The Zero Trimester. Miranda R. Waggoner
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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