As soon as a pregnancy is public, society starts telling women what to do—often resulting in guilt, bafflement, and hours of internet research. Advice from family, doctors, friends, and even governments varies from culture to culture, stoking confusion among expectant parents trying to sort through what appears to be “normal,” and find what’s right for them.
All those rules that dictate what’s “allowed”—be it drinking alcohol, eating watermelon, or cycling to work—don’t just impact the baby. They put a psychological burden on women that can last for years. A brief tour of what’s considered normal around the world reveals just how malleable pregnancy rules are, and how damaging they can be.
Let’s start with one of the biggest no-nos: alcohol. Almost all the countries listed by the International Alliance for Responsible Drinking suggest that, since no amount of drinking has been proven safe, pregnant women should abstain. The US Centres for Disease Control and prevention urges women not to drink at all in pregnancy or when trying to get pregnant, and many women stop drinking completely.
The evidence is interpreted differently elsewhere. In the UK, National Health Service guidelines don’t stipulate that women drink nothing at all, and it’s not uncommon to see a pregnant woman having a glass of wine. The same is true in France and elsewhere in Europe.
These rules often stem from decisions around health messaging—a calculation of what will be most easily understood by the most people. The German Brewers’ Association recently launched a campaign to stop pregnant women drinking at all. It claims that “every sip of alcohol during pregnancy can severely affect the health of an unborn child,” which hasn’t been proved by any specific research. Culturally, Germany simply takes a harder line.
Western rules tend to be influenced by research, but the science often isn’t clear in the case of pregnancy. That’s partly because it’s all but impossible to do randomized, controlled trials on pregnant women for any substance that might have a harmful effect, because it’s considered unethical to put pregnant women or babies at risk. Many studies on alcohol, therefore, are based on the post-hoc recollection of people who drank heavily, for example.
Emily Oster, an economist at Brown University, set out to get the facts on pregnancy dos and don’ts for her 2013 book Expecting Better, exhaustively surveying available data. On alcohol, she repeatedly found that there was no evidence to support the idea that light to moderate drinking was actually harmful to a fetus. She pointed out that one of the biggest flaws in interpreting science around pregnancy is mistaking correlation for causation: Terror of getting anything at all wrong makes us interpret results differently than we might in other situations than pregnancy.
The strict approach in the US is partly due to an “approach to parenting which begins in the womb but continues, where there’s an intense level of self-sacrifice,” Oster told Quartz. “I think it’s pretty clear we’ve pushed that [so that] it’s gotten in some ways closer to ‘If this would be something you would enjoy, you shouldn’t be doing it,’” she said.
Caffeine, also a source of much anxiety in the US, isn’t prohibited in much of Europe. Italian governmental advice suggests “limiting” coffee and other caffeine, not cutting it out. The same advice is more restrictive about eggs, however: Italian women are instructed to eat no more that two per week in pregnancy, part of a national perception that eggs are high in cholesterol.
Unpasturized cheese, as well as paté and deli meats, are a no-go in the US and UK because of worries about listeria, a very nasty bacteria that can cause miscarriage and stillbirth. Outsiders assume French women continue to eat all types of cheese, but in fact the thinking is likely more complicated—and perhaps more individual—than that. One cheese blogger suggests the restriction in France is on the age of the cheese, not the provenance of the milk. Advice produced (pdf, French) by the French ministry of health instructs pregnant women to avoid cheese made with unpasturized milk, as well as some patés and other potential sources of listeria.
Oster noted that, while listeria is certainly dangerous, it’s also rare and very difficult to avoid; many of the outbreaks she tracked turned out to be in random things like ice cream, spinach, and frozen vegetables. “In some sense it’s a risk you have to accept,” she said.
The UK and elsewhere insists pregnant women shouldn’t eat liver or liver products, because an excess of vitamin A can harm an unborn child. But Canada doesn’t list any such vitamin A restriction in its advice.
Chinese culture restricts foods thought to cool the body while pregnant and after a baby is born, like watermelon, ice, and even cold water, which is considered very important in East Asia. In China, “sitting the month” involves not showering, avoiding chills with thick socks and other clothes no matter the weather, and eating foods including nourishing soups made with pigs’ feet, peanuts, or carp.
Socks are also important in Japan during pregnancy, but pain relief during labor is rare. Epidurals—a spinal injection used extensively in France, elsewhere in Europe, and the US—are almost never used in Japan. When Oster revised her book for the Japanese market, she says, she had to remove the pain relief section because it wasn’t relevant.
The question of sushi is complex. In the US, sushi is considered off limits for pregnant women, but a conversation amongst Quartz staff revealed a range of beliefs about why: that raw fish was simply associated with food poisoning; that the problem was mercury in the tuna; that it was a specific salmonella risk; and that it was a risk because of parasitic worms present in some fish. Still, in Japan ”eating raw fish is considered part of good neonatal nutrition,” according to a columnist in the New York Times who picked apart Western fears of uncooked fish. UK guidelines suggest eating raw fish is fine so long as it’s been frozen to kill off parasites.
While the US and UK are restrictive in some areas, in other ways they are comparatively lax. Both countries advise pregnant women to toxoplasmosis, an infection carried by most cats, by not touching cat litter or soil, and washing vegetables. Other countries are much stricter. Sofia Cerqueira, a Portuguese journalist who had a baby in London last year, said in Portugal pregnant women completely avoid salads or fruit anywhere outside the home, because of fears they might not have been adequately washed. At home they use a special antibacterial product called Amukina to wash all fresh produce.
Danes are enthusiastic cyclists throughout pregnancy, and pregnant women have been known to cycle to the hospital during labor. Many swimming pools and gyms in the UK won’t allow pregnant women to use saunas, while in Finland saunas are not just highly frequented during pregnancy, they’re a traditional place to give birth. For the most part, advice on exercise in pregnancy seems less prohibitive than that on food, with women told to listen to their bodies and do what feels right to them, rather than cut out specific activities.
In theory, rules should be based on quantified risks, so why so much discrepancy between countries?
Aside from the problem of controlled trials discussed above, what is considered risky is ultimately a value judgement. The risk of developing listeria during pregnancy is 20 times higher than at other times, but still extremely rare. In an article for the Wall Street Journal, Emily Oster calculated that most “prohibited” foods carried a listeria risk of about 1 in 8,000 risk. “My best guess was that avoiding sliced ham would lower my risk of listeria from 1 in 8,333 to 1 in 8,255,” she wrote. “I just didn’t think it was worth it.”
For some context, the likelihood of dying in a car crash in the US lifetime is 1 in 114 over the course of a lifetime, according to the Insurance Information Institute. The likelihood of dying in an a fall from a ladder is 1 in 7,707.
Perceptions of risk are also typically confined to the health of the baby, says Rebecca Steinfeld, a political scientist at Goldsmiths University in London who specializes in the politics of reproduction. In giving such primacy to the baby’s health, society can “ignore or overlook the woman’s experience in a way that can be really harmful to her,” Steinfeld said.
A woman’s loss of autonomy during pregnancy—based on what’s “not allowed” because of marginal risks to the fetus—can spill over into birth and beyond. For example, women may feel pressured into labor induction or caesarian sections. Traumatic birth experiences can in turn impact post-natal depression and long-term loss of self-esteem.
Rules also make women feel individually responsible for controlling these risks, which “distracts from thinking much more critically about public policies and environmental factors that can be much more harmful to the woman and/or her child,” Steinfeld says. These include better maternal services and leave policies.
Even small judgments, such as a bartender refusing to serve a pregnant woman a glass of wine, or a stranger chiding someone for not wearing socks, can weigh on a woman’s psyche. Instead of the intense focus on potential risks to their unborn child, women should be allowed the mental space to advocate for the bigger picture, and decide what’s right for them.