The American Journal of Bioethics

Polemics and Pregnancy: A Response

to Arguments About Ethical
Obstetrical Care
Caroline Bradbury-Jones, University of Dundee
Elaine Lee, University of Dundee
In a somewhat polemic style, Charles (2011) suggests that
the American Congress of Obstetricians and Gynecologists
(ACOG) may endorse certain obstetric practices that inadvertently contribute to the problem of violence against
women. Using examples of physician response to alcohol
during pregnancy and court-ordered medical treatment,
Charles argues that some obstetric practices bear a disturbing likeness to the attitudes of abusive men in coercively
controlling womens behavior through manipulation, intimidation, and violence. We agree that violence against
women is a significant global health issue. However, there
are two elements of Charless paper that require further exploration. First is her contention that advice to pregnant
women is based on oppressive gender norms rather than
sound evidence. Second is the contention that misogynistic,
male obstetricians dominate and abuse the helpless women
in their care. It is around these two issues that we frame this
response.
Taking first the issue of alcohol advice during pregnancy, Charless principal argument is that despite ambiguities in evidence regarding actual fetal risks, obstetricians
have recommended complete abstinence. She supports the
stance of Lyerly and colleagues (2009, 35), who argue that
there has been a retreat from evidence-based advice to a
mantra of better safe than sorry. Charles refers to a press
release in which ACOG strongly urged women not to ignore the public health warnings associated with consuming
alcohol while pregnant (ACOG 2008, 1). In this, the ACOG
reiterated its long-standing position that no amount of alcohol consumption can be considered safe. Charles argues that
this abstinence-only approach is paternalistic and reflects a
regulation of pregnant womens behavior. Thus, instead of
giving women accurate, evidence-based information and
allowing them to make an informed decision, obstetricians
intentionally overstate the risks of alcohol and coercively
control womens behavior. From this she concludes that the
abstinence-only campaign holds parallels to the tactics used
by abusive men.
It is the case that ACOGs position on abstinence does
not align with the stance of other organizations. For example in the United Kingdom, following a review of available
evidence, the National Collaborating Centre for Womens
and Childrens Health (2008) advises that although there is

uncertainty regarding safe levels of alcohol consumption in

pregnancy, at a low level there is no evidence of harm to the
unborn baby. Such contradictory stances may be confusing.
Yet it seems that Charles conflates a better safe than sorry
approachwhich may indeed be paternalisticwith manipulation and intimidation, which is altogether another
issue. It is not necessarily the case that obstetricians encourage abstinence as a way of controlling women. It can be
argued that such advice, in the presence of ambiguous evidence, is a form of defensive practice. Failure of research
to identify definitively safe levels of alcohol intake means
that some health professions, not just obstetricians, offer the
safest advice available: that the only truly safe level of alcohol intake is no alcohol. This approach is grounded in
caution, rather than abuse.
In relation to sexual intercourse during pregnancy,
Charles continues to cite Lyerly and colleagues to show how
physicians have a tendency to overstate fetal risk (even in
opposition to reassuring empirical evidence) when the intervention is for the benefit of the mother, but the tendency is
to understate fetal risk when the intervention is for the benefit of the fetus or a male partner (2009, 8). She argues that
despite potential risks, websites and doctors reassure that
intercourse is safe during pregnancy and advise women to
go ahead if inclined. Thus, Charles concludes, women must
not take any risk, no matter how small or unsupported, for
their pleasure or comfort, but when the question is one of
mens pleasure, the risks are ignored.
Reference to mens pleasure is a curious stance amid
a discourse of gender norms. Here, Charless argument assumes a heterosexual relationship (which is acknowledged
in a footnote) and implies that the only partner to enjoy or
indeed value sexual intercourse is the male. Also, in terms
of evidence, Charles may be on shaky ground. As stated,
she draws on the work of Lyerly and colleagues (2009), who
allude to inadequate empirical evidence regarding safety of
intercourse during pregnancy. They make reference to the
study by Sayle and colleagues (2001) to support this view.
This is confusing, given that Sayle and colleagues reported
that data from their study provided evidence against the
hypothesis that sexual activity increases risk of preterm delivery. Hence, we found no evidence that sexual activity in
late pregnancy increased a womans risk of preterm delivery

Address correspondence to Caroline Bradbury-Jones, University of Dundee, 11 Airlie Place, Dundee DD1 4HJ, United Kingdom. E-mail:
c.bradburyjones@dundee.ac.uk

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December, Volume 11, Number 12, 2011

Obstetricians and Violence Against Women

between 29 and 36 weeks gestation (Sayle et al. 2001, 287).

Moreover, our results could indicate a protective effect of
sexual activity (Sayle et al. 2001, 288). Overall, this leads
us to question the empirical basis of Charless argument:
paradoxically, the very criticism that she levies against her
obstetrician colleagues.
The second issue that we feel warrants further discussion is Charless gendered argument regarding maternity
care. Reference is made to obstetricians rather than obstetrics, thereby personalizing the argument to individual
practice rather than developing feminist arguments about
masculinized professions. Although she admits that most
obstetricians are caring professionals, the personalized slant
of the argument is both subjective and unhelpful. This is
exacerbated by Charless pervasive assumption that obstetricians are male. However, figures from the Royal College
of Obstetricians and Gynaecologists (RCOG) in the United
Kingdom indicate a shift toward what it terms the increasing feminization of obstetrics (RCOG 2011). For example,
figures from 2010 indicate that 73% of obstetric and gynecological trainees were female. In the United States, the
demise of the male obstetricians has been observed since the
1990s (Howell, Gardiner, and Concato 2002), and the proportion of females entering the profession has continued to
increase. Given the often-posited arguments in relation to
the relative powerlessness of midwifery owing to its largely
female workforce, the same should be true of obstetrics.
If the violence of obstetricians is a gendered issue, then
a more balanced position of power should be developing
between women and obstetrics.
Moreover, Charless argument does not acknowledge
the role played by a range of health professionals in health
promotion for pregnant women. The essential competencies
of the midwife, as set out by the International Confederation of Midwives (ICM), include the promotion of health
(ICM 2010). Midwives have long been seen as having a vital role in the health of women and families. It is often the
case that midwives, and not obstetricians, offer the majority
of health promotion advice for many women in a global
context. Charles offers no criticism of the health promotion advice given by midwives, even if there are parallels
between this and the advice given by obstetricians. Either
health promotion by midwives is acceptable because the
majority are women, or midwives are accomplices in the
paternalism of the obstetrician. Either way, the issue of maternity care provided by women is not fully addressed in
Charless paper.
Further, the role of public health and health promotion
in the surveillance of populations (in a Foucauldian sense)
creates a tension of control and caring (paternalism versus beneficence) but does so across the whole spectrum of
the public and the private in pregnancy (Ogle, Tyner, and
Schofield-Tomschin 2011). It is in no way limited to obstetricians. Maintaining health in pregnancy has become a social
norm to which all women are subject. Increasingly, this social pressure is extending outward from the individual to
the partner, family, and society generally. The link between
smoking and sudden infant death syndrome (SIDS), for example, is not only one between the woman and her baby but
December, Volume 11, Number 12, 2011

includes her partner and family, which necessarily requires

the modification of the behaviors of men as well as women
(Ostfeld et al. 2010).
Lastly, and perhaps most importantly, Charless argument fails to take account of the power and control that
women can exercise over their own pregnant bodies. Her
argument implies a powerlessness among women that is
both paternalistic and erroneous. There is evidence to suggest that despite an imbalance in power relations in a medical encounter, pregnant women canand dowield their
own power (Fahy 2002).
Overall, we are supportive of any attempts to tackle the
enduring problem of violence against women. However,
we feel that Charless account is based on a gendered view
of obstetric care that is unhelpful and inaccurate. Charles
makes it clear that her intention is not to vilify the obstetric community, but to draw attention to the implications
of certain obstetric practices. In turn, our response is not
intended to vilify Charles. Rather, it is offered as a means
to further discussion and debate regarding this contentious
area of obstetric practice.

REFERENCES
American Congress of Obstetricians and Gynecologists. 2008.
Alcohol and pregnancy: Know the facts. Available at: http://
www.acog.org/from home/publications/press releases/nr0206081.cfm (accessed August 3, 2011).
Charles, S. 2011. Obstetricians and violence against women. American Journal of Bioethics 11(12): 5156.
Fahy, K. 2002. Reflecting on practice to theorise empowerment for
women: using Foucaults concepts. Australian College of Midwives
Incorporated 15(1): 513.
Howell, E. A., B. Gardiner, and J. Concato. 2002. Do women prefer
female obstetricians? Obstetrics and Gynecology. 99(6): 10311035
International Confederation of Midwives. 2010. Global standards for midwifery education. Available at: http://www.
internationalmidwives.org/Portals/5/2011/GlobalStandards/
MIDWIFERYEDUCATIONPREFACE&STANDARDSENG.pdf
(accessed July 29, 2011)
Lyerly, A. D., L. M. Mitchell, E. Mitchell Armstrong, and L. H.
Harris. 2009. Risk and the pregnant body. Hastings Center Report
39(6): 3442.
National Collaborating Centre for Womens and Childrens Health.
2008. Antenatal care: Routine care for the healthy pregnant woman. London: RCOG.
Ogle, J. P., K. E. Tyner, and S. Schofield-Tomschin. 2011. Watching
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Ostfeld, B. M., L. Esposito, H. Perl, and T. Hegyi. 2010. Concurrent
risks in sudden infant death syndrome. Pediatrics. 125(3): 447453
Royal College of Obstetricians and Gynaecologists. 2011. High quality womens health care: A proposal for change. London: RCOG Press.
Sayle, A. E., D. A. Savitz, J. M. Thorp, I. Hertz-Piccioto, and A.
J. Wilcox. 2001. Sexual activity during late pregnancy and risk of
preterm delivery. Obstetrics & Gynecology 97(2): 283289.
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