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.11 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”12 and “Don’t focus on getting healthy while pregnant—do it before conceiving.”13 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.14 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.15 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.16 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.17 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.18 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.19 The “fourth trimester” idea denotes the difficult first three months after a child is born20 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.”21 For instance, the popularity of swaddling newborns—mimicking, in a way, life in the womb—is part of this extended-trimester framework.22
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).23 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.
Figure 1. The twenty-first century pregnancy
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.”24 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).25
Figure 2. Number of publications on pre-pregnancy health or health care published in medical and health journals, 1980–2015
With the manifest aims of reducing reproductive risk and improving birth outcomes—including infant mortality, maternal mortality, preterm birth and low birthweight—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.”26 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.27
Following the release of the CDC’s 2006 report, media headlines engaged