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2015-2016 Issue III Editors' Picks National Science & Technology

It Takes Two: Paternalistic Policies Harm Maternal Health

The backlash was swift and harsh. On February 2nd, the Centers for Disease Control (CDC)— the top public health agency in America—issued a press release urging women “of childbearing years” who are not on birth control (totaling some 3.3 million women) to refrain from drinking alcohol. The reason, argued the CDC, was that these women might unknowingly be pregnant and thus at risk of passing on fetal alcohol spectrum disorders to their children. Many women claimed these guidelines were unnecessary and unfair; headlines in opinion sections across the country were derisive and mocking. The CDC reaffirmed its position. After all, its press release was only updating a similar (and little known) 2005 recommendation. Thousands of women disagreed—they would not refrain from a casual night of drinking on the off chance they might “unknowingly” be pregnant. Nor would they allow the CDC to limit their personal autonomy for a child they may not even be carrying.

A January study published by the American Medical Association urged that all adults be screened for depression because the potential benefits of doing so would far outweigh the harm. Women should be screened during and after pregnancy, it said, to test for postpartum depression. A mother’s depression might negatively affect her child. The father’s mental health was not considered.

The New York Times first reported on Zika—a virus that is sweeping Latin America and now making its way to the United States—in 2007 in a story on Micronesia. Its coverage did not focus again on Zika until December 2015, when it discussed the threat the disease poses to newborns. The epidemic has purportedly caused an increase in microcephaly—a form of brain damage that results in abnormally small heads—in babies born in Latin America. Many countries in the region have responded to the crisis by urging women to avoid pregnancy until more is known about Zika. El Salvador recommended that women forego pregnancy for two years. The country raised red flags immediately for reproductive rights advocacy groups, which claim the protocol places the burden of the virus on women without deeper analysis of its possible causes.

Public health guidelines are not policy; they do not have any binding power to enforce their recommendations. Yet when an organization like the CDC, a government agency, issues a widespread statement, it influences social norms. And these examples illustrate the power of medically-backed announcements in approving and maintaining those norms. The American CDC and El Salvador fear possible adverse health effects from alcohol, depression, and Zika respectively on society. But their fear leads to hasty recommendations that further a long legacy of state intervention on female autonomy to protect children. Rather than limit a woman’s freedom to act on behalf of her child, society should make child-rearing a more egalitarian pursuit, which would benefit parents and the child.

In a recent New York Times Magazine article, Yale Law professor Emily Bazelon traced the history of Supreme Court rulings that Justice William Brennan called, mockingly, “romantic paternalism.” (He used the phrase in striking down such precedents.) According to Bazelon, for decades, courts upheld laws that limited the number of hours women could work each day and in which professions they could work—all in the interest of protecting them.

Bazelon had cited Columbia history professor Alice Kessler-Harris, who notes the inherent sexism in such laws: “It’s really a euphemism for the public welfare: Women’s purpose is to become healthy mothers and to produce healthy children.”

While this legislation has, for the most part, been resolved (though Bazelon argues that new anti-abortion legislation also claims to protect women), the expectation that women deserve special protection—or at least extra attention— remains.

This attitude persists in public health through guidelines that tacitly “favor” children over their mothers. When the CDC urges women not to drink alcohol, or when the American Medical Association wants women screened for depression, or when El Salvador encourages women to avoid pregnancy, they are being overly cautious and unfair. But they are not trying to be spiteful. They think women should be more careful—and the state should take extra care in how it treats women—because that is the way things have always been done. But what if the child’s best interests requires a complete revision of parental roles? Rene Almeling, a Yale professor of sociology, writes in The Boston Globe, “It’s time to stop ignoring the role men play in reproductive outcomes.” Amy Rowland, Senior Public Affairs and Communication Specialist at the CDC, clarified her organization’s guidelines for women and alcohol to The Politic. Of four recommendations, just one mentioned a partner—that a partner should only be included when asked “to support [a woman’s] choice not to drink.” Such unequal recommendations will only continue to push men away from the responsibility of childcare.

The Yale Child Study Center has long been a source for new ideas in parenting and child development. Its work focuses on advancing policies that benefit children, but it also aims to help families. Walter Gilliam, director of the Edward Zigler Center in Child Development (one branch of the Child Study Center), told The Politic, “When we make the recommendation in a way that seems to speak only to the mother, it seems to put all of the guilt and all of the onus on the mother. But it also removes and alienates the father from discussions and thoughts about his role within the family.”

Gilliam noted how policy is made in many ways: from laws, from government bodies, and from changing social norms. And according to Gilliam, “You don’t want to make policies on the basis of something that is less than good science.”

He mentioned Edith B. Jackson, who taught in the Yale School of Medicine Department of Pediatrics for over three decades, as an example of a change in policy that can affect societal norms. Jackson established the “Rooming-in Project” that literally brought men into their children’s lives. Until this project changed hospital protocols throughout the country, men had to wait outside the room while their wives gave birth. The tradition had embedded a difference in parental expectations for women and men.

For Gilliam, children would be better off if society expected the father to also be a healthy, vibrant presence in his children’s lives. But this requires a drastic realignment of social norms or at least our perception of them. If we want children to be healthy, according to Gilliam, this should come naturally.

The issues of children’s health and a mother’s personal autonomy become more complicated when both are threatened by a new, unfamiliar disease. When governments like those in El Salvador and Brazil urge women to hold off on pregnancy until more is known about Zika, the onus is placed on the woman, not the government. This policy is not a solution. Christine Ricardo, a clinical fellow at the Global Health Justice Partnership, told The Politic that a shift in responsibility from the government to women ignores other, more pervasive problems. Ricardo, also a lawyer, works with the Partnership’s initiative in Brazil to address Zika. It is easier, she observed, to hold women accountable for public health than to find the root of the Zika epidemic.

Society has often minimized women’s ability to make their own decisions. A group of historians led an amicus brief backing an abortion clinic in its case before the Supreme Court (Women’s Whole Health v. Hellerstadt). The historians trace the need to “protect” women to “the doctrine of coverture,” an outdated assumption that women are the legal property of their husbands.

Public health guidelines can no longer limit a woman’s actions. Instead, they should bring fathers and other partners into the equation. Only when the CDC and other public health agencies recognize the immense power they hold in shaping public attitudes can mothers, fathers, and their children make the best choices about how to live healthy, full lives.

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