The Zero Trimester. Miranda R. Waggoner
Читать онлайн книгу.
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