We have articulated several distortions of reasoning about risk in the pregnant body. Disturbing in their own right, they also bear striking similarities to certain cultural themes that have historically shaped behavior and perception around pregnancy and birth.
The first is a longstanding theme about purity and the pregnant body. Scholars have long problematized the idea of the pregnant woman as a “vessel” whose purity is valued. Fears of the permeable pregnant body have a long history, stretching at least as far back as the seventeenth century and across many cultures. For example, in her classic book, Purity and Danger
, Mary Douglas described beliefs and rituals concerning purity around persons in liminal states such as pregnancy48
—patterns discernable in sources as wide-ranging as seventeenth century midwifery texts and twentieth century advocacy literature.49
While the early half of the twentieth century brought a brief period of overconfident assurances that the womb was a predictably protective barrier against fetal harm, this view was proven dramatically, disastrously, and publicly wrong by thalidomide. Devastating birth defects linked to the use of this drug in early pregnancy led to public outcry and to new laws that ultimately resulted in the near-exclusion of pregnant women from participation in and benefits from research trials for the next quarter century.50
The pendulum has now swung from overconfidence back to overanxiety: medicines and interventions that should be seen as therapeutic or lifesaving are instead seen as frightening or poisonous in the context of the pregnant body, and innocuous materials such as sushi can get marked as dangerous without data to support broad admonitions against them.
Such concerns about purity reflect a form of magical thinking rather than evidence-based reasoning about actual harms and dangers. As psychologists point out, magical thinking is the tendency to see causality in coincidence and to substitute rituals and taboo for empirical evidence. In the context of pregnancy, magical thinking can turn an innocuous exposure into a dangerous one—a sip of beer to poison, a bite of sushi to contamination. Such thinking is considered a familiar and natural response to uncertainty and the unimaginable.51
In pregnancy, it may be a way to try to tolerate an unsettling truth: that try as we might, what we love may perish. The temptation is to tell ourselves that if we can only find and follow the right set of “musts” and “mustn’ts,” all will be well: we will eliminate the possibility of regret and be able to manage the responsibility and potential for tragic loss that creating, gestating, and shaping a life inevitably brings.
If purity is a significant theme during pregnancy, control is the theme of American birth. The womb that was seen as a space to be protected during pregnancy can come to be viewed as a barrier
to fetal safety during birth itself (in one account, a “fortress against fetal health care”52
). In what may be their own version of magical thinking, American hospitals often respond to the boundaries of life—to birth and to death—with the comfort of intervention. If routine EFM does not help medical outcomes, it does give a stream of information that helps keep at bay the unexpected. Likewise, as death approaches, the first inclination of medical professionals is often to bring more options to the bedside—another intervention, a promising research protocol. Individuals in the palliative care and hospice community have made great strides in countering this inclination at the end of life. Our practices around birth, however, lag behind our practices around death.
The point is not that birth, as something “natural,” should be naively regarded as “safe.” Women still do die during birth, at a rate of 6.5 per 100,000 in the United States, and only about a quarter of these deaths are considered preventable.53
Preeclampsia, a pregnancy-related disease, can be life-threatening. Amniotic fluid embolism can cause horrifyingly rapid respiratory collapse and death. And neonatal birth injuries and death, though rare, do happen, even in the context of the highest quality maternity care and the absence of error.
The point, rather, is about how we perceive and reason about risks. Too often, current practices reflect reasoning that is governed more by dread than by evidence. In birth, no less than in life itself, there is an irreducible element of risk; responsible risk reasoning requires confronting the fundamental fact that the joy of birth carries with it a vulnerability to the possibility of traumatic loss.
Another strand in the tapestry has to do with themes of motherhood. Reasoning about risk during pregnancy and birth inevitably asks us to face the possibility of trade-offs between the pregnant woman’s interests and those of her fetus. Often, of course, maternal and fetal interests are far more aligned than the headlines or ethics discussions about “maternal-fetal conflict” would indicate. Usually, what’s best for the baby is what’s best for the pregnant woman, and vice versa. Sepsis from a ruptured appendicitis is good for neither woman nor fetus; a hiatus from fish is not only unhealthy for women, it may rob the fetus of nutrients important to brain development; and a mother’s struggle with severe depression (not to mention the risk of suicide) has potentially profound implications for her children. But if a model of “maternal-fetal conflict” is overwrought, so, too, would be a model that insists on the romantic alignment of maternal and fetal interests: genuine trade-offs can arise.
But when confronting such possibilities, we run headlong into an area of profound discomfort, for the idea of pregnant women trading off their own interests for those of their fetuses runs up against a cultural mandate. The dominant idea of a “good mother” in North America requires that women abjure personal gain, comfort, leisure, time, income, and even fulfillment;54
paradoxically, during pregnancy, when the woman is not yet a mother, this expectation of self-sacrifice can be even more stringently applied. The idea of imposing any
risk on the fetus, however small or theoretical, for the benefit of a pregnant woman’s interest has become anathema. A second cup of coffee, the occasional beer, the medication that treats a woman’s severe allergies but brings a slight increase in the risk of cleft palate, the particular SSRI that best treats a woman’s severe recalcitrant anxiety disorder but brings a small chance of heart defects—all are off limits, or nearly so, to a “good mother.”
Such reasoning is not applied with equal opportunity. Consider the dialogue around sexual intercourse during pregnancy. Most researchers on the topic agree that there is inadequate empirical evidence for making recommendations for couples about the safety of intercourse during pregnancy.55
Yet despite inadequate data and plausible physiologic reasons for concern (prostaglandins in sperm cause contractions, orgasm causes contractions, intercourse can cause bleeding in the context of placenta previa), most Web sites and doctors reassure that intercourse is safe during pregnancy and advise women to go ahead if they are so inclined.
The curious about-face with regard to risk in this case suggests that the acceptability of trade-offs depend in part on whose interests are being met—or constrained. For the woman’s solitary pleasure of coffee, abstinence is held out as the standard with no comfort offered to those who accept a calculated risk. Yet for heterosexual intercourse, abstinence is portrayed as optional, and reassurance given to those who partake. Which trade-offs strike us as acceptable and which as reckless in the context of pregnancy, in short, may turn in part on social relationships, power dynamics, and who, exactly, is being inconvenienced or burdened.
The pursuit of zero risk to the fetus in these ways, then, holds pregnant women to a standard to which we do not hold prospective fathers. More than that, it holds them to a standard we don’t impose on parents of born
children. We accept small risks to our children for our own sakes every day. We believe it reasonable to impose the small risk of fatality introduced every time we put our children in the car (safely restrained in a car seat), even if our errand is mundane and optional. Likewise, we recognize as reasonable the decision to live in a city that happens to have high levels of air pollution even if doing so increases the risk of our children later developing cancer.56
To be sure, balancing such risks can be among the most challenging tasks of parenthood. But we recognize that reasoning about risk is inevitable, that thoughtful, responsible trade-offs are a fact of life, and that there are times when benefit to one member of a family comes at the price of a risk to another.
Once again, our point is not that anything goes. Balancing risks to the fetus with benefit for the pregnant woman (and vice versa) should be done carefully and responsibly, with attention to evidence when it is available. And when we can eliminate a risk to the fetus—even a very small one—at no cost, then of course we should. But the pursuit of absolute zero risk to the fetus too often comes at very real costs to women and their families.
Pregnancy is often heralded as a time of hope and happiness. But when issues of risk enter—as they always do—pregnancy also challenges our ability to reason well. There is a tendency to think of safety in ways unmoored from evidence. Underneath these patterns are themes of purity, control, and forbidden trade-offs that work together and affect what we think to notice, which risks we think reasonable and which irresponsible, and how we view women themselves—at worst, as vessels, or more subtly, as agents whose needs can and should be met only if they can do so without any risk to the fetuses they carry.
As complex as pregnancy is, recommendations, guidelines, and advice should be based on evidence, not on unrealistic expectations, dread, or denial, and evidence that encompasses the full profile of risks, including those of not intervening. Further, recommendations around pregnancy should recognize the legitimacy of maternal well-being as a consideration important both for its own sake and for its importance to fetal well-being. Most centrally, we need to reason better about risk and the pregnant body not by suspending the usual modes of analysis when confronted with pregnancy, but by giving the same careful, responsible, and comprehensive assessment we hope for in all of medicine.