The Zero Trimester: Pre-Pregnancy Care and the Politics of Reproductive Risk by Miranda R. Waggoner (review)

Does life begin at conception? This contentious question has framed the debate over the morality of abortion for decades. A different but similar question—"Does pregnancy begin at conception?"—seems far more settled and even silly to ask. Yet, in The Zero Trimester: Pre-Pregnancy Care and the Politics of Reproductive Risk, sociologist Miranda Waggoner tracks and analyzes the rise of a surprising new answer from U.S. public health experts: No, pregnancy begins prior to conception. They say the health of a pregnancy and the trajectory of a (future) individual's well-being is set in motion before conception ever takes place.

The logic of this public health model is based on the idea that fetuses rely on pregnant women's bodies and the health of pregnant women is shaped primarily prior to conception. Therefore, prenatal interventions come too late. To truly improve maternal and child health, women should begin preconception care in the months, years, and even decades before pregnancy—a period the author calls "the zero trimester."

On one hand, this model makes utter sense. It can be difficult for a person to control diabetes, high blood pressure, or an addiction as soon as a pregnancy is discovered. These huge health changes take time and, often, focused medical attention. On the other hand, the implications of the preconception model can be scary for women, especially those who do not have motherhood on the mind right now. Do all young women need to eat well, exercise, take folic acid, and quit smoking in order to "show [their] love," as one CDC campaign puts it, to their future children? The anticipatory nature of a women's responsibility toward her future children can become all-encompassing. As one expert in preconception care tells the author, "A woman is a mother from the time of her own conception."

The Zero Trimesters uses interviews with key public health experts as well as thorough textual and historical analyses to answer three important questions: How did we get to this place where women are asked to bear the responsibilities of motherhood long before they become parents (and, in fact, regardless of whether they become parents at all)? How do men continue to evade these lofty expectations, despite their role in conception? And why does the model of preconception care have so much cultural resonance even while, as many of Waggoner's experts recognize, the medical and scientific evidence for it is lacking?

Central to Waggoner's answers are gender, particularly our cultural ideas about what a mother can and should sacrifice for her children, and the neoliberal model of individualizing health that dominates American medicine. She also deftly weaves together theories of medicalization, risk, the production of scientific knowledge, and political sociology to unpack this story. Waggoner's approach is even-handed and uncovers the public health experts' unexpected justification for expanding maternal responsibility. The experts she interviewed recounted how they came to believe that U.S. society values mothers, as a group, more than women. As a result, many concluded that, while "women's health" is a tough and often politically explosive sell because of its association with abortion and contraception, defining women as "pre-mothers" could actually buoy public support for expanding women's access to health care. Waggoner labels this a "reproductive justice approach"—a label I find overly generous and slightly misapplied because of the limited scope of preconception care. Nevertheless, the story she tells is compelling and insightful in portraying the political realities of investing in women's health in America.

The findings of The Zero Trimester are particularly relevant to the recent upsurge of attention to maternal and infant deaths and near-deaths. The United States has the highest rate of maternal death in the developed world and is the only country among this group where rates have been rising for the past decade and...