The Zero Trimester. Miranda R. Waggoner
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to follow medical experts’ advice about how best to raise healthy children. A hundred years ago, the medical community deployed government pamphlets and manuals to formally define proper health behavior related to pregnancy and motherhood.112 In an example of noteworthy stasis, medical and self-care advice is still today part of the construction of contemporary “moral motherhood.”113
The notion of the “future fetus” in the pre-pregnancy model is imaginable because of the way in which the fetus has become such a salient cultural and medical object within a surveillance society.114 Indeed, maternal bodies get caught in a distinctive web of expert surveillance so as to optimize both fetal and infant health outcomes. Pregnant bodies today are consistently monitored to assess risks to the fetus in particular.115 The rise of maternal-fetal medicine (MFM), fetal surgery techniques, and technoscientific practices in the second half of the twentieth century shifted obstetrical gaze toward the fetus as a separate patient, one that is distinct from the mother’s body.116 Fetal risks are often now weighed against the risks to the mother, heightening the supposed maternal-fetal conflict, in which women’s interests are putatively pitted against the interests of the fetus.117
The rise of pre-pregnancy care thus has occurred in a climate in which maternal behavior and motherhood have higher stakes than ever before. The increased social and cultural importance placed on children118 has much to do with this, as motherhood in general became an ever more rigorous endeavor over the course of the twentieth century. Sociologist Sharon Hays noted the rise of “intensive mothering” almost twenty years ago, referring to the idea that contemporary motherhood in the United States is labor intensive, expert driven, emotionally consuming, consumer driven, and child centered.119 Since the time that Hays introduced her concept, mothering has intensified into what Joan B. Wolf calls “total motherhood,” a concept that calls attention to the ubiquity of “risk analysis to prescriptions for good mothering in a risk culture.”120 Today, a new “momism” accentuates expectations in an increasingly idealized version of motherhood,121 in which mothers actively engage in risk calculations on behalf of their children’s health.122
The concepts of “intensive mothering” and “total motherhood” are helpful in gaining an understanding of contemporary messages surrounding the ever-more-diffuse health risks that are aimed at reproductively capable women. As mentioned above, in a risk culture in which individuals are expected to calculate and mitigate any potential risks,123 and in which mothers are expected to reduce all risks to their children— especially through proper health behaviors124—such risk-reducing sentiments also apply to fetal health as well as to future fetal health. For the past several decades, “assumptions of maternal vulnerability have been reconstructed around risks to the fetus mediated through the maternal body” and even the pre-maternal body.125 Some scholarly work has even tied the rise of the pre-pregnancy care to post-9/11 anxieties about terror, risk, and the need for increased protection of future children not yet conceived.126
Amplified focus on pre-pregnancy care and the rise of the zero trimester promote what I call in this book a cultural ethic of “anticipatory motherhood.” Drawing on the work of Hays and Wolf, this idea positions all women of childbearing age as pre-pregnant and exhorts them to minimize health risks to future pregnancies, even when conception is not on the horizon. This idea is further reflective of how an American ideology of motherhood is as strong as ever, making it a persistent master status and making maternal sacrifice a master cultural frame.127 The expectation today is that pregnancy—and thus children—can be perfected ahead of time.128 It follows then that the rise of the pre-pregnancy care model intersects clearly with contentious reproductive politics around family planning and the changing realities of women’s lives in the twenty-first century.
THE POLITICS OF MATERNAL AND REPRODUCTIVE HEALTH
The demographics of American women’s reproductive lives reveal that they are situated within the zero trimester more squarely than ever. Many women today spend years—if not decades—avoiding pregnancy.129 Women are waiting later in life to have their first baby and are having fewer babies overall,130 extending the so-called pre-pregnant phase to a lengthier time frame than was the case historically. Moreover, about 15% of women aged forty to forty-four report that they are childless, and this number is growing.131 Concerns of whether and when a woman will have a baby thus potentially increase social anxiety about the expanded temporal period of women’s lives when they are planning their futures. Modern views of fertility revolve around what famed demographer Ansley Coale described as a “calculus of conscious choice”132—that with the availability of contraception and family-planning techniques, women and couples are presumed to have the option to avoid pregnancies and to plan and space births according to their wishes. About half of the pregnancies occurring in the United States, however, still are categorized as unintended. The greater emphasis on a pre-pregnancy care framework around the turn of the twenty-first century has not been just due to prenatal care failing, as detailed already; it also is about women’s increasing control over their fertility, changes in fertility patterns, and the politicized nature of reproduction and health care.
Thus, a discussion of pre-pregnancy care cannot be divorced from trends in reproductive health politics, and especially abortion politics, which grew with vehemence starting in the 1970s. As Chapter 4 elaborates, the pre-pregnancy care framework advances overlap between maternal and reproductive health—realms long considered to be separate in terms of ideology and policy—and, in so doing, strategically avoids a discussion about abortion and women’s reproductive options after conception occurs. If all pregnancies are twelve-month pregnancies, then women would ostensibly have thought through their reproductive desires prior to pregnancy. The circumvention of abortion talk fits well with a broader cultural milieu that is often hostile to women’s choices that do not match a maternalist or pronatalist agenda.
Studying the zero trimester by examining cultural and pregnancy risk messages that are aimed at non-pregnant women of reproductive age shows how maternal responsibility is defined for women writ large. Much reproduction scholarship looks at issues of pregnancy and fertility or focuses on women who are either already mothers or already pregnant. Social science analyses of the pre-pregnancy period mostly have concerned infertility and assisted reproductive technologies.133 This type of analysis, however, is specifically related to women who already desire a baby and who are actively aspiring to conceive. This book instead analytically leverages the zero trimester—a concept that applies to all women of reproductive age, regardless of desire or capacity to get pregnant—through the lenses of reproductive risk and anticipatory motherhood. Moreover, ample human-reproduction scholarship has focused on the politics of reproduction. In this book, I more specifically deliberate the politics of reproductive risk—calling attention to the formation and deployment of discourse about the prevention of adverse reproductive outcomes.
Pregnancy and reproduction are private and individual processes, yet at the same time they also are highly visible public ones.134 Maternal and child health outcomes proxy a nation’s health and reflect on our health-care institutions. As such, they signal some of our most pressing social issues and problems. They also reflect shifting cultural norms, such as the concerns around unintended pregnancy. Reproductive outcomes also matter intimately to individuals, especially because most women become mothers in their lifetime.135 How women, families, physicians, and policy makers are primed to think about the risks to a healthy pregnancy is vital. One could say that, as a society, we have a generalized wish for reducing risks to pregnancy health.
The following pages document how the imperatives of prevention, concerns around the social roles of women, and the fraught politics of reproduction molded the construction of a vibrant health and policy definition of reproductive risk—one that expands medical and social control over women’s bodies, from menarche to menopause, in the twenty-first century.
OVERVIEW OF THE BOOK
To understand the rise and consequences of this twenty-first century medical and social model for pregnancy health, and the zero trimester notion that accompanies it, I pursued a multisited ethnographic approach136