Review of Weighing the Future: Race, Science, and Pregnancy Trials in the Postgenomic Era. Natali Valdez, Oakland: University of California Press, 2021, 284 pp.

Weighing the Future: Race, Science, and Pregnancy Trials in the Postgenomic Era. Natali Valdez, Oakland: University of California Press, 2021, 284 pp.

Megan Warin

The University of Adelaide

Natali Valdez’s Weighing the Future: Race, Science and Pregnancy Trials in the Postgenomic Era is a sophisticated and eloquent book about the politics of postgenomic reproduction in prenatal trials, tracing their histories, presents, and futures. Its primary purpose is to examine large-scale pregnancy trials across two international sites—the United States and the United Kingdom—and the ways in which these trials are imagined, managed, and conducted. Natali Valdez shines an ethnographic spotlight on the “Trojan horse of ‘neutral’ science and ‘healthy’ interventions” (p. 129) that underpin these trials, namely the fields of developmental origins of health and disease (DOHaD) and epigenetics, and the accompanying lifestyle interventions that are taken for granted as solutions to maternal diabetes, maternal obesity, and fetal health. The Trojan horse is indeed an apt metaphor, as Valdez carefully examines the many machinations that are hiding (and systemically obfuscated) in the belly of this rolling historical episteme. What unfolds is a superbly incisive and sensitive unfolding of these overlapping epistemic environments; of how racism, gender binaries, capitalism, and late liberalism are smuggled into the knowledge production and translation of these trials.

The book opens with the reader positioned as the “pregnant and fat” participant, waiting for your first clinical trial appointment to learn if you will be randomized into a group that counts steps and calories, weighs yourself daily, and takes meal replacement shakes. Unable to interview pregnant trial participants for ethical reasons, this second person narration is a clever ethnographic strategy to foreground the experiences of people as they enter these trials. As a story of implementation rather than findings of clinical trials, Valdez often situates the reader as participant, so we never lose sight of their emotions and experiences—the grief of pregnancy loss, needles sliding into arm veins, crippling nausea, the shame of being a fat body waiting in a clinical and institutional space—experiences that are often not seen, counted, or valued in such trials. Beginning with this narration, along with the many observations of clinical conversations and pregnant biobits, is an ingenious writing style threaded throughout each chapter and circled back to (analytically) in the conclusion, effectively foregrounding frameworks of justice and equity.

As the first ethnography of pregnancy trials, Valdez discusses the significant challenges of gaining access to her field sites. She honed her focus on a teaching and a non-teaching site in each location, both of which were part of much larger global consortiums that are in conversation with each other and design their trials in similar ways. It took three years to gain institutional permission, multiple ethics applications and review committees, and two years of prior coursework in epidemiology and child-maternal health (p. 50). In the United States, Valdez had a dual role as ethnographer and a staff member of the SmartStart trial, enabling her to become a researcher studying the doing of research. It is welcoming to see such detail about the work that precede fieldwork, which are a testament to Valdez’s high respect for all participants and the craft of research. Switching between observer and researcher on a trial enables Valdez to broaden our understanding of maternal environments, beautifully highlighting the layers and tensions between the social, political, and lived experiences of the pregnant people with the scientific view of such environments (p. 3). Moreover, for a book that attends to the treatment of race and racism, this studying up of highly educated researchers (mainly white women in elite spaces) stands in stark contrast to the participants that were recruited (pregnant women of color, low socioeconomic status). Black feminist scholarship is skilfully used to examine the production and reproduction of power relations. 

This is what is so significant about this work—the back story of implementation (rather than findings of the clinical trials) takes center stage, and Valdez meticulously reveals the epistemic environments that we rarely get to see. The ethnographic details of recruitment infrastructure—the endless hospital corridors in which participants got lost (p. 101), people protesting, passing by the chemical smells of the wet labs, damp sheets, and old food—all illustrate the ways in which the architecture, people, technologies, and biosamples are intimately enmeshed and form part of the complex and crumbling infrastructure of both public and private health care systems. These form the backdrop to important questions about the production of scientific knowledge that Valdez tackles throughout this book: Did participants enroll to receive financial incentives or much needed extra care from midwives? Were they sampled according to inaccurate improvisation of racial categories (such as Hispanic)? And did sustained disinvestment in health services shape who enrolled in the trials?

The point however, is not simply to make these mundane processes visible, but to reveal the power relations and politics that this landscape is entangled in, and how they carry forward in research findings, translation, and policy. Valdez argues that while the science around maternal weight and nutrition has changed and has been integrated into postgenomic research, the imagined solutions have not. This is because maternal environments are always reduced to individual pregnant bodies and behaviors, resulting in the same solutions concerning diets and exercise. Further, randomized control trials have historically been designed and funded in the Global North and steeped in histories of eugenics and empire. And, critically, trials are conceived and structured in racist and speculative environments, where race and racism become invisibilized, certain biological data is given more value, and speculative approaches favor futures. Even when trials find no conclusive evidence of nutritional or behavioral interventions during pregnancy impacting children’s risk of obesity, researchers pursue further studies of the same imagined problem and solution. Rather than turn attention to the assumptions that are deeply embedded in the processes and knowledge of the trials, all epistemic environments converge to offer up the same solutions, foreclosing attention to systemic inequalities of socioeconomic status, gender, and racism.

This overarching argument about the ways in which epigenetic foreclosure occurs has similarities with critiques about the lack of traction of social determinants of health. There is a strong body of evidence to say that lifestyle interventions for example around food and activity fail when it comes to addressing obesity. There are also powerful critiques of the biopolitical effects of DOHaD and epigenetics on women and people of color. Weighing the Future builds on a growing body of feminist, critical race, and STS scholarship in these fields, examining how fatness, race, and risk shape contemporary pregnancy trials. Valdez provides compelling evidence about the stunning durability of failed solutions, and the ways in which the epistemic environments of recruitment and even funding calls are cut from the same cloth. I hope that the researchers leading these international pregnancy consortiums engage with this important work and find the courage to imagine new ways of reconceptualising scientific knowledge that, as Valdez suggests, “opens up alternative solutions” (p. 203). This is a ground-breaking book, both subtle and razor-sharp in its analysis. It provides an immensely valuable critique of the workings of epigenetic foreclosure in pregnancy trials, an afterbirth that Valdez’ argues does not need to be inevitably foreclosed.