The Zero Trimester: Pre-pregnancy Care and the Politics of Reproductive Risk

The Zero Trimester: Pre-pregnancy Care and the Politics of Reproductive Risk. Miranda R. Waggoner, Berkeley: University of California Press, 2017, 280 pp.

In this engaging and well-researched study, sociologist Miranda Waggoner traces the emergence of and debates around pre-pregnancy care in efforts to improve birth outcomes in the United States. In 2006, the CDC made the decision to promote pre-pregnancy care, encouraging women to adopt health behaviors believed to foster healthy pregnancies, such as avoiding alcohol and taking folic acid supplements, even when they were neither pregnant nor intended to become pregnant imminently. As Waggoner points out, such guidelines implicitly—and at times explicitly—approached every woman as pre-pregnant, framing women’s health within a cultural ideology of maternalism.

The outcry among feminist activists was immediate. Critics charged that such health proclamations reproduced patriarchal ideologies that viewed every woman as a potential (biological) mother and that women’s health was only prioritized within the context of pregnancy. According to Waggoner, this response caught the designers of the program by surprise. Drawing on extensive interviews with experts involved in the CDC’s initiative, Waggoner argues that the push for pre-pregnancy care must be situated in the vitriolic context of U.S. reproductive politics and the deeply politicized division between women’s health and maternal health. Pre-pregnancy care models, she concludes, were embraced—albeit not without ambivalence by some—as a way to advocate for women’s well-being when not pregnant while avoiding the language of women’s health that, for its detractors, has become synonymous with abortion provision. Debates over pre-pregnancy care and its rollout thus reflect larger tensions about individual and population health, risk, gender, and responsibility that are at the heart of U.S. reproductive politics.

After establishing her analytical framework in the Introduction, Waggoner dedicates a chapter to contextualizing pre-pregnancy care within the long history of social and medical interventions to ensure healthy babies, and the shift in the goal of prenatal care from assessing specific risks of problematic pregnancies to optimizing every individual pregnancy. Ensuing chapters draw on interview data with CDC scientists, illustrating how the development of the model of pre-pregnancy care was informed by entrenched cultural ideologies that continue to associate womanhood with motherhood, and—in the absence of solid evidence about the benefits of pre-pregnancy care—apparently common sense beliefs that interventions in the non-pregnant body would decrease future risk.

The final chapters examine the roll out of pre-pregnancy care and the attendant emphasis on intentional pregnancies through the clinical tool of a “reproductive life plan.” Waggoner examines how concepts of pre-pregnancy care were taken up in popular guides to pregnancy, as well as the gendered and racialized overtones of CDC campaigns about “planners” and “non-planners” (recommendations for women planning or not planning to become pregnant in the near future) that framed pre-pregnancy self-care as an act of devotion to a future fetus. Concluding by underscoring how such debates about reproduction represent larger cultural struggles over gender and reproduction, Waggoner does not attempt to pass judgment on whether the model of pre-pregnancy care is good or bad for women, noting that it “is complicated, and it is probably both” (p. 33). However, she does suggest that policy efforts to influence population health should take a different temporal orientation; rather than focusing on the individualist approach of the “zero trimester,” health and policy professionals should advocate for the “second nine months” and the importance of social and structural interventions, such as universal health care and paid family leave, that have documented positive effects on parental and infant health.

Waggoner’s analysis is clear, compelling, and richly documented. For newcomers and students, her history of reproductive policy in the United States and her commendable use of a wide interdisciplinary literature from public health, sociology, anthropology, and clinical studies will provide a useful overview of the state of the field and current debates in studies of reproduction. For scholars more versed in the anthropology of reproduction from the 1980s forward, many of Waggoner’s arguments around cultural and biomedical ideologies of risk and the gendered responsibility for healthy pregnancy will be familiar territory. Her engagement with the literature on time and her concepts of the future fetus and anticipatory motherhood, however, are useful frameworks for capturing the ways in which the gendered responsibility for fetal health is being pushed ever further back in time, making all of women’s potentially reproductive years subject to surveillance by both clinicians and women themselves. Further, the specifics of her interview data with early proponents of the pre-pregnancy model will provide useful insights for those interested in the behind-the-scenes negotiations surrounding the production of reproductive health guidelines, particularly given the lack of robust evidence to support pre-pregnancy care.

Despite its qualitative methodology, the book reflects some disciplinary differences that may nag at anthropologists. Waggoner draws on rich interview data and analysis of websites, pregnancy health texts, and other popular material, which form the corpus of her data. There is no ethnography, as defined by attention to practice as people accommodate, selectively interpret, or resist such reproductive guidelines in ways that may not always accord with their stated beliefs and actions. The focus is also squarely on health experts, and any discussion about how women themselves may be experiencing the increased emphasis on pre-pregnancy care is speculative rather than data driven. Finally, there is little consideration of cross-cultural frameworks that shape reproductive health guidelines. As previously noted, Waggoner persuasively argues that U.S. reproductive politics and the often acrimonious relationship between women’s health and maternal health advocates was fundamental to the emergence of the pre-pregnancy health model. It would be fascinating to consider, even in passing, whether this means that other countries with similarly biomedicalized prenatal care, but without such contentious politics, are therefore eschewing this concept of pre-pregnancy care or whether it has a potentially global impact—and if so, what the consequences of this shift might be.

That being said, The Zero Trimester will be of interest to medical anthropologists and anthropologists of reproduction, particularly those interested in policy in the U.S. context. It is clearly and accessibly written without losing theoretical nuance, making it appropriate for graduate and upper-level undergraduate classes in the anthropology of reproduction, the anthropology of gender, and the anthropology of policy.

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