Analysis Maternity and Birthing

No More Needles in the Stomach: New, Non-Invasive Prenatal Test Is Introduced

Martha Kempner

The new cfDNA test can detect 98 percent of Down syndrome cases and has a 0.5 percent chance of false positives, but the medical community is still approaching it with caution.

This summer, I sat on the beach with two new mothers and their infants and listened to them swap pregnancy and birth stories, as new mothers are wont to do. I chimed in with a few highlights from my two pregnancies, including one story about my amniocentesis and when, at all of 18 weeks in utero, the fetus that would become my daughter Juliette reached into the black void on the screen in front of me and grabbed the needle. Then I asked if either of them had had an amnio and was shocked when they both said no, despite the fact that at the ages of 36 and 43 they are considered to be of “advanced maternal age.” I then asked if either of them had been given a nuchal translucency to determine whether or not the fetus might have a chromosomal anomaly like Down syndrome. “Oh no,” they explained. “They don’t do that anymore. There’s a new test.”

Seven years ago, when I had my first baby, the nuchal translucency was the new test—so new that while I had it in New York City, it was not offered to my friends in other parts of the country. By the time I was pregnant again, the nuchal had followed me out to the ‘burbs. But, apparently, in the three years since then it has been usurped by something that is newer, better, and done earlier in a pregnancy. I’d already planned to find out more when my cousin called to announce she was nine weeks pregnant with a boy. “If you’re only nine weeks along,” I asked, “how do you know it’s a boy?” “Oh,” she explained, “there’s this new test.”

The new test—which is marketed under the brand names MaterniT21, Harmony, verifi, and Panorama—is referred to as cfDNA testing because it is an analysis of cell-free fetal DNA found in the pregnant person’s blood. The test requires a simple blood draw from the mother. Fragments of fetal DNA—which makes up between 3 and 13 percent of the pregnant person’s blood during pregnancy but disappears entirely right after delivery—are isolated and analyzed for chromosomal abnormalities, including Down syndrome (also known as trisomy 21), Edwards syndrome (trisomy 18), and Patau syndrome (trisomy 13), all of which can cause serious developmental and medical issues. (All of these anomalies fall under the category of fetal aneuploidy, which refers to any condition in which there are too many or too few chromosomes.) As an added bonus, the test, which can be given as early as nine weeks into a pregnancy, can reveal the fetus’ gender.

Interestingly, some cfDNA tests can also detect anomalies of the sex chromosomes, such as Turner syndrome (in which a fetus develops with only one X chromosome instead of the normal XX female or XY male), Klinefelter syndrome (XXY), Triple X syndrome (XXX), or XXY. (For more on these chromosomal anomalies that affect gender, see Rewire’s article “The Biology of Gender.”)

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Research on the tests show that they have 98 percent ability to screen for Down syndrome and a very low rate (0.5 percent) of false positives. In one study of over 1,000 pregnancies in the United Kingdom, the rate of false positives came in at 0.1 percent.

This new testing method is preferable to the existing methods for a number of other reasons as well. Obviously, a blood test is less invasive than an amniocentesis, in which a physician sticks a large needle through a woman’s stomach into her uterus in order to retrieve amniotic fluid for testing. Another test, called Chorionic Villus Sampling (CVS), is also invasive as it involves going through the cervix to get a small sample of the placenta. Though the results of these tests are definitive (they provide a firm diagnosis) both carry a small risk of miscarriage (estimated at less than 1 percent). These are also conducted later in the pregnancy; CVS can be done between 10 and 12 weeks, amniocentesis between 15 and 20 weeks.

The “combined test,” which includes the nuchal translucency and one or two blood tests, was considered a major step forward for prenatal testing. It can be done at 11 weeks and is not at all invasive. In the ultrasound, the technician measures the space at the back of the fetus’ neck. This “translucent” space tends to be larger in fetuses with genetic anomalies, because fluid often accumulates behind their necks. Technicians also look for the presence of a nasal bone, which is another sign of normal development.

One major issue with the combined tests is that the results can be confusing, because they are presented as a probability. For example, based on age alone, a 30-year-old woman has a 1 in 1,000 chance of having a baby with Down syndrome. Using her age, the measurements taken during the ultrasound, and results from the blood test, the combined test comes back with a more personal probability. It may lower her risk to 1 in 4,000, or raise it to 1 in 250 or 1 in 30. As the March of Dimes explains, the test cannot “diagnose” Down syndrome or other birth defects but instead “helps identify pregnancies that are at higher-than-average risk of Down syndrome.”

Without a yes or no answer, the woman and her partner then have to decide if the results are within their own comfort zone or if they want to have further testing done, such as an amnio or CVS. Though everyone has their own benchmark (the test is often marked “normal” if it comes back as better than 1 in 250), my obstetrician essentially told me that if my odds were better than average for my age, I didn’t need any further tests, but if they were worse I should consider it. (I took this advice in my first pregnancy, when I was 34, but the second time around, at 38, I got nervous and asked for the amnio despite good results on the combined test.)

In a blog post on the Huffington Post, perinatologist Adam Wolfberg, argues that this presentation of results is just too confusing for patients.

Hundreds of my patients over the years have looked at me with a blank face when I said: “Your screening result says you have a 1 in 700 risk of having a baby affected by Down syndrome.” They had no idea what I meant. I would try to explain it lots of different ways, but frequently, I knew I had failed to communicate the meaning of that risk.

The results of cfDNA tests are more definitive and easier to understand, though each brand presents them differently. The verifi test, for example, simply notes whether any aneuploidy was detected and which one, while Panorama categorizes pregnancies into low-risk or high-risk based again on a woman’s personal probability for any of these conditions. According to BBC News, however, these results are markedly different than for the older tests. Low risk for Down syndrome, for example, means that the chance that the fetus has Down syndrome is less than 1 in 10,000. Kypros Nicolaides, a researcher who helped develop both the nuchal translucency and this new test, told BBC News over the summer, “This test is nearly diagnostic. It tells you almost certainly your baby has Down’s or almost certainly it does not. From a woman’s perspective, that is a much more clear message about what to do next.”

Others caution that it’s still not that easy. Dr. Michael Mennuti, chief of reproductive genetics at the Hospital of the University of Pennsylvania in Philadelphia, told the American Journal of Medical Genetics that each lab is going to have to make its own determination of where to draw the low-risk/high-risk line. “A patient with a normal pregnancy could have numbers just above the cutoff, but the lab would report her as high risk,” said Mennuti. “Likewise, a patient with numbers just below the cutoff could have an affected pregnancy but be considered low risk.”

For this and other reasons, medical groups are approaching this new test with caution. The American Congress of Obstetrics and Gynecologists (formerly the American College of Obstetricians and Gynecologists) along with the Society for Maternal-Fetal Medicine released an opinion in December 2012 that said the test was promising but should not yet be part of the routine lab work for normal pregnancies. Instead, it should be reserved for women who are 35 or older, those with a history of trisomy, and women carrying a fetus that shows abnormalities on an ultrasound consistent with trisomy. The groups explained that there is not sufficient research on the test in low-risk women or women carrying multiples to recommend it for these groups. Finally, the groups concluded, “Cell free fetal DNA does not replace the accuracy and diagnostic precision of prenatal diagnosis with CVS or amniocentesis, which remain an option for women.”

Consistent with these opinions, some experts have expressed concerns that women will not understand the limited scope of the test or appreciate that good results do not guarantee a healthy baby. Others worry that the high levels of accuracy and low numbers of false positives—which are based on laboratory studies—will deteriorate once the test is widely used by doctors and laboratories. There is also a concern that the test will be performed and results will be provided without sufficient counseling to help expectant parents understand the outcomes and make decisions based on those outcomes.

In her recent article for the Huffington Post, Katherine Bindley tells the story of one woman who was told her baby would be born with Down syndrome on the phone while sitting alone in her car. Others talk of being given the run-around when trying to ask questions, with genetic counselors referring them back to their obstetricians and obstetricians suggesting they speak to genetic counselors or pediatricians. Getting the results of these prenatal tests early may make decisions about whether to continue a pregnancy easier for some women, but it is still important that all patients have access to counselors who can help them process the news and make the best choice for themselves and their families.

Even with these cautions, many predict that this new test will soon become the norm. Dr. Wolfberg explained that at his institution, South Shore Hospital in Massachusetts, they started by offering patients a choice: the combined test, including the nuchal translucency, or the new cfDNA test. Patients, however, got confused and couldn’t understand why they were offering the older test if a newer, better one was available. So they stopped offering it. He believes others will follow suit. “My hunch is that obstetricians on the front lines—the ones who counsel pregnant women every day about their testing options—will realize that the new tests are just plain better,” Wolfberg said. “Patients of all ages—who can inform themselves more easily than ever before—will demand them too.”

Analysis Human Rights

Unanswered Questions Abound in Gynnya McMillen’s In-Custody Death

Kanya D’Almeida

One of the most pressing questions among advocates and attorneys is whether or not there is a link between a scuffle that took place during her intake in the facility and her death several hours later.

It began with a 9-1-1 call and ended with the death of a 16-year-old Black girl in a youth facility in Kentucky.

Little has been written about the girl’s case, but advocates and organizers say it is illustrative of failures at multiple points in the state’s juvenile justice system.

Gynnya McMillen was found unresponsive in her room at the Lincoln Village Regional Juvenile Detention Facility in Hardin County, Kentucky, on January 11, where she had been taken the previous morning following a domestic altercation with her mother.

In the three months since, there’s been a state investigation into her death, lawmakers have proposed legislation to investigate in-custody fatalities, and several staff members at the facility have quietly left their posts.

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And yet the teenager’s untimely death continues to be shrouded in mystery.

One of the most pressing questions among advocates, attorneys, and McMillen’s family is whether there is a link between a scuffle that took place during her intake at the facility and her death several hours later.

By Kentucky officials’ own admission, multiple adult staff members physically restrained McMillen using an “aikido” hold—a modified martial arts move—after the teen allegedly refused to remove her sweatshirt as part of a routine check-in procedure. As Graham Kates has reported for CBS News, surveillance camera footage shows staff bringing McMillen to the ground and holding her there for four minutes and 15 seconds. However, the footage fails to capture the full extent of the incident since the girl was brought down behind a counter and remains hidden from view for much of the incident, according to Kates.

In a February email to Rewire, a spokesperson for Kentucky’s Justice Cabinet (which oversees the state police, the Department of Corrections, and the Department of Juvenile Justice, among others), described the martial arts hold as a “nationally-approved system called Aikido Control Training, which is utilized by various juvenile justice agencies and mental health facilities throughout the country [and] designed to prevent injury to the child and staff.”

“Since strength of the employee is not a factor, only balance, injury to the child and staff is almost nonexistent,” Lisa Lamb, a spokesperson for the state Justice Cabinet, explained. “This control method does not use any type of strike, punch, choke, wrist lock or throw.”

But experts with decades of experience working on inmates’ rights and conditions of confinement tell a different story.

One of them is Paul DeMuro, a senior consultant at the Annie E. Casey Foundation and the current federal court monitor for a juvenile justice settlement in Mississippi. He told Rewire in a phone interview that in all his 44 years of experience he has never once heard mention of this “aikido” hold or known of any facility that has employed it as a form of restraint.

“From what I know of the case, there was no reason to use this particular restraint on this young woman,” he said. “To use that kind of force to resolve an issue as simple as a teenager saying she didn’t want to take her sweatshirt off goes against both the letter and spirit of most policies regarding physical restraints,” he added.

According to DeMuro, employees at Lincoln Village appear to have dealt with a frightened young girl as though she were a violent offender, escalating her anxiety instead of talking her through it. “Add the race and class elements,” he said, “and you have a situation in which several adult staffers are taking down a 16-year-old kid. This never should have happened—she was essentially going through a simple booking process and she wound up dead.”

Kentucky officials have vehemently denied the allegation that the girl suffered some deadly trauma or injury as a result of being tackled to the ground by multiple adult males. On March 16, the state medical examiner announced at a press conference that McMillen had died of a rare genetic disorder, called inherited long QT syndrome, which can cause “life-threatening arrhythmias [irregular heartbeats] and sudden cardiac arrest,” according to the Centers for Disease Control and Prevention.

But McMillen’s family rejects those findings. Shortly after Gynnya’s death, her sister created a Facebook page to gather and share information about the case. A series of posts, presumably written by a family member who manages the page, suggested that the “aikido” hold caused or contributed to her death.  The family has also consistently drawn attention to the fact that staff members at the facility failed to conduct mandatory 15-minute bed checks throughout the night, and were slow to perform CPR on the girl when at last she was found to be unconscious in her room.

State officials cannot refute this allegation. Investigators said at the press conference earlier this month that Lincoln Village employees acted unprofessionally by neglecting to provide adequate supervision and falsifying documents such as observation reports. After reviewing 60 hours of footage from the facility, Kentucky Justice and Public Safety Cabinet Secretary John Tilley said, “Some of the misconduct smacks of outright indifference,” pointing to one incident caught on video in which a staff member offers McMillen a sandwich and, receiving no reply, later eats the meal himself.

Tilley dismissed two employees in connection with McMillen’s death—Victor Holt and Reginald Windham, both of whom have previously been reprimanded for using excessive force on youth.

“Why Was She Arrested in the First Place?”

While much of the limited reporting around McMillen’s case has focused on events that transpired inside the detention center, juvenile justice advocates are equally concerned about why the girl was arrested in the first place.

“There is a much larger story here, about each of the points in the process where the system failed this child,” Liz Ryan, president and CEO of the Youth First Initiative, told Rewire. “For instance, why was she detained and arrested in the first place?”

Ryan believes McMillen’s case is indicative of the impacts of mandatory arrest laws, and later pro-arrest laws, that were introduced under the Violence Against Women Act (VAWA) in a bid to curb intimate partner violence, by instructing or encouraging police officers responding to domestic violence calls to remove a possible abuser from the household.

Though designed to protect women from spousal or partner abuse, the laws have had the perhaps unintended consequence of driving vast numbers of girls into the criminal justice system for altercations with their families.

According to Francine Sherman, clinical professor and director of the Juvenile Rights Advocacy Project at the Boston College Law School, girls comprise 40 percent of youth arrested for domestic assault, even though they account for just 29 percent of overall arrests nationally.

“Girls are disproportionately arrested for domestic assault, largely for altercations with their mothers,” Sherman told Rewire in a phone interview. “So the events that led up to McMillen’s arrest are not at all unusual nationally.”

Sherman, who co-authored a recent study on girls’ increasing share of the burden of youth incarceration, said that although Kentucky does not have mandatory arrest laws on the books, the state follows what are known as officer discretion laws, which have been susceptible to reliance on arrests as a means of resolving domestic disputes.

It is one of just many “pathways” that are still funneling girls into the juvenile justice system, despite an overall decrease in the national youth incarceration rate. Sherman’s research shows, for instance, that while the Juvenile Justice and Delinquency Prevention Act bars judges from jailing girls for simple status offenses (offenses that apply only to minors, such as violating a curfew), girls who fail to comply with a valid court order (VCO) regarding these offenses can still be detained. In 2014, Kentucky used the “VCO exception” 1,048 times—more than any other state.

And as multiple researchers have pointed out, Black girls are disproportionately represented in every stage of the justice system. By Sherman’s estimates, using justice department data, girls of color comprise 61 percent of incarcerated girls. “In 26 states and the District of Columbia, the placement rate for Black girls surpassed the rate for all other race and ethnic groups,” Sherman told Rewire.

Set against this backdrop, McMillen’s arrest and detention are hardly unusual; in fact, the circumstances surrounding her death are indicative of a long history of policing and punishing Black girls that advocates say has been largely sidelined.

“For decades society has placed huge pressure on Black girls: either by sexualizing their bodies, or portraying them as having ‘superhuman’ strength,” explained Chanelle Helm, a Kentucky-based organizer and researcher who has been mobilizing community support for Gynnya McMillen’s case.

“We’ve repeatedly seen Black girls being detained in violent and highly sexualized—we saw it with the officer in Texas using his entire body to restrain a Black teenager in a bathing suit; we saw the same thing with an officer assaulting a Black girl at the Spring Valley high school in South Carolina,” she added.

“If you listen to the 9-1-1 call that McMillen’s mother made right before her arrest, you see this same pattern—of the girl being called degenerate, sexualized names,” said Helm, who is a former board member of the Kentucky Alliance Against Racist and Political Repression and a member of Stand Up Sundays, part of Black Lives Matter-Louisville. “And then you see her being bodily detained by employees at the detention center.”

Helm added that Black girls going through the child welfare system often have health conditions that go undetected “due to an overall culture of negligence when it comes to [their] health.”

“Heart arrhythmias are hard to detect, especially for people who can’t afford that kind of medical care,” Helm said. “And if you’ve gone through as much as Gynnya was going through—being in the child welfare system, getting into a fight with her mother, sitting alone in that detention center—how are you going to know it’s something more than anxiety?”

Advocates Seek Far-Reaching Reforms

The question of who bears ultimate responsibility for McMillen’s death has not yet been answered. Once the Kentucky State Police wrap up their investigation, a prosecutor is expected to present the case to a grand jury to determine whether to bring criminal charges against possible defendants.

Advocates, taking their lead from McMillen’s family, say they want accountability. A Color of Change petition addressed to Gov. Matt Bevin (R) calls for the termination of superintendent Michelle Grady, who was responsible for the Lincoln Village facility, as well as any staff who were involved in the incident.

Local organizers, meanwhile, want further-reaching reforms.

“Our main goal is a complete overhaul of Kentucky’s juvenile justice system,” M.L. Butler, a member of a group called The Voices Unheard, which has been organizing around McMillen’s case, told Rewire. “We want to see the closure of the Lincoln Village facility and the decriminalization of Black youth.”

According to the state Juvenile Justice Department’s 2012 annual report, the 48-bed facility was slated for closure in 2013 in a bid to slash the department’s expenses by $2 million. It is unclear why these plans did not go through, and the state will likely have to answer this question under pressure from activists.

Butler told Rewire in a phone interview that grassroots groups are mobilizing for a protest outside the Hardin County Justice Center on April 8 to demand justice for McMillen. Many of these groups, including Helm’s Stand Up Sundays, were among the first to call attention to McMillen’s death, staging vigils outside the detention center from as far back as January and drawing a smattering of media to an otherwise completely overlooked case.

“We had 50 people at our first vigil and we’re hoping for as many, if not more, supporters on April 8,” said Butler, whose group works with the Oakland-based direct action training collection BlackOUT.

Those familiar with Kentucky’s Department of Corrections say activists are going up against a system that has shown little regard for inmates’ lives.

One of them is Greg Belzley, a Kentucky-based lawyer who has been inmates’ rights lawyer for more than two decades and sued state prisons and county jails “repeatedly” over detainee deaths and conditions of confinement, is not optimistic.

One of them is Greg Belzley, a Kentucky-based lawyer who has sued state prisons and county jails “repeatedly” over detainee deaths and conditions of confinement. He is not optimistic.

“Time and time again there is an inexcusable, horrifying, or grotesque inmate death in Kentucky. And time and time again no one is prosecuted and nothing happens,” he told Rewire in a phone interview, adding that in the two-year period from the beginning of 2012 to the end of 2013, there were more than 100 deaths in Kentucky jails and prisons.

He is particularly skeptical about a piece of legislation introduced in the house a month after McMillen’s death, which would create an independent panel of experts to review in-custody deaths across the state. Belzley’s biggest concern is that the panel would include 13 nonvoting members—almost double the number of voting members—who “represent organizations that have never shown the slightest interest in spending the time or money required to properly attend to inmates’ medical needs or seriously investigate or prosecute instances of inexcusable detainee deaths,” he said.

These include the Kentucky County Judge/Executive Association, the Commonwealth Attorney’s Association, and the state’s Jailers Association.

“Legislative efforts have made no difference—it’s been business as usual in this office,” Belzley told Rewire, adding that the root of the problem is the ingrained mindset among those directly responsible for detainees, whether jailers or medical personnel, that they do not warrant humane treatment.

“I’m working on cases right now that would turn your stomach,” he told Rewire, adding that he’s represented inmates who died of alcohol and drug withdrawal, covered in their own feces and urine, even though there was a hospital a few miles away.

“I’ve seen it happen so many times—a jailer will look in on an inmate who appears to be sleeping and unless there’s blood all over the floor or the inmate is hanging from a cord they will generally just make a note on their observation log that everything is okay,” he said.

While Belzley’s work has largely focused on adult jails and conditions of confinement, his analysis bears a striking resemblance to the kind of negligence that occurred in McMillen’s case.

“People need to start taking inmates’ lives seriously,” Belzley said. “Any responsible person who heard that a 16-year-old girl was put in a martial arts hold for over four minutes because she wouldn’t remove her sweatshirt and was found unresponsive the next morning, would say there was cause for a serious criminal investigation—and if there is probable cause to believe there was a violation of criminal laws in the treatment of this young woman, somebody needs to be prosecuted and if found guilty they need to go to jail.”

Commentary Science

Telling Sexually Active Women to Abstain From Alcohol Is Unrealistic and Ineffective

Martha Kempner

There are two public health issues that the Centers for Disease Control and Prevention was evidently trying to address: the dangers of fetal alcohol spectrum disorders and the high number of unplanned pregnancies in this country. By not keeping them separate, the agency effectively reduced all women to nothing more than fetus-vessels-in-waiting.

The Centers for Disease Control and Prevention (CDC) came under heavy criticism last week when it released new guidelines suggesting that any woman who might become pregnant should consider not drinking alcohol out of concern for their hypothetical fetus’ well-being. Had the CDC limited its advice to women who were already pregnant—or even those who were actively trying to become pregnant—it would have been likely seen as reasonable, based on existing research about the risks of alcohol during pregnancy. But the suggestion that the advice should apply to all women who are sexually active and not on birth control is overreaching and patronizing.

There are two public health issues that the CDC was evidently trying to address: the dangers of fetal alcohol spectrum disorders (FASDs) and the high number of unplanned pregnancies in this country. By not keeping them separate, the CDC effectively reduced all women to nothing more than fetus-vessels-in-waiting.

Experts believe that FASDs are widespread and under-diagnosed. Symptoms of FASDs range from mild to severe and include a variety of physical, emotional, behavioral, and learning problems. Research shows that exposure to alcohol in utero can cause structural or functional problems to the central nervous system, heart, brain, bones, and kidneys. It has been associated with higher incidents of behavior disorders, such as attention deficit/hyperactivity disorder and impaired impulse control, and learning disorders, such as difficulties with mathematics, language, memory, and problem solving.

There is no great way to measure whether it’s possible to drink just a little bit without exposing the developing fetus to any risk. We don’t do randomized controlled trials on pregnant women, for example, because it would be unethical to intentionally expose a developing fetus to any substance that might be harmful for the sake of research, and other factors such as genetics, nutrition, smoking, and prenatal care make every pregnancy different to begin with. Many studies have failed to find any negative outcomes from light drinking during pregnancy.

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Still, a report from the American Academy of Pediatrics released in October notes that drinking during the first trimester increases the odds of FASD by 12 times when compared to women who don’t drink at all. Drinking in the first and second trimester increases the odds 61 times compared to no alcohol, and drinking during all three trimesters increases the odds by 65 times. These are big risks, and the AAP concludes that simply “no amount of alcohol should be considered safe during pregnancy.”

With all that in mind, the logic behind the CDC’s advice seems simple enough. Ann Schuchat, the agency’s principal deputy director, explained to USA Today, “Alcohol can permanently harm a developing baby before a woman knows she is pregnant. About half of all pregnancies in the United States are unplanned, and even if planned, most women won’t know they are pregnant for the first month or so, when they might still be drinking. The risk is real. Why take the chance?”

But the advice the CDC released on its website is anything but simple: “More than 3 million US women are at risk of exposing their developing baby to alcohol because they are drinking, having sex, and not using birth control to prevent pregnancy.” Remember, this is not referring to pregnant women, it’s talking about all sexually active women who might become pregnant.

Upon reading this, many on the Internet cringed. As Alexandra Petri pointed out for the Washington Post, the CDC released an infographic along with its report that outlined the risks of “drinking too much” for women. For pregnant women, according to the agency, these risks include fetal alcohol syndrome disorders, miscarriage, stillbirth, sudden infant death syndrome, and prematurity. For all women, the CDC continues, risks include “violence, sexually transmitted diseases, and unplanned pregnancy.”

If the CDC wanted to remind women of the dangers of FASDs, it should have stuck to pregnant women or those trying to become pregnant. You see, many pregnant people are accustomed to taking the advice of medical organizations, our doctors, and our friends and doing some personal risk-benefit analyses. Right before I sat down to write this article, I went to the medicine chest and washed down a few aspirin with an extra cup of coffee in an effort to stop my head from pounding. I was reminded of a time when I could not do that because while pregnant and breastfeeding, I was told to limit my caffeine intake and use nothing stronger than Tylenol. I also avoided deep-sea fish (because of mercury levels) and lunch meat (because of the possibility of listeria). And despite the horrifying heartburn I had pretty much every night I did not take the proton-pump inhibitor I had been on for a few years before pregnancy because it had not been tested enough to be considered safe.

I did, however, eat soft cheese. My doctor advised me not to because of fears of bacteria, but a friend in culinary school at the time along with the guy behind the counter at the Vinegar Factory assured me that all cheese sold in the United States is pasteurized. I believed them and indulged in some brie from time to time.

One friend, meanwhile, took ibuprofen during her pregnancy because her back was too painful to walk without it. Another suffered through a major sinus infection with no painkillers because even Tylenol made her nervous. Some drank a glass of wine every now and then, and others skipped booze entirely.  

Medical advice to women changes frequently as science learns more. My mother smoked throughout her pregnancy with my sister because that was acceptable in 1970. By the time she was pregnant with me two years later she was told to cut out cigarettes, but late in the pregnancy, was ordered to drink one glass of alcohol a day to “quiet the baby.” Though that seems outrageous 40 years later, advice changed in the relatively short time between my two pregnancies as well. The second time around, I was allowed to take that proton-pump inhibitor, because it had been declared safer, but I was told to avoid peanut butter as a way to prevent an allergy in the baby.

Pregnant people are often used to reading and evaluating advice on what they can and can’t do. Tell them not to drink and many will not drink. Others may drink even less than they were planning to, and others may do whatever their doctor says; mine assured me that the occasional glass of red wine was fine.

Limiting the advice to this audience would have been a problem too, however, as it would have missed a large number of women who get pregnant each year. Why? Because, as the CDC noted, half of all pregnancies are unplanned, though not everyone decides to carry their pregnancies to term. And this was the real messaging challenge: The advice about not drinking starts from day one of pregnancy when most women, especially those who aren’t expecting to become pregnant, are unaware of their new condition. So the CDC’s message of risk elimination is understandable. There is another way to confront that, though: addressing the importance of contraception, recognizing that it is currently not equally available for all women, and advising policymakers to make it easier to access birth control.

This is how the CDC miscalculated. Telling all women who are not pregnant and not using birth control to stop drinking is an absurd strategy. It is unrealistic and undermines the real public health risk the CDC is attempting to highlight. And accusing sexually active women who are not using birth control of damaging a developing baby that they may never conceive or might not carry to term if they do is patronizing and demeaning to women. (Not to mention the fact that not all sexually active women are at risk of unintended pregnancy—women who only have sex with women, for example, are in the clear.)

Tell women who are or are planning to get pregnant that the best medical advice of the day is not to drink any alcohol. For the trickier bunch—those who aren’t trying to get pregnant but could, remind them that half of all pregnancies are unplanned. Point out the benefits of planned pregnancy, which do include avoiding unintentionally exposing a developing fetus to alcohol. If they do want to avoid pregnancy, suggest IUDs and implants, which prevent it for a minimum of three years without any effort on the part of the user. Work on making contraception more readily available and less expensive.

But don’t treat all women like pregnancies waiting to happen, don’t assume that everyone is going to get pregnant someday, don’t assume that everyone who does get pregnant will carry the fetus to term, and don’t tell them that they simply can’t drink during their fertile years.