The Zero Trimester. Miranda R. Waggoner

to the changes in women’s social roles. For instance, one article in a nursing journal started off by noting that more women than ever were entering the labor force: “Additionally, today’s working woman is increasingly interested in her health—before, during, and after pregnancy. Questions about preconceptional health needs are common . . . [a woman’s] general health and state of nutrition at conception set the stage for health throughout the pregnancy. Her infant is affected by all of her past and present health habits. Preconception nutrition counseling can have a direct positive bearing on the outcome of pregnancy.”¹³³ This statement was built on the growing recognition in nutrition studies of folic acid and fetal origins that implicated women’s health status around the period of conception as of paramount importance to the woman’s health and the health of her future fetus, but it was also concerned with changes in women’s social status.

      Going forward, the medical literature on pre-pregnancy health envisioned a new form of pregnancy risk management in the clinical setting. In the mid-1980s, additional calls percolated for obstetrics to expand formally to the pre-pregnancy period. One physician wrote that pre-conception and antenatal clinics must be the “foci of attention” for primary prevention, especially regarding alcohol risks to the fetus: “Most girls and pregnant women are aware of the danger of drugs to the unborn child in early pregnancy but unfortunately, they may not realize that alcohol is the most common drug to which they are likely to be exposed.”¹³⁴ Mentions of risks to the “unborn child” were common in this literature. In the American Journal of Obstetrics and Gynecology, physicians specializing in reproductive medicine argued that the 1980s should be the decade of expansion into pre-pregnancy and post-conception counseling.¹³⁵ This reasoning for expanding obstetrical reach included the professional landscape that had accompanied the new trend of treating the fetus as patient. It was their obligation, these physicians argued, to monitor and assist mothers from the moment of conception, which meant also to prime women for pre-pregnancy awareness of clinical need. Yet, just as physicians questioned the efficacy of prenatal care in its early beginnings, physicians from all specialties were questioning the need for pre-pregnancy care and expanded reproductive surveillance.

      In 1985, a short piece in the Lancet questioned whether “dragging” birth and pregnancy backward is really what women want.¹³⁶ As the Lancet column suggested, bringing conception into the medical realm appeared to be a new case of medicalization of the reproductive process, one that was perhaps unwelcome to women themselves. Formalizing a pre-pregnancy care service required pulling the period around conception into the medical realm and under medical supervision. This reality pointed to logistical questions about where women’s health services would be located and who would get reimbursed for so-called pre-pregnancy services.

      Letters to the editor in U.K. medical journals pointed to the professional hurdles that clinicians would have to endure with this new approach, arguing that patient demand is very low for pre-pregnancy health care.¹³⁷ One expert decried the use of pre-pregnancy clinics despite any potential gains by stating that “given the likely benefits and the investment required, particularly when there are other considerable demands on GPs’ [general practitioners’] time, it is impossible to justify the existence of specific preconception clinics.”¹³⁸

      Another physician wrote that there is nothing inherently novel in the idea of health before pregnancy and that making it a clinical event would cause unnecessary headache:

      Finally, I hope women are not really going to be encouraged to attend a booking clinic as soon as pregnancy is suspected. If all the women a couple of weeks late for a period were to see a consultant obstetrician before having at least a pregnancy test, which the GP can most appropriately arrange, then I am sure there would be little time left for gleaning a greater understanding of the causes of spontaneous abortions and fetal anomalies.¹³⁹

      Here, even in a comment supposedly targeting the pre-pregnancy health literature, the focus is on early pregnancy.¹⁴⁰ Physicians were not really debating pre-pregnancy health; they were debating how best to monitor the period of early pregnancy. This physician also clearly thought that obstetricians were encroaching on his jurisdiction as a general practitioner; he argued that he already offered general health care for women prior to pregnancy.¹⁴¹