There are really very few occasions I can think of when anyone saying “maybe you shouldn’t have a baby right now” is going to be either wise or welcomed. Even fewer where the entity saying it is a national government. But it happens.
In the recent Zika virus outbreak in South America, several countries called for women to delay pregnancy until more was known about the virus. And criticism was heaped upon those governments. Yes, the effects of Zika on an unborn baby can be terrible. Yes, there are lots of unknowns. But what women need from a government is facts, education, support, understanding. Not judgement. Not an unobtainable ideal. Governments need to understand why women get pregnant, their access to contraceptives, and how much control they have over their reproductive health. Until these issues are discussed openly, and women are empowered to truely have control over their reproduction, to talk of “delaying pregnancy” is a nonsense.
This is old news now, and we do know more about how the Zika virus is behaving. But when I read the following article this week, I couldn’t help but notice the similarities.
The Scottish report
This time it’s closer to home – Scotland and a report for NHS Greater Glasgow and Clyde. Here’s the full report. It’s an interesting read. It argues that preconception is an important time. I agree. It argues that a mother who drinks regularly during pregnancy they may harm their baby. I agree. It argues that women who are “unhealthy” before pregnancy need compassionate, supportive actions and that we need to understand why they are “unhealthy”. Couldn’t agree more. The author talks of a need to lessen the poverty gap, improve access to health services in poorer areas, and educate women in the importance of good health in the preconception period. Fine with me.
But then it goes on to make some sweeping, judgemental statements, that contradict these good intentions. Some examples:
- “Even when conception is intentional and wanted, most prospective parents are stunningly unprepared to increase their chances of a healthy pregnancy”.
- A huge generalisation, a statement loaded with judgement, and one that does nothing to look at the reasons some women cannot change their behaviours.
- “Almost all the major risks to good pregnancy and birth outcomes – domestic abuse…obesity, smoking…poor diet…depression…- should be dealt with effectively during the period prior to pregnancy.”
- Can you spot the major flaw in this argument? Actually, there’s more than one. But the most serious is the idea that domestic abuse should be “dealt with” before conception. Like the advice of the Colombian government, the author here is failing to think about the women in question. Do they have control of their reproductive health? Some do, I’m sure, but simplistic, trite phrases like this do not help those who don’t. Those in damaging, abusive relationships, unable to change or control their situation. In the context of the whole report, I believe the author means “dealt with” over a lifetime, prevented from happening. But with sensitive topics like this, wording and phrasing is key.
- “Alcohol creates a minefield of negative outcomes through which too many Scots still blindly wander”.
- I struggle to believe that the majority don’t know the risks. They may not be as risk-averse as the general population, they may not be able to take control of their addiction, but I suspect the majority know the risks. They need help, and I’m not convinced the suggested message of: ” If you are (or likely to become) pregnant, don’t drink – If you are going to continue drinking, don’t get pregnant” is going to be that magic bullet.
- “a fair proportion of middle class and wealthy women regularly drink wine with dinner in the mistaken belief that only binge drinking or deep alcoholism ‘count’ as a real risk”.
- Again, I find this hard to believe, and a little flippant. But I’m not Scottish. I am happy to be corrected on that one.
In parts, I think the problem is that the tone isn’t quite right. The author points out that many women who have postnatal depression had undiagnosed mental health issues antenatally. The call for better mental health support preconception and antenatally is a noble one, but the way it’s written, again talking about “dealing with problems” like they are finite and will just go away, doesn’t enamour me to his cause.
At other times, the need to provide an overview of a complex issue has led to an oversimplification. The author implies that, unlike depression, obesity is easy to fix. He fails to account for the common link between obesity and depression, and fails to consider the reasons women fail to lose weight before a pregnancy.
The solutions put forward in the report are reasonable. They include education on a broad level – targeting the “healthy living” message to all. This is important, as around 0.3 to a half of all conceptions in Scotland are unplanned – that means they won’t be able to get tailored advice in the immediate preconception period. That, and some behaviour changes really are very long term and require a lot of support. They won’t be “fixed” in the run up to pregnancy. The report also talks of protecting children’s rights, and offering extra support to those who may have had a difficult childhood from birth through to reproductive age. Again, a sensible approach to begin to address inequalities in health. One of the ideas I liked was that of “one key question”. Ask women when they access health care, “is there a reasonable chance of you starting a pregnancy this year?” and then if yes, tailor advice on healthy living. A sensible, easy to implement approach for those who are actively planning a family. Provided the resources and support given are non-judgemental, realistic, and supportive, I see no problem with this.
Should we ever tell someone not to get pregnant?
Contrary to the media headlines, the report doesn’t advise that we tell those with unhealthy lifestyles to delay pregnancy, though it does strongly hint at it. The suggested solutions to the complex problem of a nation’s health are small, logical steps. But the tone of the report implies judgment, simplifies complex issues, and fails to address others. It lumps in being overweight and obese with drug addiction, mental health issues of any kind with alcoholism, domestic abuse with poor diet. I can see why the author has got some stick for this.
As I said at the beginning of this little rant, I think telling anyone not to reproduce is probably a bad idea. If they are in a situation where reproduction is really inadvisable, they are probably also in a situation where they aren’t going to listen to, or aren’t able to act upon, that advice. They need to be made aware of the risks, of course. But it is ultimately their choice, and alienating them will do little to help the situation. While some women are obviously at a point in their lives where reproduction would be unwise, they need help and support, education and solutions to their immediate problems. They do not need our judgment. I agree with the report’s view that the problem is societal, and that interventions need to be life-long.
What do you think?