The biology of carrying a pregnancy isn't altered by state or country borders, so why do health guidelines vary so broadly?
Many factors are at play when decisions are made around health during pregnancy. Anna Maria Liljestrand/Flickr (CC BY-ND 2.0)
Pregnancy is a time where the future becomes paramount. Thinking about this future can be joyous or heartbreaking, as the promise of new life offers both possibility and risk — and because the future is unknown, nobody quite knows how to handle these possibilities and risks. Medical and nutritional science has offered some key insights to promote the wellbeing of expectant mothers and their babies, but the way these findings are applied varies worldwide.
Individual practices like abstaining from cheese, cigarettes, and alcohol, are ways to increase the odds of healthy, long lives for mother and baby. Health promotion also happens on a national, and even global scale with government health bodies publishing advice along with the World Health Organization. The array of advice not only attempts to protect populations from the grief of miscarriage and stillbirth but also cares for population health generally.
Many countries, including Australia, are facing a future of an ageing population. In these countries, the healthcare needs of the numerous elderly are increasing, while the relative pool of people of working age is decreasing. Here, healthy young people are particularly valuable. Healthy pregnancies and births also lower the public funding required to treat and support people with preventable disorders that emerge in gestation, such as foetal alcohol syndrome, congenital lung disorders, cleft pallet, and heart defects. It is a mix of minimising the costs of illness, and also maximising each nation’s productive potential.
According to guidelines in some countries, caffeine during pregnancy is off the table. Duncan C/Flickr (CC BY-NC 2.0)
However, around the globe women from different regions are given different advice geared at staving off the risk of an adverse outcome and promoting a healthy one. For example, caffeine is a complete no-no in the US, but up to five cups of tea a day is considered fine in the UK. Sushi is recommended for Japanese women, but carefully avoided elsewhere.
A good example is the difference in the perceived risk of listeriosis (a listeria infection) in pregnant women. Listeria is a type of bacteria that can exist in uncooked, unpasteurised foods. Although risk of listeriosis is low in the general population (1 in 140,000), it is 20 times more common among pregnant women. If a foetus or newborn infant is infected, the damage can be severe, and often fatal. The statistics show that listeriosis is not likely to happen, but one way of trying to mitigate a heartbreaking future is to eat with caution.
In various countries around the world, including Australia, the risk of listeriosis is actively mitigated in health advice given to pregnant women. Don’t eat soft cheese — brie, camembert, ricotta and feta are off the picnic blanket. Avoid deli meats, pate and pre-prepared salads too.
In some other countries, however, different advice is given. Cheese is a way of life in some European nations like France and Germany. As a Rachelle Atkins, an American who blogs about child-rearing as an expat in France, quips: "For plenty of French women, the notion of going without wine, cheese, cigarettes, or caffeine for nine months is as crazy as saying a French man must go through forty years of marriage without taking a mistress".
Consuming soft cheese presents a risk of listeria for pregnant women, but some cultures can’t live without it. Marc Kjerland/Flickr (CC BY-SA 2.0)
Aside from food culture, there are multiple ways in which the body itself is understood that create different practices and restrictions geared toward neutralising future risks. For instance, in traditional Chinese medicine, the mind and body are conceptualised as a fluid, inseparable system. Extreme emotions during pregnancy are thought to influence the organs, including the uterus. Also, to maintain balance (the energies of yin and yang), cold foods (like ice-cream) are to be avoided in case they impact the circulation of the uterus.
An additional complicating factor is how guidelines are followed, further reflecting the way future risks are perceived worldwide. A study in the British Medical Journal found that 40% of pregnant Australian women drink alcohol at least once during the nine months of gestation. The rates of drinking are higher again in New Zealand (56%), the UK (75%) and Ireland (82%). The disparities in the study exist despite the fact that official guidelines for each of these countries advise against drinking any alcohol at all.
In some cases, guidelines are subverted in an attempt to control labour and delivery outcomes. In 2006, there was concern in the UK media when the (then) public health minister claimed that it was common practice among pregnant teenagers to take up smoking. The young women had been told that smoking reduces birth weight, and were so frightened of childbirth that deliberately pursuing the side-effects of smoking actually mitigated their anxiety, as they believed that a baby with a lower birth weight would be less painful to deliver. Similar activity was found in a 2010 Australian study where informants made clear that they knew the dangers of smoking, but that they were simply responding to a threat that felt more immediate.
Fear of pain during childbirth can drive some women to make poor health choices. Salim Fadhlet/Flickr (CC BY-SA 2.0)
There is actually no evidence that giving birth to a smaller baby is any less painful, and smoking during pregnancy carries the additional heightened risks of miscarriage, stillbirth, and premature birth. Yet, it is important to understand that these activities are part of a very human compulsion to try to control the thing we are afraid of.
It seems that while the goals are rational, their pursuit is not always so. In reality, national guidelines and perceived risk seem as much based on politics, culture and society as on scientific evidence of best practice. After all, there’s not much biological difference between the pregnancies of a French woman and an Australian woman, yet in France she would not be told to give up her camembert. The distinction between the two comes from a different perception of acceptable risk.
There are multiple ways of dealing with this ambiguity, involving both scientific evidence and cultural threads. Some of it goes back to what is practical — the French are unlikely to stop eating soft cheeses, after all. Some of it is scientific — parental smoking and drinking habits have convincing data backing the claims of their long-term effects on infants. Some of it has a basis in tradition rather than peer review. It appears that risk management in pregnancy isn’t an exact science, it is a multifaceted set of decisions people make relating to factors specific to their lives, in concert with their healthcare professional. Of course, the best way to stay up to date on the guidelines applicable to your particular situation is to keep regular appointments with your GP, obstetrician or midwife.
If this article has raised any issues for you and you would like to talk to someone about it, please contact Lifeline Australia (13 11 14) or Beyond Blue (1300 22 636).
