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2 From the Womb to the Woman

THE SHIFTING LOCUS OF REPRODUCTIVE RISK

Much twenty-first-century literature covering the pre-pregnancy care model dates its emergence to a 1980 publication in the British Medical Journal. In the article, physician Geoffrey Chamberlain called for a “pre-pregnancy clinic” to give women “authoritative advice” concerning future pregnancies.¹ Although publication of this article proved to be a critical event in the medical establishment’s recognition of pre-pregnancy care, it was not nearly the beginning of its history.

Identifying the factors that pose risks to a healthy pregnancy is a timeless concern, one that has long consumed social thought and that has long vexed the medical community. Ideas about how women’s or men’s characteristics or behaviors might impact reproductive outcomes have existed since at least classical antiquity,² and it is clear even in classical texts that the importance of general reproductive health to the health of future generations was of paramount import. More than 2,500 years ago, for example, Plutarch was concerned with the health of young Spartan women and girls. For fear that they might otherwise endanger the quality of future reproduction, he wrote that “maidens” should make sure to exercise “to the end that the fruit they conceived might, in strong and healthy bodies, take firmer root and find better growth.”³

In the twentieth century, the reproductive factors that dominated medical and policy focus on birth outcomes were clustered during the period of pregnancy—and prenatal care was the medical intervention of choice for ensuring healthy pregnancy outcomes. Despite the overwhelming focus on the prenatal period in recent history, the reproductive phase on which medical investigation centers actually has been quite variable over time. Periodically, concerns about reducing risks to healthy pregnancies have focused intently on factors in the pre-pregnancy period. This chapter traces the evolution of health professionals’ thinking about how medicine and public health should intervene to ensure healthy pregnancies, focusing specifically on the extent to which medical thought has implicated pre-pregnancy health and health care as influencing reproductive outcomes. Reflecting on medical literature from the nineteenth century through the end of the twentieth century, this chapter reveals how physicians have highlighted the pre-pregnancy period with varying intensity and degree over time.⁴

The idea of “pre-pregnancy care” did not begin in 1980, and such contemporary proclamations that claim otherwise miss an unsavory history. Assertions about pre-pregnancy health have existed for millennia, but pre-pregnancy care emerged in the medical literature in the early twentieth century as a concerted strategy to facilitate eugenics-minded medicine as well as to battle syphilis. These two historical moments are highlighted in this chapter as instances when the pre-pregnancy care of women—and often men—was organized. Any other focus on pre-pregnancy health and health care largely was overshadowed in the twentieth century by the rising focus on factors in the womb and on prenatal care. As sociologist Elizabeth M. Armstrong has written, the locus of reproductive risk in the twentieth century was indeed the womb; in utero became the frame of choice in medical and scientific investigations into the causes of reproductive outcomes.⁵ The demise of prenatal care as a truly preventive tool in the eyes of health professionals by the late twentieth century, along with demographic and political shifts related to childbearing and women’s reproductive lives, caused pre-pregnancy discourse to resurge in the medical literature—in many ways shifting the locus of risk for a healthy pregnancy from the womb to the woman.

HEALTHY PREGNANCY IN THE NINETEENTH CENTURY

Fetal development was not well understood in the nineteenth century, yet there were widely held beliefs about certain factors that might put a pregnancy in peril. One dominant trope during this time was the doctrine of maternal impressions—a theory that specifically situated the cause of congenital malformations in the mental and emotional experiences of the mother while she was pregnant. In the New England Journal of Medicine and Surgery in 1824, for example, one doctor retold a story of a woman being frightened during pregnancy by a large tortoise near her house; she subsequently gave birth to a “misshapen mass.”⁶ Accounts such as this one often referred to the fetus as a grotesque creature, as in 1829 when an Ohio physician wrote to the Boston Medical and Surgical Journal to report that he delivered a premature “monster”—one that resembled a puppy—from a woman who was frightened early in her pregnancy by two fighting dogs.⁷ No medical care could ensure that a pregnant woman did not experience a social situation that might “mark” her child; rather, these kinds of stories in the professional literature served as a form of speculation about the root cause of birth defects. Pregnant women were simply told to avoid risks to their emotional state as much as possible. Maternal impressions thus constituted a theory that resonated with ideas at the time that attributed successful pregnancies to a balanced lifestyle,⁸ tying together the vicissitudes of daily social life with medical outcomes.

In the early part of the nineteenth century, the fetus and eventual infant were considered “malleable” until the child was weaned. Yet medical assumptions about the transmission of traits often led both popular and scientific thought to focus on the quality of the moment of conception⁹—an emphasis neither on pre-pregnancy nor on pregnancy but rather on the health status of both parents while conceiving. Couples were urged to be of good nature during intercourse, or else the subsequent offspring might be harmed. The pregnant woman was told then to exhibit loving and gracious qualities so as to ensure the health and the morality of the fetus.¹⁰ It was not until the middle of the nineteenth century that “heredity” as a formal concept emerged as a prominent piece of both medical explanation and social thought.¹¹ Birth defects and birth outcomes were rather mostly understood during this time as results of the state of emotions either in the pregnant woman, in the case of maternal impressions, or in both parents, as in the focus on the health of the conception.

Still, there was plenty of medical and social thought that centered on factors visible well before conception ever took place. In fact, although much prevailing medical thinking about heredity in the nineteenth century assumed that it was the exact moment of conception that conferred the “biological identities of both parents,” those identities were defined as “resultants of the cumulative interaction of all those habits, accidents, illnesses—and original constitutional endowments—which had intersected since their own conception.”¹² Twenty-first century epigenetics explanations of birth and life outcomes do not sound all that dissimilar from this sentiment. The nineteenth-century theory of diathesis focused on individual predispositions to disease as part of one’s constitutional makeup over a lifetime. For example, the offspring of someone who consumes alcohol was assumed to inherit not only the propensity to drink but also a certain “package of constitutional weaknesses.”¹³ That is, individuals’ life histories and general temperaments—those of both women and men—were highlighted as mattering for the health of future offspring. These theories and discussions largely did not implicate the need for medical care; rather, women and men were simply urged to lead proper and moral lifestyles to ensure the health of their reproductive futures.

Nevertheless, much medical emphasis specifically was placed on women and on the surveillance of women’s social behaviors. In one of the first American textbooks on pediatrics, William Potts Dewees in 1825 wrote that “the physical treatment of children should begin as far as may be practicable, with the earliest formation of the embryo; it will, therefore, necessarily involve the conduct of the mother, even before her marriage, as well as during her pregnancy.”¹⁴ This quote includes not only concern about ensuring the health of future children but also about the mother’s moral conduct. Indeed, throughout the nineteenth century, claims were made about limiting women’s social engagement for the very purpose of “protecting” their future reproductive bodies. Dr. Edward Hammond Clarke’s 1873 treatise, Sex in Education,¹⁵ set off a political firestorm as he claimed that women who pursued higher education would suffer reproductive debilities.¹⁶ Experts thus argued that women’s future pregnancies would be endangered lest they abide social conventions of the time. These messages, of course, were mostly directed at white women in America, as black women had long been regarded as important reproducers but in a very different way in terms of the future of the nation. Although children born of slaves were deemed necessary for the depraved fabric of the antebellum economy, slave women were not treated in a way that “protected their future” in any manner of the phrase.¹⁷

In the nineteenth century, physicians generally saw (white) women as “the product and prisoner of her reproductive system.”¹⁸ As such, women increasingly sought to limit their fertility through a variety of means; “potential mothers” also were castigated for their role in “race suicide.”¹⁹ To ensure the vitality of future reproductive endeavors, women were asked to do everything from exercising routinely to dressing appropriately. In a medical journal article on breastfeeding, for example, one physician wrote that “before pregnancy and even before marriage women ought to be taught to admire this really most beautiful function of woman-hood. Girls should be taught to guard their breasts and nipples from the injury false fashions of dress impose.”²⁰ All of women’s reproductive functions and body parts were under surveillance in the pre-pregnancy period—or, to use the euphemism of the time, in the “pre-marriage period”—in the service of the health and purported decency of future generations.

If a woman experienced poor reproductive outcomes, then it was assumed that she had lived a pre-pregnant lifestyle not conducive with healthful reproduction. In another 1824 article in the New England Journal of Medicine and Surgery, a physician recounted an experience with a woman who had an early spontaneous abortion. Reporting that “her health was not very good at any time, and had not improved during her pregnancy,”²¹ the physician explained that to treat a spontaneous abortion is also to treat “the patient before a second conception”—that is, in this physician’s view, the times between reproductive events blended together and should be seen as preventive care in preparation for the next (healthier) time.²² The nineteenth-century medical literature was peppered with these types of assessments of general pre-pregnancy health and ideas about how to intervene medically. Physicians were puzzled when healthy women experienced poor reproductive outcomes, tying such events to lifestyle and moral behavior.

In another medical article on spontaneous abortion, for example, a physician tried to explain how such an event could happen in women who seem otherwise very healthy. The physician attributed spontaneous abortion to life choices that were made in the pre-pregnancy phase, arguing that sometimes these women “are married late in life; have been luxurious livers . . . [and] have good health.”²³ The physician conjectured that this variety of abortion belongs to a type in which “the general health is too good for healthy pregnancy.”²⁴ In this appraisal, top-notch pre-pregnancy health actually could be detrimental—some white women’s life of luxury had not situated them well for motherhood, but it was all in the service of expositing what was deemed “proper” pre-pregnancy lifestyles. Physicians thus were clearly enamored with women’s lifestyle choices such as age at marriage and first pregnancy—likening any desires that deviated from early marriage and motherhood as potentially damaging to their future reproductive outcomes.

Physicians also were interested in whether certain physiological reproductive risks were present during the pre-pregnancy period. In 1887, writing about a rare case of a pregnancy taking place within a uterus that had structural abnormalities, a physician discussed the patient’s reproductive history prior to her pregnancy and emphasized the idea that the uterine position was likely laterally flexed prior to pregnancy, which of course was not diagnosed prior to the pregnancy.²⁵ In accounts of Bright’s disease from the same time, physicians accentuated that having the condition prior to pregnancy exacerbated the seriousness of disease during pregnancy.²⁶ Similarly, the cause of a case of puerperal eclampsia was “probably from an endometriosis existing prior to conception.”²⁷ In 1895, in a piece on metritis (inflammation of uterine wall) as a cause of miscarriage, a physician highlighted that treatments might be best before pregnancy, writing, “As to the treatment, I may say at once that it is very difficult to treat an endometritis as long as pregnancy is going on. The only good practice is the preventive treatment which is undertaken when the uterine cavity is empty in cases in which an inflammation of the uterine mucosa has occurred before the pregnancy or when it has already produced miscarriages.”²⁸ In many of these instances, physicians mentioned how pre-pregnancy care might have helped the woman’s circumstances, but there was no organized idea about proper medical care prior to conception. Pre-pregnancy health discussions were rather mostly reflective of general concerns over women’s social behaviors leading up to marriage and motherhood as well as speculations about physiological abnormalities prior to pregnancy that might pose medical risks to a woman’s reproductive capacity and future reproductive outcomes. Discussions over venereal diseases serve as good examples of just how intermingled were the worlds of social concern and medical concern, of social policy and ideas about reproductive health care interventions. The following section briefly considers the prolific medical literature on syphilis as illustrative.

VENEREAL DISEASE AS AN EARLY HUB OF

PRE-PREGNANCY DISCOURSE

Syphilis was a public-health menace around the turn of the twentieth century. A common topic in the medical literature regarding the potential health of future offspring, syphilis was usually discussed vis-à-vis social and moral interventions as well as medical interventions. One article by Abner Post in an 1889 issue of the Boston Medical and Surgical Journal was titled “Some Considerations Concerning Syphilis and Marriage” and asked the question of whether two syphilitics should marry and, by extension, reproduce. For the man in question, Post’s answer was that nothing would be worsened because he was already syphilitic, but for the woman the concern was about future pregnancies. Post’s answer to syphilitic couples wanting to conceive was to wait until they experience two full years of symptom-free living, at which point he also prescribed a course of mercury treatment before conception.²⁹ Dr. Post’s recommendation served as an early example of a precise pre-pregnancy medical intervention.

In 1912, the article “Epitome of Current Medical Literature” in the British Medical Journal discussed a case of syphilis in terms of its “conceptional” basis, highlighting the prophylactic promise of “preconceptional treatment” with regard to syphilis to produce “healthy children and to avoid conceptional infection of the wife.”³⁰ In one of the first medical mentions of a pre-pregnancy “treatment regime,” the focus remained on both the maternal and paternal influences on the quality of the conceptus. In fact, much of the literature on syphilis focused on men and their responsibilities. Many physicians in the nineteenth century accepted Colles’s Law, which posited that syphilis was passed from sperm to fetus, completely bypassing the mother.³¹

The pre-pregnancy discussions around syphilis and other “conditions” were concerned mostly with leading a “proper lifestyle” and with social concerns endemic to the pre-pregnancy period, such as marital fidelity or the spread of sexually transmitted disease. In his history of venereal disease, historian Allan Brandt notes that “these themes had particular resonance for American physicians, who were already concerned about the future of the family.”³² Many physicians during this time who were concerned about how venereal diseases were impacting the family allied with the eugenics movement, seeing venereal diseases as impacting the future of “the race.”³³ Indeed, declining birth rates of whites were seen as a sign of the demise of American values, and reproductive matters were front and center not only for public health purposes but also for population concerns. Many states passed “eugenic marriage laws” whereby only the prospective husband had to undergo a physician assessment and “receive a certification of health”³⁴ before getting married and thus, presumably, before procreating. Near the turn of the twentieth century, physicians thus believed it was in their province—as both medical and moral leaders—to advise patients against entering into “hasty marriages.”³⁵

Thomas Parran, surgeon general under Franklin Delano Roosevelt, further sought to make venereal disease a national concern, and pre-pregnancy interventions were at the forefront of his agenda. One of Parran’s suggestions included mandatory blood tests prior to marriage as well as in early pregnancy.³⁶ Beginning with Connecticut in 1935, as Brandt recounts, in many states a premarital blood test became a standard requirement for a couple prior to obtaining a marriage license.³⁷ In Connecticut in particular, if either the bride or groom was found to be infected, the couple had to wait—sometime years—before procuring a marriage license, until the said individual was found to be infection free,³⁸ a process that certainly reflected government surveillance of the pre-pregnancy period. By 1938, twenty-six states had provisions on the books prohibiting the marriage of infected individuals.³⁹ Marriage, of course, was the assumed precursor to reproduction during this time. To regulate women’s and men’s bodies in the pre-pregnancy phase was to regulate marriage.

Not all the attention in syphilis campaigns was focused on the pre-pregnancy period or on unmarried men and women. Pregnant women also came under surveillance. In 1938, New York and Rhode Island enacted laws requiring prenatal blood tests to check for syphilis, and these laws spread across the United States.⁴⁰ As Brandt documents, early and continuous treatment of syphilis in pregnancy worked, and these laws had a significant public-health impact: infant mortality rates from syphilis dropped precipitously.⁴¹ Although public-health messages regarding syphilis targeted the pre-pregnancy period and social activities such as marriage, it was actually treatment during pregnancy that turned out to be most successful. The syphilis example shows that while pre-pregnancy messages functioned as a social policy tool, medical treatment during pregnancy had the most demonstrable effect for such a specific problem as syphilis. This outcome helped propel prenatal care as the gold-standard for pregnancy health care during the twentieth century. Telling citizens what to do during the pre-pregnancy period was not found to be helpful for the most part. That is, attempting primary prevention did not work in this instance. Treatment with pregnancy care—rather than prevention, with pre-pregnancy care—emerged as the typical way to think about disease and reproductive outcomes. Pre-pregnancy care was shifted further to the margins of medical discussions about reproductive risk.

Indeed, treatment for syphilis and preeclampsia surfaced in the medical literature in the early twentieth century as model cases for the need for prenatal interventions in high-risk pregnancies. As such, focus trended away from pre-pregnancy and lifestyle factors as prenatal care gained prominence, along with the attendant assumption that medical care would fix pregnancy problems. Pre-pregnancy care messages began to be eclipsed by prenatal care discussions. Up until the rise of prenatal care, pre-pregnancy health often was discussed as either something women should maintain (through proper dress and education) or something that was out of women’s control (their pre-pregnancy reproductive tract problems) or simply as a man’s fault (with syphilis). Yet, over time, pre-pregnancy health increasingly became something of a woman’s domain, something that was highlighted as within her purview to control and preserve. Medical care increasingly became less about high-risk pregnancies (say, a syphilitic pregnant woman) and more about optimizing every single pregnancy, no matter its risk status. This shift toward greater maternal responsibility along with expanded prenatal care to populations not necessary “at risk” largely was an outgrowth of the shift in focus toward pregnancy behaviors—on prenatal care and on the womb—that dominated medical literature of the twentieth century.

THE ADVENT OF PRENATAL CARE

No formal care mechanism was in place for pregnant women in the nineteenth century. For the most part, women did not seek medical care during their pregnancies; there were few hospitals or offices where pregnancy care took place; the concept of “prenatal care” did not even exist.⁴² To achieve a successful pregnancy or birth outcome did not involve seeking medical attention throughout one’s pregnancy. There were some prenatal therapies available (such as bloodletting or abdominal palpation), should a woman present to a physician during pregnancy with a risky situation, but most clinical intervention for pregnant women in the nineteenth century was focused on lifestyle advice,⁴³ just as it was for pre-pregnant women.

At the turn of the twentieth century, doctors began more seriously to identify factors that could harm a fetus in utero rather than contemplating effects prior to pregnancy. A good example of this is found in a 1907 British Medical Journal article on the “Unborn Child,” in which a gynecologist wrote that, “Although, as a matter of fact, the deepest foundations are laid long before conception, the future health and constitution of the child are intimately bound up with the processes which go on during its intrauterine existence.”⁴⁴ In this article, the “rights” of the unborn are enumerated, which include the recognition that parents should provide “a clean and normal life before and after conception,”⁴⁵ but the growing emphasis in medicine was on the womb during pregnancy.

The organized clinical monitoring and treatment of pregnant women as we know prenatal care to be today usually is traced to an article published in the British Medical Journal in 1901. In his “Plea for a Pro-Maternity Hospital,” physician J. W. Ballantyne wrote about the need for a distinct area in the Maternity Hospital that would “be for the reception of women who are pregnant but who are not yet in labour.”⁴⁶ He was focused on preventing “morbid pregnancy,” and wrote about the importance of prenatal care for advancing preventive medicine more broadly.⁴⁷

It remained curious to medical professionals at the time why otherwise healthy women would give birth to a baby with abnormalities or why she or the infant might die in childbirth. Although there were no conclusive data that expanding prenatal care would work to offset these risks—in fact, prenatal care services were usually included as part of lists of suspected causes of maternal or infant mortality⁴⁸—prenatal care was constructed as the primary solution to infant mortality and morbidity.⁴⁹ When prenatal care was first practiced in England in the early twentieth century, protocols did not refer to the early pregnancy period but rather began instruction around the fourth or fifth month and consisted mainly of urine analysis and general advice.⁵⁰ In England, by the 1920s, prenatal care was considered the cure for all reproductive ailments.⁵¹ Prenatal care had begun its ascent as the presumed magic bullet for reducing reproductive risk in the twentieth century.

This belief in the promise of prenatal care was also emergent in the United States. During the first two decades of the twentieth century in the United States, numerous labor protections and social regulations were legislated by states and by Congress to “help adult American women as mothers or as potential mothers.”⁵² The Children’s Bureau, started in 1912, began promoting prenatal care in 1913.⁵³ In 1921, the Sheppard-Towner Maternity and Infancy Protection Act passed as the first major welfare program in the United States and was partly concerned with providing prenatal care to pregnant women. Prenatal care thus constituted part of a major policy and medical thrust in the early twentieth century. As a result, the overwhelming focus of discussions about pregnancy health risk in the early to middle part of the twentieth century was on prenatal factors.⁵⁴

Soon, however, individuals began questioning what exactly prenatal care was achieving. As Ann Oakley documents in England, the chief goal of prenatal care was to reduce risks of pregnancy and childbearing for the mother, but results on this front were not moving forward and were characterized as “obscure and perplexing.”⁵⁵ By the 1930s, physicians began looking for reasons for the “failure” of prenatal care⁵⁶: “Supervision at an antenatal clinic will not by itself save life.”⁵⁷ Years earlier, Ballantyne himself had gestured to the necessity of pre-pregnancy services in addition to the prenatal ones. In a review of his influential work Manual of Antenatal Pathology and Hygiene: The Embryo,⁵⁸ the British Medical Journal noted that Ballantyne’s concluding chapter covers how “the preconceptional period of germinal life is identical with morbid heredity.”⁵⁹

In a similar vein, a popular nursing text stated, in 1929, that prenatal care should begin “perhaps even earlier” than when a patient conceives.⁶⁰ In a 1934 combined meeting between obstetrics/gynecology and public health, experts reviewed the state of prenatal care. One of the doctors was quoted as claiming that preconception care “was almost more important than ante-natal care,” as the “best hope of progress lay in those agencies which were dealing with the health of growing girls.”⁶¹

Indeed, while prenatal care was on the rise and gaining policy traction—as it would continue to do throughout the twentieth century—the medical literature did not ignore pre-pregnancy factors completely, especially in high-risk cases or in cases shrouded in uncertainty. As one physician contemplated the effects of uterine fibroids, “In general, if a fibroid is to be regarded as a menace to life before pregnancy, the condition must be still more grave after conception occurs. Is it not the duty of the gynecologist to ward off this danger?”⁶² In the New England Journal of Medicine, speculation about spontaneous abortion continued to call attention to the pre-pregnancy period: “Preconceptional treatment may be directed toward correcting defects in the germ cells (sperm or ovum), toward the elimination of certain pelvic abnormalities and toward the treatment of systemic factors that tend to abortion.”⁶³

Physicians kept highlighting the pre-pregnancy period, but because treatment during pregnancy was increasingly considered the crucial medical tool for reducing reproductive risk—despite rumblings that it was doing nothing of the sort—discussions about pre-pregnancy health were often aimed at lamenting women’s lifestyle choices or general health status. That is, without medical or policy backing, physicians simply took to conjecturing about women’s health status before pregnancy. For example, with regard to preeclampsia, the following appeared in the New England Journal of Medicine: “It would, of course, be better to have the patient in the best physical condition before pregnancy occurred.”⁶⁴ Hypertension, in another instance, was thought to be better controlled with attention prior to pregnancy, “by the combined and co-ordinated efforts of the internist and the obstetrician and of medical and maternity clinics, or by the constant observation and study of obstetric patients before, during and for years after their childbearing careers by the physicians who attend them. . . .”⁶⁵

Pre-pregnancy health and health-care discussions continued in the medical literature, although they came to be somewhat marginal as compared to the prominent literature on prenatal care. Yet, the discussions were couched in the language of social concerns and, as such, much of the pre-pregnancy medical literature was not concerned with reducing reproductive risk per se but rather with preventing certain pregnancies in the first place. That is to say that, in the early twentieth century, pre-pregnancy health and health care discussions became mired in population health goals of the day, namely eugenics.

PRE-PREGNANCY HEALTH DISCOURSE AND

POPULATION CONTROL

In 1936, obstetrician Fred Adair wrote in the Journal of the American Medical Association that obstetrics education should include pre-pregnancy care knowledge.⁶⁶ In 1940, Adair, a professor of obstetrics and gynecology at the University of Chicago, wrote one of the earliest articles to be titled “preconceptional care.”⁶⁷ He started off the article defining “preconceptional care” as, “designed to assist in securing perfect reproduction. It rests upon fundamental eugenic and euthenic principles. It is that care and attention which is given prior to conception and involves the elimination of those individuals who are not suitable for wholesome reproduction and the seduction of those who are capable of normal reproduction.”⁶⁸

Adair’s statement here was in vogue with the medical literature on eugenics. He went on to discuss the necessity of codifying a “preconceptional viewpoint” via state control of reproduction, as his state of Illinois did in 1937 when it required potential marriage partners to be tested for venereal disease. Indeed, although the eugenics movement was beginning to wane in the United States in the 1930s, many U.S. states passed sterilization laws clearly targeting individuals for eugenic purposes.⁶⁹ Racial hygiene logic was part of a broad push in the United States for “better breeding,” which did not end when Nazism fell.⁷⁰

One of the earliest mentions of the term “preconception care” came in the meeting minutes of the 1932 Annual Sessions of the American Medical Association.⁷¹ The section on obstetrics, gynecology, and abdominal surgery was called to order by its chairman, Fred Adair, and the first paper read was on “preconceptional and prenatal care,” by Percy W. Toombs of Tennessee.⁷² In 1923, the Journal of Heredity had published a lecture by Toombs on “parenthood and race culture.”⁷³ In this talk, Toombs outlined the aims of eugenics. His language is unsettling as a precursor to a “pre-pregnancy care framework” in the United States. He wrote, for example, that “there is a constant tendency toward relative and absolute sterility among that class of society which is best fitted to produce the next generation, and the most prolific are the less fit to carry on the torch of civilization.”⁷⁴ Pre-pregnancy care discussions in the medical literature in the early twentieth century were riddled with discussions expressive of eugenic ideologies.

Remnants of pre-pregnancy care’s relationship with eugenics were still found in the 1960s,⁷⁵ but this early history is erased in contemporary pre-pregnancy health and health care literature. For example, by positioning the pre-pregnancy care model as beginning with Chamberlain’s U.K. clinics in 1980, as many present-day publications do, articles avoid the ways in which pre-pregnancy care was tied up with unsavory medical ideas in the earlier part of the century. Even when contemporary publications go back further than Chamberlain’s article—for example, a March of Dimes publication in 2002 stated that pre-pregnancy care dates to the 1960s—they don’t go back far enough.⁷⁶ Some articles cite the Dewees pediatrics textbook from the nineteenth century or even Plutarch when they mention medical concerns about pre-pregnancy health, but then gloss ahead to the 1980s when highlighting the beginning of pre-pregnancy care,⁷⁷ eliding pre-pregnancy care advocates’ earlier connection with eugenics. Pre-pregnancy health and health care ideas in the first half of the twentieth century often intersected with strategies of population control, strongly linked to eugenics.

A related strain of early pre-pregnancy care literature, also stemming from obstetrics, was used to talk about family planning more broadly. At a meeting of the Southern Medical Association’s section on obstetrics in 1939, one doctor argued that “preconceptional care” should be the preferred term over “birth control” because physicians are not trying to control births, but rather conception.⁷⁸ Speakers at the Southern Conference on Tomorrow’s Children in 1939, which included remarks from Margaret Sanger, preferred the term “preconceptional care” to “birth control” when discussing contraceptive practices.⁷⁹

Often, in this realm, pre-pregnancy health discussions had little to do with medical concerns directly and more to do with social concerns regarding pregnancy intentions and preventing unwanted pregnancies. This focus was strengthened by one of the most important advances in women’s health care in the twentieth century: the FDA approval of the birth control pill in 1960. The notion of “family planning” also was gaining prominence. As part of President Johnson’s War on Poverty, the federal government issued its first grants in support of family planning practices in 1965. In 1970, Congress enacted Title X of the Public Health Service Act to ensure family planning access for low-income women.⁸⁰ Abortion was legalized at the federal level in 1973. This policy history emerged largely separate from that of pregnancy and prenatal services mentioned above, cutting a political hole in women’s health care in the United States between services for preventing pregnancies and services for safeguarding pregnancies, a point which is revisited in greater detail in Chapter 4.

Along with the growing popularity of family planning, further advances in infertility treatments and genetic screening initiated an unprecedented ability to control conception (and birth), and the idea of “planning” could thus be systematized in the latter half of the twentieth century. As demographers theorized, reproduction came to be seen during this time as increasingly under individuals' control.⁸¹ Physicians wanted part of this control. Thus, the medical literature subsequently began to pay concerted attention to planning pregnancies with the availability of effective contraceptive technologies. Pre-pregnancy health discourse at this historical juncture in many ways became predicated on the notion of “intendedness,” as physicians argued that they could more easily monitor patients and pregnancies if those pregnancies were planned—and, by extension, solve the problems of adverse birth outcomes. One obstetrician wrote that “prenatal care can be simply a system of observations, and the observation of a patient . . . prevents nothing.”⁸² Another physician wrote, “Since the advent of reliable methods of contraception . . . women not only expect to plan, but even to time, their pregnancies. Under these circumstances, it becomes quite feasible to advise patients to see their doctor before they expect to start a pregnancy” to “influence the events in the periconceptional period.”⁸³

As eugenics discourse became an abomination and the pill became popular, pre-pregnancy care discussions within the medical literature were no longer couched in the language of “better breeding” but rather of reproductive control and advising women that they should consult a doctor before getting pregnant. Crucially, this was also a time of upheaval for the profession of obstetrics.⁸⁴ Because doctors were beginning to grasp the inadequacies of prenatal care as early as the 1960s,⁸⁵ the intersection of family planning and new moments of surveillance—namely of the pre-pregnancy period—became a site for new claims of professional jurisdiction.

THE FIRST PRE-PREGNANCY CLINICS

Prior to the mid-twentieth century, mentions of care prior to conception in the medical literature focused on discussions of heredity, eugenics, and treatment of physiological and social problems that might pose risk to a healthy pregnancy. By and large, the literature was not focused on extending a formal medical model such as prenatal care to the pre-pregnancy period. In the 1950s, however, medical articles emerged that indicated some obstetricians—especially in the United States—were trying to address adverse birth outcomes through preventive pre-pregnancy care. For example, medical articles detailed a select few “fetal salvage” initiatives that were operated through “preconceptional” treatment clinics.⁸⁶ These early clinics actually focused on inter-pregnancy care; that is, they admitted parents who had experienced a previous adverse birth or pregnancy outcome to learn more about conception, implantation, and fetal growth prior to another pregnancy. A physician in a New York clinic explained—without offering any evidence or data—that therapies were not effective once pregnancy had begun.⁸⁷ Indeed, in this early literature, “evidence” was not used in making claims for pre-pregnancy clinics. The arguments revolved around increased management of the woman, to help the obstetrician figure out what was going wrong. One obstetrician wrote of a “preconception” clinic: “In preconceptional care the effort should be to investigate families with a history of pregnancy wastage in the interval between pregnancy, to delve deeper into the realms of environmental pathology, and to increase research in the role that endometrial insufficiency and uterine anomalies play in pregnancy wastage.”⁸⁸

In 1961, a “preconceptional regimen” was discussed to address abnormalities in fetuses.⁸⁹ In 1962, in the Chairman’s Address to the section on obstetrics and gynecology at the Annual Meeting of the American Medical Association (AMA) in Chicago, the profession was called upon to care for women throughout their life—“from preconception therapy in infertility to geriatric gynecology”—or, “from the womb to the tomb.”⁹⁰

References to pre-pregnancy care were being used in myriad ways during this time. Pre-pregnancy care served as a justification when obstetrics started making a case for expanded jurisdiction into more preventive services.⁹¹ The profession always saw prenatal care as a preventive service, but some in the field wanted to do more. The chairman of the obstetrics section of AMA argued, “This, then, such as it is, is the chairman’s address—a plea for the development within ourselves of the ‘Compleat Obstetrician,’ no longer a mere midwife glorified as a specialist, but rather a fully rounded figure of stature in the mural that is medicine.”⁹² This claim was meant to argue for enhanced medical status for obstetrician-gynecologists. A similar discussion around prevention would emerge in years to come as it became clear to many obstetricians that prenatal care did not constitute active prevention but rather simply was surveillance.

A principal article in which the claims for pre-pregnancy care presaged the kinds of claims we hear today was published in 1966.⁹³ In the “Medical News” section of JAMA, “pre-pregnancy plans” were deemed the “key” to reducing infant mortality. Several obstetricians are quoted in this article as explaining that prenatal care “is not enough.” The JAMA piece made the first elaborate claims of expanding obstetrical practice: “Programs which depend upon identification of the high risk patient early in pregnancy, combined with intensive prenatal care, are not likely to materially reduce the U.S. infant mortality rate. By the time a woman is pregnant, the risk has already been compounded.”⁹⁴ The article cited a “trend” toward pre-conceptional and inter-conceptional care within obstetrics.

In 1970, a Canadian obstetrician-gynecologist made an argument for the logical extension of obstetrical practice into pre-pregnancy care.⁹⁵ In this article, Dr. Rhinehart Friesen called “pre-pregnancy care” a “logical extension of prenatal care” and revealed developments in embryology showing that “it is becoming increasingly apparent” that by four to six weeks post-fertilization, and before a woman usually presents at the physician’s office, critical fetal development has occurred:

by this time (four to six weeks after fertilization) the fetus has already passed the most critical period in its development. Furthermore, the effects of various noxious influences on the germ cells before fertilization cannot be nullified by earlier prenatal care. Obviously, exhortations for earlier and earlier prenatal care are not the answer to the problems presented by the dangers of the last few weeks before conception and the first all-important weeks after this event. If anything is to be done to influence the events in the periconceptional period, probably the most dangerous time in any individual’s lifetime, it must be done before, rather than after, the woman thinks she is pregnant.⁹⁶

The obstetrical project in the twentieth century worked to pathologize pregnancy and birth. As Arney writes in his analysis of the obstetrical profession, “obstetricians had to develop ways to ‘foresee’ pathology and act prophylactically because they could not always depend on pathology being obviously present.”⁹⁷ Friesen’s “logical” argument, as he posited it, was important because it positioned the need for obstetrical focus to cover the period around conception, thus presumably preempting any potential pathology—that is, to intervene upon, as he described the period around conception, “the most dangerous time in any individual’s lifetime.” Friesen argued for a pre-pregnancy visit to occur three months before discontinuing a contraceptive,⁹⁸ which lent early credence to the “twelve-month pregnancy” idea that would be promulgated by the March of Dimes and others at the end of the twentieth century.

From the 1950s to the 1970s, the pre-pregnancy medical discussions about expanding care and clinics largely were enamored with intensifying the obstetrical management of high-risk pregnancies, which were usually defined during this time as the experience of a previous adverse birth outcome. This clinical discussion, for the most part, thus was about “high-risk women” and inter-pregnancy care—a method that targets a specific group of women who have experienced a prior negative outcome (e.g., spontaneous abortion, birth defect), not every woman of reproductive age. This would soon all start to change through a U.K. pediatrician’s research on folic acid and birth defects.

THE CRUCIAL ROLE OF FOLIC ACID

The folic acid studies of the 1970s and 1980s marked a critical juncture in the historical trajectory of pre-pregnancy care discussions in the medical literature.⁹⁹ In 1976, a study led by the pediatrician Richard Smithells in the United Kingdom proposed a relationship between vitamin deficiencies, particularly folate, and NTDs (neural tube defects).¹⁰⁰ Historian Salim Al-Gailani notes that with the launch of a clinical trial in 1977, Smithells started to transform folic acid from a routine prenatal supplement for reducing the risk of anemia into an experimental drug to reduce neural-tube birth defects in so-called “high-risk” mothers.¹⁰¹ Smithells’ first clinical trials were for “high-risk” women during their inter-pregnancy period—that is, the trials targeted women who had had previous adverse birth outcomes, not all women of reproductive age. The findings were published in 1980 in the Lancet and suggested that folic acid taken around the time of conception could reduce the risk of recurrent NTDs by half.¹⁰² Smithells argued that this intervention was exemplary of primary prevention, better than the secondary prevention achieved through prenatal care and screening.¹⁰³ Yet, as folic acid was gaining popularity as a routine prenatal supplement, clinicians pushed back on prescribing folic acid to all pregnant women as a “blanket policy,” arguing that it masked attention to the real social problems of nutrition deficiencies.¹⁰⁴

Amid contested findings and ongoing discussions about widespread folic acid supplementation throughout the 1980s,¹⁰⁵ another randomized clinical trial, known as the U.K. Medical Research Council (MRC) study, was published in 1991 in the Lancet. The MRC study revealed that when women took folic acid supplementation before pregnancy, the risk of NTDs could be reduced.¹⁰⁶ This finding led the CDC in the United States to issue a broad recommendation for women to supplement their diet with folic acid prior to pregnancy for the purpose of reducing NTDs.¹⁰⁷ Also within months of the 1991 publication, food manufacturers initiated plans to fortify breakfast cereals; the Kellogg Company introduced a strategy to market products to “women of childbearing age” so that “babies benefit from a healthy breakfast even before they’re conceived.”¹⁰⁸ Folic acid, once intended for only high-risk individuals, became a population health strategy for all women of reproductive age, a broad strategy that nevertheless hinged on notions of personal responsibility and individualized risk prevention.¹⁰⁹ Historian Al-Gailani makes the connection between the year the 1991 study was published and the formal announcement in the United Kingdom that “preconception care” would comprise a key component of maternity care services.¹¹⁰ The construction of folic acid as a “risk-reducing drug” facilitated the advancement of clinical discussions around care for women before pregnancy, and efforts to promote pre-pregnancy care and pre-conceptional vitamin supplementation were “mutually reinforcing.”¹¹¹

In 1993, the lead author of the MRC study, Dr. Nicholas Wald, wrote the following:

The critical timing of folic acid supplementation is not known but it is likely to be immediately before and during embryonic neural tube defect closure, that is, by four weeks from the date of conception or about six weeks from the first day of a pregnant woman’s last menstrual period. There is necessarily uncertainty over when a woman will become pregnant, and she may seek medical attention only some weeks after her first missed menstrual period, which would be too late for folic acid supplementation to be effective. The general advice to women, therefore, must be to take folic acid supplementation from the time they decide to try to become pregnant. Failing that, the use of supplements immediately after a woman suspects she is pregnant is likely to confer a benefit in a proportion of cases, but to what extent is unknown.¹¹²

Wald’s quote made clear that, even though the timing of the effect was inconclusive, the period around conception was deemed newly important. After a heated scientific debate over the timing effect and the safe amount of dosage, the U.S. Food and Drug Administration (FDA) issued a final rule in 1996 to fortify the nation’s grain and cereal supply with folic acid.¹¹³ Compliance with this rule became mandatory in 1998.¹¹⁴ One government administration official remarked that the FDA rule would presume “all women are pregnant unless proven otherwise.”¹¹⁵ Pregnancy no longer presented the burden of proof for women to face recommendations for a healthy pregnancy, and thus prenatal care represented an intervention too late for preventing one of the most common congenital birth defects. The zero trimester was beginning to take shape.

Notably, the research attention to folic acid emerged alongside greater attention to the role of embryonic and fetal development in the medical literature. Obstetric ultrasound had become a common method for seeing the fetus.¹¹⁶ Medical innovation and technology thus made it easier to regard the fetus as a patient and focus more than ever on fetal health and well-being, but there was also rising visibility of the embryo soon after conception.¹¹⁷ By the 1980s, studies expanded previous research from the earlier part of the century¹¹⁸ to show that the nervous system in human embryos is in formation by approximately twenty days post-ovulation.¹¹⁹ This science matters for the present discussion because the 1980s witnessed a growing research agenda on pre-pregnancy interventions—such as folic acid—that might positively impact very early embryonic development and thus offset the risk of birth defects.

Moreover, the research on folic acid supplementation and NTDs coincided with the emergence in the 1980s of the “fetal origins hypothesis,” also known as the “Barker hypothesis.” The fetal origins hypothesis, as presented by Dr. David J. P. Barker, postulated that there are long-term effects of fetal exposures, effects that might not become visible until much later in life.¹²⁰ Indeed, immediate effects of fetal exposures—and realization that the placenta was permeable—were already apparent through birth defect disasters such as that experienced with the drug thalidomide and with the German measles epidemic of the mid-twentieth century.¹²¹ The Barker hypothesis, though, renewed concerns about life-course health as setting the stage for healthy reproduction and also bolstered an epigenetic idea; that is, Barker’s notion suggested that some underlying mechanism “programs” risk susceptibility, in which portions of the epigenome are switched on or off during the fetal period.¹²²

The foundation for a renewed medical focus on early embryonic development—and on interventions that would enhance the environment of that development—set the context for the renewed rise of “pre-pregnancy” thinking in the world of obstetrics and maternal and child health in the late twentieth century. Reproductive medicine had a new golden tool for reducing risk.

EXPANDING AND DEBATING REPRODUCTIVE SURVEILLANCE

As mentioned throughout this chapter, many contemporary maternal and child health professionals assert that pre-pregnancy care began in 1980 with an article on “prepregnancy clinics” in the British Medical Journal by Geoffrey Chamberlain. Chamberlain’s clinic initially was set up in 1978 as a place for women to learn about risks to their health and the health of their future baby. The clinic identified maternal risks (e.g., previous pregnancy complications or current conditions, such as epilepsy) and fetal risks (e.g., previous multiple births or recurrent abortions). Chamberlain argued that an obstetrician should run a pre-pregnancy clinic.¹²³ Letters in response to Chamberlain’s article questioned the novelty of his pre-pregnancy clinic idea: such a clinic had been set up in Australia in 1979¹²⁴; women in a London practice had reportedly requested pre-pregnancy “check-ups” since 1969.¹²⁵

Soon after, in 1981, the British Medical Journal ran an editorial on “preconception clinics.” It argued that the question concerning whether obstetric care should begin before conception should be given “careful consideration,” despite the fact that some physicians deem this only a “philosophical” question.¹²⁶ It would be a chance for obstetricians to counsel women with chronic conditions, the editorial argued. This piece also cited the recent “suggestions” by Smithells and colleagues in the Lancet about early evidence regarding folic acid and neural tube defects. The BMJ editorial evinced temporal reasoning in promoting pre-conception care as a new extension of the management of pre-pregnant women: “At present women usually present to the obstetrician for the first time with symptoms suggesting the fetus is already jeopardized. . . .”¹²⁷ Physicians during this time might have been dismayed at their lack of control over the early prenatal period, when embryos are growing rapidly, when women are not yet seeking care, and when the fetus is “already jeopardized.” Some letters in response to this editorial jumped on the bandwagon, adding occupational hazards and alcohol as potential exposures women should avoid in the pre-conception period to avoid harm to future embryos.¹²⁸ One physician argued that a pre-pregnancy clinic would be a great place to warn women about alcohol reduction and the impact on pregnancy, buttressing his contention with the mention that Americans and their surgeon general have already included “all women who are contemplating pregnancy” to stop drinking.¹²⁹ Another physician argued that a pre-conception visit would “improve the obstetrician’s ability to manage the pregnancy.”¹³⁰

It is clear from this discussion in the medical literature that pre-pregnancy care could increase the surveillance capacity of obstetricians over their patients. These early obstetrical proponents argued that there are specific embryological risks which might not be well understood but for which there is a need for physician oversight. The BMJ editorial, for instance, made a bold claim—one that would continue throughout subsequent medical literature on pre-pregnancy health: that potential damage to the fetus is done during the time when the pregnancy is unsupervised. If risks of adverse outcomes are in place during this early embryonic period, a discussion about the necessity of prenatal care was obviated to some commentators at the time. Prenatal care would continue to serve as treatment, not prevention.

By 1982, there was growing interest in health care around the time of conception and its impact on the reduction of birth defects and infant well-being.¹³¹ One study found that a clinic helped management of diabetes in pregnant women “particularly at the time of conception and throughout the first trimester.”¹³² These advances were mostly attributed to the greater monitoring capability that physicians had over pregnant women’s conditions and behaviors around the time conception occurred, not care in the months prior to pregnancy.

Some clinicians linked emergent ideas about pre-pregnancy care to the changes in women’s social roles. For instance, one article in a nursing journal started off by noting that more women than ever were entering the labor force: “Additionally, today’s working woman is increasingly interested in her health—before, during, and after pregnancy. Questions about preconceptional health needs are common . . . [a woman’s] general health and state of nutrition at conception set the stage for health throughout the pregnancy. Her infant is affected by all of her past and present health habits. Preconception nutrition counseling can have a direct positive bearing on the outcome of pregnancy.”¹³³ This statement was built on the growing recognition in nutrition studies of folic acid and fetal origins that implicated women’s health status around the period of conception as of paramount importance to the woman’s health and the health of her future fetus, but it was also concerned with changes in women’s social status.

Going forward, the medical literature on pre-pregnancy health envisioned a new form of pregnancy risk management in the clinical setting. In the mid-1980s, additional calls percolated for obstetrics to expand formally to the pre-pregnancy period. One physician wrote that pre-conception and antenatal clinics must be the “foci of attention” for primary prevention, especially regarding alcohol risks to the fetus: “Most girls and pregnant women are aware of the danger of drugs to the unborn child in early pregnancy but unfortunately, they may not realize that alcohol is the most common drug to which they are likely to be exposed.”¹³⁴ Mentions of risks to the “unborn child” were common in this literature. In the American Journal of Obstetrics and Gynecology, physicians specializing in reproductive medicine argued that the 1980s should be the decade of expansion into pre-pregnancy and post-conception counseling.¹³⁵ This reasoning for expanding obstetrical reach included the professional landscape that had accompanied the new trend of treating the fetus as patient. It was their obligation, these physicians argued, to monitor and assist mothers from the moment of conception, which meant also to prime women for pre-pregnancy awareness of clinical need. Yet, just as physicians questioned the efficacy of prenatal care in its early beginnings, physicians from all specialties were questioning the need for pre-pregnancy care and expanded reproductive surveillance.

In 1985, a short piece in the Lancet questioned whether “dragging” birth and pregnancy backward is really what women want.¹³⁶ As the Lancet column suggested, bringing conception into the medical realm appeared to be a new case of medicalization of the reproductive process, one that was perhaps unwelcome to women themselves. Formalizing a pre-pregnancy care service required pulling the period around conception into the medical realm and under medical supervision. This reality pointed to logistical questions about where women’s health services would be located and who would get reimbursed for so-called pre-pregnancy services.

Letters to the editor in U.K. medical journals pointed to the professional hurdles that clinicians would have to endure with this new approach, arguing that patient demand is very low for pre-pregnancy health care.¹³⁷ One expert decried the use of pre-pregnancy clinics despite any potential gains by stating that “given the likely benefits and the investment required, particularly when there are other considerable demands on GPs’ [general practitioners’] time, it is impossible to justify the existence of specific preconception clinics.”¹³⁸

Another physician wrote that there is nothing inherently novel in the idea of health before pregnancy and that making it a clinical event would cause unnecessary headache:

Finally, I hope women are not really going to be encouraged to attend a booking clinic as soon as pregnancy is suspected. If all the women a couple of weeks late for a period were to see a consultant obstetrician before having at least a pregnancy test, which the GP can most appropriately arrange, then I am sure there would be little time left for gleaning a greater understanding of the causes of spontaneous abortions and fetal anomalies.¹³⁹

Here, even in a comment supposedly targeting the pre-pregnancy health literature, the focus is on early pregnancy.¹⁴⁰ Physicians were not really debating pre-pregnancy health; they were debating how best to monitor the period of early pregnancy. This physician also clearly thought that obstetricians were encroaching on his jurisdiction as a general practitioner; he argued that he already offered general health care for women prior to pregnancy.¹⁴¹