Miranda R. Waggoner
Miranda R. Waggoner, Motherhood Preconceived: The Emergence of the Preconception Health and Health Care Initiative, 38 Journal of Health Politics, Policy & Law 345 (April, 2013)( 6 Footnotes)
Since the 1980s, maternal and child health experts have called for a new conceptualization of pregnancy risk that includes the period prior to pregnancy. In what has been known broadly in the public health and medical literature as “preconception health and health care,” [fn1] by the 2000s it was deemed accepted knowledge that a woman's health status and behavior before pregnancy could affect the health of her pregnancy and her fetus. The basic idea of preconception care is to advise reproductive-age women about any negative health behaviors or conditions that might affect a future pregnancy. Women are generally urged to get tested (for genetic predispositions and for sexually transmitted infections), take multivitamins, stop smoking and drinking, and get any health conditions such as diabetes or obesity under control before conceiving. Despite the lack of robust clinical evidence for myriad preconception care interventions, in the 1990s women were told by organizations committed to maternal and infant health, such as the March of Dimes, that a healthy pregnancy lasts twelve months. In 2004 the Centers for Disease Control and Prevention (CDC) launched the Preconception Health and Health Care Initiative, which sparked research and public health interest in this new framework. The work of the initiative paved the way for headlines promoting pre-pregnancy thinking, such as “Start taking care of your baby before you get pregnant” (Stephenson 2011) or “You may not be ready to have a baby, but your body's been preparing for years .... You have lots to do before motherhood” (CDC 2009). Since August 1, 2012, as part of the Patient Protection and Affordable Care Act (PPACA), women with private insurance plans are no longer charged a co-payment for a preconception health or well-woman clinic visit.
The crux of this analysis is a puzzle posed by the advancement of preconception care. Why did a group of experts promote prepregnancy care in spite of a poverty of evidence? Given the biological fact that gestation lasts nine months, how did we start to think that it should (for individual behavior and policy purposes) figuratively last longer than that? My argument is that the maternal and child health experts behind the pregnancy risk transformation took a “leap of faith” (Larsen 2012) in believing that preconception care could successfully address population health goals and social problems. By moving forward with an ostensibly logical idea that had little scientific basis, the experts were guided by cultural, not biomedical, logics. Moreover, by so changing the temporal definition of pregnancy risk, the preconception health and health care paradigm necessarily had to argue for the conflation of women's health and maternal health, fields long treated separately in clinical and policy spheres. This all occurred in a social policy system that tends to value pregnancy and potential motherhood, one that exalts women as mothers and not women qua women.
I find that the strategy of maternalism--defining women's needs in terms of maternal needs--guided the development and deployment of this new policy idea. The corresponding entanglement of women's health with maternal health evokes anachronistic ideas about the roles of motherhood and womanhood in contemporary society. Drawing on literature that examines how the cult of motherhood urges both pregnant and new mothers to consult experts and minimize any and all potential risks to their expected or new child (Hays 1996; Lupton 1999; Armstrong 2003; Apple 2006; Wolf 2011), I contend that the preconception care paradigm shifts not only how we think about health care delivery but also how we think about motherhood. I use the term anticipatory motherhood to refer to a framework that positions all women of childbearing age as “prepregnant” and exhorts them to minimize health risks to phantom fetuses and future pregnancies.
This article shows that over the past three decades the new public health policy focus on preconception care was constructed as a remedy to health disparities, population health failings, and health care oversights. Maternal and child health statistics, especially infant mortality, are often used as proxy measures for the state of a nation's health. In this regard the United States does not fare well, even with the provision of widespread prenatal care. In 2005, the United States ranked thirtieth in the world in infant mortality, falling behind most European countries, Canada, Australia, New Zealand, Hong Kong, Singapore, Japan, and Israel (MacDorman and Mathews 2009: 6). The percentage of preterm births has risen precipitously over the past two decades; compared with Europe, the main cause of the high infant mortality rate in the United States is preterm births (MacDorman and Mathews 2009). Moreover, adverse birth outcomes that lead to infant mortality remain a major US social problem that reveals distressing racial and ethnic health disparities. The infant mortality rate for black women is 2.4 times that of white women (MacDorman and Mathews 2008), and the maternal mortality rate for black women is 3.7 times that of white women (Miniño et al. 2007).
Regardless of its laudable goals of improving maternal and child health in the United States, the preconception care initiative was met with hostility at first, largely because it spotlighted the social roles and behaviors of women. Popular news outlets expressly worried about the public policy effects of treating all women as if they were potentially pregnant. For example, a New York Times article titled “That Prenatal Visit May Be Months Too Late” explained, “For years, women have had it drummed into them that prenatal care is the key to having a healthy baby, and that they should see a doctor as soon as they know they are pregnant. But by then, it may already be too late” (Rabin 2006). The Washington Post, in “Forever Pregnant,” critiqued preconception care: “New federal guidelines ask all females capable of conceiving a baby to treat themselves--and to be treated by the health care system--as pre-pregnant, regardless of whether they plan to get pregnant anytime soon” (Payne 2006). Sociologists have called the preconception care framework “dangerous” for women (Casper and Moore 2009: 67), and Ms. magazine profiled preconception care with the facetious title “Warning: You Could Be Prepregnant” (Williams 2011).
None of the critiques leveled at preconception care thus far have captured the complexity of the issue. It is easy to assume that preconception care is a reductionist, conservative strategy aimed at women to further embed biological essentialism in social policy. This article challenges the contemporary framing of preconception care in the popular and scholarly literature that positions it as either essential or utter nonsense. By more closely examining the emergence, context, and ascendance of preconception care advocacy, I reveal that collective action in the initiative for preconception care has been much more fraught, nuanced, and concerned with women's health than has previously been reported. To be sure, we must still worry about unintended consequences, some of which I address here. But to adequately understand the construction and social meaning of preconception care, and the context and complexity of its emergence, this essay is a necessary first step.
The larger project from which this article derives focuses on capturing the ascendance of preconception care as a new field of clinical care, a new object of research agendas, and a new subject of public health strategies. I draw on content analysis of preconception health and health care policy documents as well as articles in medical and public health journals spanning the past century. The few social science critiques of preconception care to date do not analyze data beyond limited print documents and public discourse (e.g., Casper and Moore 2009). I also rely on in-depth interviews I conducted during 2010-2011 with leading national experts (n = 57) in maternal and child health. [fn2] In-depth interviews add an important layer of analysis because they help to distinguish the “contingent” or informal discourse of scientists and experts from the more formal space of scientific publications (Gilbert and Mulkay 1984). The CDC's endorsement and promotion of preconception care in the early 2000s offers a unique and bounded case through which to explore the construction of a new policy agenda. Prior to the 2000s, preconception care lived on the margins of public health and clinical discourse; by the 2000s, with the CDC's involvement, it had become a contested terrain among people interested in women's health care. After launching the Preconception Health and Health Care Initiative in 2004, the CDC convened a national summit that included the Select Panel on Preconception Care in 2005. This activity led to the publication of recommendations for preconception care that were enumerated in a watershed 2006 report (Johnson et al. 2006). In June 2006 the CDC reconvened most of the expert panel's members along with more experts in substantive areas at the CDC's Proceedings of the Preconception Health and Health Care Clinical, Public Health, and Consumer Workgroup Meetings, which took place in Atlanta, Georgia. Most experts interviewed for my study were involved in these meetings.
The full sample of interviews includes forty-three women (approximately 75 percent) and fourteen men. The respondents span the United States geographically and include geneticists, obstetricians, economists, public health specialists, pediatricians, social scientists, epidemiologists, nurses, and policy experts, along with directors of high-profile health organizations, government agencies, women's health programs, and academic medical departments. By focusing specifically on those the CDC deemed national experts, I am capturing the ideas and dialogue of a particular group charged directly with deriving and implementing the new preconception care framework. This purposive sample, selected for its designed composition, is conceptually important for understanding the rise of the preconception care paradigm. Through these sources, I aim to show when and why this public health initiative became a CDC focus and the basis of a new paradigm for women's health. I analyze and discuss why preconception care constitutes a new and tense policy terrain and what it means more broadly for how we think about women, reproduction, risk, and health care in the United States.