switch me to a new drug that I've had a better response to (and could get in more than a 10-day supply at a time).

S

[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.)

[jducoeur]

And one should never, ever grow so complacent as to say "it can't happen here", no matter what the "it" is.

You have read the book of that name, right? Made a profound impact on me in my teenage years; it's part of why I simply *can't* just let stuff like this go...

[estherchaya.livejournal.com]

These include things such as Acutaine, Cytotec, Thalidomide, etc.

You forgot to include Depakote in your list. But I'm not bitter. No, not at all.

[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.

[beckyfeld.livejournal.com]

Actually, if you want me to get really geeky on you, I'd note that the drugs I listed are FDA Pregnancy Category "X", where Depakote is Pregnancy Category "D". If you are curious, there is a good explanation of what the different category designations are at http://depts.washington.edu/druginfo/Formulary/Pregnancy.pdf

[estherchaya.livejournal.com]

Interesting. I added Depakote, because my doctor had told me it was Category X. Anyway, I don't need you to get REALLY geeky on me. I've got a husband with a PharmD for that. I'm certain that HE never told me it was Category X, but I'm also sure I never asked. I just went with his dumbed-down explanation to me: "It would be really, really, really, really bad if you got pregnant while taking it."

But mostly, I was being bitter, since I now live on Aleve, Codeine, and various other pain medicines, which frankly isn't much better.