The Zero Trimester. Miranda R. Waggoner
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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