During previous public health emergencies, the issue of whether public health agencies should recommend that women avoid becoming pregnant because of potential risks to themselves and their newborns has been controversial. The ongoing Covid-19 pandemic has again led to questions regarding whether women should consider postponing pregnancy because of potential virus-related risks. Such discussions involve important ethical considerations.
The issue of pregnancy avoidance emerged early in the HIV epidemic, after the recognition that perinatal transmission occurred in a quarter of pregnancies among women with HIV and that both perinatally infected children and their mothers had poor outcomes. Some public health and professional organizations, including the Centers for Disease Control and Prevention (CDC), initially recommended that women with HIV postpone becoming pregnant until more was known. This recommendation raised a number of ethical concerns, including concern about the potential for moral censure of women, coercive policies, constraints on reproductive autonomy, and discrimination. In 1996, a multidisciplinary working group on HIV and reproduction recommended a policy of “contextualized counseling” that wouldn’t rule out a thoughtful decision to proceed with plans for pregnancy while acknowledging the known risks of untreated HIV for women and their offspring.1
As former CDC employees who played leadership roles in the responses to the 2009 H1N1 influenza and Zika virus outbreaks, two of us (S.A.R., D.J.J.) became aware of appeals for the CDC to recommend postponing pregnancy during these public health emergencies. During the H1N1 influenza pandemic, as data emerged showing that pregnant women with H1N1 influenza were at increased risk for complications and death, some clinicians called for the CDC to recommend that women wait until the pandemic was over to become pregnant. Given the ability to mitigate the risk of harm to pregnant women by means of influenza prevention, antiviral prophylaxis, and early treatment, the CDC instead focused its efforts on educating women and their clinicians on ways to prevent infection, the importance of early treatment, and the need for vaccination once a vaccine became available.
The issue of delaying conception was again raised during the Zika outbreak in 2016 and 2017. Because of substantial risks to the fetus, the question of whether women living in areas with active Zika virus transmission should avoid becoming pregnant was discussed. Given that such risks could be mitigated by avoiding mosquito bites and protecting against sexual transmission, the CDC recommended that clinicians discuss with patients the risks of Zika virus infection during pregnancy and ways to avoid transmission and ask patients about their reproductive life plans, rather than recommending postponing pregnancy. To better support women who wanted to avoid becoming pregnant during the outbreak, the CDC implemented efforts to improve access to contraception. Some experts, however, criticized the agency’s decision not to recommend that women living in areas with active Zika transmission avoid pregnancy.
The subject of delaying conception has once again arisen during the Covid-19 pandemic. Although data on Covid-19–related risks to pregnant women and newborns are limited, a recent study found that pregnant women with Covid-19 have 1.5 times the risk of being admitted to an intensive care unit (ICU) and 1.7 times the risk of requiring mechanical ventilation faced by nonpregnant women of childbearing age with Covid-19 but that pregnant women aren’t at increased risk for death.2 Information on adverse pregnancy outcomes associated with Covid-19 is also limited. Intrauterine transmission of SARS-CoV-2 appears to occur rarely,3 and no evidence has suggested an association between Covid-19 and birth defects; however, data suggest that preterm birth and admission to a neonatal ICU are common among infants born to SARS-CoV-2–infected women.4
In clinical contexts, advice regarding pregnancy avoidance has tended to rely on a doctrine of nondirective counseling, in which a clinician offers information about risks and approaches to minimizing them and supports patients in making informed decisions. In a few situations, however, clinicians may be more directive about pregnancy avoidance, such as when there are severe maternal risks associated with pregnancy (e.g., among women with Marfan’s syndrome with a dilated aortic root). In such cases, the issue of pregnancy avoidance has been addressed with individualized counseling rather than with public health recommendations.
The exercise of public authority in an area as deeply personal and private as the decision about whether and when to have a child requires strong justification, given the many ethical issues it raises. There are several potential areas of concern. The first relates to reproductive autonomy. Respect for autonomy is a guiding principle in medicine; reproductive autonomy has been given particular priority because of the importance that decisions about childbearing may have for a person’s self-determination, personal security, and life course. Past efforts to coerce people to avoid pregnancy (e.g., compulsory-sterilization policies) are widely considered to represent egregious ethics violations. Another concern is the potential for discrimination. Even objectively neutral policies can translate into differential experiences according to race, ethnic group, or social class. Public advice discouraging pregnancy may also inappropriately shift responsibility for pregnancy outcomes to parents and away from institutions that are ultimately responsible for mitigating harm and have the power to do so. A final concern pertains to the interests of people with disabilities. As the disability-rights community has argued, advice about avoidance of pregnancies that might result in offspring with disabilities can send a harmful message about what or who is valued. There is a morally important difference between preventing disease and preventing the birth of a child with a disability.
We believe that before public health agencies make a recommendation to avoid pregnancy during a public health emergency, several criteria should be met. First, the pregnancy-related risks associated with the emergency should be well understood. Early in the response to a new pathogen, these risks are often unknown. In some situations, such as in the event of a large-scale radiation release, however, risk would be high and potentially well understood.
Second, pregnancy-related risk should be high and well above the risk associated with other conditions or exposures that are fairly common among pregnant women. For example, the risk of congenital malformations is two to four times as high among babies born to women with pregestational diabetes as among babies born to women without diabetes. Diabetes is also associated with an increased risk of miscarriage, prematurity, growth restriction, perinatal mortality, and macrosomia, and pregnant women with diabetes are at risk for acute myocardial infarction, progression of retinopathy, nephropathy, and diabetic ketoacidosis.5 Despite these risks, many women with diabetes choose to become pregnant.
A third criterion should be that pregnancy-related risks cannot be reasonably minimized or mitigated. During the 2009 H1N1 pandemic, women could mitigate their risk of harm by taking steps to avoid infection or, if they were exposed, by receiving antiviral prophylaxis or early treatment. Similarly, during the Zika outbreak, the risk of infection could be reduced by the woman and her partner avoiding mosquito bites and after conception by protecting against sexual transmission.
Fourth, effective contraception should be readily available. Women who want to avoid pregnancy should be able to do so. Finally, educational programming that carefully and effectively lays out the risks and benefits associated with becoming pregnant during the public health emergency as compared with waiting until it ends to conceive should be widely available. Programming should be accessible to people with various educational backgrounds, be available in languages spoken by affected people, and be culturally sensitive, and it should address the potential role of partners and others in risk mitigation.
Ultimately, given the ethical concerns raised by public health recommendations regarding pregnancy avoidance, strong justification for any such advice is needed. The criteria outlined above might be fulfilled during certain public health emergencies (e.g., a radiation emergency with continuing exposure), but we don’t believe that the risks associated with Covid-19 meet the bar. The pandemic further emphasizes the need to provide information and support to women related to their decisions to pursue or delay pregnancy.