Fourth, while the pre-pregnancy care framework attempts to address persistent and dramatic racial and ethnic health disparities in maternal and child health, it does so inadequately. Within the United States, such disparities are profound. Some women are more at risk of adverse birth outcomes, and some women—due to factors such as race, class, or geographic location—have poorer pre-pregnancy health than other women. The infant mortality rate for black women is double that of white women, a gap that has increased in recent years.74 The maternal mortality rate for black women is more than three times that of white women and has also been on the rise.75 While confronting the distressing reality of such inequalities in reproductive status and reproductive outcomes, pre-pregnancy health promotion materials have perhaps unwittingly reinscribed racialized notions of reproduction.
As Chapter 5 and Chapter 6 discuss in more detail, rather than addressing widespread social problems such as structural racism, poverty, or limited access to healthy food choices, our standard public health and medical agendas simply tell all women to practice the healthiest lifestyle possible to ensure healthy babies. Additionally, reproductive agendas in the United States are almost always racialized, built on contemporaneous ideas of “good reproduction” and engaging in what Rickie Solinger calls the process of “racializing the nation.”76 At issue is whether we are willing to focus our public-health interventions more squarely on reducing poverty- or race-based disparities for at-risk women rather than pursue policies that ask all women of reproductive age to change their behavior and plan their pregnancies without the supports they might need to do so.77 Without systemic change, will only well-off women (or women seeking fertility services) be the ones to reap potential health rewards? We must ask who benefits from an expanded population health focus on pre- pregnancy health and health care.
Fifth, there is a deep disconnect in pre-pregnancy health materials between individual-level recommendations and social-level change in the landscape of maternal and child health. That is, beyond individual-level health risks and health behaviors there are, notably, vivid examples of environmental-level risks that harm non-pregnant individuals and that matter for their future birth outcomes. It is indisputable that birth outcomes have a lot to do with poverty and social conditions, including proximity to environmental contaminants before pregnancy. For instance, research reveals that long-term exposure to environmental toxins can damage genes.78 In a 2015 exposé of the New York City nail salon industry, Sarah Maslin Nir of the New York Times revealed that nail technicians, by virtue of their prolonged exposure to chemicals, are at an increased risk of having a child with birth defects. Such cases of fetal or infant health risk have less to do with individual behaviors and lifestyle choices and more to do with widespread environmental exposures over which individuals have little control—calling into question the individualized tenor of many pre-pregnancy care messages. The pre-pregnancy care model today does incorporate messages for social change and awareness of the need for life-course approaches to holistic health, such as expanded health-care coverage for all women of reproductive age. As Chapter 5 and Chapter 6 show, however, overwhelming any system-level or environmental-level discourse are health-promotion messages directing every woman as to what she should do to improve her chances for healthy reproduction, including, in some instances, urging women to avoid particular activities or exposures. To keen observers, this advice could sound reminiscent of past “solutions” that aimed to bar women of reproductive age from toxic jobs—rather than eliminate the noxious exposure in the first place—to safeguard fetuses that are not yet conceived.79 Pre-pregnancy risk factors epitomize a longstanding debate and tension in population health and public policy about how to navigate the relationship between individual-level risk and population-level prevention policies.80
Some of the debate about interactions between individual-level and environmental-level risk factors has been aided by the rise in social scientific concentration on cumulative life health81 and epigenetics scholarship that links life-course outcomes to the time in the womb or even to the mother’s lifetime experiences. The pre-pregnancy care model taps into the rise of these ideas. Scholars, however, have recently called-out such research for its inclination toward deterministic82 and mother-blaming language. In a Nature essay in 2014, historian Sarah Richardson and colleagues situate contemporary epigenetics discourse in a long history of society blaming mothers for all kinds of children’s health problems.83 Although it has been argued that pre-pregnancy care is an extension of epigenetics research,84 this book shows that the pre-pregnancy care literature predated the emergence of epigenetics as a popular scientific topic. Moreover, the experts I interviewed did not tend to couch the pre-pregnancy care model in an epigenetics paradigm. In fact, some saw epigenetics research as too simplistic, deterministic, and not necessarily concerned with the same things about which they were concerned. For example, the work of reducing unintended pregnancies—a key component of pre-pregnancy care—does not stem directly from epigenetics research. Rather, the pre-pregnancy care framework is gripped with broader ideas about—and politics surrounding—health care, family planning, motherhood, and reproduction.85 So, while pre-pregnancy care might exist nicely in step with a postgenomic/epigenetic paradigm, it stands on its own historically and epistemologically.
Finally, men matter, but reproduction talk is almost always about women. It is a human creation that women’s bodies are often solely tied to reproductive responsibility, yet such an arrangement appears as “common sense,” as simply “the way things are.” This sentiment is perhaps slowly changing. In her work a decade ago, political scientist Cynthia Daniels detailed at length how men’s exposures to harmful chemicals, most pointedly with the example of Agent Orange in the Vietnam War, impacted their subsequent reproductive years, resulting in higher susceptibility for having children with spina bifida and other birth abnormalities.86 Emerging science is showing more than ever that men’s health status impacts the health of future fetuses. For example, men who smoke cigarettes damage their sperm’s DNA, which might affect the health status of a future baby.87
Health behaviors might be particularly pertinent for men because, unlike eggs, new sperm is made every forty-two to seventy-six days, so “damaged” sperm can be replaced by newer “healthier” sperm within three months given a change in behavior or exposure88—in effect, the zero- trimester concept easily could be applied to men. To be sure, some pre-conception health materials mention men. For example, in Kentucky, the signs posted in restaurants and bars warning that drinking before conception can cause birth defects do so without express mention of women (this is unlike the Surgeon General’s warning on alcohol that is usually explicitly addressed to women who are pregnant). This decision was made so as to include men—recognizing that men’s pre-conception exposures might matter for reproductive health.89 In Texas’s Someday Starts Now campaign mentioned at the opening of this chapter and that featured television ads with images of women, web pages were devoted to both women’s health and men’s health and indicated that today’s behaviors matter for future baby health “whether you are a man or a woman.”
Yet, these mentions of men have been exceptions to the rule. As Rene Almeling and I have shown in previous work, men’s contribution to reproductive health is still largely ignored or gestured to only nominally within the medical community broadly and within pre-conception health promotion materials specifically.90 Overwhelmingly, the recommendations and rhetoric about pre-pregnancy care in promotional campaigns, and writ large, are still aimed at women—women who are not yet pregnant. Thus, while I do mention men and pre-pregnancy care at times, this book primarily focuses on how the zero trimester has been constructed for—and pitched to—women of reproductive age.
Given all of these considerations and such levels of uncertainty, one might wonder how pre-pregnancy care came to be seen as the panacea for improvement in birth outcomes. As Chapter 3 discusses, the pre-pregnancy care model has been bolstered and defined in the twenty-first century by obstetricians and health professionals who, rather than citing a clear body of scientific evidence, believe that this approach is “obviously” good for women and babies. If the evidence for pre-pregnancy health interventions is not particularly robust—or is, at the very least,