Pretending That Individual Choices Will Help Correct Structural Problems

The other day, I received a press release titled “It’s Riskier to Have a Baby in the U.S. Than in Cuba or the Czech Republic.”

This, actually, I knew. The U.S. has one of the worst infant mortality rates in the industrialized world — and one of the worst maternal mortality rates as well. And the black infant mortality rate is twice that of the white infant mortality rate, with Native American infant mortality rates and some Latino mortality rates being significantly higher than the rates among whites as well.

Given the current climate, when this press release arrived in my inbox, I expected that it was going to be a call from a women’s organization in favor of universal health care, and a comparison against other countries that do in fact have such systems. (The fact that countries we tend to look down on are so regularly used as the point of comparison, and what that suggests, is a whole other can of worms I’m not going to get into today.) Indeed, quick google searches indicate that every country listed in the press release has some sort of public health care system in place. There’d seem to be a pretty strong correlation, especially with so many up-to-date facilities in the United States, that we’re always hearing these countries with universal health care don’t have.

The press release, though, was actually promoting a book about pregnancy. And it provided “tips” — tips which use the acronym SMART — for how pregnant American women can “improve their chances of having a healthy baby”:

S = Seek prenatal care early. Tests for potential chromosome problems, including mental retardation and spina bifida (a condition that causes paralysis) can be conducted only in the first and second trimesters. A first trimester ultrasound is also the most accurate in terms of determining a due date.

M = Mention all risk factors such as a family history of diabetes, high blood pressure, Rh negative blood, premature labor, bleeding problems or genetic conditions to your healthcare professional as soon as possible. Do not omit information such as smoking or using “recreational” drugs because such activities can affect your baby.

A = Ask to have your cervix measured during your ultrasound if you have a history of premature contractions or delivery. A cervical length of 2.5 centimeters or less is a risk factor for preterm labor. If you are at risk for delivering before 37 weeks, ask your healthcare provider about receiving steroids to help your baby’s lungs develop.

R = Research your hospital and prospective physician or midwife carefully. Is the physician or midwife skilled in managing high-risk conditions? Will your care continue if you lose your insurance? Has the newborn nursery had any recent outbreaks of antibiotic-resistant infections? Is the hospital a level-three facility?

T = Test for potential problems such as gestational diabetes, sickle cell trait and cystic fibrosis, and check for appropriate fetal growth with an ultrasound.

I imagine that this might pretty solid advice (though I don’t actually know one way or the other) — if you’re actually able to follow it.

But considering the email’s opening, and the highly relevant fact that tens of millions of Americans do not have health care access, I was basically blown away by the “advice” and the necessary level of privilege that it involves — even if this kind of thing is an incredibly and increasingly common sight. And its frequency is a big part of the reason why it’s worth discussing.

It’s easy to tell women to seek prenatal care early when you assume that your audience is middle class and with insurance. It’s easy to give women tips on choosing their doctor or midwife and birthing facility when you assume that all women reading the tips have such a choice available to them at all. It’s pretty easy to tell them to have specific and expensive tests done, again, when you assume that there’s means to pay for them. It genuinely sucks to worry about what is going to happen if you lose your insurance, and such worry is evidence of an abusive system — but it’s also quite a comparative privilege to have it in the first place. And it’s really easy to tell women to disclose smoking and/or recreational drug use, when the women you’re speaking to are the kind of women (white, middle-class, citizens) who will be offered advice and help, rather than end up in a prison cell with their babies snatched from their arms.

I’m really fucking sick and tired of pretending that health concerns are individual problems. I’m so incredibly exhausted by pretending that privileged women are the ones at primary risk and that serious health concerns can be alleviated by just being smart. (Hmm, what does that call the women who don’t do the things up above because they can’t?) I’m sick of pretending that health problems can be fixed by all of us just being responsible and taking better care of ourselves when many of us just plain can’t take better care of ourselves because we live in a country where health care access — not to mention healthy food, shelter, even water — is treated like a commodity that none of us have a right to, unless we’re good, and moral, and middle class enough to be able to pay a high premium for it.

And while I believe that better prenatal care — for a lot of women, any prenatal care at all — would indeed result in fewer deaths, of both women and infants, telling women to just get up and go to the damn doctor already sure as hell won’t. Rugged individualism, turning the conversation yet again on what women are supposed to do for themselves to be considered “smart” and worthy, rather than what we can all do together to make life better for all women, isn’t going to do shit.

Give advice to women who are lucky enough to be able to follow it, certainly. But don’t frame it as a solution to a structural and institutional problem. Don’t point out that infant mortality rates in the U.S. are abysmally high and then follow up by indicating that individual women can change it one ultrasound at a time, by implying that their actions and choices are the problem.

Because there is no solution to this problem until we acknowledge that there’s a reason why it exists, and it’s not the result of individual people’s poor choices. We won’t have an impact until we agree to spend our efforts fighting against racism, classism and other prejudices, and fighting for universal health care, a wide range of accessible birthing options, and all women’s rights. We won’t get anywhere until we admit that the only real and lasting solutions to the problem are national and community ones rather than personal ones.

Until then, we’re going to stay right where we are — rights and access for privileged Americans, and invisiblity and scorn for everyone else.

0 thoughts on “Pretending That Individual Choices Will Help Correct Structural Problems

  1. The Goldfish

    One of the most shocking things, to me, about the recent US healthcare reform debate from here in the UK has been the realisation that basic reproductive stuff isn’t even covered, i.e. contraception and maternity care. It’s totally bizarre that a government would insist that every child attends school but considers prenatal care a luxury reserved for those who can afford it. And it is even more bizarre that in such circumstances, there should be any fuss raised about abortion…

  2. akeeyu

    Yeah, I hate the whole SMART thing, because then if you have a bad outcome to your pregnancy, what, it’s because you’re DUMB? Way to blame the wrong party.

    Also, I had plenty of prenatal care (early and often), but for some reason, OBGYNs are just as likely to call women hysterical as any other specialty, and my high blood pressure and preterm labor concerns were repeatedly brushed off, right up until I went into preterm labor at 23 weeks. No, wait, they brushed me off then, too, and I went into labor again a few days later.

    God forbid a specialty that deals exclusively with women actually take women seriously.

  3. akeeyu

    Oh, and I don’t know if you’ve ever seen this: Sometimes our infant/maternal mortality rates are kind of whitewashed by saying “Oh, but when you take out women who don’t get prenatal care, then we’re doing okay.”

    Right. When you take poor and disenfranchised women out of the numbers and only count women who can afford frivolous luxuries like health care and food, suddenly we only KIND of suck, instead of MAJORLY sucking, and you’d be surprised how many people find this argument acceptable to make.

  4. OuyangDan

    Sure, that can be solid advice. If you have the resources and support to do all of it. It would be great to get all of that expensive genetic screening so you can decide how to proceed. It is a great idea to research the hospital and doc or midwife…but then what? Do you really have an option if you get someone who has a history of choosing the life of the baby over the mother, even if they could both be saved w/ a little extra effort? Is the hospital one reputed for respecting the wishes of the mother…and if not, does that mother really have a choice?

    It’s pretty awesome of this mailer to throw around such great advice when there is a good chance that a majority of the people from those statistics don’t have the coverage or enough coverage to make those choices and do what is advised to try to ensure a healthy birth.

    And if it all fails…who gets blamed? The insurance companies for not covering a mom and/or baby? The hospital for not doing something right? No. The mother for not following all this advice to the letter, no matter what her circumstances are.

    Awesome awesome post, Cara.

  5. Holly

    Who wrote those “SMART” recommendations? Private insurers? YIKES.

    That’s one heck of a lot of medical care for a condition that’s NOT an illness. The list assumes that “risk” comes from babies who aren’t some standard of “perfect” — or (as you suggest) mothers who aren’t some standard of “perfect”. Blegh.

    Make childbirth safer and cheaper? Put all births in the hands of midwives in midwifery/birthing facilities (within or close by to a medical center, great) and let OBs handle only high-risk deliveries. (If you are not a high-risk case, the chance of you and your baby dying in the hospital is greater than of you and your baby dying at home.) Sort of a no-brainer, and definitely an issue well covered and brilliantly argued by feminist scholars. It’s not that women don’t have health care to get coverage… it’s that they are only allowed to get certain coverage to see certain types of providers. There is no “choice” in reproduction, at any point in the process.

  6. factcheckme

    i had the same reaction to “pregnancy for dummies.” WTF? as in, any stupid fucking whore can get pregnant, but only a “smart” one will have a healthy child (and survive its birth, herself). what does intelligence and indeed “choice” have to do with it, when so many women dont have access to medical care, or even the basics for her own survivial? good piece, thanks.

  7. Ryan

    From what I could tell, out of that whole list, there are really only two constructive suggestions. First, tell the doctor the truth. Second, do some research on your doctor/insurance carrier. All that other stuff sounds like medical jargon that a good doctor will know and test for without being asked. Without a doctor, these suggestions couldn’t possibly help a couple.

    I wish more people could see health care in these terms. Having mothers and their children survive childbirth seems like one of the most fundamental concerns society and individuals could possibly have, but I hardly ever hear any mention of it.

  8. Pingback: Sunday News Round-Up, 9/13/09 « Women’s Health News

  9. Nyara

    Very well said.

    You know what’s sad? I saw the first line- The other day, I received a press release titled “It’s Riskier to Have a Baby in the U.S. Than in Cuba or the Czech Republic.”– and immediately said “Let me guess- They put all of the blame on women?” I hate being right, sometimes.

  10. Gina

    Pretending that individual choices will help correct structural problems is a long-standing tradition in American politics. See the emphasis on things like recycling or going green instead of cracking down on huge industrial polluters or doing anything about our oil consumption on a national level for one example. Add a dose of blaming women for things outside their control (another long-standing tradition) and you’ve got a classic piece of American wisdom to disseminate.

  11. lauredhel

    Applause for this post.

    ” First, tell the doctor the truth.”

    This comment actually comes from a place of privilege, and while it sounds superficially attractive, it is not good advice for all women. If you are, for example, a poor woman of colour, telling your doctor that (for example) you had a drink or a joint or two in pregnancy could put you on the fast track to inappropriate scrutiny and child removal. Talking about a past history of psychiatric illness can do much the same (there has been a particularly terrible history of this in the UK).

    Hear hear to Holly on point “R” – making sure you birth with a specialist doctor in a “high level” facility increases your chance of damaging interventions and unnecessary surgical birth dramatically. One-to-one care with a caseload midwife, consulting specialist doctors only where absolutely necessary, is the gold standard of care.

  12. lauredhel

    Plus, ew, I’ve only just scrutinised point one closely. Firstly, there is no screening for “mental retardation” in pregnancy, only for some chromosomal conditions, none of which guarantee any particular level of intellectual disability. Secondly, many women make informed choices not to screen for chromosomal atypicalities or spina bifida while they are pregnant, and this advice seems to completely erase the possibility of that choice, instead assuming that 100% of women think that having a child with a disability would be completely unacceptable to them. (And that all women would _have_ access to abortion.)

    The last one is a dud as well – routine screening of low risk women for gestational diabetes and with routine ultrasound has been pretty comprehensively shown to be unassociated with any change in pregnancy outcomes.

  13. Pingback: smart tips and empowered births « guerrilla mama medicine

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