The Zero Trimester. Miranda R. Waggoner
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“That Prenatal Visit May Be Months Too Late,” and indicated that the guidelines applied to women of childbearing age even if they are not planning for pregnancy.28 The Washington Post, in its article “Forever Pregnant,” explained that “new federal guidelines ask all females capable of conceiving a baby to treat themselves—and to be treated by the health-care system—as pre-pregnant, regardless of whether they plan to get pregnant anytime soon” and that “so much damage can be done to a fetus” if recommendations are not heeded.29 Ms. Magazine more directly pointed to the contentious nature of the new guidelines with the mocking title “Warning: You Could be Pre-Pregnant.”30 Popular outlets cautioned of potential fetal damage if women were not mindful of the new pre-pregnancy care guidelines, but also undermined the idea to a degree by noting that some might see the idea as outlandish.
It became clear following the CDC’s report that different understandings of pre-pregnancy care were operating simultaneously. In one interpretation, public health officials were offering a forward-looking agenda to improve maternal and child health in the United States—a laudable goal to be sure. In another, critics began lambasting the idea of pre-pregnancy care as backward-looking and sexist. That such divergent viewpoints emerged shows that the idea of pre-pregnancy care struck a cultural and political nerve—something that I work to analyze and clarify throughout this book.
Indeed, the rise and meaning of pre-pregnancy care is much more complex and layered than critiques thus far have afforded. Intricacies abound in a close reading of pre-pregnancy care messages within medical and public-health discourse, revealing latent aims of the framework. For instance, proponents of this model situate it as an avenue for reproductive justice, a framework that includes improving women’s reproductive opportunities and improving access to their reproductive needs. Yet, the contradictions are numerous and powerful. In one pre-pregnancy health webinar I tuned to in 2010, a renowned pre-pregnancy care expert expressed that if a woman chooses unprotected sex, she chooses a baby. This statement excludes various options women have once they conceive, and it also incorrectly assumes that unprotected sex is always a “choice” for women. When declarations like this one pepper discussions of pre-pregnancy care, it might be difficult for people to agree that it is a model for advancing reproductive autonomy. As argued in Chapter 4, the pre-pregnancy care approach does genuinely attempt to further reproductive justice, but of ongoing concern are unintended consequences that could stem from pursuing a model with a mindset that all pregnancies can be planned and that all women of reproductive age are potential mothers. Pre-pregnancy care might not simply be about improving birth outcomes, but also could be—as are most reproductive health agendas—wrapped up in the “longstanding societal ambivalence over the social roles of women.”31
Furthermore, although some observers find pre-pregnancy care to focus on practical risk factors that might impact a woman’s health and thus her future reproductive endeavors, such a seemingly straightforward risk-factor approach is accompanied by messaging that makes risk factors sound like causes of imperfect or adverse birth outcomes: if a woman engages in untoward behavior today, her future reproductive endeavors are at risk. The rhetoric of many pre-pregnancy health promotion materials mixes language of risk prevention with that of blame.32 Take a CDC poster from 2009 that reads, “You just found out. You’re pregnant! . . . It’s too late to prevent some types of serious birth defects. . . . The time to prevent birth defects is before you know you’re pregnant.” This particular poster aimed to relay information about the potential of pre-pregnancy folic acid intake to reduce the risk of birth defects. Even though taking folic acid indeed reduces risk, not taking folic acid does not cause a birth defect. Further, the guilt-inducing, moralized message in this poster is somewhat inexplicable in that it seems to be a prevention message after the fact. Such messaging is presumably intended to make women aware of risk for their future pregnancies, to perhaps exploit what psychologists call “anticipated guilt.”33 In this way, it stokes the fire of critiques that pre-pregnancy messages place an undue burden on women of childbearing age. As I have found, the pre-pregnancy reproductive risk discourse of the twenty-first century evokes particular mechanisms and potential consequences for women that can be quite divisive. Indeed, some think pre-pregnancy care is irrational and others think it is essential. As revealed in the tenor of public-health messages that directly tie pre-pregnancy health behaviors to the risk of birth defects, it is also clear that this discourse is laced with sometimes-strident moral undertones, something to which I return in Chapter 5 and Chapter 6.
Although the notion of pre-pregnancy care was enlightening to some and maddening to others as it emerged on the national policy scene in the 2000s, the idea was not novel to many individuals working in fields of public health and medicine. There was momentum leading up to the CDC’s report among those steeped in professional discussions about persistent adverse birth outcomes (see Figure 3). As early as 1980, a British physician wrote about the need for “pre-pregnancy clinics.”34 The Institute of Medicine’s 1985 landmark study Preventing Low Birthweight was the first major medical publication to advocate changing the traditional point of obstetric care to the pre-pregnancy period,35 addressing risk factors at the pre-pregnancy stage and stating that “numerous opportunities exist before pregnancy to reduce the incidence of low birthweight.”36 The 1989 Public Health Service publication Caring for Our Future: The Content of Prenatal Care adopted and expanded the concept of pre-conception care to include risk assessment, health promotion, and intervention follow ups, explaining that “the preconception visit may be the single most important health care visit” in terms of pregnancy and health outcomes.37 Healthy People 2000, which targeted the nation’s top health goals for the approaching decade, also highlighted pre-pregnancy health as a priority.
Figure 3. Key moments in the emergence of pre-pregnancy care, 1980–2006
As Chapter 2 discusses, physicians and public-health materials have emphasized the pre-pregnancy health of women for generations, albeit with different levels of intensity and specific concerns. Moreover, the idea of pre-pregnancy care is not new to those who might be proactive about pre-pregnancy genetic screening, such as those for whom genetic predispositions to certain diseases (e.g., Tay Sachs) are prevalent in their population group. Women and men who donate their genetic material to fertility clinics are often presented with a litany of health questions, and women and men who have faced infertility also might be acutely cognizant of pre-pregnancy care. For the vast majority of the population, however, health concerns around conception remain informal or nonexistent.
What is novel in the twenty-first century is the institutionalized nature of pre-pregnancy care as a model framework for reducing reproductive risk—an approach in which clinicians and public health officials now understand “proper” pregnancy care to include improving health behaviors, addressing risk factors, and pursuing treatments prior to pregnancy in a formalized way. As part of this framework, women are expected to care for their health prior to pregnancy. This includes planning their reproductive lives, improving lifestyle behavior, and seeking medical care. Moreover, clinicians are expected to assess women’s health status prior to pregnancy and offer appropriate care interventions aimed at the woman as a pre-pregnant body. In practice today, this care framework serves as a main organizing principle for public-health campaigns, population health studies, and women’s health care.
SITUATING THE ZERO TRIMESTER IN THE
HISTORY OF PRENATAL CARE
It is impossible to understand the social creation of the “zero trimester” without understanding the historical rise and fall of the promise of prenatal care to improve U.S. birth outcomes. Prior to this century, most health professionals might have thought absurd the pre-pregnancy messages cited at the start of this chapter. The prevailing medical model for ensuring pregnancy health for almost one hundred years had been prenatal care—the idea being that if women engage in healthy behaviors and receive good clinical care during the nine months of pregnancy, then birth outcomes should be