“What if…?” On prenatal precautions and superstitions, and the burden of blame

Lying in bed the other night, drifting off to sleep thinking of holidays and cookie traditions and solstice eclipses, I jerked alert with a sudden, horrible realization: I have not been taking B vitamins. And without B vitamins — folate/folic acid in particular –, babies get neural tube defects. It’s Science. Everyone knows this. And once one knows one is pregnant, it’s really too late, because it’s most critical in those very first weeks, when the neural tube is first being formed. And for whatever reason, I, though trying to conceive, had completely forgotten about this Most Vital Fact and have neglected to take any form of prenatal combination vitamin or folic acid substitute and so I have doomed1 my child to cleft palate, or spina bifida, or, my nightmare when I was on a drug with a significant increase in NTDs, anencephaly.

Except that’s not true.

The truth is that a maternal diet low in folate (found primarily in leafy greens) is associated with an increase of neural tube defects noticeable on a population scale, enough so that in the USA we enrich nearly all grain products with folic acid2. The truth is that even without supplementation, the risk of NTDs are still really quite low. There’s also decent evidence that we piss away most of the content of artificial, pressed-together single-dose multivitamins. So for most people, especially those with halfway decent diets who do not regularly suffer from starvation or malnutrition, skipping vitamin supplementation is a pretty safe choice.

Except that’s not true, either. Hear me out.

The risk for choosing to avoid supplementation — or any other prenatal practice dictated as standard by society — isn’t, primarily, physical or nutritional: it’s social and emotional. The risk isn’t that one will have a child with a neural tube defect (which, even with food- or supplement-based folate intake far exceeding the ridiculously low minimums set by the FDA, is entirely possible) or other “imperfection”, the risk is that one will have a child with an atypicality and be blamed for not doing everything possible to prevent it.

The risk is that one will spend an entire pregnancy obsessing and worrying over what one “ought” to have done better, taken more of, eaten less of. The risk is that one will blame oneself for the rest of one’s life should it happen. The risk is that one will live with a constant refrain of “What if?” running in the back of their brains, never ceasing, never slowing, never backing down in the face of reason or rationality or science or practical assessment of odds because what if. What if something’s wrong because I didn’t take vitamins, did drink a beer, ate too much tuna? What if I could have prevented this condition/disease/disability/death if I had only done this differently, better, not at all? What if, what if, what if?

When we have taken all precautions — based in science and fact, or superstition and “everyone knows”3, or some muddled combination thereof — that are deemed appropriate by our society, well then, things just happen sometimes, and though still at risk for the whispers (or outright statements) that we must have done something wrong, we also often get sympathy (or pity) and are assured of our inculpability. But if we didn’t? Ah, then, we are at fault, inescapably, unforgivably. Then it — our baby born brainless, our newborn unable to nurse, our child needing yet another surgery — obviously wouldn’t have happened if only we had done better/more/what we were supposed to.

And so we take our vitamins, get the tests, avoid soft cheeses4 and deli meats, and pray nothing goes wrong and we will not be victim to the unbearable blame.

*****

Appendix, or Apologia: Of course there are good reasons for some of our prenatal precautions, and there is almost always at least some seed of reality behind each of them (except the all-soft-cheeses here in the USA — that one I’m fully willing to mock). I’m hardly arguing against ignoring all precautions, or saying that people only follow them out of preemptive defense. We each take the information we have and perform absolutely brilliant feats of risk-benefit calculations on it, and make the best decisions out of the choices available to us given the resources we have. My point is not that pregnant people are sheep, or prenatal precautions are entirely pointless, for there are Prenatal Do Nots that I indeed do not do5, and some proscriptions I proverbially thumb my nose at6, and some precautions — the folate — that I wish I had done. My point7 rather is that fears, not so much of the risk but of the social repercussions of bypassing expected precautions, are absolutely included in our calculations. And sometimes, when we deviate, they keep us up at night.

  1. Because having any form of physical variation such as spina bifida is of course automatically DOOOOOOOM. For the unfamiliar, this footnote is sarcasm.
  2. Why we don’t instead, say, make leafy greens — and vegetables generally — more accessible to everyone who wants them is a rather different rant.
  3. And oh, how often one masquerades as the other!
  4. Despite all USian cheeses being required to be pasteurized or aged sufficiently that risks of listeria are considered nonexistent; some soft cheeses somewhere in the world aren’t, and so have an astronomically small risk of carrying pathogens, and so best to avoid all soft cheeses everywhere, obviously.
  5. Such as deep abdominal work — when not a part of Maya Abdominal Massage — which is really a bummer because my psoas needed some lovin’ this week and didn’t get it.
  6. Oh holiday homemade eggnog with raw eggs and a dash of rum, how I adore thee!
  7. In this post, because oh will there ever be more posts on pregnancy and kyriarchy and social pressures and the arbitrary nature of Western pregnancy and birth, should this currently-seed-size collection of cells stick around for the entire ride.
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23 Responses to “What if…?” On prenatal precautions and superstitions, and the burden of blame

  1. My first thought as I read through this was “Ah, the
    downside of too much knowledge.” You know all this stuff, and
    therefore feel all this pressure to Do Something About It, to take
    it into account. Even when you choose to ignore something–you have
    to make the choice. Sometimes ignorance IS bliss. Anyway, happy
    obsessing. I’ve decided in my old age that the secret to a happy
    life is to have something good to mildly obsess about, and I can’t
    think of anything better, for you, right now, than pregnancy/new
    baby. (when I say “mildly”, I mean only that it adds to your life
    and aliveness, rather than preventing you from functioning.). (I’m
    beginning to understand why you do all those footnotes.)

  2. Oh so true. I could write volumes on the blame game that comes when your birth doesn’t go as planned, and you end up with child who isn’t “typical” – doctors, in-laws, random strangers who feel they have the right to ask impolite questions until they figure out how you fucked up your kid….If you don’t start out with telling them how you blame yourself, it’s the inquisition all over again, and if you do start out with blaming yourself, you’re shamed for having been so negligent.

    Being a mom is hard work…and I think it’s just easier for people to blame moms than to be helpful. Less work for them, and they get to feel superior.

  3. several years ago, people smoked & drinked
    & ate whatever during pregnancy.. my birthmother almost
    surely did! Most of us are fine… and then what about seat belts
    & helmets, etc… I guess we’re just living in another,
    more cautious world! Not a bad thing for sure…

  4. In many cases, the vehemence in blaming comes from the emotional fear of it happening to you. If only the unfortunates are not unfortunates, but instead Those Bad People or even Those Misguided People who Screwed Up, it’s easier to convince yourself it won’t happen to you. Even though I’m philosophically opposed to blaming people, if I can find some reason that what happened to them won’t happen to me, I feel better.
    It’s not really healthy to blame, but I think it is often understandable.

    As far as the folic acid- my mother tried for 16 years and, despite several false-starts, never carried to term… until folic acid. So I swear by it, since I might not exist without it.
    Still, I didn’t take any during the early period of my textbook-normal/healthy (albeit unplanned) pregnancy and everything was fine- it’s really not worth worrying about.

  5. I’ve worked my whole life with people with serious developmental disabilities. Disability happens. Folic acid or not, 1 or 3 beers or not, sometimes chromosomes replicate, or translocate, or do what they want. I think the reason we freak out so much is that it is much much scarier to admit that most of the time, we can’t do anything about it. I will be over 35 when the babies are born (I am expecting twins) and decided not to do genetic tests for the same reason — a little knowledge is dangerous. I feel unqualified to make assumptions about the life of a being that is a diagnosis before he/she is a living, breathing child.

    I’ve heard every pregnancy-related, vaccine-related, lifestyle related theory there is by mothers rehashing What Went Wrong. And there is usually no answer.

    I’m now a gestational diabetic and I’m freaking a bit about that and eating very strictly because I lost a cousin to stillbirth and his mom had gestational /type II diabetes (I was never sure and this was 35 years ago…) But that’s my hang-up. And there’s clear evidence that controlling blood sugar in GD leads to better outcomes. But it’s one of the few things I can control in this crazy experience of having my body taken over by two creatures…

  6. Thank you, thank you, thank you. (And thank you, thank you, thank you.)
    And belated congratulations!
    Now that you have boychick, at least you know that worrying-while-pregnant (and being criticized, and criticizing yourself) is only the beginning of what happens when you are a parent. Hardcore practice for a very hard-to-beat monster.

  7. This is one of those things I went through when I was poor and pregnant with my first. I didn’t have the luxury of having every little thing to prevent every little thing. I had to use my money wisely, and spent it on good food instead. I did have a bottle of folic acid tablets, though. And a bottle of prenatals that I couldn’t stomach so it went largely unused. I also had a book! It was called “What’s Going on in There?” (http://www.amazon.com/Whats-Going-There-Brain-Develop/dp/0553378252) It was really helpful as it was chock full of actual studies with actual risk percentages of all the various warnings we all hear. Most things were very marginally risky. I enjoyed my sprouts and deli meats, and even bleu cheese (shock! horror!) without a worry. Hell, I even drank a whole beer the day before I figured out I was pregnant.

  8. Four years ago, I decided to start trying to get pregnant, so I began Doing Everything Right. I lost weight, quit smoking, drank obnoxious amounts of water, meditated, took a prenatal vitamin every day, had the paint in my old house tested for lead, stopped drinking, blah, blah, blah. Then I failed to get pregnant at all. Then science helped me get pregnant, only to have miscarriage after mysterious miscarriage after miscarriage. Now, after being diagnosed with and treated for a syndrome, an -ism, and a -philia, I’m 20 weeks pregnant (the furthest I’ve ever gotten), and I can tell you that I’m a LOT less concerned this time around with Doing Everything Right. It’s either going to work out or it’s not, but I’ve come to see that I have a lot less to do with it than I thought.

  9. I was overly cautious with my first pregnancy. My rationale was if we know these things (listeria, etc) then we should do what we can to reduce the risk no matter how small because there is a whole shit ton of risk we *can’t* control. But then, when pregnant with my second, I discovered the whole pasteurized soft cheeses argument and decided that I wouldn’t refrain from them this time around. I also occasionally had some preprepared salads (a few Subway sandwiches) though I still tried to avoid them. In short, I was less cautious but still aware of the risks and tried to do what I could.

    Everyone makes their own choices based on the info at hand but I do think people need to be more accomodating to what choices we do make. What I’m getting at is this: When I was avoiding everything They say to avoid, I got crap from people telling me I was being ridiculous. Did I tell *them* not to eat the things I was avoiding when they were pregnant? No. But they felt the need to belittle me for doing what I thought was right. Not only that, but it is nearly impossible to actually follow all those rules. I tried and suffered a lot of stress in the process. Available food options become next to nil. And, vice versa, I got Looks when I ate brie while pregnant with my second. Damned if you do, damned if you don’t.

    Anyway, that was a ramble saying pretty much what you were saying. Nice, huh? Also, I would like to officially lodge my disappointment at the lack of Doctor Who reference in this post. You denied a triple dog dare, you must pay!

  10. I had serious nausea throughout both of my pregnancies, although most severely during the first trimester. Which isn’t uncommon, at ALL. I dutifully took those prenatal vitamins, because oh, the horror if I didn’t. And at least half the time, I threw them up out the car door on the way to work or someplace equally inconvenient.

    And yet, I did feel like I had to do ‘all I could’. Even as I knew that it likely wasn’t making any difference, thanks to the fact I couldn’t keep the vitamins down. The fear that my baby would have a problem and I would be TO BLAME was too real.

    I think that we clearly need to re-examine the way we view and approach pregnancy altogether. It’s not a test that we’re graded on, but you wouldn’t know it if you read most books or attended most prenatal classes. How we change our outlook, I don’t know. But the current situation is all about mother-blame and fear and I kind of hate it.

  11. I think my story is similar to many. My first pregnancy was all about no caffeine, no drinking, lots of vitamins and healthy food (when I could stomach them) and lots of rules. It got interesting when I had to have surgery when 22 weeks pregnant. My two subsequent pregnancies had some fewer rules, but no less worry. And my third saw another surgery while pregnant (almost third trimester).

    They each turned out fine, except one small thing that fascinates me and causes me to seek out an explanation to this day. Was it me? Was it a weird genetic something or other? What? And I do seek a way to blame myself (or let myself off the hook). Letting go of that would be/will be/is difficult.

    I don’t believe in the philosophy that if we lived through it, it must be ok. But I also think we need to reevaluate all that we think we know about pregnancy and birth. Why must we live with two extremes all the time? It would be nice to have a little balance from time to time.

  12. My (only) pregnancy wasn’t near as strict as some people are saying here – perhaps partly because I’m in Australia, and it was nearly ten years ago? Prenatal multis have never been standard of care here, though, only folate. I was mildly worried about not having been on folate at conception, but the OB who did my 12-week screening ultrasound pished at that and said that people like me with a reasonable, balanced diet really don’t need to fret about it. I wasn’t so much fretting about survivable spina bifida issues, but about anencephaly.

    I drank a coffee or two a day and a wine a week after first trimester (I was too sick anyhow much of that time), and a wine a day while lactating. When I wanted some ham or brie, I just whacked it on a pizza so it got hot before eating; but Listeria risk foods were not a big deal because I rarely are out (again, the hyperemesis). I took a whooooole pile of antiemetics of various sorts, throughout pregnancy, and a fair bit of analgesia also (for complications from the hyperemesis), and refused to feel guilty about that for a second. Even had an emergency chest X-ray.

    There has recently an increase in US-style fear-mongering around pregnancy and lactation here, unfortunately. I hope there is some way to arrest or reverse that trend.

  13. Lauredhel: I think the trend in Australia is interesting.
    There’s a whole pile of stuff. For example, there’s the substantial
    cross-over in publishing, so many people relying on books for info
    are getting fundamentally US-culture information, even if checked
    over and adapted. There’s also, unfortunately, a generational thing
    where the older (non-medical) people advising me that “back in the
    day” cheese and alcohol consumption in pregnancy went unremarked
    also advise me in the same conversations that they don’t see what
    all the fuss is about restraining babies and children in moving
    vehicles (at all, not just to the latest standards). So the two
    become associated: there’s “what’s all the fuss about, mainstream
    parenting in the 1970/1950s/whenever was the peak of parenting” and
    all changes from that are lumped together as “sensible modern
    precautions” or “this extreme modern worrying” depending on your
    point of view. The idea that each change may be more or less
    evidence-based and based on bigger or smaller risks has been lost
    in my personal discussions at least. That’s anecdotal
    parent-to-parent stuff: I can’t comment on medical advice because I
    was never given any. My one pregnancy to date was just high risk
    enough that all the focus was on measurable signs of fetal or
    maternal illness, eclipsing attention to much smaller risks of
    listeriosis or FAS etc. (Which wasn’t entirely good, but it gets
    off-topic here.)

  14. FYI, it is possible to get unpasteurized soft cheese in the
    USA, although one is INCREDIBLY unlikely to stumble across it
    accidentally. It is a higher quality cheese than most USAian
    cheeses and so tastes MAGNIFICENT. I am not an unpasteurized
    milk/cheese fan in general but dang, that blue cheese was awesome.
    I ate it while pregnant.

    • Brigid Keely — the information I found all indicated that the unpasteurized cheese legally for sale in the USA had to be aged for at least 60 days, long enough to eliminate any listeria risk. So it does exist, just not quite the same as might be found elsewhere.

      Also, blue cheese = ew. :-P

  15. Your first footnote there kind of struck a sour note with
    me. The more severe forms of spinal bifida are fatal. My sister in
    law’s first pregnancy ended in the stillbirth of a baby boy with
    spinal bifida.

    • Anon — I’m sorry for your sister’s (and your) loss. My point was not to belittle or minimize all forms of NTDs (because, as you say, and as I am well aware, some of them are incompatible with life) but rather to note that neither do they all automatically equal “doom”. I know many excellent people who were born with spina bifida; I would not unwish them or their lives, and while acknowledging the real fear NTDs strike in prospective parents (including me), I will not insult those people by saying, except sarcastically, that spina bifida is always a horrible, awful thing.

      I could have phrased that part in my post with more consideration and nuance, however, and so I apologize for whatever pain it caused you.

  16. Have you tried any PNF/proprioceptive neuromuscular facilitation for your psoas? I’ve found it to be equally as helpful in activating & chilling out my psoas as hands-on work for it. There may be someone around Portland who does it, as an instructor of PNF (Shuna Morelli) is in Olympia, and perhaps her teacher is actually based in Portland. Maybe you know about this already from your massage training, but I didn’t hear of it until my continuing education classes after getting licensed (in WA). I could send you my handout (scanned or something) if you want and someone could do it to you as you walk them through it. You can see my email address, right? Of course all the caveats apply (i.e. do this if you feel as though it would be good for you and your back – you’re the training LMT-to-be and know your history. I only have vague hints that you’ve had back issues periodically.), but I trust that you’re on it.

  17. Oh yes, the Watiff monsters. Nasty creatures, those. We were just tweeting about that last week- all the Things You’re Supposed to Avoid While Pregnant, lest you be attacked by the Pregnancy Police.

    Anecdata: pg 1, planned, did everything “right”, except that I was on Zoloft. He was born premature at 32w, no known cause. Will turn 6 in 3 weeks and has no apparent medical issues.
    pg 2, planned. Early miscarriage led to the discovery I’d been carrying twins. HG. Couldn’t eat much and couldn’t keep anything down for the first 5 months. Boatload of ultrasounds. Copious amounts of anti-emitics. When I could eat, I preferred sashimi. Yes, raw fish. Born at 38 weeks, now age 3 and also apparently healthy.
    pg 3, SURPRISE! Spent early pre-testing weeks around a multitude of noxious and toxic chemicals. Had bleeding scare early on, resulting in prescription for progesterone supplements. Survived on feta, grape tomatoes, and Kalamata olives for several weeks, then sashimi and the occasional neck of beer. Born at 37.5 weeks, now 6 months and thankfully nothing of concern apparent to me or his pediatrician. Though he does seem to have some kind of baby superpowers, as he’s been crawling since birth.

    My personal mission is to help equip every woman with the resources and tools she needs to educate herself and feel confident in her choices, whatever they may be. I feel there’s so many toxins in our environment we’re all kind of screwed anyway, so we should just do the best we can and trust that everything will ultimately work out, regardless of our plans.

  18. I LOVE THIS POST! I am 15 weeks pregnant with my second child. Like many of your commenters (commentors?), I was pretty “safe” during my ‘first’ pregnancy (had an early miscarriage before my son). This time around I am a little less worried (obsessed?) about things. With all of my decisions however? Guilt is on the brain. Can I live with the possible consequences? Guilt is a horrible thing that seems to inflict moms to the nth degree. There seems to be so much on the line and we are the only people responsible. I remember my sister telling me that she couldn’t wait till she had the baby just so that her husband could share in all the responsibility. I bet many of us know and appreciate that feeling.

    (I will admit that I have only read this post from you and know absolutely nothing about you. However, I can’t wait to explore your site and learn more! You are a fabulous writer. I can’t wait to share you with my readers.)

  19. Amen, sistah! Someone gave me a link to this post because I forgot to take my multivitamin yesterday AND today (go figure, with the stress of being called away to the hospital yesterday and then to the ICU today). I wasn’t really sweating it, but then the doc wants me to take FOUR folic acid pills per day! It seems a bit much, but… what might happen if I don’t?

    I totally understand not wanting to risk being wrong. I had to make that choice when it came to not vaccinating my older daughter. It came down to this: I was more willing to be wrong than my husband. But then that is a whole other topic.

    Sushi, though, fits this post better! I have been asking EVERYONE I know (doctors or mothers, anyway) about sushi. It is on that avoid list. And of course it would seem silly to risk my unborn child’s health for some simple pleasure such as sushi – why not just wait 9 months. But it seems a silly restriction. I found 1 mom that ate it during 2 pregnancies with no dire consequences. I went nuts eating sushi that day and was then sick for 2 days! Argh! That did NOT help my argument! :-P

    • Momma Jorje — The reason usually quoted for sushi is “it’s RAWWWW ZOMG!!!!”, because, improperly prepared, there’s some minuscule risk of food poisoning. Which is, in my rarely-humble opinion, bullshit. The better reason for avoiding or limiting sushi is oceanic pollutants: not only is it fish, often top-chain fish (like tuna) which concentrates POPs (persistent organic pollutants, like mercury), but it doesn’t go through a cooking process, which can help remove some of the fats, which is what carries the pollutants.

      All that said, I absolutely enjoy a piece or two of salmon sushi every week or three, even while pregnant. I don’t eat a ton of fish, and mostly eat organic foods, so I’m ok with the amount of POPs I ingest thereby. (And, it really, really shouldn’t be on pregnant people to avoid pollutants, but on companies and governments to prevent their release into the environment in the first place!)

      • lol – if you check out my post Japanese Women Have Worms, it is all about this sushi issue. I had someone tell me that it was safe if it had been frozen. When I made myself sick, I had an entire serving of tuna AND an entire serving of salmon! I suspect I truly overdid it.

        I’ve been transferred around a bit with this pregnancy and I just keeping asking every doctor, resident, nurse, etc. It is as if as long as I can get one person to approve of it, I’m safe from whatever it is they say is so risky about it! lol

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