The Zero Trimester. Miranda R. Waggoner
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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.
2 From the Womb to the Woman
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