With news that the newly approved COVID-19 vaccines may now be offered to pregnant and breastfeeding women in the UK, Emma Schofield reflects on why informed debate and respect for bodily autonomy are so central to discussions around women’s reproductive health.
For most women, becoming pregnant brings with it a number of changes, some of which may be expected, while others may come as something of a surprise. Sickness and nausea in the first trimester? Not exactly welcome, but generally anticipated. A yearning for cranberry sauce in mid-June? Hardly out of the ordinary for pregnancy. The sudden realisation that your health, size, shape and related choices are suddenly everyone else’s business? Maybe not something most pregnant women would say they expected.
From the minute you become pregnant something changes; your health immediately becomes an accepted topic of discussion by everyone from friends and family, to random strangers in the supermarket or on social media. Everyone has an opinion and all too often they feel comfortable with passing that opinion on, without filter. Thoughts and unsolicited advice on managing sickness and backache come thick and fast from every angle, while horror stories about the reality of childbirth abound, along with comments about the size and shape of your bump. The input doesn’t even end when the baby is born: thoughts and views on the comparative benefits of breast or bottle feeding, weening and sleep training continue to be offered, whether they are sought or not. Anecdotes and superstitions are everywhere, but what tends to be sorely lacking are actual facts, facts which are grounded in medical and scientific research. Which is what makes the issue of the COVID-19 vaccine all the more galling for pregnant and breastfeeding women. Unsolicited advice about parenting can, perhaps, be defended by the fact that it is frequently well meant and not generally intended to question the intelligence of the pregnant woman or new mother. Generally these comments are not loaded with hysteria and fear. The same cannot always be said when it comes to the matter of healthcare for pregnant or breastfeeding women.
For myself, the first sign that things were shifting was around halfway through a planned pregnancy when at a routine antenatal appointment I found myself being referred to as ‘Mum’, rather than by my name. I initially assumed that this was a one-off, someone trying to be nice and capture the excitement of my journey towards parenthood. As time went by and I attended more appointments, it began to grate. The medical checks I was undergoing were serious, there was nothing frivolous about the scans, tests and monitoring which were happening, some of them were both stressful and invasive and yet I frequently found myself being spoken to and about as simply ‘Mum’. Grateful as I was for the care being provided, it still made me want to scream; I was still me and my body was still my own, even if it was currently busy growing another person. I’m sure there was no malice in it, but it made me feel like a vessel, as if my identity was being slowly eroded and as if my status as a prospective mother was now the dominant part of who I was. In some ways I suppose it was, my desperation to deliver a healthy child certainly occupied most of my thoughts and undoubtedly influenced every decision I made from opting for a decaffeinated coffee in the mornings, to deciding to take the pre-natal supplements suggested by my midwife. Yet most importantly, I continued to make those decisions. Sometimes I asked questions, read information from reliable sources and engaged in discussion with my partner, but ultimately each of the decisions was mine.
Take, for example, the whooping cough vaccine; pregnant women in the UK are advised by the NHS to have the whooping cough vaccine in the third trimester of pregnancy in order to provide the baby with initial protection from the disease in their first weeks of life. Having considered the potential benefits of doing so, I decided to have that vaccine. Similarly, women approaching labour are asked to make a birth plan, which includes decisions on medical care in the event that something goes awry during labour, and also encourages mothers-to-be to give consent for procedures such as the provision of a Vitamin K injection for the baby as soon as they are born. For each of these choices I listened to the advice I was given, read up on the potential benefits and risks of each option and then made a decision. It was the exact same approach I had used with all medical decisions before I became pregnant and yet I still found myself being spoken to, and about, by a small number of people as if I had temporarily had my brain replaced with a lump of sponge. I continued to work throughout my pregnancy and experienced the bizarre juxtaposition of days where I went straight from a workplace where I was referred to by my professional title and where my opinion was listened to and respected, to sitting in a clinic being asked ‘and how are Mum’s ankles looking today?’ by someone who I suspected was not fully listening to the answers I gave. It’s part of the contradiction which is having a baby. On the one hand women are encouraged to be proactive in planning for and undergoing pregnancy and childbirth, on the other they are all too often spoken down to, or denied genuine autonomy.
This problem is not a new one. The fact is that the denial of bodily autonomy when it comes to pregnant and breastfeeding women predates the COVID-19 pandemic by several centuries. While things have undoubtedly moved on considerably since the days where pregnant women were confined to their beds and breastfeeding was expected to take place in seclusion, there is still some way to go. In spite of the use of birth plans, survey results in 2017 found that 15% of respondents were not given any choice about where to have their baby, while a landmark Dignity in Childbirth survey conducted in 2013 by the Birthrights organisation revealed that 31% of respondents had felt that they were not in control of their birth experience and 18% felt that health care professionals had not listened to them while pregnant or giving birth. The results of this survey sparked a five year Maternity Transformation Programme and have informed a number of changes which have taken place across the NHS in the intervening years. Nonetheless, a joint submission to the UN in 2019 from Birthrights, the Royal College of Midwives and the White Ribbon Alliance included further evidence that such issues were still far from uncommon among women giving birth in the UK. These findings coming in spite of the fact that repeated studies have shown that while some pregnant women perform less well on tasks involving memory recall or attention span, there is no evidence of impaired mental capacity or decision-making ability as a result of pregnancy and breastfeeding. There is, therefore, no excuse for talking down to these women or treating them as if they are unable to make their own choices about the right medical treatment for their individual circumstances.
The COVID-19 pandemic has once again heightened these issues surrounding autonomy in pregnancy. Women who gave birth in 2020 have already been denied so much: no one permitted to accompany them to scans or appointments, no birth partner to provide reassurance and support in early labour, no visitors during hospital stays, reduced birth choices in some areas of the UK, healthcare appointments both during and after pregnancy cancelled or reduced to the bare minimum, medical support for abortion and miscarriages reduced, the list is endless. All of which is in addition to the crippling isolation of finding themselves cut off from support from family and friends thanks to lockdown rules which in Wales, unlike in England, make no exemption to enable parents with a child aged under one to benefit from the support of an extended household. Then, at last, came the recent news that the Pfizer BioNTech COVID-19 vaccine had been approved by the MHRA, a glimmer of hope on the horizon, shortly followed by the announcement that this vaccine would not be available to pregnant or breastfeeding women. It is natural that this may in part be due to a lack of scientific data and that drugs companies are, understandably, nervous about green lighting a vaccine without full data, but that does not lessen the blow which came from this announcement. Women should not be asked to choose between having the vaccine, or breastfeeding their baby, not when a third option is available. Informed, sensible and calm discussion about the science behind the vaccine and its potential benefits and risks could offer a way forward, yet it featured nowhere in this initial announcement.
In sharp contrast, the new MHRA advice, issued just a few days ago, is that both the Pfizer and Oxford vaccines should in fact be offered to clinically vulnerable pregnant women. Pregnant women who are frontline health or social care workers should also now be able to discuss the option of vaccination. Likewise, the Joint Committee on Vaccination and Immunisation has concluded that as there is no known risk in giving the jab to breastfeeding women, they too should be offered the option of vaccination, once they become eligible. In all scenarios, emphasis is placed on the significance of informed discussion; two words all too often missing from decisions surrounding pregnant and breastfeeding women. An average of more than three quarters of a million women become pregnant in the UK each year, with some 80% of women who give birth to a live baby initially choosing to breastfeed. Yet the decision to become pregnant or to breastfeed is not synonymous with surrendering all bodily autonomy. A pregnant or breastfeeding woman is just as capable of making an informed decision about their medical treatment options as anyone else. Pregnant and breastfeeding women are still expected to work, with many placing themselves at risk during the pandemic. As a consequence, pregnant health and social care workers have continued to work throughout the crisis, with a small number tragically paying the ultimate price. Is it really okay to ask those women to continue to work, without even providing them with the opportunity to discuss the potential risks and benefits of a vaccine which colleagues and peers will be given automatically?
Where no clear scientific advice exists to the contrary, the choice of whether to take the vaccine or not is ultimately one which should lie with women and their healthcare team. Yet for this approach to work, it is essential that pregnant and breastfeeding women should be both spoken to and listened to in exactly the same way as any other individual, with their personal medical history taken into account. Fear should not be permitted to override sensible and practical discussion between a patient and their healthcare team about the best option for them. Hysteria should not replace calm and measured debate about what is in the best interests of a mother and her baby. Only then, will women be able to retain full autonomy over their health as the country struggles to find its way out of this pandemic.
Dr Emma Schofield is a Wales Arts Review Senior Editor.