The Zero Trimester: How did we begin to think that pregnancy should last longer than 9 months?

In June 2018 we were pleased to announce the recipients of the 2019 SKAT Section Awards, which will be presented at the SKAT business meeting on Saturday, August 10th at 5:30pm in the Central Park West room (2nd Floor) at the Sheraton New York.

In this Q&A, we highlight the winner of the 2019 Robert K. Merton Book Award, Dr. Miranda Waggoner.  Her book, the Zero Trimester: Pre-Pregnancy Care and the Politics of Reproductive Risk  (University of California Press, 2017), was also named a 2017 C. Wright Mills Award Finalist by the Society for the Study of Social Problems.  In it, Waggoner explores why a “healthy” pregnancy now requires care and attention across a woman’s entire reproductive life.  Below, in conversation with SKAT’s Emily Vasquez, Waggoner explains what the rise of the “zero trimester” can tell us about contemporary reproductive politics in the United States, offers advice for STS scholars embarking on ethnographic research carried out among biomedical experts, and shares details of her new research.

Q. What is the “zero trimester”?

A.  The “zero trimester” is the time period before pregnancy, when women today are urged to prepare their bodies for a healthy pregnancy. It is a term I came up with when studying the scientific, medical, and cultural emergence of the pre-pregnancy care model (also known as preconception care).

Some quick context: In the early 2000s, the CDC began an initiative to improve the pre-pregnancy health of women in order to improve birth outcomes in the United States. Previously, the primary policy and medical approach to improving birth outcomes was improving prenatal care (that is, care during pregnancy), but despite improved prenatal care, the U.S. continued to be plagued by terrible maternal and infant health statistics as compared to other wealthy nations. Prenatal care is essentially surveillance—it can diagnose and treat problems that arise during a pregnancy, yet it does nothing to prevent these problems in the first place. Don’t get me wrong, prenatal care can be important care for individual women, but widespread utilization of prenatal care hasn’t actually resulted in improved population health. So, this pre-pregnancy model was intended to be a primary prevention paradigm. The idea was that if women can get healthy before pregnancy, then maybe the risk of adverse birth outcomes will be reduced.

What sparked my interest in this topic—and this is something I address in the book—is that this idea lacked an evidence base. When I looked for evidence, I found that the pre-pregnancy model was based on the “common sense” that healthier women will make healthier babies. In other words, weak science was turned into conventional wisdom through the work of medical scientists and health experts, and this approach had consequences for medical and cultural thinking about risk and responsibility.

When clinicians and public-health messages started calling on women to optimize their bodies for pregnancy, they were essentially encouraging women to act as if they are pregnant before they are pregnant, and this created a new kind of “responsible motherhood” that was defined in terms of pre-pregnancy lifestyle and behaviors. This approach has often translated into recommendations about an actual trimester, as women are told to be as healthy as possible for three months prior to conception. But as I show in the book, the scope of the zero trimester is more expansive than this three-month frame. Experts today tout healthy behaviors from menarche to menopause in order to ensure best health outcomes for future babies—and these recommendations are given to women who might not even yet know whether they want to pursue motherhood in the future. So, essentially, all women of reproductive age are within the “zero trimester” during their non-pregnant years. In the book, my principal aim is to examine the pre-pregnancy period as a socially produced trimester and what it means about our shifting ideas about risk and reproduction.

When I was doing background research on the topic, I came across a poster produced by the March of Dimes that said: “It actually takes 12 months to have a healthy baby.” I wanted to know where this idea of a 12-month pregnancy came from. How did we begin to think that pregnancy should last longer than 9 months? What does this shift in the definition of pregnancy mean for how we think about and provide pregnancy care? What does this shift mean for how we think about the temporality and scope of reproductive risk and responsible motherhood?

Q. What does attention to pre-pregnancy care tell us about contemporary U.S. reproductive politics? 

A. The move among health professionals toward focusing on pre-pregnancy care was precipitated not just by an idea in medicine and science; it was also a case of medical thinking being tied up with cultural ideals and political imperatives.

What I found when researching this book is that the impetus for pre-pregnancy care was not just about improving maternal and child health, but also about improving reproductive care. Before the Affordable Care Act, the only time that a low-income woman got comprehensive health care coverage was during pregnancy, and women’s health practitioners have long been frustrated by this fact—that they can’t provide optimal care for women before or after pregnancy, only during. Also, pre-pregnancy care was supposed to bridge two areas in women’s health care: reproductive care, which has long been associated with contraception and abortion (and thus considered contentious), and maternal and child health care, which has long been associated with prenatal and maternity care (and thus considered politically “safe”). By defining pregnancy as lasting longer than twelve months, experts could argue that women need pregnancy care coverage for much longer than just the nine months of pregnancy. And this strategy also meant that the field could avoid talk of abortion—the logic being that with proper pre-pregnancy care, the rate of “accidental” pregnancies will drop and most pregnancies will be planned. Of course, this approach is shortsighted, as women will still need access to the full gamut of reproductive-health services even if they receive pre-pregnancy care. But it reveals just how difficult it is for health practitioners and policy makers to talk about women’s reproductive health care needs in a climate that is increasingly hostile to abortion.

Focusing medical and public-health attention on the zero trimester was supposed to be a safe move because it defined pregnancy as encompassing more of a woman’s life, and it has historically been more politically palatable to focus on pregnancy health rather than on pregnancy prevention—an area that, again, includes contraception and abortion.

One of the things I find so interesting, though, is that in recent years both reproductive health care and maternal health care have come under attack from conservative politicians. One example of this is the Republican-led argument that maternity care services should not be defined as “essential” health care. Pregnancy care is no longer a “safe” zone. Since the book came out, we have seen increased hostility to maternal and reproductive health care, so this will be an ongoing area of concern for scholars, clinicians, and policy makers.

Q. In the book, you write that the “zero trimester” is a case of increasing medicalization but that it is also something different?  Could you explain? 

A. It is part of increasing medicalization, as more of a woman’s reproductive life is brought under the purview of pregnancy care in the pre-pregnancy care framework. But only seeing it as a case of medicalization is too simple because this is a case that hinges on risk mitigation of a putative health risk that might or might not become an actual risk in the future. So it is about biomedicalizing the potentiality of risk. STS scholars have beautifully documented other cases of preemptive clinical interventions and the scientific and medical trend toward harnessing future risk, but I argue that pre-pregnancy care is unique in that it is characterized by its future-body focus. Much of the previous work on future risk has concerned extant bodies, but pre-pregnancy care targets two bodies, one present body and another future body: the potentially-pregnant woman and her future fetus. This attention to a not-yet-conceived, non-existent being is part of a broader trend of anticipatory medicine, but it is also possible because of increasing political and scientific visibility of the fetus in recent decades. Scientists and health professionals now think in terms of future fetuses, and they are urging reproductive-aged women to do the same.

Q. How does the rise in medical and public health attention to pre-pregnancy care relate to growing interest in epigenetics? 

A. They are related, for sure. The rise of the pre-pregnancy care model was fueled by scientific and public-health interest in epigenetics, especially frameworks like DOHaD (Developmental Origins of Health and Disease) that link life-course health outcomes to the womb environment or even to the mother’s lifetime exposures and experiences. One expert told me that it is important to remember that, “a woman is a mother from the time of her own conception.” I find this statement terribly problematic, but it is in line with a lot of epigenetics research.

However, the pre-pregnancy care model pre-dated the scientific rise of epigenetics. One chapter in the book analyzes medical thinking about pre-pregnancy care from the nineteenth century to today, and what this analysis reveals is that pre-pregnancy care is not a new idea. It’s been mentioned in the medical literature for over a century. But it was re-discovered in the late twentieth century by physicians and health experts, and it was promoted as a “new” idea to address reproductive risk (and the politics of such risk) for the twenty-first century. The CDC then codified this idea into an actionable set of recommendations and care model.

Also, it’s worth noting that the scientists and physicians and public-health experts I spoke with did not tend to put pre-pregnancy care in the same scientific bucket as epigenetics. Interestingly, some respondents clearly explained that the pre-pregnancy care model is concerned with goals such as reducing unintended pregnancies, which do not figure much in the scientific interest in epigenetics. So, I write in the book that pre-pregnancy care definitely intersects with key strands of epigenetics thinking, but it also kind of stands on its own as a historical and epistemological phenomenon.

Q. Your research entailed interviewing numerous high-level experts at the CDC and elsewhere involved in pre-pregnancy care initiatives. What recommendations can you offer to emerging SK&T researchers on how to best engage expert interlocutors in their critical science studies research? 

A. First, I think it is important to find a person in the field with whom you can establish a good rapport, as this person can anchor your fieldwork: they can help you connect to other experts as well as help you with technical questions about the scientific area along the way. I benefited greatly from having such a person at the CDC during my research for the book. More to your question, I find it very helpful to consider that expert respondents often are very interested in what you are studying—typically, these are individuals who have spent much of their professional life researching or working in this topic area, and they are often invested in discussing it, even with someone who might come at the topic from a different angle. I was always pleasantly surprised in the field when respondents genuinely wanted to know more about my research and how it might interface with what they were doing. In a similar vein, I found it very fruitful to understand and acknowledge that we are all, to some degree, on the same page. In this case, that page was about advancing social justice for women, mothers, and children. In the book, I acknowledge that the science and health professionals I spoke with might not (probably don’t) agree with my arguments, but that we are all part of the important conversation of trying to advance maternal and child health. So, I have often found it useful to approach the research, the experts, and my writing in terms of synergy between my work and theirs—and to remember that this synergy moves forward critical dialogue.

Q. Returning to the contradictions inherent in the rise of pre-pregnancy care, you write in The Zero Trimesterthat in this approach “we see progress; we also see reversion.” As you translate your findings for those tasked with policymaking, how have you managed this nuance and complexity in your messages? 

A. This is a great question! I do embrace complexity and nuance in the book, which can be a risky approach for communicating with policy makers, as not everything I write can be easily translated into bullet-points or tweets.

But I think it’s so important in a scholarly treatment of a subject to pay attention to the complicated and the complex, because this approach helps us grasp what all needs to be understood and attended to in order to craft smart solutions. Simple fixes that do not take into account complexity are myopic. For example, the pre-pregnancy model has focused primarily on improving the health behaviors of individual women. Ignored, then, were other approaches that would substantially improve maternal and child health. Maternal and child health in the U.S. would greatly benefit from robust, broad-based policies and programs that aim to reduce poverty and protect the environment. By only focusing exclusively on women, the pre-pregnancy model also advanced the unhelpful notion that women’s bodies are the only ones that matter for reproduction and child health. Of course, men’s health is crucially important, too. The approach also didn’t address the root causes of racial disparities in maternal and child health, and these disparities are wide and deeply troubling.

What I want the book to do is expand our thinking about solutions, especially because we know that individually based solutions just don’t work at a population level. And, in this case especially, such an approach has the potential effect of increasing anxiety among women and exacerbating the culture of mother-blame that has been so detrimental to women and their children in our society.

Q. What comes after the The Zero Trimester?  Could you give us a preview of your current research?

A. My current project is about the exclusion and inclusion of pregnant women in biomedical research. Pregnant women have long been deemed a “vulnerable” population and so are typically excluded from clinical trials. This “vulnerable” designation has impeded knowledge production about pregnancy, leading to a level of ignorance in pregnancy care that is stunning: clinicians often treat and prescribe medicines for pregnant women without reliable safety information.

The interesting pivot point here is that recent changes in the regulatory landscape remove pregnant women from the “vulnerable” populations list, meaning that clinical research with pregnant women now has the potential to expand and fill knowledge gaps about reproductive risk. I am tracing this history of exclusion and production of ignorance with regard to pregnant women and biomedical knowledge, and then I am also following the current shift toward inclusion and production of knowledge. This project includes interviews with scientists, clinicians, regulators, and patients to understand how various actors are shaping and responding to changes in ethical guidelines and categories. As in my first book, I’m also paying close attention to the social and political factors involved in this cultural shift in biomedicine.

I recently received a career development award for this project from The Greenwall Foundation, which will provide me with mentorship in bioethics as well as with funding for research time. I’m very excited about the potential for this work to advance dialogue between science studies and bioethics in the areas of reproductive risk, research ethics, and meanings of human difference and vulnerability.

About Miranda Waggoner

Miranda Waggoner is an assistant professor of sociology at Florida State University and affiliated with FSU’s Center for Demography & Population Health. Waggoner’s research examines the social, ethical, and cultural dimensions of biomedical knowledge production. For more details visit http://www.mirandawaggoner.com/.