If there is one issue that stirs the hearts of doulas, birth workers, and birth activists of all stripes, it is informed consent. That presumes the existence of both information that is available and understood, and autonomy. That is, we believe women (and all birthing people) are capable and entitled to make their own decisions about their bodies and the baby they are carrying. But autonomy has a really troubling history in our culture. As far as the feminist movement has come in bringing women autonomy in their careers, in their sexuality, we still as a culture have a great distrust that women can make the “right” decisions regarding their unborn babies. Of course, this plays out in the in abortion debates: whose decision is it whether a woman maintains or terminates her pregnancy? We see it in extreme cases of court-ordered cesareans and women charged as criminals for suffering a miscarriage or stillbirth (yes, these are real). On the everyday level, birth activists get incensed around the language of permission that is so often used in birth and maternity care: “The hospital doesn’t allow you to eat in labor”; “my doctor won’t let me have a VBAC”; “If your baby hasn’t been born by 41 weeks, we will induce,” etc. ad nauseum. (See Birth Monopoly, "You're Not Allowed to Not Allow Me" ) All of this displays a deep distrust in women to make their own decisions. It is paternalismat its core: “don’t worry your pretty little head about this; the doctors, the scientists, the politicians (all historically male professions, even if they now admit women into their ranks) will tell you what to do.
Now enter the CDC’s recent recommendation that all sexually active women not on birth control from their first period until menopause refrain from all alcohol intake ever. The first I heard of this, it seemed laughable, like it must have come from an Onion article. But when I understood its reality, the anger set in. How dare they try to control the daily choices of women like this? How condescending! How paternalistic! And I am hardly alone in this feeling (See Birth Anarchy, The Atlantic, Salon, Forbes). I would like to give them the benefit of the doubt; they are actually concerned about preventing cases of fetal alcohol spectrum disorder in unplanned pregnancies, and they just didn’t realize how tone deaf their message was. But this only represents the prevalence of the paternalism surrounding women’s reproductive choices. Women are reduced to potential baby-makers, 33 million potential baby-makers, that is, 33 million potential babies are at risk of FASD.
So what’s wrong with this sweeping recommendation? Let’s break it down. First is that such a generalization leaves an awful lot of people and scenarios out. What about women who choose to be abstinent and are therefore not on birth control: they could get raped right? Maybe they shouldn’t ever drink either. What about those who have same sex partners? Do they need birth control too? Apparently, they forgot about them, but I guess a lesbian might be raped as well. What about women who rely on their partners to use a condom? Are the men responsible? (Probably not) What about the times when birth control fails? What about women who would terminate if they had an unplanned pregnancy? Maybe all women should just not drink ever, right? Maybe they shouldn’t drive cars either; they might crash and endanger the baby after all. At some point, it just gets ridiculous.
And what about all the women who for medical, religious, or personal reasons choose not to use birth control. What about women for whom birth control is inaccessible? Every form of birth control has its own risks, not only of failure, but of more serious side effects, such as blood clots (ie. the pill) or ectopic pregnancy (ie. an IUD). Whether to use birth control requires an assessment of risk. The CDC’s recommendation fails to take this into account. The risk of fetal alcohol syndrome is real, but the research isn’t as cut and dry as the CDC’s recommendation suggests. The language is actually that there is "no known safe amount of alcohol use during pregnancy" (my emphasis). This doesn’t mean even a single drop will cause harm, it does mean that we don’t know whether one drink is safe but five is not, and therefore it’s better to be safe than sorry. Some research has suggested low levels of alcohol is safe (see here) and other research points out the potential damage that even a little alcohol has on the developing fetus (see here). And this potential risk has to balanced against the risk of birth control itself, or we’re back to saying all women should never drink, ever. Risk is inherent. We will never get a state where there is no risk. So who gets to choose what risk an individual woman is comfortable taking with her body and her pregnancy?
This is where we come back to informed consent, especially the informed part. The CDC has an important role in educating the public and creating awareness around the issue of alcohol and pregnancy. So far, they’re doing a pretty good job. Almost all pregnant women or those trying to become pregnant know to avoid alcohol. We see the signs in the restrooms at every restaurant that serves alcohol. And with the exception of those dealing with addiction, compliance is pretty good. The CDC sees the need to further educate people who are not actively trying to become pregnant but might have unplanned pregnancies and who are still consuming alcohol. Then by all means, please continue to educate the public about the risks of alcohol use and pregnancy. And we certainly need work to make contraceptives safer, more affordable, and more available. But, most of all, let’s trust women to evaluate the risks and make an informed decision for themselves. This is where the CDC could learn from doulas. As non-medical professionals, we do not offer medical advice or recommendations, but we are experts at presenting evidence-based information in a non-biased way. We trust women and their partners to be able to evaluate that information and make the decisions that are right for them. If, as we believe, a woman is capable of weighing the risks of a VBAC and a repeat cesarean and making the decision that is best for herself and her actual baby, then she can also decide whether or not to have a glass of wine with dinner.