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CHAPTER 1
Someday, Now
PRECONCEIVING RISK AND MATERNAL RESPONSIBILITY
Having a healthy pregnancy is no longer contingent on being pregnant in the first place. In February 2016, the federal Centers for Disease Control and Prevention (CDC) released a statement urging women of reproductive age to avoid alcohol if they were not using birth control, lest they harm a pregnancy that might or might not be present. The idea was vast: the CDC indicated that about 3 million American women were putting potential pregnancies at risk, but any woman between 15 and 44 years old was defined as "pre-pregnant," thus targeting, in effect, about 61 million American women. This measure attracted considerable social commentary and ridicule, but it hardly represented a new idea in public health. In 1981, Surgeon General Edward Brandt issued a warning that women "considering pregnancy" should refrain from alcoholic beverages. Since 1992, Kentucky has required bars to post warnings that drinking alcohol prior to conception can cause birth defects when, in fact, it cannot. The idea of pre-pregnancy health promotion surged after 2006, when the CDC released a report recommending improvement of the pre-conception health and health care of U.S. women of childbearing age. Alcohol was just one of many pre-pregnancy risk factors listed in this report, and public health warnings issued since 2006 have not been limited to drinking.
In late 2012, for instance, Texas initiated a public-awareness campaign, called Someday Starts Now, for improving the health of the state's babies. In television spots, young women performed everyday activities — chatting with friends, exercising — accompanied by a looming bubble box filled not with dialogue, but rather with numbers indicating a long-in-the-future baby's due date, sometimes years away. This approach had the visual effect of dangling future motherhood above the women's heads. The campaign's associated website stated, "your health today is important — and even more important to the baby you might have someday." The text further offered: "If there's a baby in your future, even if it's months or years from now, today matters. Take control. Stop smoking, eat right and exercise and do something about your stress." After seeing this television spot, one blogger wrote, "Texas is Reminding Me I'm Just a Baby Vessel Again."
The CDC and Texas campaigns represent but two illustrations of a growing tendency in medicine and public health to mark the beginning of healthy and responsible motherhood not at the birth or adoption of a child, not during pregnancy or at conception, but rather at an earlier point in time: pre-pregnancy. Similarly, in its recommendations for healthy pregnancy behavior, the March of Dimes — a national organization committed to improving birth outcomes in America — points directly to the three months prior to conception, claiming that a proper pregnancy today should actually last twelve months.
These public health statements are jarring. Perhaps because of the invariant biological fact that a typical human pregnancy lasts about nine months, it is disconcerting to read that it instead should be thought of as a lengthier process. Given feminist progress over the past half century, the thought of women of reproductive age as primarily mothers-in-waiting seems problematic. Also given that the focus on pregnancy health for more than a century has been on pregnancy behaviors, the thought of focusing on health behaviors prior to pregnancy is astounding. At the same time, these public-health assertions are somewhat expected. The sentiment that healthy babies stem from fit, responsible women echoes age-old societal preoccupations with women's bodies, behaviors, and reproductive outcomes. Anticipating and hedging future risk is reflective of our contemporary age of risk aversion and individualized responsibility for health. Concerns about the health of future generations have long manifested in cultural and political anxieties around family planning, fetal health, and women's roles in society.
Pre-pregnancy care is a framework that emerged as the new panacea for ensuring healthy pregnancies and healthy infants in the United States in the twenty-first century. It now is a dominant medical and cultural schema for reducing risks to healthy pregnancies, and it includes prescriptions for both health care and self-care. To have good pre-pregnancy health is to render pregnancy less risky, the thinking goes, and might improve the overall health of women, children, and society. What is emphasized, then, in contemporary health discourse is that for any woman of childbearing age, in the case of pregnancy health, someday is now.
Such messages are not coming only from health organizations. The notion of pre-pregnancy care has also entered the marketplace — touted as the fix for population health issues ranging from obesity to autism. Women today can buy vitamins specially marketed for the pre-pregnancy period as well as advice books such as Get Ready to Get Pregnant: Your Complete Prepregnancy Guide to Making a Smart and Healthy Baby. Newspapers run headlines such as, "Start taking care of your baby before you get pregnant" and "Don't focus on getting healthy while pregnant — do it before conceiving." Even tabloids have expanded their surveillance rhetoric and routinely conjecture about whether celebrities are potentially planning a pregnancy through monitoring their day-to-day behaviors (e.g., "She was seen avoiding alcohol! She might be thinking about getting pregnant!").
What accounts for this current moment in which birth outcomes are defined in terms of a woman's whole adult life — well before she ever decided if and when to get pregnant and have a baby? What accounts for the contemporary reproductive landscape in which, as in the Texas health campaign, due dates are projected onto non-pregnant women and a healthy pregnancy is defined as lasting longer than nine months? How is it that now, in the twenty-first century, young women are essentially asked to act as responsible mothers before motherhood is their imminent reality?
This book confronts these questions by tracing the shifting boundaries of pregnancy health risk and maternal responsibility in America at the turn of the twenty-first century — by examining how and why the trend and task of perfecting pregnancies has extended at the front end of three trimesters. It proposes that this pre-pregnancy care model introduces a "zero trimester" — a concerted focus on the months or years prior to conception in which women are urged to prepare their bodies for a healthy pregnancy. The term "zero trimester" has not been previously used in academic, popular, or medical parlance; it is my own neologism that reflects growing sentiments among health professionals and others that individual women should adopt an attitude of anticipation when it comes to pregnancy health. The zero trimester concept, then, refers to the period when a woman is not pregnant but when she is supposed to act as if she is pregnant. The notion of the zero trimester is easily marketed as the three months prior to pregnancy, for example when organizations such as the March of Dimes claim that a pregnancy lasts twelve months. This line of thinking, however, assumes that a woman will know exactly when she will conceive. Thus, the onus of pre-pregnancy maternal responsibility could be vast, without temporal bounds. Some health professionals even point to a woman's lifetime of experiences as mattering to the health of a pregnancy. During my research for this book, one expert told me, without hyperbole, that "a woman is a mother from the time of her own conception." All of women's pre-reproductive years are in the zero trimester.
The idea of extended time for pregnancy has linguistic precedent, as the boundaries between discourses about fetuses and about newborns have become more fluid. The fetus has been represented and personified as childlike in popular and medical imaginations over the past several decades, parallel to both the work of pro-life activists as well as advances in medical technologies (such as sonograms) that render the contents of wombs visible. Additionally, thanks to some popular infant-rearing and sleep books like The Happiest Baby on the Block, the concept of the "fourth trimester" has become part of many new parents' lexicons in recent years. The "fourth trimester" idea denotes the difficult first three months after a child is born and reflects the sentiment that these three months are essentially an extension of fetal development. As medical writer Susan Brink's book on the topic explains, "the fourth trimester has more in common with the nine months that came before than with the lifetime that follows." For instance, the popularity of swaddling newborns — mimicking, in a way, life in the womb — is part of this extended-trimester framework.
Thus, it is this cultural moment — one that has seen the rising importance of the fetus and expanding notions of trimesters — in which the zero trimester has materialized and flourished, changing, as it has, medical and social conversations about reproductive risk. Extending the fetal stage prior to as well as beyond pregnancy has become more typical within twenty-first century health-risk discourse. The zero trimester and fourth trimester are modern inventions, flanking the clinical period of pregnancy (see Figure 1). In explaining the social and medical contours of how current health messages targeting women of reproductive age emerged, this book centers on the conceptualization of the pre-pregnancy period as a constructed trimester within a particular social, cultural, and political context of shifting ideas about risk and reproduction.
WHAT THE "ZERO TRIMESTER" INCLUDES
As mentioned above, contemporary pre-pregnancy care messages are informed by the U.S. Centers for Disease Control and Prevention's decision to begin promoting pre-pregnancy health and health care in the twenty-first century. In 2006, the CDC released a list of pre-conception health recommendations in the widely-circulated Morbidity and Mortality Weekly Report (MMWR), entitled "Recommendations to Improve Preconception Health and Health Care — United States." This public health report was central to the emergence and trajectory of the pre-pregnancy care model. Following the release of the MMWR, the CDC convened a set of expert workgroups (clinical, public health, consumer, and policy) to filter recommendations and follow through with the report's goals. The result was numerous publications in the medical and public health literature about how to improve pre-pregnancy care among American women. More pre-pregnancy health promotion campaigns followed, and conversations within medicine and public health about pregnancy health quickly turned more squarely than ever before to the pre-pregnancy period (see Figure 2).
With the manifest aims of reducing reproductive risk and improving birth outcomes — including infant mortality, maternal mortality, preterm birth and low birth weight — the basic idea of pre-pregnancy care is to advise and treat any negative health behaviors or conditions that might impact a reproductive-aged woman's future pregnancy. The MMWR outlined a concrete, though abstract, definition of pre-conception care as "a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management." According to the report, all providers who routinely see and treat women of reproductive age should be attuned to pre-pregnancy health and health care. They should be asking women — regardless of the nature of the clinical visit — what their reproductive plans might be and giving advice in accordance. The report also called for systematic changes in health care provision to offer additional coverage to pre-pregnant women. Women themselves are generally encouraged to partake in self-care, seek out testing (for genetic or hereditary predispositions and for sexually transmitted infections), take multivitamins (especially with folic acid), stop smoking cigarettes and drinking alcoholic beverages, and get conditions such as diabetes or obesity under control prior to conceiving. To an uncritical observer, these interventions might sound reasonable and desirable. That is, these recommendations carry a valence that is hard to argue with: Who would be against healthier mothers and babies? What became exasperating to some commentators is that the new model appeared to be a reawakening, of sorts, of the sentiment that women's bodies are only vessels for someone else — that women are mothers-in-waiting, and that it is the job of public health and medicine to control women's bodies for the sake of the greater good. In this way, observers pointed early on to how pre-pregnancy care might be perilous for women.
Following the release of the CDC's 2006 report, media headlines engaged in both fear mongering and skepticism. The New York Times published an article entitled, "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. 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 healthcare 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. Ms. Magazine more directly pointed to the contentious nature of the new guidelines with the mocking title "Warning: You Could be Pre-Pregnant." 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."
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Excerpted from "The Zero Trimester"
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