Open, honest conversation is essential for any doctor-patient relationship. But it is even more essential in prenatal care, when the health of the mother, the health of the pregnancy and the health of the fetus are all at stake, and when decisions about treatment require both doctors and pregnant patients to be well-informed in order to weigh the risks and benefits of various behaviors and treatments.
The fracas last month about an announcement that no amount of drinking is safe during pregnancy – which overlooked evidence that some drinking does not pose substantial risks to the developing fetus and led to accusations that medicine is infantalizing women by assuming they can’t understand the nuances in play – exposes a much larger problem: pregnant patients and their doctors are often less than honest with each other.
And it goes far beyond drinking. Four states – Arizona, Kansas, Montana and Oklahoma – have laws, all passed since 2010, allowing doctors to conceal fetal birth defects if they suspect parents will choose an abortion.
And according to the reproductive rights group The Guttmacher Institute, 18 states have laws requiring healthcare providers to report pregnant women for suspected drug use; four of these states require healthcare providers to test the women for drugs. Depending on the state, pregnant women who test positive for illegal drugs can be charged with child abuse, committed to mandatory drug treatment and denied their parental rights.
Doctors understandably chafe at these requirements, which threaten patient confidentiality and trust: the American College of Obstetricians and Gynecologists and many other medical groups protest that such laws encourage patients to lie to their doctors about their substance use, which may prevent them from getting needed treatment, and may even discourage them from procuring essential prenatal care.
Unfortunately, even when pregnant women do seek care, they often find that doctors ignore, minimize or fail to treat their ailments in the name of unspecified fetal risks. Doctors are legitimately wary: the Food and Drug Administration does not require medications to be studied in pregnant women before they are approved, and the Centers for Disease Control estimates that there is adequate safety data for just 10% of drugs. More than 40% of obstetrician-gynecologists (OBGYNs) surveyed by the American College of Obstetricians and Gynecologists (ACOG) said they lack sufficient data to provide high-quality advice to pregnant patients about treatment risks and benefits.
But worries over liability are also a major factor in preventing free and open communication about the limitations of knowledge about how drugs affect pregnancy. In the same ACOG study, nearly 40% of OBGYNs said that fears about being sued over birth defects or pregnancy complications keep them from honestly discussing drug risks with their pregnant patients. Rather than presenting the existing data and explaining to patients how much is not known about drug safety in pregnancy, doctors prefer not to prescribe, to refer patients to other doctors or to prescribe older drugs that are presumed safer but are often less effective.
This approach is not just cowardly and evasive, it is potentially dangerous. If inadequately treated, many conditions, including diabetes, depression and asthma, pose serious risks not just to the woman, but also to the fetus. Referrals to other doctors fragment care and can lead to dangerous medication interactions if physicians don’t keep each other in the loop. And, doctors refusing to prescribe needed medications encourages pregnant women to self-medicate with over-the-counter drugs and supplements. Nearly 30% of women report using herbal medications during pregnancy, and 4 in 5 do so without a doctor’s recommendation (OBGYNs also report that pregnant women are much less likely to ask them about the safety of OTC and herbal remedies than about prescription drugs).
Many women erroneously believe that over-the-counter medications and supplements are safer than prescription drugs, even though OTC treatments carry their own risks and the FDA doesn’t hold supplements to the same safety and efficacy standards required of prescription drugs.
Yes, a pregnant woman can consult a pharmacist, pore over packaging information or search the internet, but she’d be better off having a frank conversation with her doctor about the risks and benefits of all the available treatment options so that she can decide what’s best for her and her pregnancy. That means, despite many barriers, women and their doctors need to build a mutually trusting, honest clinical relationship. If doctors don’t initiate that, pregnant women should insist.
