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1Someday, Now

PRECONCEIVING RISK AND MATERNAL

RESPONSIBILITY

Having a healthy pregnancy is no longer contingent on being pregnant in the first place. In February 2016, the federal Centers for Disease Control and Prevention (CDC) released a statement urging women of reproductive age to avoid alcohol if they were not using birth control, lest they harm a pregnancy that might or might not be present. The idea was vast: the CDC indicated that about 3 million American women were putting potential pregnancies at risk, but any woman between 15 and 44 years old was defined as “pre-pregnant,” thus targeting, in effect, about 61 million American women.¹ This measure attracted considerable social commentary and ridicule,² but it hardly represented a new idea in public health. In 1981, Surgeon General Edward Brandt issued a warning that women “considering pregnancy” should refrain from alcoholic beverages.³ Since 1992, Kentucky has required bars to post warnings that drinking alcohol prior to conception can cause birth defects⁴ when, in fact, it cannot. The idea of pre-pregnancy health promotion surged after 2006, when the CDC released a report recommending improvement of the pre-conception health and health care of U.S. women of childbearing age.⁵ Alcohol was just one of many pre-pregnancy risk factors listed in this report, and public health warnings issued since 2006 have not been limited to drinking.

In late 2012, for instance, Texas initiated a public-awareness campaign, called Someday Starts Now, for improving the health of the state’s babies. In television spots, young women performed everyday activities—chatting with friends, exercising—accompanied by a looming bubble box filled not with dialogue, but rather with numbers indicating a long-in-the-future baby’s due date, sometimes years away. This approach had the visual effect of dangling future motherhood above the women’s heads. The campaign’s associated website stated, “your health today is important—and even more important to the baby you might have someday.”⁶ The text further offered: “If there’s a baby in your future, even if it’s months or years from now, today matters. Take control. Stop smoking, eat right and exercise and do something about your stress.”⁷ After seeing this television spot, one blogger wrote, “Texas is Reminding Me I’m Just a Baby Vessel Again.”⁸

The CDC and Texas campaigns represent but two illustrations of a growing tendency in medicine and public health to mark the beginning of healthy and responsible motherhood not at the birth or adoption of a child, not during pregnancy or at conception, but rather at an earlier point in time: pre-pregnancy. Similarly, in its recommendations for healthy pregnancy behavior, the March of Dimes—a national organization committed to improving birth outcomes in America—points directly to the three months prior to conception, claiming that a proper pregnancy today should actually last twelve months.⁹

These public health statements are jarring. Perhaps because of the invariant biological fact that a typical human pregnancy lasts about nine months, it is disconcerting to read that it instead should be thought of as a lengthier process. Given feminist progress over the past half century, the thought of women of reproductive age as primarily mothers-in-waiting seems problematic.¹⁰ Also given that the focus on pregnancy health for more than a century has been on pregnancy behaviors, the thought of focusing on health behaviors prior to pregnancy is astounding. At the same time, these public-health assertions are somewhat expected. The sentiment that healthy babies stem from fit, responsible women echoes age-old societal preoccupations with women’s bodies, behaviors, and reproductive outcomes. Anticipating and hedging future risk is reflective of our contemporary age of risk aversion and individualized responsibility for health. Concerns about the health of future generations have long manifested in cultural and political anxieties around family planning, fetal health, and women’s roles in society.

Pre-pregnancy care is a framework that emerged as the new panacea for ensuring healthy pregnancies and healthy infants in the United States in the twenty-first century. It now is a dominant medical and cultural schema for reducing risks to healthy pregnancies, and it includes prescriptions for both health care and self-care. To have good pre-pregnancy health is to render pregnancy less risky, the thinking goes, and might improve the overall health of women, children, and society. What is emphasized, then, in contemporary health discourse is that for any woman of childbearing age, in the case of pregnancy health, someday is now.

Such messages are not coming only from health organizations. The notion of pre-pregnancy care has also entered the marketplace—touted as the fix for population health issues ranging from obesity to autism.¹¹ Women today can buy vitamins specially marketed for the pre-pregnancy period as well as advice books such as Get Ready to Get Pregnant: Your Complete Prepregnancy Guide to Making a Smart and Healthy Baby. Newspapers run headlines such as, “Start taking care of your baby before you get pregnant”¹² and “Don’t focus on getting healthy while pregnant—do it before conceiving.”¹³ Even tabloids have expanded their surveillance rhetoric and routinely conjecture about whether celebrities are potentially planning a pregnancy through monitoring their day-to-day behaviors (e.g., “She was seen avoiding alcohol! She might be thinking about getting pregnant!”).

What accounts for this current moment in which birth outcomes are defined in terms of a woman’s whole adult life—well before she ever decided if and when to get pregnant and have a baby? What accounts for the contemporary reproductive landscape in which, as in the Texas health campaign, due dates are projected onto non-pregnant women and a healthy pregnancy is defined as lasting longer than nine months? How is it that now, in the twenty-first century, young women are essentially asked to act as responsible mothers before motherhood is their imminent reality?

This book confronts these questions by tracing the shifting boundaries of pregnancy health risk and maternal responsibility in America at the turn of the twenty-first century—by examining how and why the trend and task of perfecting pregnancies has extended at the front end of three trimesters. It proposes that this pre-pregnancy care model introduces a “zero trimester”—a concerted focus on the months or years prior to conception in which women are urged to prepare their bodies for a healthy pregnancy. The term “zero trimester” has not been previously used in academic, popular, or medical parlance; it is my own neologism that reflects growing sentiments among health professionals and others that individual women should adopt an attitude of anticipation when it comes to pregnancy health.¹⁴ The zero trimester concept, then, refers to the period when a woman is not pregnant but when she is supposed to act as if she is pregnant.¹⁵ The notion of the zero trimester is easily marketed as the three months prior to pregnancy, for example when organizations such as the March of Dimes claim that a pregnancy lasts twelve months.¹⁶ This line of thinking, however, assumes that a woman will know exactly when she will conceive. Thus, the onus of pre-pregnancy maternal responsibility could be vast, without temporal bounds.¹⁷ Some health professionals even point to a woman’s lifetime of experiences as mattering to the health of a pregnancy. During my research for this book, one expert told me, without hyperbole, that “a woman is a mother from the time of her own conception.” All of women’s pre-reproductive years are in the zero trimester.

The idea of extended time for pregnancy has linguistic precedent, as the boundaries between discourses about fetuses and about newborns have become more fluid. The fetus has been represented and personified as childlike in popular and medical imaginations over the past several decades, parallel to both the work of pro-life activists as well as advances in medical technologies (such as sonograms) that render the contents of wombs visible.¹⁸ Additionally, thanks to some popular infant-rearing and sleep books like The Happiest Baby on the Block, the concept of the “fourth trimester” has become part of many new parents’ lexicons in recent years.¹⁹ The “fourth trimester” idea denotes the difficult first three months after a child is born²⁰ and reflects the sentiment that these three months are essentially an extension of fetal development. As medical writer Susan Brink’s book on the topic explains, “the fourth trimester has more in common with the nine months that came before than with the lifetime that follows.”²¹ For instance, the popularity of swaddling newborns—mimicking, in a way, life in the womb—is part of this extended-trimester framework.²²

Thus, it is this cultural moment—one that has seen the rising importance of the fetus and expanding notions of trimesters—in which the zero trimester has materialized and flourished, changing, as it has, medical and social conversations about reproductive risk. Extending the fetal stage prior to as well as beyond pregnancy has become more typical within twenty-first century health-risk discourse. The zero trimester and fourth trimester are modern inventions, flanking the clinical period of pregnancy (see Figure 1).²³ In explaining the social and medical contours of how current health messages targeting women of reproductive age emerged, this book centers on the conceptualization of the pre-pregnancy period as a constructed trimester within a particular social, cultural, and political context of shifting ideas about risk and reproduction.

Figure 1. The twenty-first century pregnancy

WHAT THE “ZERO TRIMESTER” INCLUDES

As mentioned above, contemporary pre-pregnancy care messages are informed by the U.S. Centers for Disease Control and Prevention’s decision to begin promoting pre-pregnancy health and health care in the twenty-first century. In 2006, the CDC released a list of pre-conception health recommendations in the widely-circulated Morbidity and Mortality Weekly Report (MMWR), entitled “Recommendations to Improve Preconception Health and Health Care—United States.”²⁴ This public health report was central to the emergence and trajectory of the pre-pregnancy care model. Following the release of the MMWR, the CDC convened a set of expert workgroups (clinical, public health, consumer, and policy) to filter recommendations and follow through with the report’s goals. The result was numerous publications in the medical and public health literature about how to improve pre-pregnancy care among American women. More pre-pregnancy health promotion campaigns followed, and conversations within medicine and public health about pregnancy health quickly turned more squarely than ever before to the pre-pregnancy period (see Figure 2).²⁵

Figure 2. Number of publications on pre-pregnancy health or health care published in medical and health journals, 1980–2015

With the manifest aims of reducing reproductive risk and improving birth outcomes—including infant mortality, maternal mortality, preterm birth and low birthweight—the basic idea of pre-pregnancy care is to advise and treat any negative health behaviors or conditions that might impact a reproductive-aged woman’s future pregnancy. The MMWR outlined a concrete, though abstract, definition of pre-conception care as “a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management.”²⁶ According to the report, all providers who routinely see and treat women of reproductive age should be attuned to pre-pregnancy health and health care. They should be asking women—regardless of the nature of the clinical visit—what their reproductive plans might be and giving advice in accordance. The report also called for systematic changes in health care provision to offer additional coverage to pre-pregnant women. Women themselves are generally encouraged to partake in self-care, seek out testing (for genetic or hereditary predispositions and for sexually transmitted infections), take multivitamins (especially with folic acid), stop smoking cigarettes and drinking alcoholic beverages, and get conditions such as diabetes or obesity under control prior to conceiving. To an uncritical observer, these interventions might sound reasonable and desirable. That is, these recommendations carry a valence that is hard to argue with: Who would be against healthier mothers and babies? What became exasperating to some commentators is that the new model appeared to be a reawakening, of sorts, of the sentiment that women’s bodies are only vessels for someone else—that women are mothers-in-waiting, and that it is the job of public health and medicine to control women’s bodies for the sake of the greater good. In this way, observers pointed early on to how pre-pregnancy care might be perilous for women.²⁷

Following the release of the CDC’s 2006 report, media headlines engaged in both fear mongering and skepticism. The New York Times published an article entitled, “That Prenatal Visit May Be Months Too Late,” and indicated that the guidelines applied to women of childbearing age even if they are not planning for pregnancy.²⁸ The Washington Post, in its article “Forever Pregnant,” explained that “new federal guidelines ask all females capable of conceiving a baby to treat themselves—and to be treated by the health-care system—as pre-pregnant, regardless of whether they plan to get pregnant anytime soon” and that “so much damage can be done to a fetus” if recommendations are not heeded.²⁹ Ms. Magazine more directly pointed to the contentious nature of the new guidelines with the mocking title “Warning: You Could be Pre-Pregnant.”³⁰ Popular outlets cautioned of potential fetal damage if women were not mindful of the new pre-pregnancy care guidelines, but also undermined the idea to a degree by noting that some might see the idea as outlandish.

It became clear following the CDC’s report that different understandings of pre-pregnancy care were operating simultaneously. In one interpretation, public health officials were offering a forward-looking agenda to improve maternal and child health in the United States—a laudable goal to be sure. In another, critics began lambasting the idea of pre-pregnancy care as backward-looking and sexist. That such divergent viewpoints emerged shows that the idea of pre-pregnancy care struck a cultural and political nerve—something that I work to analyze and clarify throughout this book.

Indeed, the rise and meaning of pre-pregnancy care is much more complex and layered than critiques thus far have afforded. Intricacies abound in a close reading of pre-pregnancy care messages within medical and public-health discourse, revealing latent aims of the framework. For instance, proponents of this model situate it as an avenue for reproductive justice, a framework that includes improving women’s reproductive opportunities and improving access to their reproductive needs. Yet, the contradictions are numerous and powerful. In one pre-pregnancy health webinar I tuned to in 2010, a renowned pre-pregnancy care expert expressed that if a woman chooses unprotected sex, she chooses a baby. This statement excludes various options women have once they conceive, and it also incorrectly assumes that unprotected sex is always a “choice” for women. When declarations like this one pepper discussions of pre-pregnancy care, it might be difficult for people to agree that it is a model for advancing reproductive autonomy. As argued in Chapter 4, the pre-pregnancy care approach does genuinely attempt to further reproductive justice, but of ongoing concern are unintended consequences that could stem from pursuing a model with a mindset that all pregnancies can be planned and that all women of reproductive age are potential mothers. Pre-pregnancy care might not simply be about improving birth outcomes, but also could be—as are most reproductive health agendas—wrapped up in the “longstanding societal ambivalence over the social roles of women.”³¹

Furthermore, although some observers find pre-pregnancy care to focus on practical risk factors that might impact a woman’s health and thus her future reproductive endeavors, such a seemingly straightforward risk-factor approach is accompanied by messaging that makes risk factors sound like causes of imperfect or adverse birth outcomes: if a woman engages in untoward behavior today, her future reproductive endeavors are at risk. The rhetoric of many pre-pregnancy health promotion materials mixes language of risk prevention with that of blame.³² Take a CDC poster from 2009 that reads, “You just found out. You’re pregnant! . . . It’s too late to prevent some types of serious birth defects. . . . The time to prevent birth defects is before you know you’re pregnant.” This particular poster aimed to relay information about the potential of pre-pregnancy folic acid intake to reduce the risk of birth defects. Even though taking folic acid indeed reduces risk, not taking folic acid does not cause a birth defect. Further, the guilt-inducing, moralized message in this poster is somewhat inexplicable in that it seems to be a prevention message after the fact. Such messaging is presumably intended to make women aware of risk for their future pregnancies, to perhaps exploit what psychologists call “anticipated guilt.”³³ In this way, it stokes the fire of critiques that pre-pregnancy messages place an undue burden on women of childbearing age. As I have found, the pre-pregnancy reproductive risk discourse of the twenty-first century evokes particular mechanisms and potential consequences for women that can be quite divisive. Indeed, some think pre-pregnancy care is irrational and others think it is essential. As revealed in the tenor of public-health messages that directly tie pre-pregnancy health behaviors to the risk of birth defects, it is also clear that this discourse is laced with sometimes-strident moral undertones, something to which I return in Chapter 5 and Chapter 6.

Although the notion of pre-pregnancy care was enlightening to some and maddening to others as it emerged on the national policy scene in the 2000s, the idea was not novel to many individuals working in fields of public health and medicine. There was momentum leading up to the CDC’s report among those steeped in professional discussions about persistent adverse birth outcomes (see Figure 3). As early as 1980, a British physician wrote about the need for “pre-pregnancy clinics.”³⁴ The Institute of Medicine’s 1985 landmark study Preventing Low Birthweight was the first major medical publication to advocate changing the traditional point of obstetric care to the pre-pregnancy period,³⁵ addressing risk factors at the pre-pregnancy stage and stating that “numerous opportunities exist before pregnancy to reduce the incidence of low birthweight.”³⁶ The 1989 Public Health Service publication Caring for Our Future: The Content of Prenatal Care adopted and expanded the concept of pre-conception care to include risk assessment, health promotion, and intervention follow ups, explaining that “the preconception visit may be the single most important health care visit” in terms of pregnancy and health outcomes.³⁷ Healthy People 2000, which targeted the nation’s top health goals for the approaching decade, also highlighted pre-pregnancy health as a priority.

Figure 3. Key moments in the emergence of pre-pregnancy care, 1980–2006

As Chapter 2 discusses, physicians and public-health materials have emphasized the pre-pregnancy health of women for generations, albeit with different levels of intensity and specific concerns. Moreover, the idea of pre-pregnancy care is not new to those who might be proactive about pre-pregnancy genetic screening, such as those for whom genetic predispositions to certain diseases (e.g., Tay Sachs) are prevalent in their population group. Women and men who donate their genetic material to fertility clinics are often presented with a litany of health questions, and women and men who have faced infertility also might be acutely cognizant of pre-pregnancy care. For the vast majority of the population, however, health concerns around conception remain informal or nonexistent.

What is novel in the twenty-first century is the institutionalized nature of pre-pregnancy care as a model framework for reducing reproductive risk—an approach in which clinicians and public health officials now understand “proper” pregnancy care to include improving health behaviors, addressing risk factors, and pursuing treatments prior to pregnancy in a formalized way. As part of this framework, women are expected to care for their health prior to pregnancy. This includes planning their reproductive lives, improving lifestyle behavior, and seeking medical care. Moreover, clinicians are expected to assess women’s health status prior to pregnancy and offer appropriate care interventions aimed at the woman as a pre-pregnant body. In practice today, this care framework serves as a main organizing principle for public-health campaigns, population health studies, and women’s health care.

SITUATING THE ZERO TRIMESTER IN THE

HISTORY OF PRENATAL CARE

It is impossible to understand the social creation of the “zero trimester” without understanding the historical rise and fall of the promise of prenatal care to improve U.S. birth outcomes. Prior to this century, most health professionals might have thought absurd the pre-pregnancy messages cited at the start of this chapter. The prevailing medical model for ensuring pregnancy health for almost one hundred years had been prenatal care—the idea being that if women engage in healthy behaviors and receive good clinical care during the nine months of pregnancy, then birth outcomes should be optimized and infant morbidity and mortality reduced.³⁸ The Children’s Bureau first advocated clinical prenatal care in the early twentieth century,³⁹ but this concept did not take root as a universal expectation of pregnant women until the 1980s.⁴⁰ The ’80s became known within the maternal and child health field as one of a “prenatal care revolution” because of the great increase in numbers of women seeking and accessing care.⁴¹ Maternal and child health experts were hopeful that this surge in prenatal care utilization would reveal its “magic bullet” status, translating into vast improvements in population health. Quite surprisingly and contrary to the expectations of many, however, birth outcomes did not improve the more prenatal care American women sought and received. At the end of the twentieth century, infant health and survival in the United States ranked among the worst in the industrialized world and improvement in rates of adverse birth outcomes had stagnated.⁴²

Such it was that a paradox had emerged—more and more women were accessing prenatal care services without parallel improvements in birth outcomes. When prenatal care seemed not to be doing enough, prenatal education was then pushed as the next big answer.⁴³ Sociologist Elizabeth Mitchell Armstrong writes that prenatal education, such as childbirth classes offered by hospitals, was “proposed as a solution to one of the most troubling social facts of contemporary America: despite the billions of dollars lavished on health care, despite ever-higher concentrations of medical technology, babies continue to die in this country at a much higher rate than elsewhere in the industrialized world.”⁴⁴ Because many countries use infant and maternal mortality and morbidity rates as proxies for national health,⁴⁵ the United States did not distinguish itself as healthy or progressive in the 1980s. Experts began to question the evidence bolstering prenatal care. Maternal and child health scholar Lorraine V. Klerman wrote in 1990 that it was perhaps time to “question past orthodoxies” and “loosen the link between prenatal care and infant mortality” because “public health experts know that the reduction of infant mortality requires much more than prenatal care.”⁴⁶ In the interviews I conducted for this book, experts told me time and again that prenatal care basically does very little, if anything, to address the nation’s most pressing maternal and child health problems.

Although prenatal care might be very effective at diagnosing and treating problems that surface during a pregnancy, it does not prevent many of those issues from arising in the first place. It is especially ineffective at preventing the major causes of poor infant health outcomes: low birthweight and preterm birth.⁴⁷ Moreover, health professionals are quick to note that almost half of U.S. pregnancies are unplanned, meaning that women often enter pregnancy without health care or healthy behaviors on their mind, and unintended pregnancies are often linked to a greater risk of an adverse birth outcome.⁴⁸ Many experts argue that U.S. women are just not healthy enough—and do not plan ahead well enough—and therefore are putting the health of the next generation at risk. In this vein, and as Chapter 4 discusses in more detail, health experts began to question policies that only provide comprehensive health care to women when they are pregnant, rather than before and beyond motherhood. Thus, around the turn of this century, many maternal and child health professionals considered prenatal care—the perceived panacea for improving the population’s birth outcomes—nothing more than a mere salve.⁴⁹ As one historian has written, “prenatal care is no magic bullet and never will be.”⁵⁰

What was considered the best way forward? How do medical and public health experts tackle population health problems when the best idea to date has not worked? Near the turn of the twenty-first century, maternal and child health experts began contending that the answer to improving birth outcomes and to reducing infant mortality and maternal mortality was both prenatal care and pre-conception care,⁵¹ or medical and health attention before pregnancy ever begins, in addition to care during pregnancy itself⁵²—that is, to construct a zero trimester. If prenatal care seemed to be the answer for the twentieth century, then pre-pregnancy care would be the answer for the twenty-first.

In 2004, the Centers for Disease Control and Prevention launched the Preconception Health and Health Care Initiative, signaling a formal swing in policy focus toward improving women’s health status through a focus on both individual women’s self-care and improvement in health-care services for women of reproductive age prior to pregnancy. But how far prior? The answer was to move the temporality of pregnancy health risk and maternal responsibility to actions taken in the months—or sometimes even years—before pregnancy, thus situating essentially any body of reproductive age as posing risk to healthy reproduction.

This book examines this redefinition of reproductive risk; it is about a knowledge shift in the field of maternal and child health—about a search for a panacea in pregnancy care. It looks at the collective response to pressing population health and social problems when the clinical “fix” has failed, and it is about how a somewhat ambiguous idea of “pre-pregnancy care” came to “make sense” in medical and public-health discourse today.

DOES THE ZERO TRIMESTER MATTER?

EVIDENCE AND AMBIGUITY

Of course, prenatal care did not become obsolete and instead has been bolstered time and again by social policy initiatives.⁵³ Prenatal care remains an “article of faith” in our culture,⁵⁴ and individuals, couples, doctors, health policy, and insurance companies continue to highly value it. To repeat, prenatal care does have individual-level benefits such as addressing and diagnosing problems that arise during a pregnancy, and the central argument of this book in no way posits that women’s access to prenatal care services should be curtailed. What is germane here is that prenatal care does little in the way of primary prevention—a point that the medical experts I interviewed readily and repeatedly made. This means that prenatal care is reflective of our medical culture to treat rather than prevent.⁵⁵ It inscribes maternal responsibility as a “good” expectant mother seeking prenatal care throughout her pregnancy. Pre-pregnancy care, then, might seem an obvious next step for individuals and organizations immersed in the idea that seeking prenatal care marks responsible pregnancy behavior: if it is good, then the earlier the better. The added component of pre-pregnancy care was meant to complement, not supplant, the “old” prenatal model, and in so doing expand the sphere of medical and maternal responsibility for establishing healthy pregnancies.

Although the pre-pregnancy care model in some ways might be an empowering and smart way for women and physicians to approach family planning and reduce risk—and, indeed, the focus on pre-pregnancy care offers an important corrective to longstanding policies that have ignored the critical intersections between maternal health and reproductive health and that have in some ways impeded reproductive justice (a point explored at length in Chapter 4)—it in other ways might function as yet another attempt to control women and their behaviors, by placing their non-pregnant lives within new crosshairs of public scrutiny. To be sure, much of the criticism surrounding the pre-pregnancy care model has stemmed from the fact that pregnant women have long been construed as “public property” in America,⁵⁶ where, at an interactional level, strangers feel empowered to touch pregnant women’s bellies and, at a structural level, the criminal justice system targets pregnant women for their behaviors. Surveillance of, and anxiety around, women’s pregnant bodies remains typical. Imagine a visibly pregnant woman drinking at a bar in the United States; the social sanctioning that follows is perhaps inevitable. Then, imagine a non-pregnant woman drinking at a bar. Does anyone look at her and worry about her future fetus? Not likely. For a very long time, medicine, public health, and even the lay public have focused intently on policing a woman’s behaviors when she is clearly pregnant. Few people—and few physicians—would think of telling a non-pregnant woman who drinks alcohol that she is possibly harming her chances of having a healthy baby someday. Yet this message is part of the CDC’s 2016 public-health statements urging women of reproductive age to avoid alcohol. Even if the message might be well-intentioned in some respects, these types of directives run the risk of unintended consequences—namely of creating an atmosphere that escalates not only individual guilt among women but also social policing and public retribution against women who deviate from customary norms.

But is the hypothetical non-pregnant woman drinking at a bar actually endangering her future fetus? Do everyday choices and behaviors matter for future reproductive outcomes? It might make intuitive sense to be at one’s healthiest before reproducing, but the evidence is ambiguous regarding whether specific pre-pregnancy behaviors will impact fetal health. With respect to alcohol, for example, the CDC’s 2006 report stated that at “no time during pregnancy is [it] safe to drink alcohol, and harm can occur early, before a woman has realized that she is or might be pregnant” and that “alcohol-related birth defects can be prevented if women cease intake of alcohol before conception.” Nowhere in this recommendation was the claim that pre-pregnancy drinking will affect the future health of the fetus or child. Rather, the predominant worry was that a woman will continue drinking without knowing she is pregnant. The public-health recommendation is to discontinue drinking prior to pregnancy so as not to continue drinking someday during pregnancy.

Although pre-pregnancy alcohol messages reveal how pre-pregnancy recommendations can be patently misleading and disingenuous, other examples allow us to better grasp the pre-pregnancy model’s reasoning. There is good evidence to suggest that controlling certain chronic conditions prior to pregnancy improves individual chances for positive birth outcomes. For example, medical researchers have found that women with diabetes (both type 1 and type 2) are at increased risk of miscarriage and adverse birth outcomes, and that these risks can be mitigated through pre-pregnancy planning.⁵⁷ Another good example is HIV status, in which women who are HIV-positive could benefit from pre-pregnancy counseling about ways to prevent transmission to a future infant.⁵⁸ Moreover, public health officials and physicians are increasingly worried about widespread chronic conditions among women, such as obesity. Obese women have elevated risks for complications during pregnancy and childbirth,⁵⁹ and thus it might be very beneficial for such women to lose weight prior to pregnancy, both for their own general health and for their pregnancy health. At the same time, obesity has multiple causes and might not be easily remedied in a pre-pregnancy care visit. Other “epidemics” are troubling to health experts as well, such as the rising rates of opioid addiction among reproductive-aged women. Certainly, responsible health advice to a reproductively-capable woman who is addicted to opioids would be to avoid or delay pregnancy. Such advice, though, could be entirely unhelpful to the woman’s broader life circumstances that situate her at risk for addiction, disease, or adverse birth outcomes.⁶⁰ Furthermore, while some pre-pregnancy risks are real, determining how individual risks—amid numerous social or environmental risks—become linked directly to birth outcomes might be telling for how and upon whom population health directives position responsibility. Is it possible to square the need to mitigate risk for particular individual women with the broad-based calls for all women of reproductive age to change their everyday behavior and act as if they are potentially pregnant?

As mentioned above, federal health reports have noted since the 1980s that a pre-pregnancy health-care visit might be of paramount importance to pregnancy outcomes. Since then, numerous organizations and scholars have touted pre-pregnancy care as the key intervention to improving maternal and child health in this country. But despite the faith expressed in pre-pregnancy care among many maternal and child health policy experts, there are significant gaps in clarity about the extent to which blanket recommendations to improve pre-pregnancy health and health care among all women of reproductive age will produce better birth outcomes in America.

First, temporal confusion abounds when it comes to discussions of pre-pregnancy care and the risk of adverse birth outcomes. The point of most pre-pregnancy behavioral interventions does not reflect evidence of clear connections between one’s pre-pregnancy health behavior and identifiable fetal harm. Pre-pregnancy health discourse often actually is focused even more specifically on the early pregnancy period, not the pre-pregnancy period itself. With regard to smoking, for instance, the CDC has stated that of women who smoke, only 20% “successfully control tobacco dependence during pregnancy, [thus] cessation of smoking is recommended before pregnancy.”⁶¹ In other words, even for smoking—something generally considered to be bad for everyone—the principal concern is that women will not be able to stop smoking once they become pregnant and that women will continue smoking before they learn that they are pregnant, not that smoking at some point in one’s life prior to getting pregnant equals increased risk for an adverse birth outcome.⁶² Another example is folic acid consumption, which is covered in more detail in Chapter 2. Experts consider folic acid to be the best evidence for a pre-pregnancy intervention because of the effect it has on reducing the risk of neural tube defects such as spina bifida in developing fetuses. Folic acid is highly effective at reducing birth defects if it is consumed in very early pregnancy. Folic acid consumption thus might be a profound risk-reducing mechanism for women planning a pregnancy because they might become pregnant, but it does not reduce all risk of neural-tube defects and does not work through years-long consumption. Suggestions that folic acid should be consumed by all women of reproductive age throughout their reproductive years situates all such women as perpetually potentially pregnant. That is, with pre-pregnancy care messages and interventions, the focus no longer is on women at risk but on all women of childbearing age.⁶³

Such widespread targeting stems from the fact that a key aim of pre-pregnancy interventions is to cover the periods of fertilization, implantation, and early pregnancy. In defense of the need for pre-pregnancy care, experts cite the first few weeks of embryonic development, which includes integral central nervous system and cardiac development, as a period when women are often unaware of their pregnancy and unintentionally forgo attentive health practices.⁶⁴ In as much as experts invoke scientific knowledge about the impacts of pre-pregnancy interventions, the chief hope is to target pregnancy intentions, a theme elaborated upon in Chapter 3. That is, the focus is on social behavior that foregrounds planning, and not on imminent medical risk. Pre-pregnancy care recommendations attempt to safeguard conception and early pregnancy because many pregnancies are unintended. Even women who intended to become pregnant, however, do not usually know the exact moment of conception. Thus, despite the temporal confusion of many pre-pregnancy health messages that falsely lead women to contemplate that every health behavior engaged in today might affect their fetus of tomorrow, zero tolerance now extends to the zero trimester.

Next, and more generally, we know very little about what actually causes most birth defects.⁶⁵ Studies point to a profound lack of etiological understanding of what makes a healthy—or unhealthy—pregnancy and birth, and medical experts often do not understand the root cause of most poor birth outcomes.⁶⁶ In fact, the two major causes of infant mortality—congenital anomalies and preterm birth—are not well understood by the medical community.⁶⁷ Moreover, in contrast to media-perpetrated stereotypes, most neonatal deaths occur among women in their twenties and early thirties who do seek medical care and who do not use illicit drugs.⁶⁸ In other words, the majority of adverse birth outcomes are to seemingly healthy women. Some measure of responsibility might lie with institutionalized medical practices, and not women’s behavior. For example, analyses of the increase in preterm births find that high rates of labor induction, cesarean deliveries, and assisted reproductive technologies might be key drivers—factors that are not necessarily related to the pre-pregnancy health status of women but rather to the institutionalized culture of medical intervention in reproduction.⁶⁹

Third, there are discrepancies in understandings about the health status of women of reproductive age. In recent population-based research, almost 89% of women of reproductive age reported good, very good, or excellent health, and about 75% of women of reproductive age had health coverage during the month before their most recent pregnancy.⁷⁰ At the same time, a quarter of women of reproductive age reported smoking cigarettes in the three months prior to pregnancy; about half reported drinking alcohol. Only about 30% reported taking a multivitamin or folic acid supplement.⁷¹ These numbers lead experts to note that there is room for improvement in expanding knowledge about what constitutes good pre-pregnancy health. Even so, it is worth noting that we also do not know much about how pre-pregnancy health status has changed among women of reproductive age over the years; before the CDC’s recommendations for improving pre-pregnancy care were published, few states monitored pre-conception health indicators specifically.⁷² Data do exist, however, on general health behaviors and health risks of non-pregnant women over time. Such data suggest that some behaviors have improved since the CDC’s recommendations, such as substantial reductions in smoking and drinking. Conversely, reports of binge drinking, obesity, or having diabetes, as well as self-reported health, all significantly worsened over the same time frame.⁷³

Fourth, while the pre-pregnancy care framework attempts to address persistent and dramatic racial and ethnic health disparities in maternal and child health, it does so inadequately. Within the United States, such disparities are profound. Some women are more at risk of adverse birth outcomes, and some women—due to factors such as race, class, or geographic location—have poorer pre-pregnancy health than other women. The infant mortality rate for black women is double that of white women, a gap that has increased in recent years.⁷⁴ The maternal mortality rate for black women is more than three times that of white women and has also been on the rise.⁷⁵ While confronting the distressing reality of such inequalities in reproductive status and reproductive outcomes, pre-pregnancy health promotion materials have perhaps unwittingly reinscribed racialized notions of reproduction.

As Chapter 5 and Chapter 6 discuss in more detail, rather than addressing widespread social problems such as structural racism, poverty, or limited access to healthy food choices, our standard public health and medical agendas simply tell all women to practice the healthiest lifestyle possible to ensure healthy babies. Additionally, reproductive agendas in the United States are almost always racialized, built on contemporaneous ideas of “good reproduction” and engaging in what Rickie Solinger calls the process of “racializing the nation.”⁷⁶ At issue is whether we are willing to focus our public-health interventions more squarely on reducing poverty- or race-based disparities for at-risk women rather than pursue policies that ask all women of reproductive age to change their behavior and plan their pregnancies without the supports they might need to do so.⁷⁷ Without systemic change, will only well-off women (or women seeking fertility services) be the ones to reap potential health rewards? We must ask who benefits from an expanded population health focus on pre- pregnancy health and health care.

Fifth, there is a deep disconnect in pre-pregnancy health materials between individual-level recommendations and social-level change in the landscape of maternal and child health. That is, beyond individual-level health risks and health behaviors there are, notably, vivid examples of environmental-level risks that harm non-pregnant individuals and that matter for their future birth outcomes. It is indisputable that birth outcomes have a lot to do with poverty and social conditions, including proximity to environmental contaminants before pregnancy. For instance, research reveals that long-term exposure to environmental toxins can damage genes.⁷⁸ In a 2015 exposé of the New York City nail salon industry, Sarah Maslin Nir of the New York Times revealed that nail technicians, by virtue of their prolonged exposure to chemicals, are at an increased risk of having a child with birth defects. Such cases of fetal or infant health risk have less to do with individual behaviors and lifestyle choices and more to do with widespread environmental exposures over which individuals have little control—calling into question the individualized tenor of many pre-pregnancy care messages. The pre-pregnancy care model today does incorporate messages for social change and awareness of the need for life-course approaches to holistic health, such as expanded health-care coverage for all women of reproductive age. As Chapter 5 and Chapter 6 show, however, overwhelming any system-level or environmental-level discourse are health-promotion messages directing every woman as to what she should do to improve her chances for healthy reproduction, including, in some instances, urging women to avoid particular activities or exposures. To keen observers, this advice could sound reminiscent of past “solutions” that aimed to bar women of reproductive age from toxic jobs—rather than eliminate the noxious exposure in the first place—to safeguard fetuses that are not yet conceived.⁷⁹ Pre-pregnancy risk factors epitomize a longstanding debate and tension in population health and public policy about how to navigate the relationship between individual-level risk and population-level prevention policies.⁸⁰

Some of the debate about interactions between individual-level and environmental-level risk factors has been aided by the rise in social scientific concentration on cumulative life health⁸¹ and epigenetics scholarship that links life-course outcomes to the time in the womb or even to the mother’s lifetime experiences. The pre-pregnancy care model taps into the rise of these ideas. Scholars, however, have recently called-out such research for its inclination toward deterministic⁸² and mother-blaming language. In a Nature essay in 2014, historian Sarah Richardson and colleagues situate contemporary epigenetics discourse in a long history of society blaming mothers for all kinds of children’s health problems.⁸³ Although it has been argued that pre-pregnancy care is an extension of epigenetics research,⁸⁴ this book shows that the pre-pregnancy care literature predated the emergence of epigenetics as a popular scientific topic. Moreover, the experts I interviewed did not tend to couch the pre-pregnancy care model in an epigenetics paradigm. In fact, some saw epigenetics research as too simplistic, deterministic, and not necessarily concerned with the same things about which they were concerned. For example, the work of reducing unintended pregnancies—a key component of pre-pregnancy care—does not stem directly from epigenetics research. Rather, the pre-pregnancy care framework is gripped with broader ideas about—and politics surrounding—health care, family planning, motherhood, and reproduction.⁸⁵ So, while pre-pregnancy care might exist nicely in step with a postgenomic/epigenetic paradigm, it stands on its own historically and epistemologically.

Finally, men matter, but reproduction talk is almost always about women. It is a human creation that women’s bodies are often solely tied to reproductive responsibility, yet such an arrangement appears as “common sense,” as simply “the way things are.” This sentiment is perhaps slowly changing. In her work a decade ago, political scientist Cynthia Daniels detailed at length how men’s exposures to harmful chemicals, most pointedly with the example of Agent Orange in the Vietnam War, impacted their subsequent reproductive years, resulting in higher susceptibility for having children with spina bifida and other birth abnormalities.⁸⁶ Emerging science is showing more than ever that men’s health status impacts the health of future fetuses. For example, men who smoke cigarettes damage their sperm’s DNA, which might affect the health status of a future baby.⁸⁷

Health behaviors might be particularly pertinent for men because, unlike eggs, new sperm is made every forty-two to seventy-six days, so “damaged” sperm can be replaced by newer “healthier” sperm within three months given a change in behavior or exposure⁸⁸—in effect, the zero- trimester concept easily could be applied to men. To be sure, some pre-conception health materials mention men. For example, in Kentucky, the signs posted in restaurants and bars warning that drinking before conception can cause birth defects do so without express mention of women (this is unlike the Surgeon General’s warning on alcohol that is usually explicitly addressed to women who are pregnant). This decision was made so as to include men—recognizing that men’s pre-conception exposures might matter for reproductive health.⁸⁹ In Texas’s Someday Starts Now campaign mentioned at the opening of this chapter and that featured television ads with images of women, web pages were devoted to both women’s health and men’s health and indicated that today’s behaviors matter for future baby health “whether you are a man or a woman.”

Yet, these mentions of men have been exceptions to the rule. As Rene Almeling and I have shown in previous work, men’s contribution to reproductive health is still largely ignored or gestured to only nominally within the medical community broadly and within pre-conception health promotion materials specifically.⁹⁰ Overwhelmingly, the recommendations and rhetoric about pre-pregnancy care in promotional campaigns, and writ large, are still aimed at women—women who are not yet pregnant. Thus, while I do mention men and pre-pregnancy care at times, this book primarily focuses on how the zero trimester has been constructed for—and pitched to—women of reproductive age.

Given all of these considerations and such levels of uncertainty, one might wonder how pre-pregnancy care came to be seen as the panacea for improvement in birth outcomes. As Chapter 3 discusses, the pre-pregnancy care model has been bolstered and defined in the twenty-first century by obstetricians and health professionals who, rather than citing a clear body of scientific evidence, believe that this approach is “obviously” good for women and babies. If the evidence for pre-pregnancy health interventions is not particularly robust—or is, at the very least, quite scattered—then positioning the pre-pregnancy model as a foremost approach in reducing birth defects, infant mortality, or other adverse outcomes is questionable.

Is it ethical, or even reasonable, to tell women that the self-care and health-care behaviors they engage in today will influence the health of their future fetus, even when this might not entirely be the whole story—and especially if they have no power over the factors that might matter most?⁹¹ The environmental and epigenetic examples provided above reveal that pre-conception harm might be at the environmental—rather than individual—level and might occur to men as well as to women. Nevertheless, the focus of the zero trimester is predominately on individual behavior change among women alone, not on men or social institutions. It is aimed at making and keeping a potential pregnancy in the forefront of women’s minds at all times, often at the expense of focusing on systemic factors that might put women at lesser risk of unintended pregnancy or adverse birth outcomes in the first place.⁹² Given these foci, it is imperative to analyze the tenor of the pre-pregnancy care approach to understand how population health strategies are shaped—and also to critically assess how such a strategy hinges on medical science and on cultural assumptions and political sensibilities about women, reproduction, and responsibility. Is this an instance of empowering women or of making women feel guilty for birth outcomes that are not solely—or even mostly—within their realm of control? Does pre-pregnancy care place too great a burden on women of reproductive age?

To be clear, this book’s aim is not to adjudicate the effectiveness of pre-pregnancy care. As detailed above, some evidence suggests that it is inconsequential and misleading; some evidence suggests that it is profoundly important. Proponents argue that this twenty-first century way of thinking about reproductive risk is the best and most effective path forward for improving maternal and child health in America; critics argue that it is pernicious and counterproductive and treats women unnecessarily like baby vessels. This book, rather, focuses on why the magic-bullet solution of “pre-pregnancy care” emerged when it did, particularly amid such variable interpretations of its message and effects, and what it tells us about the contemporary politics of women’s health, motherhood, and public health prevention strategies. It scrutinizes the cultural and political logics that have intersected with and informed the rise of a medical and public health agenda in the early part of this century.

Sociologists of medicine and science have long observed that what has become conventional medical and health wisdom is intricately tied up with what is considered conventional social wisdom. That is, social, cultural, and political currents shape and are shaped by scientific and medical knowledge. I now turn to contextualizing the rise of the pre-pregnancy care framework in such currents. Bolstering its emergence in the beginning of the twenty-first century were three overlapping trends: the pervasiveness of risk discourse within surveillance medicine, the enduring strength of motherhood ideology, and the ongoing fraught landscape of reproductive politics and women’s changing lives.

THE TEMPORAL (BIO)POLITICS OF HEALTH RISK

Part of understanding why and how the pre-pregnancy care idea emerged when it did requires taking account of a broader trend related to risk. Risk is today typically thought of as a consequence of individual decision-making,⁹³ and individuals are expected to manage risk through their consumption and health practices.⁹⁴ Neoliberal tendencies drive contemporary public-health initiatives by touting the importance of individual risk-reducing behavior.⁹⁵ Public health today also generally emphasizes anticipating future and unintended health consequences via the “precautionary principle”⁹⁶—the idea being that if something is suspected of being risky, then those risks should be avoided altogether.⁹⁷ The pre-pregnancy care model is another attempt to eradicate uncertainty in modern risk culture⁹⁸ in which individuals are preoccupied with the future and primed to take precautions to prevent or avoid risks.⁹⁹

In medicine, too, individualized and risk-averse approaches have recently centered on advanced anticipation of risk, that is, on the practice of intervening upon potential risks that are presumed to appear in the future. For instance, scholars have focused on tendencies in contemporary medicine toward treating healthy populations as if they are primed for illness.¹⁰⁰ Historian Charles Rosenberg uses the examples of emergent pre-diseases, such as elevated cholesterol or pre-hypertension, to refer to “proto-disease states.”¹⁰¹ Pharmaceuticals target future risk as well; chemoprevention, for example, involves giving a drug (tamoxifen) to women who are deemed “high risk” for breast cancer but who are otherwise healthy and show no signs of illness.¹⁰² Contemporary biomedical technologies serve to “control the vital processes of the body and mind,” becoming “technologies of optimization,”¹⁰³ and medical jurisdiction over disease now extends to “health itself”—“it is no longer necessary to manifest symptoms to be considered ill or ‘at risk.’”¹⁰⁴ In this way, we see an escalation of health-care interventions focusing on “pre” phases, which includes pre-pregnancy care. Indeed, the pre-pregnancy care model of risk reduction dovetails with sociological insights into how contemporary medical knowledge has diffused into lay understandings of responsibility for health more generally.

To be sure, individuals themselves are expected to optimize their health in every way possible, partially through anticipating any potential risk. This phenomenon is typified throughout the health and wellness industry; for example, employers and health insurance companies are increasingly offering financial incentives for workers to get “wellness” checks or to sign tobacco-free attestations, with the goal of assessing present and potential health risks. Current fixation with optimizing health risks is reflective of the modern biopolitical moment, one in which the “calculated management of life” works to control the behavior of both individual bodies and populations.¹⁰⁵ Reproductive health concerns are not atypical in this regard. Indeed, from alcohol to fish consumption, medical and public health expectations about reducing reproductive risk fill our public airwaves,¹⁰⁶ serving to shape and monitor behavior.

Medical sociologists have noted that this rise of “surveillance medicine,” especially since the latter part of the twentieth century, has included increased medical screening and public health campaigns, conjuring the need for “anticipatory care . . . transform(ing) the future by changing the health attitudes and health behaviors of the present.”¹⁰⁷ Anticipation is exactly what the pre-pregnancy care framework seizes upon. Reproduction and science studies scholars Vincanne Adams, Michelle Murphy, and Adele Clarke have written that “anticipation is rapidly reconfiguring technoscientific and biomedical practices as a totalizing orientation” and that “anticipation pervades the ways we think about, feel and address our contemporary problems.”¹⁰⁸ These scholars theorize about “anticipatory regimes,” in which the management of the future “requires projecting ever further back into younger years, positing the future as urgent in ever earlier moments of organismic development.”¹⁰⁹ Additionally, exemplary sites of anticipatory regimes, according to Adams, Murphy, and Clarke, are often highly biomedical and gendered. When it comes to the next generation’s health, the vector of anticipatory risk is often a woman.¹¹⁰ Thus, all women of reproductive age are placed in a holding category for anticipatory care practices and interventions. In pre-pregnancy care, non-pregnant women of childbearing age are classified clinically through a framework in which the “future arrives as already formed in the present, as if the emergency has already happened.”¹¹¹

The new temporal space of pre-pregnancy risk surely is indicative of this anticipatory phenomenon in biomedicine and public health policy. Yet, pre-pregnancy risk also extends and layers previous anticipatory risk discourse in interesting and novel ways, which I elaborate upon in Chapter 3. With the zero trimester, greater levels of anticipation than have been documented exist, targeting two bodies: the potentially-pregnant woman and her future fetus. Attention and anticipation are thus partly directed toward a not-yet-conceived, non-existent being. Pre-pregnancy care can be seen as the crest of a wave of new public health and medical discourses and interventions that simultaneously focus on one present body and (at least) one future body—on the next generation through a present pre-reproductive body.

THE MATERNAL IMPERATIVE

The rise of this dual-body future emphasis is possible because of—and is characterized by—its gendered dimension. Women are typically asked to bear the burden of minimizing reproductive risk. Mothers, in particular, have long been exhorted to follow medical experts’ advice about how best to raise healthy children. A hundred years ago, the medical community deployed government pamphlets and manuals to formally define proper health behavior related to pregnancy and motherhood.¹¹² In an example of noteworthy stasis, medical and self-care advice is still today part of the construction of contemporary “moral motherhood.”¹¹³

The notion of the “future fetus” in the pre-pregnancy model is imaginable because of the way in which the fetus has become such a salient cultural and medical object within a surveillance society.¹¹⁴ Indeed, maternal bodies get caught in a distinctive web of expert surveillance so as to optimize both fetal and infant health outcomes. Pregnant bodies today are consistently monitored to assess risks to the fetus in particular.¹¹⁵ The rise of maternal-fetal medicine (MFM), fetal surgery techniques, and technoscientific practices in the second half of the twentieth century shifted obstetrical gaze toward the fetus as a separate patient, one that is distinct from the mother’s body.¹¹⁶ Fetal risks are often now weighed against the risks to the mother, heightening the supposed maternal-fetal conflict, in which women’s interests are putatively pitted against the interests of the fetus.¹¹⁷

The rise of pre-pregnancy care thus has occurred in a climate in which maternal behavior and motherhood have higher stakes than ever before. The increased social and cultural importance placed on children¹¹⁸ has much to do with this, as motherhood in general became an ever more rigorous endeavor over the course of the twentieth century. Sociologist Sharon Hays noted the rise of “intensive mothering” almost twenty years ago, referring to the idea that contemporary motherhood in the United States is labor intensive, expert driven, emotionally consuming, consumer driven, and child centered.¹¹⁹ Since the time that Hays introduced her concept, mothering has intensified into what Joan B. Wolf calls “total motherhood,” a concept that calls attention to the ubiquity of “risk analysis to prescriptions for good mothering in a risk culture.”¹²⁰ Today, a new “momism” accentuates expectations in an increasingly idealized version of motherhood,¹²¹ in which mothers actively engage in risk calculations on behalf of their children’s health.¹²²

The concepts of “intensive mothering” and “total motherhood” are helpful in gaining an understanding of contemporary messages surrounding the ever-more-diffuse health risks that are aimed at reproductively capable women. As mentioned above, in a risk culture in which individuals are expected to calculate and mitigate any potential risks,¹²³ and in which mothers are expected to reduce all risks to their children— especially through proper health behaviors¹²⁴—such risk-reducing sentiments also apply to fetal health as well as to future fetal health. For the past several decades, “assumptions of maternal vulnerability have been reconstructed around risks to the fetus mediated through the maternal body” and even the pre-maternal body.¹²⁵ Some scholarly work has even tied the rise of the pre-pregnancy care to post-9/11 anxieties about terror, risk, and the need for increased protection of future children not yet conceived.¹²⁶

Amplified focus on pre-pregnancy care and the rise of the zero trimester promote what I call in this book a cultural ethic of “anticipatory motherhood.” Drawing on the work of Hays and Wolf, this idea positions all women of childbearing age as pre-pregnant and exhorts them to minimize health risks to future pregnancies, even when conception is not on the horizon. This idea is further reflective of how an American ideology of motherhood is as strong as ever, making it a persistent master status and making maternal sacrifice a master cultural frame.¹²⁷ The expectation today is that pregnancy—and thus children—can be perfected ahead of time.¹²⁸ It follows then that the rise of the pre-pregnancy care model intersects clearly with contentious reproductive politics around family planning and the changing realities of women’s lives in the twenty-first century.

THE POLITICS OF MATERNAL AND REPRODUCTIVE HEALTH

The demographics of American women’s reproductive lives reveal that they are situated within the zero trimester more squarely than ever. Many women today spend years—if not decades—avoiding pregnancy.¹²⁹ Women are waiting later in life to have their first baby and are having fewer babies overall,¹³⁰ extending the so-called pre-pregnant phase to a lengthier time frame than was the case historically. Moreover, about 15% of women aged forty to forty-four report that they are childless, and this number is growing.¹³¹ Concerns of whether and when a woman will have a baby thus potentially increase social anxiety about the expanded temporal period of women’s lives when they are planning their futures. Modern views of fertility revolve around what famed demographer Ansley Coale described as a “calculus of conscious choice”¹³²—that with the availability of contraception and family-planning techniques, women and couples are presumed to have the option to avoid pregnancies and to plan and space births according to their wishes. About half of the pregnancies occurring in the United States, however, still are categorized as unintended. The greater emphasis on a pre-pregnancy care framework around the turn of the twenty-first century has not been just due to prenatal care failing, as detailed already; it also is about women’s increasing control over their fertility, changes in fertility patterns, and the politicized nature of reproduction and health care.

Thus, a discussion of pre-pregnancy care cannot be divorced from trends in reproductive health politics, and especially abortion politics, which grew with vehemence starting in the 1970s. As Chapter 4 elaborates, the pre-pregnancy care framework advances overlap between maternal and reproductive health—realms long considered to be separate in terms of ideology and policy—and, in so doing, strategically avoids a discussion about abortion and women’s reproductive options after conception occurs. If all pregnancies are twelve-month pregnancies, then women would ostensibly have thought through their reproductive desires prior to pregnancy. The circumvention of abortion talk fits well with a broader cultural milieu that is often hostile to women’s choices that do not match a maternalist or pronatalist agenda.

Studying the zero trimester by examining cultural and pregnancy risk messages that are aimed at non-pregnant women of reproductive age shows how maternal responsibility is defined for women writ large. Much reproduction scholarship looks at issues of pregnancy and fertility or focuses on women who are either already mothers or already pregnant. Social science analyses of the pre-pregnancy period mostly have concerned infertility and assisted reproductive technologies.¹³³ This type of analysis, however, is specifically related to women who already desire a baby and who are actively aspiring to conceive. This book instead analytically leverages the zero trimester—a concept that applies to all women of reproductive age, regardless of desire or capacity to get pregnant—through the lenses of reproductive risk and anticipatory motherhood. Moreover, ample human-reproduction scholarship has focused on the politics of reproduction. In this book, I more specifically deliberate the politics of reproductive risk—calling attention to the formation and deployment of discourse about the prevention of adverse reproductive outcomes.

Pregnancy and reproduction are private and individual processes, yet at the same time they also are highly visible public ones.¹³⁴ Maternal and child health outcomes proxy a nation’s health and reflect on our health-care institutions. As such, they signal some of our most pressing social issues and problems. They also reflect shifting cultural norms, such as the concerns around unintended pregnancy. Reproductive outcomes also matter intimately to individuals, especially because most women become mothers in their lifetime.¹³⁵ How women, families, physicians, and policy makers are primed to think about the risks to a healthy pregnancy is vital. One could say that, as a society, we have a generalized wish for reducing risks to pregnancy health.

The following pages document how the imperatives of prevention, concerns around the social roles of women, and the fraught politics of reproduction molded the construction of a vibrant health and policy definition of reproductive risk—one that expands medical and social control over women’s bodies, from menarche to menopause, in the twenty-first century.

OVERVIEW OF THE BOOK

To understand the rise and consequences of this twenty-first century medical and social model for pregnancy health, and the zero trimester notion that accompanies it, I pursued a multisited ethnographic approach¹³⁶ and carefully examined public-health campaign documents, medical literature, policy decisions, public health reports, newsletters from maternal and child health organizations, my field notes from attendance and participation in national meetings on pre-conception health, and cultural materials such as popular advice books. For this book I also drew heavily from in-depth interviews I conducted with fifty-seven health experts who helped forge the pre-pregnancy care framework through the federal government’s sponsorship. Using a “core set” method from science studies,¹³⁷ I interviewed a central group of experts—identified by the CDC as some of the top people in the field—who participated in the national meetings of the CDC’s Preconception Health and Health Care Initiative in the 2000s, during which time they were charged with developing an advocacy plan for, and a definition of, pre-pregnancy care.¹³⁸ Included in these interviews were high-profile scientists, physicians, public-health experts, government health officials, and respected maternal and child health clinicians from across America.¹³⁹ Using this wide-range of sources, this book offers a nuanced story of the complex ascendance of the “zero trimester” in the United States.¹⁴⁰ At its heart, this book is an examination of a new way of thinking and talking about women’s reproductive health—aimed at a better understanding of how current messages targeting the behaviors of reproductive-aged women came to be possible.

Focusing on the medical literature regarding pregnancy health risk from the nineteenth century to the publication of the seminal 2006 CDC MMWR recommendations, Chapter 2 discusses the extent to which medical thinking about the antecedents of healthy pregnancies and births has vacillated among extremes—from thinking that a woman’s (or in some cases a man’s) mental and physical state during the moment of conception is paramount, to thinking that everything a woman does during pregnancy matters, to thinking that everything a woman does prior to pregnancy is of principal importance. Pre-pregnancy risk factors were not new in the medical literature, but by the end of the twentieth century they were rearticulated by experts as a path-breaking approach to understanding reproductive risk. Hence, pre-pregnancy discourse was reframed to include myriad medical and social problems—such as pregnancy intentions—and culminated in the publication of the CDC’s 2006 report.

Chapter 3 and Chapter 4 look beyond the “official” knowledge evinced in medical literature and incorporate the words and ideas of experts involved in developing and disseminating the pre-pregnancy care framework for the twenty-first century. Chapter 3 seeks to understand exactly how experts who worked with the CDC’s initiative defined risks to healthy pregnancies, as well as how they thought and talked about reproductive risk and responsibility. Drawing on interviews with these experts, this chapter details how they drew on long-held notions about strong ties between women’s bodies and reproductive outcomes in constructing knowledge about future risk. They also discussed the lack of robust evidence available to bolster a pre-pregnancy care model, relying instead on the facile idea that it just “makes sense” that healthier women will produce better outcomes.

Chapter 3 shows how thinking around pre-pregnancy care relied on reductionist notions of women’s bodies and roles, but Chapter 4 complicates the story by showing how experts understood that framing the health of women of reproductive age in terms of pregnancy was necessarily responsive to a particular political valence. In Chapter 4, I reflect on the state of women’s health care and policy that undergirds the contemporary vibrancy of the pre-pregnancy care framework. Pre-pregnancy care was in part created to advance reproductive justice by bridging the long-divided realms of maternal care and reproductive care, and in so doing avoided potential political minefields. This bridging work helped to expand women’s health care during their reproductive years. The idea of couching women’s health in terms of maternity status successfully followed a long tradition of maternalist policy making in America. Chapter 3 and Chapter 4 together bolster the idea that problems of knowledge are also problems of social order.¹⁴¹

Chapter 5 and Chapter 6 look at the message’s roll out. Specifically, Chapter 5 details how pre-pregnancy care has been taken up clinically and culturally. In recent years, health organizations have operationalized pre-pregnancy care by using a clinical tool called the “reproductive life plan.” With this questionnaire, clinicians aim to ask all women of reproductive age about their desired maternal status in the future and advise them to take precautionary action in accordance. Moreover, women’s magazines and popular advice books and websites have seized on this moment. Women and prospective parents are now inundated with information about how their reproductive years should revolve around maternity. This pre-maternal focus, I argue, betrays a neoliberal trend in which individual responsibility is paramount.

Chapter 6 analyzes how the pre-pregnancy care model has influenced public health promotion by analyzing a specific CDC campaign from 2013 called “Show Your Love.” This campaign invited women of reproductive age to “show love” to their future babies, urging them to act as mothers even if they were not envisioning motherhood in their near future. In this chapter, I argue that the power of this messaging potentially changes how we think about what constitutes intensive motherhood. As is shown, this campaign—at least in its initial installment—used racialized messages that depict white women as responsible planners and women of color as “non-planners,” reifying dominant tropes about the types of women who embody reproductive responsibility and thus further stratifying and racializing reproductive health.

In the concluding chapter, I reconsider the social and medical trends that have intersected with this knowledge shift in understanding pregnancy health risk. The emergence of pre-pregnancy care is about disappointment with maternal and infant health care in America, the stubbornness in thinking that links all reproductive outcomes to women’s individual behaviors, and about the tendency in contemporary medicine and public health toward the anticipation of risk. But it is also about our inability in the United States to consider abortion within a comprehensive and responsible discussion about reproductive health; it is about the rising medical and political visibility of the fetus, our growing desire to perfect pregnancies, the rise of anticipatory motherhood, and social and medical concerns about women’s changing life-course patterns.

The public-health messages highlighted at the beginning of this chapter are different from a decades-long medical and public health focus on the nine months of pregnancy. The focus is today, rather and decidedly, on the zero trimester—on the non-pregnant woman’s body and future motherhood status. The growing sentiment that women should improve their pre-pregnancy health to reduce reproductive risk is part of broader medical and cultural tendencies toward focusing on the pre-pregnancy health of women. The rise of the “zero trimester” is not simply about medical and health concerns; it is more broadly about struggles and entanglements over the cultural power and social ideologies that shape women’s bodily experiences and population-health imperatives.

On a final introductory note, it is perhaps necessary to emphasize that, over the course of this research, I have struggled with respect to whether I regard the pre-pregnancy care model as “good” or “bad” for women. I am sympathetic with critiques that claim the model is “dangerous for women,” and I highlight many instances in this book where I believe this to be so. And yet, through speaking with many experts and following this topic over time, I understand that the pre-pregnancy care model is one that hinges on reproductive-justice notions of expanded health services for all women, regardless of whether they eventually become mothers. This book does not provide a conclusive answer as to whether the model is backward and reductionist or progressive and liberating. It is complicated, and it is probably both.

This book rather aims to highlight the historical, cultural, and political underpinnings of pre-pregnancy care, embracing instead of eschewing all the nuances that come with such an analysis. The concluding chapter returns to questions of how, going forward, we might think with, around, and beyond this model in reproductive health. The intervening chapters offer empirical findings that upend conventional wisdom on both sides of the debate while offering an argument that pre-pregnancy care is neither wholly hostile to feminist progress nor the saving grace for women and babies in America. At the very least, the rise of the “zero trimester” does mean that notions of womanhood and motherhood are intertwined as much as ever before, if not more so.