Women & Children Last

Though their initial failure to repeal the Affordable Care Act (ACA) and replace it with the American Health Care Act (AHCA) might have stung, Republicans did not give up on health-care reform. Yet even with a revised bill’s recent passage in the House, contention persists over continuation the Affordable Care Act’s list of “essential health benefits” that insurers are required to cover. These include outpatient and laboratory services, preventative and pediatric services, and maternity care.

This last category has drawn fire from critics of Obamacare, for whom it symbolizes the folly of forcing people to pay for insurance provisions they will never use. Pressed by Rep. Mike Doyle (D-Pa.) to explain which essential health benefits he found objectionable, Rep. John Shimkus (R-Ill.) replied, “What about men having to purchase prenatal care?” Shimkus compared this requirement to “buy[ing] a cabin in Montana that you’re never going to use.” And he was not the only one to question the wisdom of requiring all health insurance to cover maternity care. Columnist Charles Krauthammer advised, “Best to mandate nothing. Let the customer decide. A sixty-year-old couple doesn’t need maternity coverage. Why should they be forced to pay for it?” Krauthammer added, “I don’t know about you, but I don’t need lactation services.” On Twitter and Facebook, people wondered aloud whether Shimkus understood men’s part in occasioning the need for maternity care. Some said that if men should not have to pay for care that only women need, then women should not have to pay for Viagra.

Those who view prenatal care as an essential benefit have grounds to protest. But prenatal care isn’t like Viagra. Men’s interest in prenatal care is not primarily about sex. They have an interest in prenatal care because they wouldn’t be alive without it. Each of us exists because some woman nurtured us for the first nine months of our lives, the ones before our birth—and ideally she received some help with that. Prenatal care offers medical oversight of a woman during the period of her pregnancy, encouraging her to take care of herself and watching out for possible complications. Good maternity care prevents needless suffering, as well as the high costs associated with preterm births and low birth weights. Both the pregnant woman and the fetus are the recipients of prenatal care. Caring for the former is the most effective way of caring for the latter.

While prenatal care relies on medical oversight, much of its success depends on the actions of pregnant women themselves. What they eat, how much rest they get, how they protect themselves from harm—all can bear in powerful ways on the future health of their children. Regrettably, such actions often go unnoticed except when they receive negative attention, as when women are blamed for harms indirectly brought to the fetus through poverty, addiction, or exposure to disease. Upholding the value of prenatal care should prompt us to appreciate how much good mothers do for their children before birth. A woman who takes good care of herself during pregnancy presents a compelling combination of goods, two (or more) parties flourishing because of that care.

To object to having to pay for insurance that covers prenatal care because one knows one will never use it is to misunderstand how health insurance works and what it’s for. Health insurance is not an arrangement where payers choose only the services they know (or, rather, think) they will need. Buyers may have some choice when it comes to premiums, deductibles, and coverage, but the system assumes, first, that buyers cannot know in advance all the services they might need one day and, second, that risks are properly shared by a pool of people, some of whom will need more medical care than others. If essential health services were not covered by all insurance plans but were instead offered separately only to those likely to need them, the costs of maternity care would be borne entirely by prospective mothers. Such an insurance system would make childbearing enormously—and, for some, prohibitively—expensive. This would be both bad policy and bad PR; it would imply that Republicans have little regard for mothers or motherhood.

Disparagement of maternity coverage is particularly glaring in light of the history of prenatal care. Popularized in the early twentieth century, prenatal care was a new approach applied to an old and distressing problem: the death and sickness of women and infants. Progressive reformers and child-health advocates, as well as obstetricians, noticed that if several factors were monitored before birth, disasters during birth could be prevented. By the middle of the century, prenatal-care proponents were pressing this approach not just for a few women likely to have problems but for all women, to encourage their health and that of their children.

Reformers often appealed to the national interest: the whole country had a stake in helping women foster the health of babies. Julia Lathrop, the first director of the U.S. Children’s Bureau from 1912 to 1921, lamented America’s high infant-mortality rates and looked to prenatal care as one of the chief remedies. In the wake of World War I, Lathrop oversaw a 1918–19 “Children’s Year,” which she promoted with the slogan “The health of the child is the power of the nation.” The 1921 Sheppard-Towner Act helped fund prenatal care and educate women about it. President Herbert Hoover hosted a 1930 conference on children’s health at the White House, whose proposals included: “for every child full preparation for his birth, his mother receiving prenatal, natal, and postnatal care.” In a maternity manual published during World War II, Dr. Mario Castallo and Audrey Walz told mothers that if they gave the fetus “the right start,” they would “benefit untold generations,” for “upon that mite rests our whole system of government. Nowhere is it so important as in a democracy that its citizens should be capable of shouldering their share in a ‘government of the people’.... The procreation of healthy children and the protection of the mother-to-be and her unborn child is of vital importance to your country.”

We need not endorse the overzealous pronatalism threading through some of that language to affirm that the health of the next generation is a concern of the present one, and that assistance provided to women engaged in childbearing is a worthwhile investment. Prenatal care is about as striking an example of the harmony of interests as can be found: a woman taking care of her own health in the process of taking care of someone else’s, a branch of medicine devoted to the intersection of those health concerns and to bringing long-term benefits out of more intensive short-term treatments.

This is not a blanket endorsement of prenatal care as it is currently practiced. As with health care overall, there are troubling disparities between the kind of prenatal care available to the rich and the kind available to the poor. Rates of fetal and maternal mortality and morbidity remain alarmingly high in the United States. A 2015 study by the World Health Organization found U.S. maternal-mortality figures higher than those of most other rich countries, and half of these deaths were declared preventable. Rates of preterm birth in the United States are more than 40 percent higher for black women than for white women, earning this country a “C” on the annual March of Dimes report card in 2016. And there are better and worse ways to devote resources to pregnancy care. Advocates of midwifery have long supported more personalized approaches to the care of pregnant women, with greater focus on maternal nutrition. A community-based arrangement like CenteringPregnancy, which offers peer-supported and patient-centered care, could improve outcomes while costing less than more conventional medical approaches.

So, like everything else, prenatal care could be improved. But to fail to recognize it as a common good—to identify it as a peculiar benefit just for women or, worse, as the female equivalent of Viagra—is to misunderstand something crucial about both health care and humanity. Motherhood should not be understood as just a luxury or a lifestyle choice. No country can survive without it. It’s lamentable that some lawmakers and pundits should now need to be reminded of this.