Is it ethical, or even reasonable, to tell women that the self-care and health-care behaviors they engage in today will influence the health of their future fetus, even when this might not entirely be the whole story—and especially if they have no power over the factors that might matter most?91 The environmental and epigenetic examples provided above reveal that pre-conception harm might be at the environmental—rather than individual—level and might occur to men as well as to women. Nevertheless, the focus of the zero trimester is predominately on individual behavior change among women alone, not on men or social institutions. It is aimed at making and keeping a potential pregnancy in the forefront of women’s minds at all times, often at the expense of focusing on systemic factors that might put women at lesser risk of unintended pregnancy or adverse birth outcomes in the first place.92 Given these foci, it is imperative to analyze the tenor of the pre-pregnancy care approach to understand how population health strategies are shaped—and also to critically assess how such a strategy hinges on medical science and on cultural assumptions and political sensibilities about women, reproduction, and responsibility. Is this an instance of empowering women or of making women feel guilty for birth outcomes that are not solely—or even mostly—within their realm of control? Does pre-pregnancy care place too great a burden on women of reproductive age?
To be clear, this book’s aim is not to adjudicate the effectiveness of pre-pregnancy care. As detailed above, some evidence suggests that it is inconsequential and misleading; some evidence suggests that it is profoundly important. Proponents argue that this twenty-first century way of thinking about reproductive risk is the best and most effective path forward for improving maternal and child health in America; critics argue that it is pernicious and counterproductive and treats women unnecessarily like baby vessels. This book, rather, focuses on why the magic-bullet solution of “pre-pregnancy care” emerged when it did, particularly amid such variable interpretations of its message and effects, and what it tells us about the contemporary politics of women’s health, motherhood, and public health prevention strategies. It scrutinizes the cultural and political logics that have intersected with and informed the rise of a medical and public health agenda in the early part of this century.
Sociologists of medicine and science have long observed that what has become conventional medical and health wisdom is intricately tied up with what is considered conventional social wisdom. That is, social, cultural, and political currents shape and are shaped by scientific and medical knowledge. I now turn to contextualizing the rise of the pre-pregnancy care framework in such currents. Bolstering its emergence in the beginning of the twenty-first century were three overlapping trends: the pervasiveness of risk discourse within surveillance medicine, the enduring strength of motherhood ideology, and the ongoing fraught landscape of reproductive politics and women’s changing lives.
THE TEMPORAL (BIO)POLITICS OF HEALTH RISK
Part of understanding why and how the pre-pregnancy care idea emerged when it did requires taking account of a broader trend related to risk. Risk is today typically thought of as a consequence of individual decision-making,93 and individuals are expected to manage risk through their consumption and health practices.94 Neoliberal tendencies drive contemporary public-health initiatives by touting the importance of individual risk-reducing behavior.95 Public health today also generally emphasizes anticipating future and unintended health consequences via the “precautionary principle”96—the idea being that if something is suspected of being risky, then those risks should be avoided altogether.97 The pre-pregnancy care model is another attempt to eradicate uncertainty in modern risk culture98 in which individuals are preoccupied with the future and primed to take precautions to prevent or avoid risks.99
In medicine, too, individualized and risk-averse approaches have recently centered on advanced anticipation of risk, that is, on the practice of intervening upon potential risks that are presumed to appear in the future. For instance, scholars have focused on tendencies in contemporary medicine toward treating healthy populations as if they are primed for illness.100 Historian Charles Rosenberg uses the examples of emergent pre-diseases, such as elevated cholesterol or pre-hypertension, to refer to “proto-disease states.”101 Pharmaceuticals target future risk as well; chemoprevention, for example, involves giving a drug (tamoxifen) to women who are deemed “high risk” for breast cancer but who are otherwise healthy and show no signs of illness.102 Contemporary biomedical technologies serve to “control the vital processes of the body and mind,” becoming “technologies of optimization,”103 and medical jurisdiction over disease now extends to “health itself”—“it is no longer necessary to manifest symptoms to be considered ill or ‘at risk.’”104 In this way, we see an escalation of health-care interventions focusing on “pre” phases, which includes pre-pregnancy care. Indeed, the pre-pregnancy care model of risk reduction dovetails with sociological insights into how contemporary medical knowledge has diffused into lay understandings of responsibility for health more generally.
To be sure, individuals themselves are expected to optimize their health in every way possible, partially through anticipating any potential risk. This phenomenon is typified throughout the health and wellness industry; for example, employers and health insurance companies are increasingly offering financial incentives for workers to get “wellness” checks or to sign tobacco-free attestations, with the goal of assessing present and potential health risks. Current fixation with optimizing health risks is reflective of the modern biopolitical moment, one in which the “calculated management of life” works to control the behavior of both individual bodies and populations.105 Reproductive health concerns are not atypical in this regard. Indeed, from alcohol to fish consumption, medical and public health expectations about reducing reproductive risk fill our public airwaves,106 serving to shape and monitor behavior.
Medical sociologists have noted that this rise of “surveillance medicine,” especially since the latter part of the twentieth century, has included increased medical screening and public health campaigns, conjuring the need for “anticipatory care . . . transform(ing) the future by changing the health attitudes and health behaviors of the present.”107 Anticipation is exactly what the pre-pregnancy care framework seizes upon. Reproduction and science studies scholars Vincanne Adams, Michelle Murphy, and Adele Clarke have written that “anticipation is rapidly reconfiguring technoscientific and biomedical practices as a totalizing orientation” and that “anticipation pervades the ways we think about, feel and address our contemporary problems.”108 These scholars theorize about “anticipatory regimes,” in which the management of the future “requires projecting ever further back into younger years, positing the future as urgent in ever earlier moments of organismic development.”109 Additionally, exemplary sites of anticipatory regimes, according to Adams, Murphy, and Clarke, are often highly biomedical and gendered. When it comes to the next generation’s health, the vector of anticipatory risk is often a woman.110 Thus, all women of reproductive age are placed in a holding category for anticipatory care practices and interventions. In pre-pregnancy care, non-pregnant women of childbearing age are classified clinically through a framework in which the “future arrives as already formed in the present, as if the emergency has already happened.”111
The new temporal space of pre-pregnancy risk surely is indicative of this anticipatory phenomenon in biomedicine and public health policy. Yet, pre-pregnancy risk also extends and layers previous anticipatory risk discourse in interesting and novel ways, which I elaborate upon in Chapter 3. With the zero trimester, greater levels of anticipation than have been documented exist, targeting two bodies: the potentially-pregnant woman and her future fetus. Attention and anticipation are thus partly directed toward a not-yet-conceived, non-existent being. Pre-pregnancy care can be seen as the crest of a wave of new public health and medical discourses and interventions that simultaneously focus on one present body and (at least) one future body—on the next generation through a present pre-reproductive body.
THE MATERNAL IMPERATIVE
The rise of this dual-body future emphasis is possible because of—and is characterized by—its gendered dimension. Women are typically asked