Women’s pain in pregnancy and beyond is often minimised

Some recent discussions of pain relief during pregnancy frame the issue of paracetamol use as a maternal-foetal conflict, ignoring science, eroding trust in doctors, dismissing women’s pain, and limiting women’s autonomy. ‘Toughing it out’ is not the answer.

Last week, US president Donald Trump held a press conference announcing the results of his administration’s investigations into the root causes of autism. During the event, he shared several recommendations for the use of acetaminophen (paracetamol) in pregnancy, namely that women should not use it.

Medical experts have criticised the claims as dangerous and poorly informed, and researchers have shown that the recommendations are politicised interpretations of weaker medical studies. In Australia, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists’ recommendations for paracetamol use in pregnancy remain unchanged.

While most expert attention has been paid to debunking the administration’s claims and communicating insights from our best scientific knowledge on the topic, less attention has been given to the tenor of the president’s announcement. How can the ethics of pregnancy help us to understand the rhetorical moves of this speech and how we treat women in pregnancy and beyond?

The ethics of pregnancy care

Trump’s recommendation to avoid paracetamol use in pregnancy is predicated on the assumption that doing so is harmful to the foetus. In this instance, it is recommended that a pregnant woman avoid pain relieving medication on the basis that it may cause autism. Putting aside the fact that there is little evidence of the harmful effects of paracetamol use in pregnancy, the White House press conference framed this issue as a maternal-foetal conflict – an instance of maternal interests (in pain or fever relief) conflicting with the interests of the foetus (of not developing autism). According to the White House, the maternal-foetal conflict should be resolved in favour of the foetus with the recommendation that paracetamol use be avoided in all but the most severe cases. In medicine and maternal decision making, prioritising the foetus is very common, but is hardly a foregone conclusion.

Yet in this instance, and in many other obstetric cases, the central conflict is not between the mother and foetus, but between the mother and others who believe they know better.

Here, the adversary is the White House, and the effect of their remarks is the erosion of trust between the pregnant patient and their physician. This is because the pregnant woman must now contend with information that may contradict her doctor’s advice. Such intervention is “counter-productive relative to the goal of promoting foetal health”, researchers Baylis, Rodgers and Young inform us, since this erosion of trust prevents doctors from providing “the education which would promote the birth of healthier babies”.

Secondly, the maternal-foetal conflict framing ignores the fact that the interests of mother and foetus are inextricably linked. Currently, many health experts are at pains to communicate that paracetamol is a safe for treating fevers and providing pain relief, and that sustained fevers in pregnancy can result in miscarriage, birth malformations and, later, still birth while untreated significant pain can also result in complications. Even in cases where there are certain risks to a foetus, withholding or delaying treatment can potentially lead to increased maternal and foetal morbidity and mortality. The White House’s rhetoric simplifies the often challenging or agonising decisions women and their physicians routinely make during pregnancy.

These examples show that protecting a woman’s health is oftentimes the strongest path to guaranteeing foetal and neonatal outcomes. More than this, recommendations that are laden with unscientific bias erode trust in physicians and limit a woman’s capacity to make informed choices, infringing upon women’s autonomy and potentially risking greater foetal harm.

Toughing it out

It was the experience of giving birth that led the author Anushay Hossain to reflect on the treatment of women’s pain. In The Pain Gap, she writes “Doctors still don’t always believe women when they describe their pain, or they dismiss women’s symptoms as being psychosomatic.” For Hussain, the concept of hysteria is useful to explaining a woman’s experience of the medical system. The common characterisation of women’s pain as hysterical, she writes, shifts blame and judgment onto women. The conversation becomes ‘is your pain real? Is it that bad? Why can’t you cope with it?’

This was the text and subtext of the White House press conference last week. On many occasions in his speech and responses to media outlets, Trump told women to ‘tough it out.’ And if you can’t tough it out? “You know, it’s easy for me to say tough it out, but sometimes in life where a lot of other things, you have to tough it out also. Don’t take Tylenol.” Once again, the blame for pain falls at the feet of women.

Setting aside the aforementioned evidence that women ‘toughing it out’ leads to worse outcomes for their foetuses, telling women to tolerate their pain is not only cruel, but also an example of medical misogyny. Medical misogyny describes the gendered ways patients experience healthcare, often marked by missed diagnoses, delayed treatments, and the dismissal or minimisation of symptoms, including but is not limited to pain. It is startlingly common in Australia with 2 out of 3 women reporting experiences of discrimination in healthcare. For non-white women, the experience is worse.

How should we respond?

To address these widespread issues, governments in Australia and the United Kingdom, among others, have established inquiries into women’s pain and reproductive health. More recently, the Sydney Morning Herald has collected patient testimonies that detail women’s experiences of medical misogyny, bringing about wider awareness of the issue and adding urgency to the call for systemic change.

At a time when many individuals and institutions are working to dismantle the gendered and racial barriers to accessing quality healthcare, dismissing women’s suffering and asking them to ‘tough it out’ reinforces a long history of medical misogyny that leaves women unheard, untreated and unwell.