Laura Pemberton was in labor and ready to give birth at her home in Florida when a sheriff arrived at her door, took her into custody, strapped her legs together, and forced her to go to Tallahassee Memorial Regional Medical Center, where doctors had instigated urgent court proceedings. They claimed that Pemberton was risking the life of her unborn child by attempting to have a vaginal birth after having had a previous cesarean surgery. The judge ordered the woman to undergo the operation, which she did against her will later that day in 1996.
Regina McKnight, 21 years old and pregnant, suffered a stillbirth that led to her arrest and conviction on homicide charges in South Carolina in 2001. Although the stillbirth later proved to be the result of an infection, prosecutors argued that McKnight caused the stillbirth because she used cocaine. A jury found her guilty after 15 minutes of deliberation and she was sentenced to 12 years in prison.
Pregnant with her second child in 2005, 20-year-old Rachael Lowe went with her husband to a hospital to get help for her addiction to Oxycontin. An emergency room doctor reported her to Wisconsin state officials and Lowe wound up confined against her will in a psychiatric ward, where she received no prenatal care. She remained incarcerated for more than 25 days before a doctor testified that Lowe’s addiction posed no significant risk to the health of the fetus and a judge ordered her release.
These actions against pregnant women (among more than 400 documented by Lynn M. Paltrow and Jeanne Flavin in the Journal of Health Politics, Policy and Law in April 2013) sprang to mind when I read The new science of blaming moms, an eye-opening commentary by Jonathan Metzl, M.D., Ph.D., director of the Vanderbilt Center for Medicine, Health and Society.
Metzl’s concerns are the misuse of research on the developmental origins of health and disease, and the growing emphasis on the ways a mother’s habits during gestation can “program” her offspring for a future of obesity, heart disease, diabetes, and other ills via epigenetic effects:
We’re back to blaming mothers in health research—or so it would seem. A number of recent epigenetic arguments drop the responsibility for children’s later-life diseases, behaviors, and emotions firmly into the laps of their moms.
Metzl goes on to warn that:
…history teaches us that sometimes when we talk about the pathology of mothers, we aren’t actually talking about mothers at all. As we learned all-too-well in the 1940s, concerns about the behaviors of mothers are sometimes shaped, not by the actions of actual mothers, but by fatherly concerns that women aren’t acting “as they should.” In this sense, we need always be wary of societal and scientific narratives that blame mothers, even as our science moves us ahead.
Blaming mothers, it seems, is an enduring reflex reaction of our society. Nineteenth century medical texts blamed birth defects and criminal tendencies on the mother’s diet, nerves and even the company women kept during pregnancy, Harvard professor Sarah S. Richardson, Ph.D., and co-authors note in a commentary in the journal Nature that echoes some of Metzl’s concerns. In the 1930s and 40s, neurologists attributed autism to “refrigerator mothers” lacking sufficient emotional warmth, a claim unsupported by evidence which nevertheless persisted as late as the 1970s. Amid media hysteria in the 1980s and 90s about crack cocaine and “crack babies,” pregnant women who used crack had their children taken away and were sentenced to prison even as research revealed that fetal exposure to cocaine is no more harmful than exposure to tobacco or alcohol.
And now, careless portrayal of epigenetics and research on the developmental origins of disease poses a real threat to women, Richardson and colleagues say:
Although it does not yet go to the same extremes, public reaction to [developmental origins] research today resembles that of the past in disturbing ways. A mother’s individual influence over a vulnerable fetus is emphasized; the role of societal factors is not. And studies now extend beyond substance use, to include all aspects of daily life … exaggerations and over-simplifications are making scapegoats of mothers, and could even increase surveillance and regulation of pregnant women.
These worries don’t seem far-fetched, given the experiences of Pemberton, McKnight, Lowe and the hundreds of other women documented by legal scholars Paltrow and Flavin.
Pemberton, who sued Tallahassee Memorial Regional Medical Center for violation of civil rights and lost, later gave birth vaginally to three more children – calling into question the doctors’ claims about the likelihood of harm.
McKnight’s homicide conviction was overturned in 2008. The South Carolina Supreme Court said the state had relied on “outdated” research on the effects of cocaine on a fetus. McKnight pleaded guilty to manslaughter and was released from prison after serving eight years.
Lowe remained in state custody for several days after the judge ordered her release from psychiatric confinement. She remained under state surveillance and had to provide urine samples for the remainder of her pregnancy. She was fired from her job.
In most of the 413 cases reviewed by Paltrow and Flavin, officials arrested, detained, or forced women to undergo medical interventions even though the officials lacked legislative authority to do so or were acting contrary to significant appellate court decisions – and always against the consensus among public health organizations and medical groups that such actions undermine the health of children and women. A majority of the women were poor. Nearly three-fourths qualified for indigent legal defense. More than half were African American.
Disadvantaged women may be most likely to be harmed by misguided interpretations of research on the developmental origins of disease.
“Concerns about maternal obesity or smoking often function as thinly veiled critiques of the parenting practices of lower-income women or women of color,” Metzl says. “In these instances, we risk misidentifying social or economic pathologies as family ones, and blaming low-income mothers when we should be investing in the economic programs and support systems designed to help them spend more time with their kids in the first place.”
Richardson and co-authors made four specific recommendations, which I’ve paraphrased below, that scientists, science communicators, and policy makers would do well to heed.
- Remember to think about fathers and paternal effects, too. There’s data showing that diet and stress can alter sperm in ways that increase risk of heart disease, autism and schizophrenia in offspring. Not to mention the father’s influence – for good or bad – on a mother’s mental and physical wellbeing.
- Convey the complexity and unknowns. Developmental exposures are intertwined with genetics, socio-economic circumstances, and environmental factors that remain poorly understood.
- Recognize the role of society. Efforts to change people’s health habits should first identify factors that put people “at risk of risks,” for example, overcrowded and dangerous neighborhoods with failing public schools and limited access to affordable, wholesome food. The idea is to avoid ineffective public health campaigns aimed at changing behaviors that are powerfully influenced by conditions left untouched by the intervention.
- Avoid making claims about animal studies as if they applied directly to people. A study on pregnant mouse diets does not call for dire news reports about women potentially harming their babies (such as this one by the BBC, or this one by The Independent.)
[I posted an earlier version of this piece at Covering Health, where I report on the social determinants of health.]