Physicians kept highlighting the pre-pregnancy period, but because treatment during pregnancy was increasingly considered the crucial medical tool for reducing reproductive risk—despite rumblings that it was doing nothing of the sort—discussions about pre-pregnancy health were often aimed at lamenting women’s lifestyle choices or general health status. That is, without medical or policy backing, physicians simply took to conjecturing about women’s health status before pregnancy. For example, with regard to preeclampsia, the following appeared in the New England Journal of Medicine: “It would, of course, be better to have the patient in the best physical condition before pregnancy occurred.”64 Hypertension, in another instance, was thought to be better controlled with attention prior to pregnancy, “by the combined and co-ordinated efforts of the internist and the obstetrician and of medical and maternity clinics, or by the constant observation and study of obstetric patients before, during and for years after their childbearing careers by the physicians who attend them. . . .”65
Pre-pregnancy health and health-care discussions continued in the medical literature, although they came to be somewhat marginal as compared to the prominent literature on prenatal care. Yet, the discussions were couched in the language of social concerns and, as such, much of the pre-pregnancy medical literature was not concerned with reducing reproductive risk per se but rather with preventing certain pregnancies in the first place. That is to say that, in the early twentieth century, pre-pregnancy health and health care discussions became mired in population health goals of the day, namely eugenics.
PRE-PREGNANCY HEALTH DISCOURSE AND
POPULATION CONTROL
In 1936, obstetrician Fred Adair wrote in the Journal of the American Medical Association that obstetrics education should include pre-pregnancy care knowledge.66 In 1940, Adair, a professor of obstetrics and gynecology at the University of Chicago, wrote one of the earliest articles to be titled “preconceptional care.”67 He started off the article defining “preconceptional care” as, “designed to assist in securing perfect reproduction. It rests upon fundamental eugenic and euthenic principles. It is that care and attention which is given prior to conception and involves the elimination of those individuals who are not suitable for wholesome reproduction and the seduction of those who are capable of normal reproduction.”68
Adair’s statement here was in vogue with the medical literature on eugenics. He went on to discuss the necessity of codifying a “preconceptional viewpoint” via state control of reproduction, as his state of Illinois did in 1937 when it required potential marriage partners to be tested for venereal disease. Indeed, although the eugenics movement was beginning to wane in the United States in the 1930s, many U.S. states passed sterilization laws clearly targeting individuals for eugenic purposes.69 Racial hygiene logic was part of a broad push in the United States for “better breeding,” which did not end when Nazism fell.70
One of the earliest mentions of the term “preconception care” came in the meeting minutes of the 1932 Annual Sessions of the American Medical Association.71 The section on obstetrics, gynecology, and abdominal surgery was called to order by its chairman, Fred Adair, and the first paper read was on “preconceptional and prenatal care,” by Percy W. Toombs of Tennessee.72 In 1923, the Journal of Heredity had published a lecture by Toombs on “parenthood and race culture.”73 In this talk, Toombs outlined the aims of eugenics. His language is unsettling as a precursor to a “pre-pregnancy care framework” in the United States. He wrote, for example, that “there is a constant tendency toward relative and absolute sterility among that class of society which is best fitted to produce the next generation, and the most prolific are the less fit to carry on the torch of civilization.”74 Pre-pregnancy care discussions in the medical literature in the early twentieth century were riddled with discussions expressive of eugenic ideologies.
Remnants of pre-pregnancy care’s relationship with eugenics were still found in the 1960s,75 but this early history is erased in contemporary pre-pregnancy health and health care literature. For example, by positioning the pre-pregnancy care model as beginning with Chamberlain’s U.K. clinics in 1980, as many present-day publications do, articles avoid the ways in which pre-pregnancy care was tied up with unsavory medical ideas in the earlier part of the century. Even when contemporary publications go back further than Chamberlain’s article—for example, a March of Dimes publication in 2002 stated that pre-pregnancy care dates to the 1960s—they don’t go back far enough.76 Some articles cite the Dewees pediatrics textbook from the nineteenth century or even Plutarch when they mention medical concerns about pre-pregnancy health, but then gloss ahead to the 1980s when highlighting the beginning of pre-pregnancy care,77 eliding pre-pregnancy care advocates’ earlier connection with eugenics. Pre-pregnancy health and health care ideas in the first half of the twentieth century often intersected with strategies of population control, strongly linked to eugenics.
A related strain of early pre-pregnancy care literature, also stemming from obstetrics, was used to talk about family planning more broadly. At a meeting of the Southern Medical Association’s section on obstetrics in 1939, one doctor argued that “preconceptional care” should be the preferred term over “birth control” because physicians are not trying to control births, but rather conception.78 Speakers at the Southern Conference on Tomorrow’s Children in 1939, which included remarks from Margaret Sanger, preferred the term “preconceptional care” to “birth control” when discussing contraceptive practices.79
Often, in this realm, pre-pregnancy health discussions had little to do with medical concerns directly and more to do with social concerns regarding pregnancy intentions and preventing unwanted pregnancies. This focus was strengthened by one of the most important advances in women’s health care in the twentieth century: the FDA approval of the birth control pill in 1960. The notion of “family planning” also was gaining prominence. As part of President Johnson’s War on Poverty, the federal government issued its first grants in support of family planning practices in 1965. In 1970, Congress enacted Title X of the Public Health Service Act to ensure family planning access for low-income women.80 Abortion was legalized at the federal level in 1973. This policy history emerged largely separate from that of pregnancy and prenatal services mentioned above, cutting a political hole in women’s health care in the United States between services for preventing pregnancies and services for safeguarding pregnancies, a point which is revisited in greater detail in Chapter 4.
Along with the growing popularity of family planning, further advances in infertility treatments and genetic screening initiated an unprecedented ability to control conception (and birth), and the idea of “planning” could thus be systematized in the latter half of the twentieth century. As demographers theorized, reproduction came to be seen during this time as increasingly under individuals' control.81 Physicians wanted part of this control. Thus, the medical literature subsequently began to pay concerted attention to planning pregnancies with the availability of effective contraceptive technologies. Pre-pregnancy health discourse at this historical juncture in many ways became predicated on the notion of “intendedness,” as physicians argued that they could more easily monitor patients and pregnancies if those pregnancies were planned—and, by extension, solve the problems of adverse birth outcomes. One obstetrician wrote that “prenatal care can be simply a system of observations, and the observation of a patient . . . prevents nothing.”82 Another physician wrote, “Since the advent of reliable methods of contraception . . . women not only expect to plan, but even to time, their pregnancies. Under these circumstances, it becomes quite feasible to advise patients to see their doctor before they expect to start a pregnancy” to “influence the events in the periconceptional period.”83
As eugenics discourse became an abomination and the pill became popular, pre-pregnancy care discussions within the medical literature were no longer couched in the language of “better breeding” but rather of reproductive