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This week, the CDC issued an announcement that has already proved controversial: The agency recommends that all sexually active women of childbearing age who drink alcohol should also be taking birth control, in case they unknowingly become pregnant and expose the fetus to alcohol-related developmental issues.
Setting aside the gender essentialism of the suggestion that only women can get pregnant (and that all women between 25-44, its target range, are fertile), there are layers of issues with the CDC's scaremongering announcement that should be of grave concern. The agency is throwing its hat into the ring in the escalating battle for reproductive autonomy in the United States — and this isn't the first time.
First, some context: Fetal alcohol syndrome (now better known as fetal alcohol spectrum disorder) is linked with the consumption of alcohol during pregnancy. The threshold of alcohol needed to cause fetal impairment isn't clear, though it's been the subject of numerous studies and considerable debate. Some recommendations speak out strongly against any alcohol at all during pregnancy, while others suggest that a drink now and then is acceptable.
Ultimately, the issue needs more study — and a private conversation with an obstetrician regarding a specific pregnancy. Expectant parents have to independently balance the risk (potential FASD) with the reward (such as one beer after a hard day of gardening — authorities already agree that binge drinking and consistent heavy drinking in pregnancy categorically cause FASD).
The CDC and many other agencies and health authorities recommend not drinking during pregnancy, as a commonsense measure to prevent a spectrum of disorders that can potentially cause significant impairments, or even end a pregnancy. It's also entirely sensible to advise patients who are planning to get pregnant to stop drinking alcohol and using other substances known to cause fetal anomalies, as it's nearly impossible to tell when, exactly, someone will get pregnant, and the first weeks of pregnancy often go undetected in people who aren't actively trying for a baby, but are still loosely prepared to have one. Really rigorous measures surrounding potential fetal exposure also pertain to some prescription drugs, like Accutane, which will not be issued without proof that a patient is infertile or on birth control, because it's such a severe teratogen.
This recommendation, however, goes a step further by saying that "all sexually active women" should be taking birth control if they drink. In other words, people should be protecting a fictional and entirely hypothetical fetus. The release plays right into the growing construct of pregnancy as an object of continual fear.
If this sounds familiar, it should. Public health agencies have long recommended that women take folic acid during pregnancy to prevent spina bifida and other neural tube anomalies, which can lead to severe impairment. This is quite a reasonable suggestion, given the severity of some neural tube anomalies, and telling patients who plan to get pregnant that they should start taking folic acid is similarly a good idea.
But the CDC changed that recommendation, however, saying that:
All women between 15 and 45 years of age should consume folic acid daily because half of U.S. pregnancies are unplanned and because these birth defects occur very early in pregnancy (3-4 weeks after conception), before most women know they are pregnant.
Again, the agency was overstepping its bounds to suggest that every person capable of getting pregnant take a supplement to prepare for an entirely theoretical pregnancy. This recommendation is particularly sobering in light of the recent PBS feature on the huge problems with the supplement industry, including the sales of mislabeled, adulterated, and dangerous products in a largely unregulated market. Patients relying on such supplements to protect the health of a developing fetus could experience tragic outcomes as a result of relying on supplemental folic acid — which is not, by the way, a recommendation to stop taking this supplement, but rather a recommendation to exercise caution when purchasing one.
As with alcohol, the risks from folic acid deficiency can be severe, but suggesting that every single person capable of getting pregnant has an obligation to a fetus that doesn't exist yet is a little unsettling. It positions patients as little more than incubators patiently awaiting their eventual fate as fetus carriers, rather than human beings capable of making their own reproductive choices — like, for example, a 26-year-old woman who likes to go out for drinks with friends and has absolutely no intention of getting pregnant or keeping a pregnancy, should one occur.
After all, birth control has a failure rate, so should people be on the safe side and just not drink at all if they have sex ever in case their birth control doesn't work?
At the Washington Post, Alexdra Petri notes that this fits within the larger framework of issuing condescending tips to women that consist of "holding them responsible for other people's behavior." The CDC also warns women that alcohol can cause pregnancy, along with "violence" and sexually transmitted diseases.
Pregnancy, unless my biological classes were considerably lacking, requires the meeting of two gametes — a sperm and an ovum. No matter how much Chardonnay you drink, you're not getting pregnant. Violence requires someone behaving violently. STI transmission involves sexual contact between an infected person and someone who is not.
What the CDC seems to be saying here is that people who drink alcohol should be blamed if other people take advantage of their reduced capacity, which ties into issues like blaming women for their own rapes.
There is a growing sense in the United States that people with the capability of getting pregnant are "forever pregnant" or "pre-pregnant," as people commented in 2006 when the Bush Administration began heavily promoting policies like these. In fact, there's a term specifically for this approach to reproductive health: "Preconception care."
For hopeful parents who are trying to get pregnant, comprehensive health care to support a pregnancy is vital, but for those who don't want to get pregnant, it's insulting to suggest that they should obey rigorous health requirements to protect a fetus that doesn't exist, just because they might get pregnant. Certainly, people are free to individually ignore these recommendations, but this conversation is taking place within a larger landscape of increasingly restrictive laws surrounding reproductive rights.
It's especially interesting in this context because the same government that's telling people to stop drinking if they're not on birth control is the one that's slashing health care and trying to deny access to birth control. Because people cannot access these things, they're forced into an uncomfortable corner — they can't get the birth control they need to prevent unwanted pregnancy (perhaps one reason for the very high unplanned pregnancy rate the CDC cites as justification for the guidelines), nor can they get the benefits they need to receive comprehensive sexual and reproductive health care, let alone prenatal care.
The CDC needs to stick to public health, not appointing itself the boss of people's bodies. There are numerous smart, sound recommendations to be made about fetal exposure, but telling everyone who could possibly get pregnant that they ought to be conducting their lives as though they're going to get pregnant at any moment is deeply offensive. It also sets super dangerous precedents that will reinforce legal notions surrounding the oppression and control of pregnant — and now, apparently, pre-pregnant, bodies.
Photo credit: Marnie Joyce, Creative Commons.