What ethical complications arise when physicians imagine all women of reproductive age to be potential moms, whether or not these women ever want or plan to become pregnant?
That’s what worries University of South Florida philosophy and internal medicine professor Rebecca Kukla. She says that the “preconception care movement”–the recent push by organizations such as the March of Dimes, the Office of Minority Health and the American Pregnancy Association, along with health initiatives like Every Woman California, to offer prenatal care to all women has troubling implications, particularly for the low-income, minority women who are the movement’s target.
The seeds of this initiative were planted in 2006 when the Centers for Disease Control (CDC) released its “Recommendations to Improve Preconception Health and Heath Care” as part of its Morbidity and Mortality Weekly Report. One of the goals of the recommendations was to “assure that all women of childbearing age in the United States receive preconception care services,” and the CDC pushed implementation of the recommendation as part of the U.S. Department of Health and Human Service’s “Healthy People 2010” objectives.
On the surface, preconception care sounds positive. When women visit their doctors they will receive “education on fertility, screening for HIV/AIDS and counseling on lifestyle modifications that improve pregnancy outcomes,” Kukla explains. Preventative care is a positive thing and it makes sense to promote healthy behaviors and eliminate risk factors that can result in premature births, low birth weights or infant mortality.
What is troubling, however, is that preconception care sends a potentially coercive message that pregnancy should necessarily result in birth or that, as Kukla puts it, “the ‘purpose’ of women’s health care is the protection of babies and society.” Said Kukla in a recent talk [PDF] at SUNY Binghamton:
The goal [of preconception care] is to reinterpret primary care for women with childbearing capacity as preconception care, regardless of whether they intend to become pregnant. It literally treats the non-pregnant body as on its way to pregnancy. Do lesbians, women who are carefully contracepting and not interested in having children, 13 year olds, women done having kids, really want their bodies seen as prenatal, understood in terms of reproductive function?
When women’s bodies are viewed as always “pre-pregnant,” physicians may treat light alcohol use or recreational drug use–behaviors that are acceptable for men–as irresponsible. Similarly, women may be expected to go on diets for the sole purpose of creating a more hospitable womb. Organizations such as the LA Best Babies Network remind us that “foods high in fat and sugar don’t help babies grow,” but what are the social implications of asking non-pregnant women to think about children every time they take a bite–particularly if those women are struggling to survive financially? Healthy eating can be expensive, and it may be difficult for women in poverty–the very targets of preconception care campaigns–to eat nutritious meals without additional financial assistance.
Early advocates of preconception care knew that it would be a “hard sell” for sexually active women who aren’t planning on becoming pregnant, says Kukla, so organizations such as the March of Dimes re-branded preconception care as something that is not solely about fetal health [PDF].
“We ended up repackaging [preconception care] as a well-woman health package,” says Carol Bradley, executive director of Northeast Florida Healthy Start Coalition. Similarly, the Magnolia Project, a federally funded Healthy Start initiative, describes itself as a project focused on “empowering women’s health and wellness.”
Preconception care’s pro-natal message is still obvious, however, and deeply troubling, particularly at a time when abortion bans are limiting women’s access to safe, legal abortions; when crisis pregnancy centers are proliferating across the U.S.; and when pregnant women are dying because they cannot afford vital prenatal services.
Kukla also observes that preconception care has the potential to compromise the quality of care regularly available to women, since it views women in terms of “reproductive lifespan” –a period of life that begins in adolescence and ends around the age of 44:
Treating chronic conditions … so as to maximize (potential) fetal outcomes is not always best for the woman. Interpreting everything through the lens of reproductive health skews which conditions we care most about and whose health we prioritize. Where do these initiatives leave care for women who can’t get pregnant–transgendered, post-hysterectomy, etc.? Is their need for diabetes control, substance abuse treatment … any less important? [And what about] care for women who are past ‘reproductive lifespan’? End of reproductive life and the end of life are equated in much of the preconception literature.
The goal of reducing maternal and infant mortality and morbidity is a good one, but preconception care initiatives seem less interested in improving access to comprehensive, quality health care for all women than in preparing women of the “right” age to reproduce.
Photo from Wikimedia under Creative Commons 3.0
Update: This has been corrected to note that Rebecca Kukla is a professor at the University of South Florida.
