As headlines broke this morning surrounding proposals made by the National Institute for Health and Care Excellence (Nice), which would see any – and all – maternal alcohol information routinely recorded on children’s health records, questions were quickly raised about the legality of such a system. As we have noted in our briefing on the Draft Quality Standards, which centre on the diagnosis of foetal alcohol spectrum disorders (FASD), one vital aspect has not been accounted for: the consent of the pregnant woman herself.
While improving diagnosis and support services for those with FASD are clearly laudable aims, the proposals assume that women would be happy to forego their legal rights to privacy and confidentiality in healthcare, by virtue of her pregnancy. Women, quite literally, are being written out of the emerging guidelines on alcohol use during pregnancy – indeed, the word ‘woman’ is not mentioned once in Nice’s equality impact assessment, despite the major focus of the Draft Quality Standards centring on changing her behaviour.
Even though women are routinely bombarded with ‘advice’ warning them of the impact their behaviour could have on their developing foetuses, their ability to make the best decisions for themselves and their pregnancy is increasingly being written out of the script. From drinking the odd cup of coffee to managing their emotional wellbeing, women are defined as the main source of risk to their pregnancy and ultimately, aren’t trusted to make any such decisions which may depart from ‘guidance’. Women are expected to do anything and everything within their power – even to their detriment – to eliminate any amount of risk in their pregnancy, and anything less earns them the designation of the title ‘bad mother’ – before her child is even born.
“We need to trust women in their abilities to understand the relevant evidence, or lack thereof, and make their own decisions about their pregnancies.”
What these standards do is act on the ‘precautionary principle’ (the notion of ‘why risk it?’) through highly coercive means, essentially transforming their advice into mandate. We have seen this through the introduction of routine carbon monoxide monitoring under the guise of ‘expected’ antenatal care, despite the fact that women are already asked about their smoking status. Arguably it’s this development, which passed without much scrutiny, that helped pave the way for the proposals we’re reading about today.
While the current guidance from the UK Chief Medical Officer endorses the message ‘the safest level of alcohol consumption is not consumption at all’, it needs to be articulated such a position is not based on evidence of harm from low level drinking, but rather, an inability to rule out a low risk of harm. At a policy level, we need to trust women in their abilities to understand the relevant evidence, or lack thereof, and make their own decisions about their pregnancies. Yet what we’re seeing through the introduction of Nice’s proposals is an institutionalised response of mistrust in women’s agency and their ability to be honest with their healthcare providers.
“Instead of pressing on under the view that women are in constant conflict with the needs and interests of the foetus, it is time to rewrite women back into the script.”
Women need to be able to form trusting and open relationships with their healthcare providers, and the proposal of mandatory screening threatens that. Rather than enabling physicians to be free in tailoring their advice and support surrounding alcohol consumption in line with women’s individual needs and preferences, these proposals impose a prescriptive standard which could compromise the ability to have individual health concerns met. In commenting on today’s headlines, the Royal College of Midwives confirm this position, arguing that ‘midwives are best placed to make assessments concerning what information to document during antenatal appointments’.
Instead of pressing on under the view that women are in constant conflict with the needs and interests of the foetus, it is time to rewrite women back into the script. We need to ensure that our approach to pregnancy ensures that women are provided with the necessary information, enabling them to make their own decisions for themselves and their pregnancies. We need to ensure that any approach to pregnancy advice or guidance is delivered in a way that is free from judgment, stigma or coercion.
Ultimately, we need to trust women in their decision-making – and Nice’s proposals just don’t cut it.
Rachel Arkell is a research associate at the BPAS Centre for Reproductive Research and Communication. The consultation period for the NICE Quality Standards on FASD closes on September 18. Individuals are encouraged to comment using the comments form on the project webpage.