Perspectives: The CDC apparently wants to do all the thinking for women
Editor's Note: This column was written by women's health experts from the University of Pittsburgh and other institutions.
In a Vital Signs report released Feb. 2, the U.S. Centers for Disease Control and Prevention issued updated guidelines on alcohol intake during pregnancy. A torrent of social-media posts and articles from major news sources ensued, expressing sentiments that ranged from mocking to incredulous to angry. Some accused the agency of being “incredibly condescending” with its “insulting advice.”
As women's health-care physicians and researchers, we too were surprised by the CDC's language. We are well aware of the existing public health recommendations that women who are currently pregnant or trying to become pregnant abstain from alcohol. While there is little dispute that exposure to high levels of alcohol in pregnancy can result in serious birth defects and developmental problems in children, the evidence is less clear regarding the effect of modest amounts of alcohol on fetal development. Previous recommendations thus already reflected a conservative approach to the evidence.
What is new and uncharted territory in the CDC's latest recommendations is the expansion of abstinence recommendations beyond women who are actively seeking pregnancy or already pregnant, to all women who are having sex and might become pregnant because they are not using contraception. In a press release, Coleen Boyle, Ph.D., director of CDC's National Center on Birth Defects and Developmental Disabilities, said that doctors should advise women to completely abstain from drinking not only if they are pregnant or trying to get pregnant, but also if they are “sexually active and not using birth control.”
This advice was based on findings from national data that “an estimated 3.3 million American women between the ages of 15 and 44 are at risk for having an alcohol-exposed pregnancy because they were drinking and having unprotected sex with men.” The message thus aims to reduce the risk of alcohol exposure in unintended pregnancies before women realize they are pregnant.
While well intentioned, this language feels extreme, especially given that it is not based on new evidence about the effects of alcohol in the first few weeks of a pregnancy. Public-health messages are often crafted as simple statements designed to be broadly applicable and to prioritize avoidance of risk. Broad-brush public-health messages such as this, however, can have the unintended effect of diminishing women's ability to weigh the risks for themselves based on accurate information. Women's decisions about sex and contraception often involve a complicated balancing of risks and benefits, including whether they would continue a pregnancy if it were to happen and how they would feel about the potential outcomes of abortion or childbirth. By advising complete abstinence rather than informed choice, the result is a paternalistic, one-size-fits-all prescription rather than helpful information that empowers women to make informed decisions based on varied and competing facts and values.
A further unintended effect of the framing of the CDC's public health message is the implication that women are vessels of procreation and that their behavior should be policed because of their reproductive potential. As one writer admonished, by assuming that all women who are not pregnant are simply pre-pregnant, the recommendation “presumes that women are mothers first, and individuals second.” These messages can perpetuate the shaming of women for their behaviors, an effect that is further amplified when behaviors are linked to reproduction. The infographic that was originally released with these recommendations, and later removed from the website, included a list of dire outcomes without attending to the magnitude of or mechanism underlying risk, potentially bordering on scaremongering rather than �providing useful information. We found the inclusion of risk of violence particularly problematic as the focus on women's alcohol use, rather than the source of the violence itself, echoes the recurrent emphasis on women putting themselves at risk for rape by drinking alcohol, rather than on the behavior of rapists.
In light of the current hostile political climate toward women's reproductive rights, poorly framed public-health messages can unintentionally support the erosion of reproductive autonomy. Oversimplified messaging that paints gray areas in black and white could serve as convenient launching pads for legislation designed to control women and their bodies and to prioritize fetuses over women. Instead, messages that focus on helping women to make informed decisions may ultimately achieve a better end through empowerment rather than alienation. As advocates of both health and autonomy, we must be deliberate in what we say and anticipate the real-world implications of how we say it.
Contributors: Abigail Aiken, MD, PhD, Princeton University; Sonya Borrero, MD, MS, University of Pittsburgh; Lisa Callegari, MD, MPH, University of Washington; Christine Dehlendorf, MD, MAS, University California, San Francisco; Mark Evans, MSPH