“The good news is that CDC and other researchers are working to gather more information on medications used during pregnancy. We are working hard to understand how specific medications might affect an unborn baby. Although the studies mentioned below are just one step toward determining the risk of different medications during pregnancy, they contribute to the information available to help women and their healthcare providers make treatment decisions during pregnancy.”
Note that the Centers for Disease Control (CDC, who is no friend of feminism), is working hard to understand how medications affect “unborn babies”, not how medication affect pregnant people, and certainly not how poverty, racism and other systems of oppression harm us and our birth outcomes. Also note the social control implied in women and their health care providers making “treatment decisions” in pregnancy-treatment decisions like autonomously caring for one’s own body and needs by taking a pain killer. So yes, once again, fetuses are so much more important than the pregnant vessels they reside in, or the communities they will grow up in, and women need medical management, not bodily autonomy. And that is the problem with the widely reported study in JAMA Pediatrics that attempted to tie use of tylenol (acetaminophen) in pregnancy to later behavioral problems in children.
This study is called Association of Acetaminophen Use During Pregnancy With Behavioral Problems in Childhood and its a misogynistic shit show, for several reasons. But first, a summary of the study:
- The study’s authors, Evie Stergiakouli, Anita Thapar, and George Davey Smith, looked at a large database, called a birth cohort. A birth cohort database is when researchers get permission from pregnant people (or even people of childbearing age) to follow them for a set period of time. These individuals fill out surveys at specific intervals (say, when they are 12 weeks and 32 weeks pregnant, and when their kids are 3 months, 9 months, 1 year, 3 years and 7 years old). Surveys ask people about their health, what they are doing on the day they fill out the survey, whether they have specific conditions, whether they are getting prenatal care or whatever else the researchers want to know. Note that this birth cohort, the Avon Longitudinal Study of Parents and Children, is a group of women (note narrow definition of gender) from a single county in England, who were followed for reasons totally unrelated to tylenol use. There are some important questions about how well what happened in a single county in England applies to the rest of us.
- The authors looked at 3 points in time when pregnant women filled out surveys: when they were 18 weeks pregnant, when they were 32 weeks pregnant and when their kids were 7 years old. While the study is new, the women involved filled out the surveys in 1991 or 1992 (pregnant), and in 1998 or 1999 (when the kids were 7). The 90s were a long time ago.
- As part of many, many other questions, pregnant women were asked if they took tylenol, and 53% of women said they did take tylenol at 18 weeks. 42% took tylenol when they were 32 weeks pregnant. Because such a large percentage of the people included took tylenol, it is hard to say that tylenol caused any of the results, for the same reasons that while a majority of people who choose to perpetrate domestic violence also shower at least once a week, we can’t really say that showering causes a person to commit a crime.
- As part of many, many other questions that women answered when their kids were 7, they were asked to fill out a 40 question assessment of their kid’s behavior. This assessment, the Strengths and Difficulties Questionnaire, or SDQ, has some issues. The SDQ is what’s called a screening instrument, which means that it screens for potential behavioral problems, but absolutely, by definition, cannot tell you whether a kid actually has behavioral problems. It’s also very culturally biased, and assumes that all people define behavioral problems the same way.
- They compared the SDQ scores of kids whose mothers did and didn’t say they took tylenol, and found a slightly higher rate of slightly higher SDQ scores among the kids whose mothers took tylenol. Remember that the SDQ can’t tell you if the kid actually has a behavioral problem, and half the mothers took tylenol.
- They say they looked at confounding factors. Confounding factors are things that can effect both sides of the equation, in this case both whether you take tylenol and what score your kid gets on the SDQ. They looked at how much money women made, whether their partners (hello heteronormativity and disregard of single parents!) took tylenol, and whether the women reported taking tylenol after their kid was born. A big problem with that last one is that people get told that the only pain killer they can take when they are pregnant is tylenol. After the kid is born, they might still be taking pain killers, but they might have switched back to what they took before they were pregnant, so there’s that. They also looked at a bunch of genetics, though we have not yet identified a gene that’s definitively associated with behavioral problems.
This is how the authors interpret the study:
Children exposed to acetaminophen prenatally are at increased risk of multiple behavioral difficulties, and the associations do not appear to be explained by unmeasured behavioral or social factors linked to acetaminophen use…Although these results could have implications for public health advice, further studies are required to replicate the findings and to understand mechanisms.
And this is how the media interpreted the study:
Acetaminophen, long the mainstay of a pregnant woman’s pain-relief arsenal, has been linked to behavioral problems in children born to mothers who used it during pregnancy….the authors contend that the study results do heighten concerns that fetal exposure to acetaminophen can give rise to neurodevelopmental problems. (The LA Times, August 16, 2016)
So, there are some technical problems: The authors used an already existing database that was developed for other purposes and selected out just a few pieces of information. This happens all the time in research, and it’s a major red flag. Like, if I ask you about your connection with your best friend, and you say you like to eat dinner with them, including spaghetti, tofu and going out to that one burrito place where they skinned their knee that time, it’s hardly a definitive study about spaghetti and patterns of pasta consumption. Secondly, they looked at just 3 isolated points in time, instead of complex relationships, which is another red flag. For example, if you take the survey on a day when your head is killing you, and you took tylenol that morning, you’d probably report it. If you haven’t taken tylenol in the last week, and you’ve been told over and over that it’s safe in pregnancy, you might not think to list it on a survey question about which medication you take in pregnancy and not end up in the “took tylenol” group. (This is called misclassification bias). Also, it’s a long jump from having a slightly higher score on a screening instrument like the SDQ to actually having a behavioral problem, but the authors don’t talk about that. And there is all sorts of cultural bias, if not out and out racism and classism, in the SDQ, because, like most instruments, it was developed by and for upper middle class white folks. (This is called instrumentation bias, as well as a threat to construct validity).
And, though they talk about ruling out confounding factors, they actually don’t. That’s where we start getting into the reproductive justice-related problems with this study. There are a lot of reproductive-justice related problems with this study:
- We LOVE to blame women, parents, and especially pregnant people for just about everything. Like, one wrong move when you are pregnant and your child is permanently fucked. This is super convenient, because when systems of oppression cause lasting impacts on our bodies, minds and opportunities, we can easily just blame a pregnant person for doing something normal (over half the participants took tylenol, remember?) when they were pregnant with us. Way to shift blame, and blame people with the least power, who happen to have popped a tylenol when they were pregnant.
- Along those lines, we LOVE to make harm and bad outcomes about individual bad decisions, and not systems of oppression. Because you know what makes people pop tylenol when they are pregnant, or any other time? Poverty and environmental injustice, that’s what! Like, in my hometown of Boston, when we absolutely consciously bulldozed a major highway through a community of color that was impoverished by redlining and other public planning decisions, we ensured that a highly disproportional amount of air pollution moved into Dorchester. And you know what a highly disproportional amount of air pollution means for residents? That’s right, headaches, muscle aches, increased rates of (painful) chronic illness, and plenty of other reasons a person might take more tylenol than their counterparts in West Roxbury, Brookline, Newton and other communities that were spared the major highway and the pollution burden, also by design. Might these same factors have an impact on children’s bodies, brains and behavior? Please don’t tell me you’ve removed confounding factors from your analysis until you’ve considered racism, classism, redlining and environmental justice, mmkay?
- And while we are talking about institutionalized racism, let’s talk about the well-documented inequities in how our health care system treats the pain of people of color, as compared to their white counterparts. In short, our society considers the pain of white people as real pain, and white people in pain are given real pain relief- stronger medications than tylenol, physical therapy, counseling, surgical options, “alternative” treatments like acupuncture and massage. People of color in pain are dismissed, thought to be faking it in search of attention or drugs. Medical students and clinicians routinely assess the same condition as less painful in a person of color, and prescribe fewer or no pain medications. Pharmacies in neighborhoods of color are significantly less likely to be stocked with pain medications, and therefore residents of communities of color are less likely to be able to fill their prescriptions. We are coming down off of centuries of bullshit white insistence that people of color are less human, and therefore feel less pain, and the legacies is by no means dead (see above). In light of these inequities, who is likely to have their pain adequately treated and who is likely to be making do as best they can with tylenol? So, already, “taking tylenol” is a code for “not white”, and the study is racially coded, even before we throw in a dog whistle word like “behavioral problem”. This whole study becomes about white supremacy and othering-those others who take tylenol (instead of going to the massage therapist their doctor prescribes) and who behave differently from us-us being the white authors and funders of the study, but also the culture of research, which is steeped in the same white supremacist beliefs that caused our medical institutions to insist that people of color imagine their pain, leaving tylenol as the single available treatment.
- And what exactly is a behavioral problem? Is it like drapetomania, the behavioral problem (look it up, it’s historical fact) that caused enslaved people to try to escape slavery? Does wanting to smash the patriarchy and telling Mansplainy Douche at my job to shut the fuck up and stop claiming my ideas as his own mean that I have a behavioral problem? Are behavioral problems bad, or are you just being ableist again, science n media? Aside from the already discussed fact that the SDQ is a culturally biased, racist screening tool that can’t actually tell you if your kid even actually has a behavioral problem, let’s check our assumptions just a little. And let’s take a minute to thank the “behavioral problems” that brought us Malcolm X, Angela Davis, Rigoberta Menchu and Maya Angelou. Disorders are all about who is in power and doing the diagnosing.
So, in summary, take tylenol when you’re pregnant and smash the state. Raise the kid you pop out to dismiss shitty science and the even shittier language of misogyny, racism and ableism we use to frame it.
Stergiakouli E, Thapar A, Davey Smith G. Association of Acetaminophen Use During Pregnancy With Behavioral Problems in Childhood. JAMA Pediatrics. 2016;170(10):964-970. doi:10.1001/jamapediatrics.2016.1775