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“Preconception Care” and the Transformation of Women’s Health Care into Reproductive Medicine

In this paper I examine the recent, vigorously touted “preconception” care movement in the United States. With the 2009 publication of What to Expect Before You Are Expecting, and the Center for Disease Control’s 2006 guidelines urging that all primary care for women of reproductive age be treated as “preconception” care, the time when women’s bodies are interpreted as maternal bodies is extended backwards to before conception even occurs – and indeed, often to before women are even planning to become pregnant. The new CDC guidelines explicitly warn that “the average woman of reproductive age encounters the medical system 3.8 times per year and any of these occasions may be a woman’s last before she becomes pregnant.”

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“Preconception Care” and the Transformation of Women’s Health Care into Reproductive Medicine

  1. 1. “ Preconception Care” and the Transformation of Women’s Health Care into Reproductive Medicine Rebecca Kukla Professor of Philosophy and Obstetrics and Gynecology University of South Florida [email_address]
  2. 2. <ul><li>Two main arguments and a conclusion: </li></ul><ul><li>From a health care point of view, the project of intensive parenting has already been extended backwards through pregnancy. </li></ul><ul><li>The “preconception care” movement is extending this even farther back, prior to pregnancy and through much of women’s lives. </li></ul><ul><li> Health care for women is transforming into risk management for future children, including merely imaginary future children. </li></ul>
  3. 3. What kinds of health care do pregnant women need? <ul><li>When we think of health care for pregnant women, we think of reproduction-related care, ‘prenatal’ care, geared towards healthy birth. </li></ul><ul><li>But pregnant women continue to have a variety of health needs of their own. </li></ul><ul><li>There’s lots of information available about the various health conditions pregnant women may face… </li></ul>
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  12. 12. But this instrumental approach is not limited to pregnancy… <ul><li>Cultural association between ‘women’s health’ and reproductive health. </li></ul><ul><li>Maternal-child health a growing specialty, emphasized in global health initiatives. </li></ul><ul><li>Office of minority health: “If your women are healthy, your babies are going to be healthy and your society will be healthy.” </li></ul>
  13. 13. ‘ Preconception’ care <ul><li>Preconception care is care for women who are not pregnant but could in theory become so. </li></ul><ul><li>The goal is to reinterpret primary care for women with childbearing capacity as preconception care, regardless of whether they intend to become pregnant. </li></ul><ul><li>Literally treats the non-pregnant body as on its way to pregnancy. </li></ul><ul><li>Official priority for Center for Disease Control, US Office of Minority Health, many others. </li></ul>
  14. 14. ‘ Preconception’ care <ul><li>CDC guidelines for preconception care: All primary care for women of reproductive age should be treated as preconception care, since “the average woman of reproductive age encounters the medical system 3.8 times per year and any of these occasions may be a woman’s last before she becomes pregnant.” </li></ul><ul><ul><li>Women’s bodies as naturally ‘poised for pregnancy’ – non-pregnant state is always fleeting, on its way to vanishing. </li></ul></ul>
  15. 15. ‘ Preconception’ care is not just for those planning to get pregnant <ul><li>On the contrary, especially targeted at minority/low income women not planning to be pregnant. </li></ul><ul><li>One of the best times to integrate preconception care into primary care is “ during a visit that includes a negative pregnancy test . Because this is a time when many women learn how easily an unintended pregnancy can occur.” </li></ul><ul><ul><ul><li>California Preconception Care Initiative, letter to providers. Emphasis in original. </li></ul></ul></ul>
  16. 16. ‘ Preconception’ care is not just for those planning to get pregnant <ul><li>“ Preconception care is a ‘hard sell’ for women who, even if sexually active and not using birth control, don’t think they’ll ever get pregnant. We ended up repackaging it as a well-woman health package.” </li></ul><ul><ul><ul><li>Executive director, Northeast Florida Healthy Start Coalition </li></ul></ul></ul>
  17. 17. So what is preconception care? <ul><li>Counsels lifestyle modifications that improve pregnancy outcomes – quit smoking, lose weight if needed, etc. </li></ul><ul><li>Control underlying conditions that affect pregnancy outcome – diabetes, hyperthyroidism, etc. </li></ul><ul><li>Education on fertility, prenatal health. </li></ul><ul><li>Health interventions that are not done during pregnancy, such as catching up on vaccinations. </li></ul><ul><li>Screening for HIV, Hepatitis, etc. </li></ul><ul><li>Screening for domestic abuse. </li></ul>
  18. 18. Transforming ALL of women’s health care into reproductive care? <ul><li> Preconception care is designed to extend into almost all domains of health care. </li></ul><ul><li>All these different types of medicine now become branches of reproductive health care when addressed under the rubric of preconception care. </li></ul>
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  20. 20. Transforming ALL of women’s health care into reproductive care? <ul><li>Preconception care is also extending across the lifespan: </li></ul><ul><li>CDC: “2 nd national summit on preconception health and health care: advancing the health of women and infants before, between, and beyond pregnancy” </li></ul><ul><li>March of Dimes: Preconception care for girls should begin before adolescence in pediatric clinic. </li></ul><ul><li>Office of Minority Health: “[Preconception care] starts before birth and it goes from the cradle to the grave.” (??) </li></ul><ul><li>ASTHO preconception fact sheet: “Preconception care … should take place in an ongoing manner over the course of a woman’s lifespan, beginning in early adolescence, before she is able to become pregnant, and continuing through her reproductive years.” </li></ul>
  21. 21. Why is all this a problem? Isn’t it good for us to make addressing all these health needs a priority? Won’t women benefit? Well, they often will benefit, but…
  22. 22. Why is all this a problem? <ul><li>It reduces women to their reproductive function. </li></ul><ul><ul><li>“ In the future, prenatal care may be redefined to include care for women across the reproductive live span” (Van Dyke et al, JAAPA 2008) </li></ul></ul><ul><ul><li>“ Whether you've begun your conception campaign already or you're just starting to think about getting pregnant, it’s never too late--or too early--to start optimizing your preconception profile. ( What to Expect Before You’re Expecting , Blurb) </li></ul></ul><ul><ul><li>2. Sends strong, potentially coercive/alienating pronatalist message. </li></ul></ul>
  23. 23. Why is all this a problem? <ul><ul><li>3. Compromises in quality of care. Treating chronic conditions, etc., so as to maximize (potential) fetal outcomes is not always the best for the woman, even if it helps. For instance: </li></ul></ul><ul><ul><ul><li>Choice of drugs with lower teratogenic risk, even when less effective. </li></ul></ul></ul><ul><ul><ul><li>Aggressive rather than conservative treatment choices for diseases affecting pregnancy outcomes. </li></ul></ul></ul><ul><ul><ul><li>Care for the woman is the ‘packaging’ but not the guiding goal. </li></ul></ul></ul>
  24. 24. Why is all this a problem? <ul><ul><li>Unreasonable permanent restrictions imposed on non-pregnant women. </li></ul></ul><ul><ul><li>Normal behaviors such as light drinking treated as irresponsibly risky. </li></ul></ul><ul><ul><ul><li>Among the goals of preconception care is “eliminating alcohol and recreational drug use before the woman becomes pregnant.” But in this same article: preconception care is supposed to include “all women with reproductive potential” (Van Dyke, JAAPA) </li></ul></ul></ul><ul><ul><li>Stringent standards for weight, prescription drug use, etc, imposed as permanent burdens. </li></ul></ul>
  25. 25. Why is all this a problem? <ul><ul><li>Interpreting everything through the lens of reproductive health skews: </li></ul></ul><ul><ul><ul><li>which conditions we care most about (those that affect fetal outcomes). </li></ul></ul></ul>
  26. 26. Why is all this a problem? <ul><ul><li>Interpreting everything through the lens of reproductive health skews: </li></ul></ul><ul><ul><ul><li>whose health we prioritize – </li></ul></ul></ul><ul><ul><ul><li>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, etc. any less? </li></ul></ul></ul><ul><ul><ul><li>Care for women who are past ‘reproductive lifespan’? End of reproductive life and end of life equated in much of the preconception literature. </li></ul></ul></ul>
  27. 27. Conclusion: <ul><ul><li>The culture of intensive parenting and child-oriented risk management is distorting women’s health care. </li></ul></ul><ul><ul><li>Women’s health care is being swallowed up by reproductive health care, potentially to the detriment of women. </li></ul></ul><ul><ul><li>Tenuous, unproven benefits to possible future children who do not exist and may not even be planned are not worth this cost. </li></ul></ul>

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