UK Health Group Wants to Test All Pregnant Women for Smoking

by Cara on June 24, 2010

in Europe, International, misogyny, paternalism, patriarchy, pregnancy, reproductive justice, women’s health

Just last week, I was defending the National Institute of Clinical Excellence (NICE) in the UK for its recommendations regarding age-appropriate sex education. This week, I find myself needing to ask what in the hell they’re thinking.

NICE has recommended that all pregnant women should be given carbon monoxide tests in order to determine whether or not they’re smoking, so that they can be given advice on quitting. Instead of, you know, asking them.

The National Institute for Health and Clinical Excellence said carbon monoxide tests should be carried out on every expectant mother.

If implemented, every woman would have the breath test at her first ante-natal appointment.

Midwives criticised the test, saying it could make the women feel “guilty”.

NICE said the guidelines were not aimed at penalising smokers but were designed to help women and their families give up smoking during and after pregnancy.

“During pregnancy, smoking puts the health of the women and her unborn baby at great risk both in the short and long-term, and small children who are exposed to second-hand smoke are more likely to suffer from respiratory problems,” Professor Mike Kelly, Nice director of the centre of public health excellence, said.

“One of our recommendations is for midwives to encourage all pregnant women to have their carbon monoxide levels tested and discuss the results with them.

“This isn’t to penalise them if they have been smoking, but instead will be a useful way to show women that both smoking and passive smoking can lead to having high levels of carbon monoxide in their systems.”

The guidelines were welcomed by the Royal College of Midwives, but it urged “non-judgemental” support for women smokers.

Right. Except that the way to be “non-judgmental” isn’t by telling women up front that they can’t be trusted. And by telling them that they can’t be trusted specifically once they’ve become pregnant — thus indicating that their bodies are no longer their own. Paternalism, misogyny, and policing of women’s bodies don’t have great track records.

Look, absolutely no one is saying that smoking while you’re pregnant is a good idea. While it’s hardly the automatic death sentence for fetuses that a lot of people make it out to be, evidence suggests that it’s not a great idea for either the woman or future baby. And lots of women do smoke during pregnancy. But it’s rarely because they don’t know the risks (at least in most Western countries), or because they’re careless, stupid women who hate their babies and want bad things to happen.

Women smoke during pregnancy usually because they’re unable to stop. There’s currently a culture in a lot of places that suggests one can drop smoking whenever she wants — that it’s a question of personal choice. We have a tendency to not treat nicotine addiction as a real, serious addiction just like any other. And that’s saying an awful lot, as addictions to other substances are also frequently treated like issues of willpower rather than of physiological and psychological dependency.

It’s also true that a lack of support also tends to factor into why many smokers, pregnant or not, are unable to quit. Clearly, more support is needed. But the way to provide more support isn’t through coerced tests and humiliation. Right now, many pregnant women don’t tell their doctors if they smoke or use other substances. Again, the reason is rarely malicious or negligent, but concern over being judged, guilted, shamed, and/or even punished. The issue is that many women can’t trust their health care providers to react with compassion and care rather than blame and disapproval. And trust is not built by a person in a position of authority expressing a lack of trust in the person in a subordinate position. One would imagine that empathy would go a lot farther than a carbon monoxide test, any day.

While the guidelines don’t seem to make the test mandatory, it’s unlikely to be easy to opt out. Any woman who refuses to take the test, regardless of whether she does so based on principle or any other reason, is likely to be highly suspected of “hiding” something, and lectured by precisely the kind of judgmental health provider that is causing the problem to begin with.

Here’s the thing. People smoke. Some of them do it during pregnancy, and of them, few actually want to. The problem isn’t a lack of “detection,” it’s a culture that shames women as bad mothers and bad people for smoking, and treats addiction as a crime that needs to be “detected” and stamped out by society for the greater good, in the first place.

As much as it generally pains me to say these words, the Daily Telegraph has it right. Rosie Murray-West writes:

Even the Royal College of Midwives seems a little dubious about the plans, worrying that women will feel judged and as if they aren’t being believed. “Use of the monitor has the potential to make women feel guilty and not engaged,” says Royal College education manager Sue MacDonald.  “It is crucial that health practitioners, including midwives, focus on being supportive rather than making women feeling guilty.”

I’m looking forward to the supplementary barrage of tests that NICE will be bringing out later. Perhaps the sniff test to check we haven’t been eating unpasteurised cheeses, or the credit card statement test to check for illegal indulgence in sushi?  Or they could just focus on supporting people who are trying to get through one of the most testing periods in their lives – without unnecessary testing.

Women are people. Even when they’re pregnant. Let’s start treating them that way, hmm?

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{ 8 comments }

1 Social Worker June 24, 2010 at 2:13 pm

This is somewhat reminiscent of the ultrasound dialogue a few weeks back.
This smoking test, and any test that provides helpful information, should be AVAILABLE for women to use to support them in their decisions; not FORCED.
And, again, how does the medical establishment enforce this? If I don’t want to take any particular test, I don’t have to, unless I’ve agreed to a particular job or some such situation where drug testing is “mandatory.”
I don’t know that this question was ever fully addressed with the ultrasound law and I wonder again here. What happens if a women refuses? Is there a penalty of some kind?
That’s a terrifying thought.

The trust between a medical professional and patient is paramount. For me, this raises many ethical fears of what I could be told to report on my patients “for their benefit.”

2 SunlessNick June 24, 2010 at 5:45 pm

Paternalism, misogyny, and policing of women’s bodies don’t have great track records.

And neither does couching them as “help.”

3 Cara June 24, 2010 at 5:46 pm

SW, in terms of the ultrasound laws, if the woman refuses, she would be denied the abortion — it would be illegal for a doctor to perform the abortion without it. As for this, again, it seems to just be a recommendation, not a requirement. But I imagine that lots of women would be coerced into it with “why not do it if you’ve got nothing to hide?” and treated with suspicion, and so on.

4 yazikus June 24, 2010 at 6:54 pm

The thing about this that gets me is that there are basically two types of tests for pregnant women. Tests to find out something neither the doctor/midwife or mother knows, and tests to tell the provider that the mother is doing something illegal. Smoking isn’t currently illegal for pregnant women, so a test to tell a woman if she has been smoking is ridiculous.
She knows if she has been, and it’s not illegal for her to, so why bother with the test?

5 Social Worker June 24, 2010 at 8:25 pm

I think one point, if it’s OFFERED versus FORCED, is that the woman would gain knowledge of the specific carbon monoxide levels in her bloodstream and how his could affect the fetus.
Again, if she wants this info, then it’s good.

Thanks for the clarification on the ultrasound law, Cara. That, I think, is just wrong. Receiving a procedure based on a forced test is reprehensible.

6 Wellescent Health Blog June 25, 2010 at 12:42 am

In addition to being a test that will promote judgment of pregnant women who smoke, another important factor is that tests cost more than asking. Why perform a test for which no treatment will be provided? Telling a woman that smoking is dangerous to her child is the only real form of ‘treatment’ and it can be given regardless. Performing tests like these simply direct funding away from other tests that could actually improve an individual’s health.

7 ailuridae June 25, 2010 at 2:43 am

I’m 38 weeks pregnant, and was having a lot of trouble getting time off to go to doctor’s appointments. I asked if I could skip some of them–not even tests, just appointments in which they check my blood pressure, ask if I have any questions, and send me on my way in 15 minutes.

They immediately threatened to drop me as a patient if I skipped them. Their claim was that they would not be able to account for any “complications” that may arise, and refused to be medically liable. They also refused to sign my FMLA paperwork which would have forced my employer to allow the time off.

It’s not easy to find a doctor, particularly one that’s covered by insurance. Trying to switch mid-pregnancy would be devastating, emotionally, possibly physically, and likely financially. Yet, in America at least, a doctor can drop a patient at any time so long as their life isn’t in danger. I’m sure that doctors would simply refuse to see patients that didn’t comply with the carbon monoxide tests on the grounds that they refused to be “liable” for the possibility of complications arising from not knowing whether or not a woman smoked.

8 Emily June 29, 2010 at 6:12 pm

Can I just point out that this is in the UK so the doctors would not refuse patients that didn’t comply with the carbon monoxide testing. Unlike in the USA doctors here are not concerned about being “liable” for complications as we do not have a litigation culture. Doctors don’t pick and choose their patients.

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