ParentsJanuary 10, 2018

About that ‘paracetamol in pregnancy’ study: don’t panic


You might have seen headlines claiming paracetamol in pregnancy could reduce your daughter’s future fertility. We asked no-bullshit Spinoff Parents scientist Dr Jess Berentson-Shaw to tell us what it all really means.

Oh no the lady rats are taking too many drugs in pregnancy. Somebody control their behaviour for the love of the Great Rat Goddess, before they hurt their babies!

I jest, but really do we really need to be talking so publicly about another non-human study done on pregnant rodents and how this “may” translate to pregnant people?

It is no secret that I have a major issue with how we talk about research and evidence in the context of people who are pregnant. Pretty much every time a study about pregnancy-related issues are discussed – whether it be about medication use, food, exercise, sleeping, stress or work – unconscious bias against women rears its massively ugly head. And it is hurting both women and the science we do.

What we need is high quality science carried out with women front and centre, we need scientists and the scientific system to focus on what matters to women, and we need respect for people as entities distinct from their pregnancy.

But let me first go back to Mrs Ratty and the paracetamol.

Don’t panic, nothing has changed in terms of pain relief recommendations

Let’s start with the current study of interest, a review of three studies on rodents. It looks at the use of paracetamol in the period immediately after rodents do the wild thing and suggests there may be some impact on the developing reproductive systems of the female rodent foetuses. Animal trials are notoriously difficult to apply to humans for a number of reasons, the main one being – gasp – we are not rats. For the data to apply to humans there would need to be human trials – which people are understandably reluctant to do (though there are plenty of arguments for pregnant people being included in drug trials, not least because it is important that pregnant people don’t get excluded as we further our scientific understanding).

There are human studies that look at how pharmaceuticals affect developing foetuses (often by observing effects in a group of women and children who took the medicine during pregnancy), and these are useful studies to draw upon. To date this research suggests that there is no major concern in the use of paracetamol in pregnant women at recommended doses.

The particular rat study being discussed provides no additional evidence for a change in behaviour with regard to pain relief use in pregnancy, which is kind of the main point. Use the recommended dose, no more, because these drugs are still drugs, but don’t make yourself miserable trying to suffer through those throbbing headaches or the unbearable hip pain that often comes with pregnancy.

So that is that particular trial. Let me now commence my rant about women and science and reproduction.

Scientific studies are unconsciously biased against those who are pregnant

I am not suggesting that studies into how pharmaceutical use in pregnancy affects a foetus should not be done. I am however suggesting what we choose to study, what we choose not to study, and how we talk about the findings needs to change with regard to women, most notably in pregnancy.

Inevitably small studies like this make it into the media and tend to make women worry more than they already do. For me pregnancy was 40 or so weeks of anxiety and feeling awful, and then feeling even more awful that I might be doing something to harm the baby. I worried I was eating the wrong cheese at the wrong temperature, too much cake, not enough cake, sleeping on the wrong side, not doing enough exercise, exercising too much, drinking too much coffee, taking too much Panadol, taking too many anti-nausea drugs (I had hyperemesis gravida, which is debilitating nausea that can hospitalise you). I spent most of my first pregnancy in a full-time research job and all my spare time doing a whole lot more research to check which recommendations were based on solid science and which were just about telling pregnant women there are no acceptable risks. Ace.

However, on top of that individual worry, such studies – and the language we use to discuss them – can work to enforce the stereotypes our society holds about women and their role in society.

Women as vessels

Too many studies about pregnancy, and the public discussions that follow, reinforce the idea that women are simply ‘vessels for the next generation’ – as opposed to people with their own needs and experiences that we should understand and address. When women are centred in research, it can look and feel quite different. If only the wellbeing of the child is, then too often women’s behaviours, their choices in pregnancy, are the implied source of any future ‘problem’ with their child.

I am not in any way saying this is the intent of those undertaking and commenting on the research, but that is unconscious bias for you. Often we never intend to hurt people, but we do. I did my doctorate research on pregnancy and birth and, looking back, I held some problematic attitudes about pregnancy. We are all biased, we cannot help it.

Unconscious bias means culturally embedded views of certain groups (stereotypes we are not even aware of because they are ever present in our society) lead our thinking and conversations and behaviours. This bias leads us in a way that can further confirm unhelpful, even negative beliefs and further disempower the group we are talking about.

Our society is filled with deeply entrenched views about the role of women with regard to reproduction: who is most important, who gets to make choices about women’s bodies, and who gets to decide what matters with regard to the health and well-being of women and babies. The problems many women still face in accessing contraceptives, our laws around abortion, and the disempowering experiences of being a “pregnant patient” are all evidence of the barriers to women’s autonomy when it comes to reproduction.

We lose the plot slightly about pregnancy as a society and suddenly autonomous humans become public property.

We cannot help but bring our cultural stereotypes into our everyday conversations, our actions, and yes, even into our science. (You can read a bit more about unconscious bias in the context of ethnicity here and I have also written about unconscious bias in the context of how we make policy.)

Science and research is often unconsciously biased against women

Dr Nicola Gaston did some fundamental research on why science is very much still behaving in a biased way against women. I recommend her excellent book Why Science is Sexist. Research groups led by men, or made up mainly of men, tend to favour employing more men. More research funding goes to men. Universities may have plenty of women at undergraduate level, but get to the top tiers and they are unbalanced in terms of both gender and ethnic diversity. Work by Angela Saini shows that science itself has been providing false data about the differences between women and men (notably women’s supposed inferiority).

Ultimately, science and the scientific system favours a particular type of person. This imbalance matters, because in the case of research in pregnancy, the lives and experiences of women are more likely to be researched through the lens of people who hold (often unknowingly) assumptions about them and their role in the society. Note that all genders can hold unconscious bias against women because society, and the beliefs held within a society, is a system we are all part of.

What does this bias look like in research? It looks like research topics being chosen that are based on existing stereotypes about gender. The topics most important to women can be ignored (for example there is a critical lack of research on nausea in pregnancy). It can mean funding is more likely to go to men doing research on pregnancy related issues (funding in science is a complicated matter but well established senior academics attract the funding and they are more likely to be men). It can mean that the way the study is constructed and the outcomes that are chosen may not be what matter to women or may reinforce certain biases.

The interpretation of findings and the subsequent discussions of what the evidence means happen through the lens of society’s bias about women and pregnancy. They inevitably become focused on what women should and should not do, as opposed to how we can change a system. It is not inevitable that these biases occur – we have developed good ways to identify or overcome bias within a study – but it’s hard to overcome unconscious bias across a system more generally until something is done to make it visible, to make it conscious.

Science deserves our most creative and innovative approaches, undertaken by the best people, and women and babies deserve that too. It cannot happen with major unbalance in the system.

Science needs to act differently to empower women who are pregnant instead of blaming them

How can things change for both science and women? Here are some ideas:

  • The first step to fixing a problem is recognising you have a problem. Dr Carla Houkamau has some good first steps to help individuals see their own unconscious bias and get used to the feelings that come with that recognition.
  • Scientific bodies can provide training for their staff in unconscious bias.
  • Get to grips with equity, as opposed to equality. Equity means doing the innovative and additional things that are needed to attract, keep, and open spaces up to women in science, for example funding women in research as they are doing in Australia.
  • Science and media can be cognisant of how they frame discussions about pregnancy-related research. Avoid alarming headlines, don’t focus on studies that do not change current practices; be aware of women-blaming, stereotypes and tropes that are framing the conversation; give the real relative risk – for example, if the risk of an unwanted outcome has gone from 0.5% to 0.8% chance this is important context for women; ask about women who don’t use a drug and what their important outcomes are – are they suffering? And DO talk to pregnant women about what matters to them and report on that.
  • Research (and the funding bodies that support it) needs to focus more on the conditions of women’s lives. For example, overcoming barriers to accessing contraception and abortion; developing and funding research that looks at how to overcome the effects of insufficient resources on women and their developing baby’s immune systems; enabling younger women to achieve economic well-being after having children; pushing funding into self-determining approaches to changing smoking in pregnancy; ways to improve food security for women on low incomes; supportive labour policies for families etc. Its less sexy, but it’s far more effective in improving lives.
  • Centre women in research about pregnancy, sk what matters to them, then consider harms to a baby in the context of that. For example, pregnancy can be painful and exhausting – what pain relief works best for women in different contexts and comes with the lowest risk of harm to both her and the developing foetus?
  • Respect and listen to women. Consider what balance of risks are women themselves prepared to accept in the context of high quality conversations about evidence. Don’t decide for them and then blame them if they cannot stick to the rigid and ever-increasing list of ‘rules’. Risk information is for women and their families to consider. It’s not everyone else’s business. It’s not their choice. That is what informed consent really means.

It is possible to change our research systems to be more balanced and focused on all people. It starts by looking hard at how people think about and frame research. It makes for much better science. More importantly, it makes the lives of those people science is done for infinitely better.

Dr Jess Berentson-Shaw  is a researcher and public communicator. She consults on effective evidence-based policy, and helps people and organisations engage the power of good storytelling to change minds. Follow Dr Jess on Facebook.

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