Although pre-pregnancy alcohol messages reveal how pre-pregnancy recommendations can be patently misleading and disingenuous, other examples allow us to better grasp the pre-pregnancy model’s reasoning. There is good evidence to suggest that controlling certain chronic conditions prior to pregnancy improves individual chances for positive birth outcomes. For example, medical researchers have found that women with diabetes (both type 1 and type 2) are at increased risk of miscarriage and adverse birth outcomes, and that these risks can be mitigated through pre-pregnancy planning.57 Another good example is HIV status, in which women who are HIV-positive could benefit from pre-pregnancy counseling about ways to prevent transmission to a future infant.58 Moreover, public health officials and physicians are increasingly worried about widespread chronic conditions among women, such as obesity. Obese women have elevated risks for complications during pregnancy and childbirth,59 and thus it might be very beneficial for such women to lose weight prior to pregnancy, both for their own general health and for their pregnancy health. At the same time, obesity has multiple causes and might not be easily remedied in a pre-pregnancy care visit. Other “epidemics” are troubling to health experts as well, such as the rising rates of opioid addiction among reproductive-aged women. Certainly, responsible health advice to a reproductively-capable woman who is addicted to opioids would be to avoid or delay pregnancy. Such advice, though, could be entirely unhelpful to the woman’s broader life circumstances that situate her at risk for addiction, disease, or adverse birth outcomes.60 Furthermore, while some pre-pregnancy risks are real, determining how individual risks—amid numerous social or environmental risks—become linked directly to birth outcomes might be telling for how and upon whom population health directives position responsibility. Is it possible to square the need to mitigate risk for particular individual women with the broad-based calls for all women of reproductive age to change their everyday behavior and act as if they are potentially pregnant?
As mentioned above, federal health reports have noted since the 1980s that a pre-pregnancy health-care visit might be of paramount importance to pregnancy outcomes. Since then, numerous organizations and scholars have touted pre-pregnancy care as the key intervention to improving maternal and child health in this country. But despite the faith expressed in pre-pregnancy care among many maternal and child health policy experts, there are significant gaps in clarity about the extent to which blanket recommendations to improve pre-pregnancy health and health care among all women of reproductive age will produce better birth outcomes in America.
First, temporal confusion abounds when it comes to discussions of pre-pregnancy care and the risk of adverse birth outcomes. The point of most pre-pregnancy behavioral interventions does not reflect evidence of clear connections between one’s pre-pregnancy health behavior and identifiable fetal harm. Pre-pregnancy health discourse often actually is focused even more specifically on the early pregnancy period, not the pre-pregnancy period itself. With regard to smoking, for instance, the CDC has stated that of women who smoke, only 20% “successfully control tobacco dependence during pregnancy, [thus] cessation of smoking is recommended before pregnancy.”61 In other words, even for smoking—something generally considered to be bad for everyone—the principal concern is that women will not be able to stop smoking once they become pregnant and that women will continue smoking before they learn that they are pregnant, not that smoking at some point in one’s life prior to getting pregnant equals increased risk for an adverse birth outcome.62 Another example is folic acid consumption, which is covered in more detail in Chapter 2. Experts consider folic acid to be the best evidence for a pre-pregnancy intervention because of the effect it has on reducing the risk of neural tube defects such as spina bifida in developing fetuses. Folic acid is highly effective at reducing birth defects if it is consumed in very early pregnancy. Folic acid consumption thus might be a profound risk-reducing mechanism for women planning a pregnancy because they might become pregnant, but it does not reduce all risk of neural-tube defects and does not work through years-long consumption. Suggestions that folic acid should be consumed by all women of reproductive age throughout their reproductive years situates all such women as perpetually potentially pregnant. That is, with pre-pregnancy care messages and interventions, the focus no longer is on women at risk but on all women of childbearing age.63
Such widespread targeting stems from the fact that a key aim of pre-pregnancy interventions is to cover the periods of fertilization, implantation, and early pregnancy. In defense of the need for pre-pregnancy care, experts cite the first few weeks of embryonic development, which includes integral central nervous system and cardiac development, as a period when women are often unaware of their pregnancy and unintentionally forgo attentive health practices.64 In as much as experts invoke scientific knowledge about the impacts of pre-pregnancy interventions, the chief hope is to target pregnancy intentions, a theme elaborated upon in Chapter 3. That is, the focus is on social behavior that foregrounds planning, and not on imminent medical risk. Pre-pregnancy care recommendations attempt to safeguard conception and early pregnancy because many pregnancies are unintended. Even women who intended to become pregnant, however, do not usually know the exact moment of conception. Thus, despite the temporal confusion of many pre-pregnancy health messages that falsely lead women to contemplate that every health behavior engaged in today might affect their fetus of tomorrow, zero tolerance now extends to the zero trimester.
Next, and more generally, we know very little about what actually causes most birth defects.65 Studies point to a profound lack of etiological understanding of what makes a healthy—or unhealthy—pregnancy and birth, and medical experts often do not understand the root cause of most poor birth outcomes.66 In fact, the two major causes of infant mortality—congenital anomalies and preterm birth—are not well understood by the medical community.67 Moreover, in contrast to media-perpetrated stereotypes, most neonatal deaths occur among women in their twenties and early thirties who do seek medical care and who do not use illicit drugs.68 In other words, the majority of adverse birth outcomes are to seemingly healthy women. Some measure of responsibility might lie with institutionalized medical practices, and not women’s behavior. For example, analyses of the increase in preterm births find that high rates of labor induction, cesarean deliveries, and assisted reproductive technologies might be key drivers—factors that are not necessarily related to the pre-pregnancy health status of women but rather to the institutionalized culture of medical intervention in reproduction.69
Third, there are discrepancies in understandings about the health status of women of reproductive age. In recent population-based research, almost 89% of women of reproductive age reported good, very good, or excellent health, and about 75% of women of reproductive age had health coverage during the month before their most recent pregnancy.70 At the same time, a quarter of women of reproductive age reported smoking cigarettes in the three months prior to pregnancy; about half reported drinking alcohol. Only about 30% reported taking a multivitamin or folic acid supplement.71 These numbers lead experts to note that there is room for improvement in expanding knowledge about what constitutes good pre-pregnancy health. Even so, it is worth noting that we also do not know much about how pre-pregnancy health status has changed among women of reproductive age over the years; before the CDC’s recommendations for improving pre-pregnancy care were published, few states monitored pre-conception health indicators specifically.72 Data do exist, however, on general health behaviors and health risks of non-pregnant women over time. Such data suggest that some behaviors have improved since the CDC’s recommendations, such as substantial