Carrying On: Another School of Thought on Pregnancy and Health 9781978801042

Citation preview

Carrying On

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Critical Issues in Health and Medicine Edited by Rima D. Apple, University of Wisconsin–­Madison and Janet Golden, Rutgers University–­Camden Growing criticism of the U.S. healthcare system is coming from consumers, politicians, the media, activists, and healthcare professionals. Critical Issues in Health and Medicine is a collection of books that explores ­these con­ temporary dilemmas from a variety of perspectives, among them po­liti­cal, ­legal, historical, so­cio­log­i­cal, and comparative, and with attention to crucial dimensions such as race, gender, ethnicity, sexuality, and culture. For a list of titles in the series, see the last page of the book.

Carrying On

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Another School of Thought on Pregnancy and Health

B r i t ta n y C l a i r

rutgers u niversity press new bru nswick, camden, and newark, new jersey, and london

 Library of Congress Cataloging-in-Publication Data Names: Clair, Brittany, 1986– author. Title: Carrying on : another school of thought on pregnancy and health / Brittany Clair. Description: New Brunswick : Rutgers University Press, [2022] | Series: Critical issues in health and medicine | Includes bibliographical references and index. Identifiers: LCCN 2021016157 | ISBN 9781978801004 (paperback) | ISBN 9781978801035 (cloth) | ISBN 9781978801028 (epub) | ISBN 9781978801042 (pdf) Subjects: LCSH: Pregnancy—Popular works. Classification: LCC RG525 .C72 2022 | DDC 618.2—dc23 LC record available at https://lccn.loc.gov/2021016157 A British Cataloging-­in-­Publication rec­ord for this book is available from the British Library. Copyright © 2022 by Brittany Clair All rights reserved No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, with­ out written permission from the publisher. Please contact Rutgers University Press, 106 Somerset Street, New Brunswick, NJ 08901. The only exception to this prohibi­ tion is “fair use” as defined by U.S. copyright law. References to internet websites (URLs) ­were accurate at the time of writing. Neither the author nor Rutgers University Press is responsible for URLs that may have expired or changed since the manuscript was prepared. The paper used in this publication meets the requirements of the American National Standard for Information Sciences—­Permanence of Paper for Printed Library Materials, ANSI Z39.48-1992. www​.­rutgersuniversitypress​.­org Manufactured in the United States of Amer­i­ca

 To all my Marys—­I miss you, I thank you, I love you

Contents

Preface ​ ​ ​ix List of Abbreviations ​ ​ xv Introduction: On Carrying On ​ ​ 1

1 Provide ​ ​ 5



2

Endure ​ ​ ​31

3

Grow ​ ​ ​62

4

Eat ​ ​ ​85

5

Watch ​ ​ ​102



6

Move ​ ​ ​122



7

Sleep ​ ​ ​142

8

Plan ​ ​ ​162

9

Commence ​ ​ ​178





Acknowl­edgments ​ ​ ​199 Notes ​ ​ ​201 Index ​ ​ ​255

vii

Preface

Less than two weeks ­after I completed writing and editing this manuscript, in the early spring of 2020, I sat and watched as the world crumbled around me, chastened and brought to heel by an unseen coronavirus. I cannot even begin to imagine the thoughts and feelings among the millions of American w ­ omen who are expecting right now, who are d ­ oing their best to navigate the mystery of pregnancy and to prepare for birth in a world characterized by uncertainty above all e­ lse. I imagine that they are taking each day in turn, as the prenatal care system they expected—­ including many of the decisions and milestones this book contemplates—­ fractures into something unforeseen and wildly unpredictable. They are truly carry­ing on, dauntless by necessity. I marvel at watching my d ­ aughter, now two years old, play with my son, four. They run and jump, sing and dance, oblivious to the devastation and death and frustration that have sprung up all around them. And yet, the COVID-19 pandemic ­will reshape their lived experiences—as students, as ­ ill never ­daughter and son, as c­ hildren and citizens of the world. They w know what they missed, or evaded, never know what would have been, ­because we all only know what we live, what we see, who we are t­ oday, at this moment. And at this moment, we are all asking questions. About every­t hing—­ about the way we work, the way we shop, the way we commute, the way ix

x P r e fa c e

we visit and travel and dress and eat. And in the pro­cess, we are beginning to rethink the pillar industries and institutions of our society: government, education, the media, medicine. ­Because right now, as ever, adaptation is a prerequisite for survival. As I watch how maternity care is adapting to the pandemic, I won­der what the prenatal care system, as it currently exists in this country, is d ­ oing for ­women, and ­whether it’s worth preserving as it stands. By all accounts, any recognizable conception of “prenatal care” arose in the early 1900s; it originated, by and large, based on concerns about infant welfare and infant mortality (not concerns about pregnant w ­ omen). By design, prenatal care was structured to identify complications or abnor­ malities among pregnant w ­ omen, with the understanding that d ­ oing so would reduce infant (and l­ater, maternal) mortality rates—­but the extent to which it has remains unclear.1 Even well into the twenty-­first ­century, the exact purposes and benefits of prenatal care are very much unresolved. Writing in 2001, experts Greg Alexander and Milton Kotelchuck explained that “the evidence for the effectiveness of prenatal care remains equivo­ cal.” Their overall synopsis was bleak: Unfortunately . . . ​t he efficacy of many of the traditional aspects of the content of prenatal care has never been established with any scientific rigor. Furthermore, periodic assessments of the scientific evidence for prenatal care practice standards have not been accompanied by pro­ gressive changes in prenatal care content and practice, even though it has suggested that clinical guidelines should be reassessed . . . ​t he rig­ orous scientific evidence of [prenatal care’s] effects on health outcomes, health-­related be­hav­iors, health care utilization, and health care costs is meager and insufficient.2

Meager and insufficient? This scathing summation was no outlying perspective—­consistently since the 1990s physicians and public health pro­ fessionals have called Amer­i­ca’s prenatal care system into question, and for good reason.3 Far from being a leader in maternal health, the United

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xi

States ranks dismally in terms of infant and maternal mortality. W ­ omen giving birth in the United States face greater odds of d ­ ying than in any other developed country on the planet, and ­women of color suffer far higher rates of pregnancy-­related morbidity and mortality, contributing to gross health in­equality at large. Over the last de­cades, despite “more” care (and more costs), t­ hings have actually gotten worse for expecting ­women—­not better.4 Indeed, in 2019 doctors and health professionals agreed that Amer­i­ca has an “undeniable” maternity care crisis.5 Since 2000, the maternal mor­ tality ratio in the United States has steadily increased, from twelve per hundred thousand live births to nineteen per hundred thousand in 2017, and ­women of color are between two and three times as likely to die from ­causes related to pregnancy compared with white ­women.6 Clearly, our static, one-­size-­fits-­a ll approach to delivering prenatal health care (which itself is designed to serve privileged, insured w ­ omen) is failing untold ­women who lack access to information, resources, and care.7 It is startling, in fact, to confront how l­ ittle the prenatal care delivery system has changed since its origins more than 120 years ago. In some ways, our system rests more on tradition than on evidence.8 ­There is no medical consensus, for example, about exactly how many prenatal appoint­ ments confer the most benefit; but the current visit schedule of twelve to fourteen recommended visits for a healthy singleton pregnancy is derived from the C ­ hildren’s Bureau’s 1930 edition of Prenatal Care—­which bor­ rowed its timetable from a 1929 statement issued by Britain’s Departmen­ tal Committee on Maternal Mortality and Morbidity called Ante-­Natal Clinics: Their Conduct and Scope. One scholar called that text the “Magna Carta of prenatal care,” and our own protocols in the twenty-­first ­century align remarkably closely to it, despite mounting international evidence that challenges its prescribed schedule.9 Pointing this out, one team of obstetricians called the modern prenatal visit calendar “arbitrary.”10 Like so many other arenas, in response to COVID-19 prenatal care pro­ tocols modified more in a ­matter of weeks than they had in the ­century

xii P r e fa c e

prior. In the initial wave of the pandemic in the spring of 2020, many nonessential office visits w ­ ere cut entirely or amended, routine screenings and testing procedures w ­ ere kept to a minimum, visitors w ­ ere excluded from momentous junctures (like ultrasounds), and the conventional wis­ dom of what constitutes “essential” was turned on its head. In a particu­ larly dark moment, New York City hospitals barred any visitors from l­ abor and delivery wings, and laboring ­women ­t here ­were asked to leave their partners, ­family, friends, doulas at the door. Thankfully, that policy was reversed within a m ­ atter of days. But other “pandemic changes” to maternity care have held steady. In some places, pregnant w ­ omen have been invited to share in their own health care: to take their own vitals and mea­sure­ments then report back at virtual well-­visits, or voice their preferences for how ­they’d like to attend their appointments— in person or virtually. Prenatal education classes have gone viral, and internet resources abound. For some, t­ hese do-­it-­yourself changes may be ­ thers, they may be nerve-­wracking; for still ­others, they empowering; for o are simply unavailable. The pandemic has thrown systemic in­equality into stark relief: thousands of pregnant w ­ omen lack the ability to partake in digital appointments or navigate remote learning, much less support, and we risk leaving this vulnerable population ­behind. Not to mention, ­women from all walks of life are undergoing prenatal care—as well as ­labor and delivery and the postpartum period—­more isolated than ever before. Only time w ­ ill tell what we are to make of the modifications underway. But perhaps from the once-­inconceivable position in which we stand, we might recognize the seed of opportunity: the chance to embark on a fresh wave of conversations about what ­matters to prenatal health. Each of us does ­t hings e­ very day—in pregnancy and childbirth as in the rest of our lives—­w ithout apparent reason. In the pro­cess of writing this book (and then living through the first months of a pandemic that looks to stretch many more into the f­ uture) I have come to recognize that although I consider myself a devotee of medical evidence, t­ here are a ­great many ­things I do despite available evidence indicating their futility.

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xiii

When I was pregnant, I took multivitamins, indulged in prenatal ultra­ sounds, drank prenatal tea. Perhaps o ­ thers of my decisions w ­ ere more firmly supported by evidence—­exercise daily, forgo pro­cessed foods, avoid alcohol—­but we are all subject to our own leanings. The paradox of prenatal care—­that we abide by protocols based more on convention and good intention than on substantive evidence—­permeates pregnancy. I enacted this paradox ­every day, in one way or another. To be very clear, I am not suggesting that prenatal care is futile—­without it, a w ­ oman is seven times more likely to deliver prematurely and five times more likely to lose her infant. It is precisely b­ ecause prenatal care is so valuable that we must improve it. Nor would I suggest that prenatal care is unusual for being a problematical descendant of its original structures. Systems all around us, from schools and hospitals to po­liti­cal institutions and businesses, echo their past forms and functions. Years ago, I remember hearing a physician say in a radio interview that trying to adapt medical school curricula to more appropriately serve twenty-­first ­century doctors in training would be like “trying to turn a cruise ship around in a back­ yard swimming pool.” This book is my attempt to rethink from another school of thought what I perceived to be the pivotal moments of interaction between pregnant ­women and the prevailing medical prenatal care standards. I focus pre­ dominantly on scientific medicine (“biomedicine”) ­because that is the establishment through which I moved, and it is also the establishment that more than 90 ­percent of American ­women utilize. I ask questions, and find only some answers. What I wanted to know, r­ eally, was this: how and why did so much of the confusing and contradictory information and guidelines on pregnancy come to exist? I wrote and edited this book before COVID-19 detained the world—­a development that has and ­will continue to fundamentally alter the expe­ rience of pregnancy in Amer­i­ca. In moments of crisis, priorities change shape; I imagine some of t­ hose t­ hings that kept me awake at night, won­ dering, ­will change for ­women who are pregnant now or become pregnant

xiv P r e fa c e

in the near ­future. And yet some ­t hings likely ­w ill not, b ­ ecause the uncer­ tain anticipation of bringing new life into the world is perennial. In March, in a moment of egocentric panic, I worried that the COVID-19 pandemic would render this book obsolete. Now, I worry that it w ­ on’t— that in a post-­COVID world we ­will fall back to business as usual and stop asking what constitutes “essential” care, stop retooling the prenatal visit schedule, stop rethinking how to empower and support pregnant ­women equitably, stop revising the script, stop asking questions. The coronavirus pandemic is the worst public health crisis Amer­i­ca has seen in a c­ entury. It is tearing down our individual and collective sense of “normal” and has made a mockery of everyday experiences ­we’ve taken for granted, threatening to undo our society as we know and understand it. But perhaps it has also forced our hand, compelled us to carry onward and maybe even upward, given us no option but to try to turn the ship around in the swimming pool—or e­ lse rebuild a better vessel entirely.

Abbreviations

ACA

Affordable Care Act

ACOG

American College of Obstetricians and Gynecologists

ADHD

Attention deficit hyperactivity disorder

BMI

Body mass index

CDC

Centers for Disease Control and Prevention

DES Diethylstilbestrol DHA

Docosahexaenoic acid

EEG Electroencephalography FDA

Food and Drug Administration

hCG ­Human chorionic gonadotropin IOM

Institute of Medicine

IV Intravenous JAMA

Journal of the American Medical Association

LMP

Last menstrual period

NIH

National Institutes of Health

NRC

National Research Council

NTD

Neural tube defect xv

xvi A b b r e v i at i o n s

NVP

Nausea and vomiting of pregnancy

PSQI

Pittsburgh Sleep Quality Index

RDA

Recommended daily allowance

REM

Rapid-­eye movement

WHO

World Health Organ­ization

Carrying On

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Introduction on carry­ing on

When I was pregnant with my first child, it took months before I felt I could relax. I ­wasn’t necessarily the proverbial ball of nerves, but I was deeply anxious. During my first trimester, I spent hours each week researching miscarriage statistics and viability studies. I tried to be buoy­ ant, nonchalant, assured, but I c­ ouldn’t help myself. I was afraid of the worst. I was apprehensive. I was consumed with ascertaining—on a daily basis—­the diminishing odds of something ­going wrong. I spoke in uncer­ tain terms—­if I am still pregnant, if I have a baby in December, if we have a child. As it turned out, every­t hing went wonderfully. I had an utterly unre­ markable pregnancy (“I ­can’t find anything wrong with you!” my doctor joked at ­every prenatal visit), and a grueling but equally unremarkable birth. ­ ill not succumb to my fears. This time I aspire to a sense of calm. I w I ­will not retreat into anxiety. I am having a baby. Prob­ably in December, maybe in January. I ­will become a m ­ other again. My husband w ­ ill become a ­father again. My son w ­ ill become a b ­ rother. My ­family is growing. But— But I cannot deny myself or my instincts. I am pregnant; I am a histo­ rian; I am a ­mother; I am a patient; I am someone who questions. I want to learn; I want to understand; I want to analyze. I need to study. To me, 1

2

Ca r ry i ng On

this is a luxury. I ­w ill indulge in my own pregnancy through scholarship. Iw ­ ill let my curiosity roam ­free, and I w ­ ill follow it obligingly. I am: the ­daughter of a surgeon, the s­ ister of a surgeon, wife to a physician, a student of medical history. I am: innately skeptical; introverted; prone to overanalyzing even the minutiae of my life; a lover of plans, detailed sched­ ules, itineraries. I believe: in knowledge, in expertise, in research, in experi­ ence. I am also: among the more than 3.5 million pregnant w ­ omen in the United States who seek a doctor’s care each year, and among the untold num­ bers of pregnant ­women who seek some better understanding of that care. What follows is my own wandering learning proj­ect. It is not a self-­help book, a pregnancy guide book, or a medical text. It is not definitive; it is not unconditional; it ­w ill not tell you what to do or how to behave. It is, however, exhaustive. It is research based. It is careful. It is earnest. It is a companion for anyone e­ lse who has harbored curiosities about preg­ nancy, who has wondered about the extraordinary h ­ uman challenge of bringing new life into the world, who is primed to ask questions and dig below the surface. It is a thought pro­cess, and its home is in the gray area: it does not manipulate tidy answers or proffer advice, but instead contends with the real­ity that medical science is fluid. It re­spects that pregnancy is constantly in flux.

I ­will spend roughly each month of my pregnancy contemplating one mile­ stone or issue that consumes my mind. The questions I ask reflect my own background and biases—­I am white and financially secure; I grew up with countless privileges that enabled me to pursue gradu­ate educa­ tion and writing and motherhood on my own terms; I am navigating the system with an obstetrician and a laptop; and I plan to deliver my child in the same hospital where my husband works, where my son was born. I make no claim that what I want to know necessarily signals what ­every other pregnant ­woman may or may not want to know. Or that I am even asking the “right” questions in the first place.

I n troduction

3

But I hope that ­t here may be some overlap. My research into each of my inquiries incorporates outlining basics, tracking historical origins, surveying twenty-­first c­ entury evidence and customs, consulting multiple disciplines’ perspectives, and mapping the ter­ rain for ongoing debates. I want to apprehend t­ hese topics, to unravel their interdisciplinary connections, to gain insight into society’s approaches t­ oward them. As soon as I become pregnant, I begin to won­der about my prenatal multivitamin, so I delve into the history of multivitamins and sort through de­cades of research on their uses and effects during pregnancy. In my sec­ ond month of pregnancy, I find solace in learning every­t hing I can about morning sickness; studying my condition becomes my survival mecha­ nism. When my nausea begins to ease, my thoughts turn to my changing shape, my expanding physique. I hunt for the origins of the false notion that pregnant ­women should “eat for two,” and I explore the constantly changing medical recommendations for weight gain during pregnancy. Every­thing I learn about prenatal weight gain raises new questions about prenatal nutrition. I spend my fourth month of pregnancy working to ascertain where all the conflicting medical advice about diet and food in pregnancy came from, and w ­ hether or not I should follow any of it. In anticipation of my fetal anatomy scan at twenty weeks, I set out to tell the story of how ­we’ve come to be able to observe life growing in utero, and where this stunning technological accomplishment looks to be taking us in the f­uture. By my sixth month of pregnancy, I am growing increasingly irritated by comments that I need to start “taking it easy” and “be careful,” and I won­der where our society’s apprehension about exercise during preg­ nancy originated. I resolve to see what science and medicine have to say. At the beginning of my third trimester, I start obsessing over sleep. With sound sleep becoming more elusive with e­ very passing day, and the certainty of massive sleep deprivation looming, I grow desperate to learn every­thing I can that might help me to understand sleep during preg­ nancy more fully, to sleep better and feel more rested, and to decrease my

4

Ca r ry i ng On

anxiety about my imminent sleep poverty. Inevitably, I begin to consider childbirth during my eighth month, and so I spend time exploring the legacy of birth plans. And with my due date fast approaching, and my mind racing, I turn my attention to the onset of ­labor and begin investigating the history of ­labor induction. And then I wait. Through my intellectual travels I discover more meaning in my preg­ nancy. Comprehension eludes me, but I do find some self-­assurance. I gain a sense of calm and control through understanding. No amount of informa­ tion can extinguish the anticipation and uncertainty that typify the nine-­ month journey from conception to childbirth, but letting myself get carried away with my curiosities is a comfort. It reminds me that pregnancy, and every­thing we know and feel about it, is always being reconceived.

On the spectrum spanning from “pregnancy is a wondrous miracle and the most joyous experience of a w ­ oman’s life” to “pregnancy is unpleas­ ant,” I fall somewhere in the ­middle (although I admittedly lean ­toward the latter). My philosophy is discriminating. I see pregnancy as neither romantic nor insufferable, neither whimsical nor miserable. I am as dis­ interested in discovering pregnancy’s fabled glow as I am in enumerating its commensurate afflictions. I have no gospel to preach, and I ascribe to no pregnancy ideology—­other than pragmatism. Pregnancy is hard. It is demanding; it is incon­ve­nient; it is sensational; it is a burden; it is a gift. It is self-­sacrificial. I strug­g le with the awesome surrender pregnancy commands e­ very single day; Carrying On is the fruit of my management strategy. It is my own intellectual plunge, my attempt to find balance, to seek reason, to practice cogitation. My only agenda is to engage, and I invite you to engage with me. This is my pilgrimage.

chapter 1

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Provide

I awkwardly maneuver to pee on a stick, then set the test on the floor just in front of me. How many times have I done this? I can feel my heart dancing with anticipation as I watch pink dye creep across the test. It’s started working. I count to myself while I slowly wash my hands, dry them. I turn around to pluck my stick up off the floor, willing something to appear. As if my fixed, urgent gaze could make any difference; this fortune cookie has already been written. I keep staring, excitement building. I squint. Like magical ink materializing on the Marauder’s Map in Harry Potter, a sec­ ond line appears. I am pregnant. In just that second, every­t hing changes. I hate to admit it, but I can hardly wait to call my doctor’s office. It’s the weekend, but I call just ten minutes a­ fter the office opens on Mon­ day morning. I know I am pregnant, but I want more: more confirma­ tion, more information, more details. I am a planner. I love mapping ­t hings out, knowing the next steps, scheduling the ­f uture, writing it all down. I know exactly when I ovulated, so I can figure out my estimated due date very easily, on my own. The staff’s instruction to come in for a blood test to mea­sure my ­human chorionic gonadotropin (hCG) levels— specifically to estimate how far along I am—­strikes me as illogical. I know my dates. 5

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Ca r ry i ng On

And yet I am grateful, thrilled even, that they ask me to come any­ way. This is exactly what I want: verification, data, hope. When I am directed to schedule an early ultrasound, I similarly do not see the point, but I am delighted to make the appointment: more verification, more data, more hope. I meet with the nurse, answer some questions. She takes notes and nods along while I tell her my dates and my history. I’m multitasking, stuffing Cheerios cereal into my son’s chubby fin­gers while he squirms in his stroller beside me. “Hmm? Yes, I’m taking prenatals,” I affirm. “Wonderful.” The nurse is still nodding. She tells me when to book my next appointment, then directs me down the hall for blood work, sending me off with a smile. My results come in a few days ­later, and I have what I came for: confirmation. I am pregnant. At once, every­t hing is dif­fer­ent. And yet every­t hing is the same.

I’ve taken a prenatal multivitamin ­every day for over two years. I first picked some up when my husband and I de­cided to think about having our first child. We said we would “just see what happens,” but for us, like so many ­others, the choice to discontinue contraception was functionally a choice to have a child. Now. Our saying “­we’ll see what happens” was a hedge, a self-­defense mechanism. Just in case. In real­ity, we ­were impatient. And we w ­ ere very, very lucky: our son was born ten months ­later. Afterward, I ­didn’t stop taking prenatals; I was nursing. I’m mostly vegan, too, so I also thought it was a good idea to take a multivitamin anyway, pregnancy and lactation aside—­just in case I was deficient in something. Just in case. My vitamins: a nightly nutrient insur­ ance policy in a b ­ ottle. To­night, I cup the tablet in my hand. I scan the ingredient list, marvel­ ing at the bean-­sized innovation I swallow so devotedly ­every eve­ning ­after

Prov ide

7

dinner, and I am overcome with questions. What is this? Why am I taking it? How many ex­pec­tant m ­ others before me have done the same t­ hing?

The Appearance of Vitamin Magic The word vitamin comes from the original term “vitamine,” coined in 1912 to designate the “vital amines”—­t he stuff of life. And that is what they ­really are: organic substances the body requires to grow and function well. Each vitamin—­there are thirteen (not to be confused with minerals, of which ­there are fifteen essentials)—­performs a specific and necessary task in the body. Yet the body does not make vitamins on its own, and so they must be obtained. When they ­were first discovered, singular vitamins afforded near-­ miraculous outcomes in cases of deficiencies. Restoring vitamin C to some­ one suffering from scurvy, or vitamin D to a child with rickets, is nothing short of a rescue. In cases of deficiency, vitamins have sensational healing powers indeed; they are a triumph of modern science. And yet, contrary to popu­lar belief ­today, ­there is almost no reason to think that consum­ ing extra vitamins does anyone any good.1 Singular vitamins like vitamin A and vitamin D became available to the public in the mid-1930s, and the first multivitamin tablets, containing amalgams of micronutrients, hit shelves in the 1940s.2 Their arrival coin­ cided with major shifts in the American food industry and in dietary pat­ terns. With pro­cessed food replacing local, fresh, homemade foodstuffs, Americans ­were primed for the message that they needed vitamins: pro­ cessing stripped foods of their nutrients, leaving families vulnerable. Mul­ tivitamins w ­ ere touted as “nutritional insurance” right from the start. And the hype hit home. Over the course of the 1930s, vitamin sales increased more than ten­ fold, from $12 million a year to almost $83 million a year. By 1942, annual sales w ­ ere $136 million, and 25 ­percent of Americans ­were taking vitamins. The blockbuster nature of ­wholesale vitamin production was a complex

8

Ca r ry i ng On

product of the consumer market, successful advertising, and scientific admiration—­a cultural orchestration far more than a medical one. Inter­ estingly, the American Medical Association campaigned against vitamins from the get-go. In the 1920s, it deemed the promotion of vitamins “a gigan­ tic fraud” and went on to continue criticizing their widespread use as a delusion for de­cades.3 ­Until it ­didn’t. Over time, medical solidarity opposing vitamins broke down piece by piece, so that by the end of the ­century doctors ­were proudly publicizing their own vitamin use. Perhaps the most vis­i­ble collapse of medicine’s unified contempt for vitamins began in the 1960s when the famed scientist and Nobel Laureate Linus Pauling started proclaiming the won­ders of vitamin C, alleging that megadoses could cure every­thing from the common cold to cancer. In the wake of such unfounded declarations, a movement emerged with the goal of more stringent requirements and supervision over vitamin claims and production; regrettably, it failed. In the 1970s, the Proxmire Amendment denied the U.S. Food and Drug Admin­ istration (FDA) regulatory powers over supplements. By the late 1980s, a ­little more than a third of men and nearly half of American ­women reported using vitamins, minerals, or other supplements. As doctors have increas­ ingly recommended vitamins for medicinal purposes, t­ hose numbers have continued to climb—­even without evidence.4 In the mid-1990s, new legislation (the Dietary Supplement Health and Education Act) passed, rendering supplements safe u ­ nless proven other­ wise. In other words, supplements w ­ ere assumed safe u ­ ntil any evidence of harm surfaced, something that typically occurs only ­after widespread use. As a direct result of this ruling, the FDA emerged with virtually no regulatory power over the entire supplement industry—it cannot approve or deny supplement production, or even make demands of supplement manufacturers. It also has no authority to police potency or dosage stan­ dards. As physician Pieter Cohen notes, the lenient safety specifications devised in the 1990s resulted in a massive flood of new supplement prod­

Prov ide

9

ucts onto the market: from about 4,000 supplements available for purchase in 1994 to 55,000 just twenty years ­later in 2012. ­Today ­t here are some 85,000 supplement products on the market, none of which are subject to any third-­party oversight. With virtually no one monitoring t­ hese tens of thousands of products, prob­lems arise. In 2009, a ConsumerLab report examined twenty-­nine top-­selling multinutrient products (marketed for adults and ­children) and found that eight suffered quality issues or failed to meet the claims on their labels, and twelve contained amounts of certain substances that ­were much too high for healthy consumers.5 In her account of the history of vitamins, Vitamania, historian Rima Apple documents a pattern: “de­cade ­after de­cade . . . ​t he same scenario is repeated: scientists report on the beneficial effects of vitamins; the media and particularly manufacturers publicize the claims; skeptical scientists declare that the American consumer is being hood-­winked; government agencies propose regulations to control the advertising, labeling, and sale of vitamin pills; and concerned consumers assert their right to take their vitamins without government interference.” 6 This feels familiar. So where do prenatal vitamins fit into this basic narrative? Ads for prod­ ucts with cutesy names like “Gestatabs” and “Prenalac” appeared in pro­ fessional obstetric lit­er­a­ture not long ­after multivitamins ­were developed. In The Maternity Racket, Cheryl Lemus suggests that obstetricians in the 1930s and 1940s, confronted with vitamin publicity and new nutritional research implying that pregnant w ­ omen ­were not eating correctly, grew increasingly receptive to the idea of vitamins for their pregnant patients. With (supposed) reason to believe that most pregnant w ­ omen ate poor diets and a progressively urgent desire to limit their patients’ caloric intake and weight gain, some obstetricians saw vitamins as a useful remedy. As Lemus points out, though, t­ hese male obstetricians’ focus on pregnant ­women’s food and nutrient intake stemmed at least partly from their

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assumptions that pregnant w ­ omen w ­ ere literally incapable of making appropriate decisions about what to eat and how to consume a healthful diet.7 Such paternalistic ideologies aside, it is clear that vitamins geared spe­ cifically ­toward pregnant ­women ­were developed, and aggressively mar­ keted, as early as vitamins themselves. (Furthermore, ­women in general have been targeted more than men in vitamin sales, and they have always used more vitamins than men.8) One of my grand­mothers gave birth to sixteen c­ hildren, spanning from the 1950s through the 1970s. (No, not kidding—­she’s truly remarkable.) She told me that she always took pre­ natal vitamins; they w ­ ere always available at the drug store. So prenatal vitamins are far from a new commodity; pregnant w ­ omen have taken them for generations. But none of the products available to our great-­grandmothers, grand­mothers, and even many of our m ­ others w ­ ere backed by any evidence whatsoever—­u ntil the 1980s, when researchers discovered that folic acid deficiencies in early pregnancy w ­ ere associated with devastating effects.

Magic at Work: The Story of Folic Acid When the nurse at my doctor’s office asked me if I was taking prenatal vita­ mins, she could have just asked me if I was taking folic acid. For all the evidence underpinning folic acid, it tends to be sidelined, overshadowed ­ hole. by prenatal vitamins as a w Folate is a water-­soluble vitamin, meaning it’s able to dissolve in ­water. It’s part of the vitamin B complex (vitamin B9), and was identified in 1941

­after being isolated from spinach. In Latin, folium means leaf, and fo­liage

is the most abundant source of folate. By 1945, researchers had synthesized folate. (The pro­cessed version, called folic acid, is actually easier to absorb ­ oman becomes pregnant, her than naturally occurring folate.)9 When a w folate needs increase by about 50 ­percent, to an estimated 600 mg/day.10 Falling short of t­ hose demands can be catastrophic. Indeed, scientific and

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medical consensus holds that folate deficiency plays a critical role in the formation of neural tube defects (NTDs)—­t he evidence, scholars agreed by 2000, was “beyond doubt.”11 Neural tube defects occur when something goes awry during embryo­ genesis, the complex pro­cess that takes place in the first c­ ouple of months of pregnancy, during which a fertilized egg matures into an embryo. An embryo’s neural tube—­which ­w ill eventually comprise the baby’s brain and spinal cord—­develops via neurulation. Once it forms, the neural tube should close very quickly thereafter—­only about twenty-­eight days ­after conception. When that ­doesn’t happen, the exposed neural tissue suffers damage, resulting in devastating conditions such as spina bifida and anencephaly.12 The first reports linking folic acid to unwanted pregnancy outcomes—­ congenital malformations in particular—­were published in the mid-1960s. They came on the heels of evidence that pregnant ­women who had ­cancer, and ­were prescribed a chemotherapeutic folic acid antagonist (­aminopterin—­a close relative of methotrexate, a drug still frequently used for a variety of cancers and rheumatologic conditions), gave birth to more babies with neural tube defects. The two 1960s studies w ­ ere ret­ rospective case series investigating underprivileged w ­ omen’s folate levels and their pregnancy outcomes. One specifically compared w ­ omen who had given birth to babies with severe central ner­vous system malforma­ tions with matched controls. Both found a significant relationship between fetal malformations and “defective folate metabolism in the m ­ other.” Folate deficiency was associated with major prob­lems.13 In the wake of the hypothesis that folic acid was implicated in a higher risk for neural tube defects, researchers designed more studies in the 1970s. Their work suggested the folic acid theory was correct. A landmark 1980 piece in the medical journal The Lancet described a prospective trial involving ­women who had a prior NTD pregnancy. In the experimental group, pregnant ­women took multivitamin supplements that contained folic acid (starting from 1 month before conception and continuing

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through their second missed period). The control group took no such sup­ plements, and the results w ­ ere remarkable: among the w ­ omen who had taken the supplement containing folic acid, the neural tube defect inci­ dence rate was only 0.6 ­percent, but among the w ­ omen who had not taken a supplement, the rate of NTDs was 5 ­percent. ­These results w ­ ere exciting, but t­ here was still more work to do. The study participants had elected to be in the supplement group, which meant that se­lection bias could be at work. In other words, the ­women who had opted to take the supplement with folic acid might have been dif­fer­ent from or healthier than ­women who declined it. Plus, ­because folic acid was distrib­ uted in the com­pany of a multivitamin with iron, it was impossible to be sure that folic acid itself was directly responsible for the improvements.14 In 1983, the British Medical Research Council launched a massive proj­ ect intended to ­settle the m ­ atter. It conceived a double-­blind randomized controlled trial across thirty-­three sites spanning seven international bor­ ders. More than 1,800 ­women at high risk for an NTD-­affected pregnancy ­were divided into four groups. One took folic acid alone, one took folic acid and a multivitamin, one took only a multivitamin (without folic acid), and one took nothing. The folic-­acid-­only group saw major benefits: daily supplementation had a 72 ­percent protective effect against NTDs. The mul­ tivitamins without folic acid appeared to do nothing. Th ­ ese results w ­ ere so conclusive that the investigators terminated the study prematurely in 1991, saying it would be unethical to continue. Thus, the study confirmed suspi­ cions; it provided definitive evidence that folic acid had impressive preven­ tative powers against neural tube defects—in the highest-­risk population of ­women, no less.15 The next logical step was to investigate ­whether ­t hese results extended to the general population. In 1992, a proj­ect published in the New ­England Journal of Medicine showed that the benefits of folic acid supplementation did extend to all pregnant w ­ omen. In a randomized controlled trial con­ ducted in Hungary, w ­ omen took ­either a multivitamin supplement with 0.8 mg folic acid or a placebo, beginning preconceptually and continuing

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through their second missed period. The placebo group witnessed many more cases (six) of congenital malformations, while ­t here ­were zero cases of NTDs among the supplemented ­women’s babies. Statistically speaking, this documented a 100 ­percent NTD risk reduction. A later proj­ect with study participants in Boston, Toronto, and Phila­ delphia produced similar results: taking 0.4 mg folic acid reduced the risk of NTDs among the general population. The New ­England Journal of Medicine authors exclaimed that “given the results of this study, we think that all w ­ omen planning pregnancy should receive a vitamin supplement con­ taining folic acid.”16 In light of such evidence, the U.S. Centers for Disease Control and Pre­ vention (CDC) issued a formal recommendation in 1991: ­women with a previous NTD-­affected pregnancy should take 4 mg folic acid as soon as they start planning a pregnancy. In 1992, the U.S. Public Health Ser­vice extended that message and advised all w ­ omen of childbearing age to con­ sume 0.4 mg folic acid ­every day to prevent NTDs. In the coming years, other professional health and medical bodies followed suit.17 In the meantime, the FDA was so certain of folic acid’s benefits that it authorized the fortification of grain products with folic acid beginning in 1996; compliance was mandatory by 1998. Decisions such as this are not taken lightly—­infusing foods with vitamins on a mass-­population scale has major economic and public health consequences. In the past, the gov­ ernment has only enacted fortification when scientists have been uni­ formly and overwhelmingly convinced of its potential benefits. In the 1920s, iodine was added to salt to reduce goiter, a prob­lem whereby the thyroid gland grows too large. Vitamin D was added to milk to help pre­ vent rickets in the 1930s. In the 1940s, flours and breads ­were fortified with parts of the vitamin B complex (niacin, thiamin, and riboflavin) as well as iron to stave off deficiencies like beriberi and anemia. Folic acid was the first major fortification since t­ hose de­cades.18 Admittedly, ­there are still some kinks that need to be ironed out regard­ ing folate. In the first place, it’s not entirely clear ­whether ­women should

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keep taking folic acid beyond the first trimester. In any event, ­doing so certainly ­won’t help prevent neural tube defects.19 Timing is also a trying issue on the front end. In the United States, some 50 ­percent of pregnan­ cies are unplanned—­which means that by the time most w ­ omen discover they are pregnant, it’s already too late to reap the full benefits of folic acid’s preventative effects.20 Additionally, ­t here are unanswered questions about the effects of for­ tification. At the very least, the presence of vitamins in our food compli­ cates ­things. It makes daily intake levels, which are already challenging to calculate, even more so. And many experts are growing concerned about the general implications of mass fortification combined with the wide­ spread supplementation Americans practice.21 Prior to fortification, approx­ imately 10 to 12 ­percent of Americans w ­ ere deficient in folate. Within just a few years of fortification, that rate plummeted to only 1 ­percent. Thanks to fortification, folate deficiency in the United States has become something of a rarity; it’s unusual, to say the least. According to mathematician Daphne Adler, ­women are much more likely to be deficient in other micronutrients (such as vitamin B6, or vita­ min D, or iron, or calcium) than they are in folate. Thus, in theory, ­because most Americans are now obtaining plenty of folic acid through their diets, we could question ­whether additional folic acid supplementation is ­really necessary. But given how much we know about how impor­tant folic acid is, it would be unthinkable to conduct studies to evaluate this. And I’m certainly not pushing the issue.22 But ­these are ancillary puzzles. The evidence linking folic acid insuf­ ficiency to NTDs is as robust as we could hope for. It paved the way for stunning achievements in public health in this country and abroad. The numbers speak for themselves: in the late 1990s, spina bifida rates dropped by 23 ­percent, and anencephaly incidence fell by 11 ­percent. In just a few years, total NTDs declined by almost 20 ­percent.23 Some recent work even suggests that preconception and first-­trimester folic acid supplementation

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is associated with lower rates of all kinds of congenital anomalies—­not just NTDs.24 This remains to be seen, but folic acid’s ties to NTD prevention alone are worth it; the stuff confers undeniable benefits during early pregnancy. ­Today, the most respected medical authorities all around the globe con­ tinue to attest to folic acid’s ability to safeguard against NTDs. Every­one from Cochrane reviewers to the American College of Obstetricians and Gynecologists (ACOG), to the Royal College of Obstetricians and Gyne­ cologists (in the United Kingdom), to the World Health Organ­ization (WHO), and to the CDC recommends that ­women consume 0.4  mg (400 micrograms) of folic acid daily beginning one month before concep­ tion and continuing at least through the first trimester to prevent NTDs.25 This global consensus—­that folic acid confers such demonstrable advantages in the earliest stages of pregnancy that it should be universally recommended to all ­women capable of becoming pregnant—­emerged gradually over a period of de­cades, but it was gospel by the turn of the twenty-­first ­century. It continues to be, and rightly so—­the history of folic acid is a success story, a practical application of scientific findings to improve h ­ uman health and happiness. It was nice to begin my research on such a happy note.26 But folic acid is only one of dozens of components in my prenatal mul­ tivitamin. What do the rest of them provide?

Disappearing Powers I was surprised to learn that prenatal multivitamins have not been uni­ versally recommended. For the most part, t­ here h ­ asn’t been much evidence indicating that the rest of the contents in prenatal vitamins are necessar­ ily advantageous for ­women who a­ ren’t malnourished. Experts remain divided regarding iron and vitamin D, but as for every­thing ­else, it’s hard to tell if it’s any use. Broadly speaking, synthetic versions of vitamin C,

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vitamin E, iodine, calcium, docosahexaenoic acid (DHA), and fish oil have not been linked to apparent benefits, and sometimes are even associated with worse outcomes.*,27 The science ­behind vitamin supplementation is—­and always has been—­ ambiguous. The result, as historian Rima Apple describes, is that science becomes up for grabs. Anyone and every­one can employ science to their own ends. This sounds discouraging. To be fair, t­ here are numerous obstacles standing in the way of scien­ tists trying to assess the benefits (or costs) of vitamin supplementation, both in general and during pregnancy. Personally, I find the field of nutri­ tion science so replete with caveats as to sometimes (maybe even often) be downright irritating. In her book Vitamania (apparently this is a popu­ lar title for works about Amer­i­ca’s vitamin craze), journalist Catherine Price opens with a telling quip from a nutritionist: “the more we know, the more we ­don’t know.”28 Indeed, it is difficult not to call the fundamental building blocks of nutrition science into question. Caloric requirements, vitamin needs, mac­ ronutrient breakdowns, and even individual foods’ calorie values can all be subject to interpretation. “Nutritionism,” faith in the narrow belief that healthful eating can be thoroughly understood simply by quantifying nutrients, is also predisposed to reductionism, as Michael Pollan has so elegantly argued. It’s grossly oversimplified.29 Vitamins themselves are still mysterious actors in the h ­ uman body and ­human health. We know we need them, and we know that gross deficien­ cies can wreak havoc, but, as Price writes, “scientists still ­don’t fully under­ stand all the nuances of what vitamins do in our bodies, how they do it, or what the long-­term effects of moderate deficiencies might be.”30 Micro­ nutrients are exceedingly challenging to study. They can be cumbersome * Calcium, however, has been used effectively to help manage hypertension—­high blood pressure—­a nd related hypertensive complications during pregnancy, espe­ cially in ­women with very low calcium intakes.

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to mea­sure accurately (in bodies and on plates), and many of them can be assessed according to vari­ous scales (such as vitamin D). In any given indi­ vidual, test outcomes can vary by season (also with vitamin D) or even over the course of a day (as is the case with vitamin C, which can spike ­after eating citrus). Such fickle features understandably impede research­ ers’ ability to construct accurate nutritional requirements and guidelines. Recommended daily allowances (RDAs) illustrate further complexities. RDAs are the determined intake levels needed for most healthy ­people, on average, to sufficiently meet their nutrition requirements and avoid deficiencies. A component of the dietary reference intakes developed by the Food and Nutrition Board of the Institute of Medicine, RDAs are full of loopholes. Calling them into question is easy—we could poke holes all day. RDAs tend to be accepted as universal and determined, but they are wavering and ambiguous. As Price describes them, RDAs are “works in pro­gress.” Devised for public health purposes, they d ­ on’t apply perfectly or universally on an individual basis. As the very organ­ization that gen­ erated RDAs explained: “scientific data have not identified an optimum level for any nutrient for any life stage or gender group.”31 If we could get over some of this under­lying uncertainty, we’d just uncover more. For example, micronutrients differ in their bioavailability: our bodies can utilize some nutrients more efficiently and effectively than ­others, and e­ very person is dif­fer­ent. Bioavailability is both highly sensi­ tive and highly subjective. Take iron: ­humans can make better use of heme iron, which is found in animal-­based foods like meat, seafood, and poultry, than they can non-­heme iron, which is mostly found in plants, especially nuts, beans, and vegetables. Exacerbating the difference, animal foods enhance iron absorption even further whereas many plant foods (even ­those that offer lots of iron) inhibit iron absorption. Adding to all of this, iron absorption is contingent on what ­else a person eats: dairy impedes iron absorption while vitamin C might improve it. Even food preparation can affect bioavailability—­cooking on certain surfaces, such as cast iron, might boost iron’s availability.32 And it’s not just iron—­t he same conditionality

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applies to vitamin D, which every­one synthesizes differently based on individual micronutrient intake, sunlight exposure, sunscreen habits, skin pigmentation, and geographic location, among other ­factors.33 More importantly, research clearly shows that consuming nutrients from real foods is vastly dif­fer­ent from consuming synthetic supplements. In some cases—as with DHA—­supplements appear to be entirely point­ less, while naturally existing DHA appears to be wildly beneficial. For other nutrients, supplements can cause side effects; iron supplements often instigate irritation and stomach prob­lems such as constipation or nausea (which can be doubly problematic for pregnant ­women already suffering from nausea or vomiting). Uniformly, the complex interplay of micronu­ trients in foods like fruits and vegetables confers health benefits that pro­ cessed isolated doses simply cannot offer. Supplements are not necessarily universally inferior to naturally existing micronutrients, but nutrition­ ists and scientists agree that the best sources of nutrients are foods—­hands down, no further questions. ­ atter: how can we tell, and what Of course, herein lies the crux of the m should we do, if we ­aren’t quite getting enough from our diets? Any answer to this question—­evasive as it is to begin with—­becomes all the more consequential during pregnancy, especially given that experts tell us that ­ omen do need more of certain vitamins and minerals (they need pregnant w more folic acid, more iron, more iodine, and more calcium, for example). This makes sense—­nutrient requirements tend to increase throughout pregnancy ­because a ­woman’s blood volume and plasma volume expand, her uterus and placenta are growing, and she’s sustaining an increasingly large fetus. But as in all ­t hings dealing with nutrition, it’s more complicated than you think: the body can adapt to meet heightened demands, to offset insuf­ ficiencies. It accommodates. A pregnant ­woman is capable of progres­ sively enhanced nutrient absorption—as her body requires more, and her risk for deficiency amplifies correspondingly, her body picks up the slack.

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She makes better use of incoming vitamins and minerals, using what’s available more efficiently to provide for herself and her ­future offspring.34 Similarly, a w ­ oman’s body undergoes real change during pregnancy. In every­t hing from cardiac be­hav­ior and respiration to metabolism, kidney function, and musculoskeletal changes, the pregnant body differs. In other words, the standard lessons in any general anatomy and physiology text­ book do not necessarily translate when a ­woman is pregnant.35 Historically, that g­ reat medical proj­ect to learn about the ­human body has been a male one. In the ancient and premodern worlds, the female body was a deviation—­and a vessel. The early history of medicine is replete with the writings of male scientists, academics, and physicians who probed and philosophized about the male body with intense curiosity and scru­ tiny, while only occasionally speculating about the divergent form, the female body. But sex bias in medicine is no ancient phenomenon. Male doctors con­ tinue to outnumber female doctors (although, in 2017, for the first time, more ­women than men enrolled in medical schools across the United States), and most medical knowledge has literally derived from men. Indeed, many of modern medicine’s milestone clinical ­trials enrolled only male participants (even animal studies are skewed ­toward male subjects, as are studies intended to treat exclusively w ­ omen’s health issues), and yet their findings have been equally applied to ­women’s bodies. (Furthermore, although medicine has traditionally excluded ­women from formal study, it has periodically used their bodies—­especially t­ hose of w ­ omen of color—­ for experimentation. Examples of such wrongful exploitation abound in the historical rec­ord.36) But ­women’s bodies are not men’s bodies. The longstanding male bias in medicine and medical research has had two interrelated consequences. In the first place, medicine simply knows far less about the female body and its unique symptomology. One doc­ tor described the situation to a New York Times reporter like this: “We

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literally know less about ­every aspect of female biology compared to male biology.”37 This dearth of information, in turn, has led to devastating consequences for ­women’s health. As journalist Gabrielle Jackson wrote in her book Pain and Prejudice, “diseases presenting differently in w ­ omen are often missed or misdiagnosed, and t­ hose affecting mainly w ­ omen remain largely a mys­ tery: understudied, undertreated and frequently misdiagnosed or undi­ agnosed.”38 In a report for the Institute of Medicine, two researchers further explained that the “information deficits” in medicine’s understanding of ­women’s health and the female body actually create a situation in which ­women carry an undue burden of risk: they are clinically treated using approaches devised, studied, and evaluated in men.39 The consequences are far-­reaching indeed, spanning from clinical errors (or ignorance) and subpar care, to a lack of phar­ma­ceu­ti­cal options and the subtle psycho­ logical ramifications of simply being a female patient. All the sequential prob­lems that stem from this male bias are exacer­ bated in pregnancy, as pregnant ­women are even more underrepresented in research than ­women in general. And pregnant w ­ omen of color, who are even less vis­i­ble in the medical canon, are two to three times more likely to die from pregnancy-­related complications compared with white ­women. The situation is less than ideal (obviously), besides being unequal. And combined with the numerous rabbit holes scattered across the field of nutrition, it is not very surprising that the research evaluating vitamin sup­ plementation in pregnancy is wanting. Aside from the under­lying (and vast) gaps in our understanding of nutrition science and prenatal health, ­there are numerous practical chal­ lenges associated with merely managing such studies. It is a strug­gle to control for the manifold differences among ­women and their lifestyle hab­ its; proj­ects assess dif­fer­ent outcomes (preterm birth, birth weight, pre­ eclampsia, and maternal depression are just a few examples), making it

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tough to compare apples to apples; and studies investigate dif­fer­ent micro­ nutrients or combinations of micronutrients, which can make broad con­ clusions even more difficult to discern. Attempts to conclusively isolate and appraise the effects of any par­tic­u­lar supplement are like trying to find a needle in a haystack. The result is a disjointed body of work, with few dis­ tinct verdicts. Ideally, researchers would run prospective randomized controlled ­trials to compare pregnancy and birth outcomes for ­women consuming specific supplements against w ­ omen consuming placebos, but in a culture where prenatals are universal, this simply is not feasible or ethical. In the West­ ern world, most research takes place retrospectively, meaning that ­women are asked about supplementation ­a fter the fact. This kind of retroactive survey is subject to bias, besides being difficult to interpret.40 All kinds of confounding f­actors cloud the data. For instance, w ­ omen who take pre­ natal vitamins tend to be healthier, live in h ­ ouse­holds that earn more money, and not smoke, all of which are in­de­pen­dently associated with improved pregnancy and birth outcomes. An ironic twist is that multivi­ tamin users typically consume more micronutrients to begin with; b ­ ecause they reap more from their daily diets, they are consequently less likely to benefit from additional supplements.41 On that note, evidence demonstrating that prenatal multivitamins con­ fer benefits comes almost exclusively from the developing world. Most of the best studies with favorable outcomes have been conducted in countries with ­limited resources, high rates of malnourishment and vitamin defi­ ciencies, and ­limited access to health care. Th ­ ese results are not necessarily transferrable to resource-­rich nations such as the United States. Even the WHO, whose job it is to consider the well-­being of the entire planet and prioritize international public health, recommended only routine folic acid and iron supplementation during pregnancy up ­until 2020, when it updated its guidelines to recommend multivitamins (a change that was instituted ­after I was pregnant and ­after this book was completed, in fact).42

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The most recent Cochrane reviews* of prenatal multivitamin use, in 2017 and 2019, drew most of their evidence from low-­or middle-­income countries (such as rural Nepal, rural western China, a handful of African nations, Pakistan, and Bangladesh). In ­those places, multivitamin use did correlate with significant decreases in low-­birth-­weight births (defined as less than five pounds, eight ounces, regardless of an infant’s gestational age at birth; on average, babies born in the United States weigh eight pounds), small-­for-­gestational-­age births (that is, smaller than would be expected based on gestational age—­often in the bottom tenth percentile for weight), and preterm births. In the United Kingdom, however, multi­ vitamin use has not been associated with ­t hose same benefits—­having no effect on preterm birth, small-­for-­gestational-­age rates, low-­birth-­weight incidence, or maternal prob­lems such as anemia and preeclampsia. (Mul­ tivitamin supplementation was, however, associated with lower rates of preterm birth for ­women with very low body mass indexes ­under 20.) In 2017, Cochrane authors concluded that their findings “support the effect of [multivitamin] supplements with iron and folic acid in improv­ ing some birth outcomes”—­but only extended their recommendation to “low and middle-­income countries where [micronutrient] deficiencies are common among ­women of reproductive age.” 43 In their more recent reas­ sessment, Cochrane reviewers essentially reiterated the same perspective, emphasizing the potential benefits of prenatal multivitamins for pregnant ­women living in low-­and middle-­income countries. ­These reports, alongside other research, suggest that in developed coun­ tries, like the United States, t­ here is scant evidence to justify widespread prenatal multivitamin usage.44 Among ­women without deficiencies, the effects of prenatal multivitamins are “poorly understood,” said two obste­ tricians in the Eu­ro­pean Journal of Obstetrics.45 Multivitamins might help * Cochrane reviews are in­de­pen­dently conducted systematic analyses that respond to vari­ous questions pertaining to health and medicine—­performed by experts who weigh all the available evidence on a given topic, they are internationally regarded as one of (if not the) highest-­quality sources of evidence-­based medicine.

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reduce the incidence of common but serious prob­lems such as low-­birth-­ weight and small-­for-­gestational-­age babies, and they also are associated with lower rates of stillbirth.46 But then again, multivitamins might not be much of a help. They d ­ on’t prevent miscarriage or reduce infant mortality.47 And beyond the bene­ fits we know folic acid or iron supplements can deliver, they may not ­ omen,” one recent medical review from have any o ­ thers.48 “For most w the United Kingdom summarized, prenatal multivitamins “are unlikely to be needed and are an unnecessary expense.” ­Women should focus on eating well and getting folic acid, the authors suggested.49 Overall, ­there is clearly a dearth of evidence, and we are especially short on the highest-­quality evidence from randomized controlled t­ rials (not to mention ­those conducted in developed countries akin to the United States).50 From where I’m sitting, that’s a prob­lem, and I won­der if I should toss my prenatal multivitamins in the trash and just take folic acid. But I’m still reluctant. If folic acid won the blue ribbon, a c­ ouple of other particles might deserve honorable mentions. ACOG and the WHO both advise ­women to take daily iron supplements during pregnancy (27 mg and 30 to 60 mg, respectively) ­because the pregnant body needs more iron. Compared to about 18 mg daily before she conceives, a pregnant ­woman needs about 27 mg iron daily (pregnant vegetarians need even more: about 48 mg). Actually, pregnant ­women also need progressively more iron over time ­because their blood volume increases with each passing week of pregnancy. By the time they go into ­labor, about a third of ­women living in industri­ alized countries could have iron depletion.51 Low iron can impact the immune system and energy levels, and iron-­deficiency anemia (a lack of healthy red blood cells) is associated with increased risks for preterm ­labor, intrauterine growth prob­lems, and perinatal depression—­a ll obvious prob­lems we want to avoid.52 Yet the iron guidelines are not unan­i­mous. In the United Kingdom, the National Institute for Health and Care Excellence does not recommend

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routine iron supplementation during pregnancy ­because it can cause “gas­ tric irritation and constipation or diarrhea.” (The organ­ization does sug­ gest screening for iron, however, to identify iron deficiency.)53 Meanwhile, vitamin D supplementation recommendations are almost perfectly reversed, albeit equally unsettled. A 2016 Cochrane review sum­ marized that “the evidence on ­whether vitamin D supplementation should be given as a part of routine [prenatal] care to all ­women to improve maternal and infant outcomes remains unclear.”54 (In late 2019, the updated Cochrane review on this subject noted that vitamin D supplementation may reduce the risk of gestational diabetes, but also that it might make “­little or no difference” in mitigating other adverse outcomes.) In this case, the lack of scientific data seems to be a greater reflection of just that—­a lack of data—­t han a reflection of what pregnant ­women should do about vitamin D.55 As vitamin D expert Bruce Hollis, a professor at the Medical University of South Carolina, explains, the current vitamin D recommen­ dations for pregnancy are “based on ­little, if any, scientific evidence,” so they are “clinically irrelevant with re­spect to maintaining nutritional vita­ min D status.”56 Clinically irrelevant? One of the only ­t hings we know for sure about prenatal vitamin D supplementation is that it does increase vitamin D levels. Although inad­ equate vitamin D levels have some correlation with adverse outcomes, researchers have yet to link vitamin D supplementation with improved pregnancy outcomes.57 ­There are many ways to assess vitamin D, but the standard test is a serum blood-­level mea­sure­ment, expressed as nano­ grams/milliliter (ng/mL). Maddeningly, ­there is no universal standard for “deficiency” or “insufficiency.” The U.S. National Institutes of Health information page on vitamin D states that anything above 20 ng/mL is prob­ably fine “for most ­people,” but many specialists believe that mini­ mum levels should mea­sure at least 32 ng/mL. ­Because t­ here is no defined “optimum level” for pregnant ­women, esti­ mates of vitamin D deficiency in pregnancy vary widely, ranging from

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averages of 5 ­percent to 50 ­percent in the United States, and reaching as high as 84 ­percent worldwide.58 (One article in the American Journal of Obstetrics and Gynecol­ogy asserted that vitamin D deficiency during preg­ nancy “is a worldwide epidemic.”59) Based on the apparent prevalence of deficiency, more U.S. physicians are coming out in ­favor of (higher) vita­ min D supplements, and guidelines in the United Kingdom advise that pregnant w ­ omen take a modest daily vitamin D supplement (400 inter­ national units, or IU).60 The American College of Obstetricians and Gynecologists does not recommend routine vitamin D supplementation, however; nor does it even recommend universal screening to check ­women’s vitamin D levels.61 ACOG’s Committee Opinion (its formal position, meant to advise clin­ ical practice) on vitamin D in pregnancy (devised in 2011 and reaf­ firmed in 2017) set forth its ­simple rationale for ­t hese guidelines: “­t here is insufficient evidence” to justify other­w ise. Although ACOG acknowl­ edged the possibility that pregnant or lactating ­women might need more than the RDA of 600  IU of vitamin D (as dictated by the Food and Nutrition Board at the Institute of Medicine), the organ­ization still concluded that ­women only need to be screened if t­here is reason to suspect they have a deficiency. (In the case of deficiency, it suggests tak­ ing 1,000–2,000  IU daily.) Excepting that, ACOG said, “routine vita­ min D supplementation during pregnancy beyond that contained in a prenatal vitamin [400 IU] should await the completion of ongoing ran­ domized clinical t­ rials.” 62 I ­don’t take issue with ACOG’s decision about vitamin D ­because ­there is a lack of evidence that supplementing with vitamin D extends benefits. But ­here is my question: ACOG ­doesn’t officially recommend a prenatal multivitamin, so how and why does its committee opinion on vitamin D appear to be banking on pregnant ­women consuming them? This ­isn’t to say that obstetricians d ­ on’t advise their patients to take them (they do) or that they ­shouldn’t (I’m not a physician). But it does raise questions. Pre­ natal multivitamins are apparently so omnipresent in the United States

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as to be taken for granted—so how is this impacting our continued, fal­ tering attempts to try to understand supplementation during pregnancy?

What’s Worth It? Vitamins are not merely benign, and sometimes less is more. Excessive doses can be harmful to users, and some substances, such as vitamin A, are even associated with fetal malformations.63 So without clear evidence, why are any ­women taking prenatals, and why are our doctors and nurses asking us about them?* It turns out that the enigma of multivitamins is not confined to prenatals—­far from it. The supplement industry is worth $30 billion, and it’s growing. Millions of Americans are enamored with vitamins, and the rapidly mounting pile of evidence against their efficacy has had ­little impact on supplement usage. Experts are at a loss to explain how the spate of data challenging the perception that multivitamins “work” in any capac­ ity has yet to make even a dent in consumer patterns; the best explana­ tion they can come up with is the age-­old notion of “nutritional insurance.” They, along with journalists, historians, and physicians, reveal that the legacy of vitamins—­our widespread unsuspecting faith in their magical curative powers—­has deep cultural roots. The answer to one snide Slate headline—­“Study Finds Multivitamins Are a Complete Waste of Money, Why Do We Keep Taking Them?”—­remains unresolved. The Slate article was in fact a commentary on an Annals of Internal Medicine piece entitled “Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements.” That piece, coauthored by a group of physicians working at prestigious medical institutions such as Johns Hopkins Univer­ sity, urged against routine supplement use. “We should translate null and * I am not alone in asking t­ hese questions. With headlines such as “Wait, Are Prena­ tal Vitamins Actually a Scam?” and “Do Pregnant W ­ omen ­Really Need a Multivita­ min?,” recent media pieces are tapping into ­t hese concerns.

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negative findings into action,” the authors wrote. “The message is s­imple: Most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided . . . ​We believe the case is closed.” 64 Doctors stress that routine vitamin use should especially be discour­ aged among the general population. As Pieter Cohen, a physician and professor of medicine at Harvard, wrote plainly in the Journal of the American Medical Association in 2016, “for the majority of adults, supplements likely provide ­little, if any benefit.” 65 Maybe that is exactly the prob­lem—­“ for most p ­ eople.” Social science research clearly shows that most Americans do not think they are “most ­people.” The average American thinks he is better than average, dif­fer­ent, and special. I try to avoid this trap, but I’m unable to escape it: I am a vegan, I remind myself; I am pregnant; I am healthy; I am not “the general population.” But the unconvincing evidence on multivitamin supplementation in pregnancy mirrors the unconvincing evidence on multivitamin supple­ mentation at large. Why, then, does t­here seem to be so much hype about prenatal multivitamins? One reason is prob­ably b ­ ecause prenatals are an easy way to try to make sure ­women are getting folic acid. In fact—­flying in the face of my own biased perceptions of prenatal multivitamins as universal—­many w ­ omen do not know or think to take them. I am at the beginning of a second planned pregnancy, am fully insured, am financially stable with work flex­ ibility and have access to health resources. But this is not the norm. According to a 2017 March of Dimes poll, only a third of w ­ omen reported taking a prenatal vitamin before they knew they ­were pregnant (and we know that this is exactly when they need to do so in order to obtain the full benefits of taking any such supplement). Furthermore, Hispanic and Black ­women ­were even less likely to have begun to take a multivitamin before learning they w ­ ere pregnant (27 ­percent and 10 ­percent less likely,

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respectively)—­a highly significant ­factor considering that babies born to ­women of color are also more likely to suffer from neural tube defects.*,66 A study out of Boston found similarly disconcerting results: the public health message about folic acid has not reached ­women in vulnerable populations. Among the nearly 8,000 low-­income mother-­baby pairs enrolled in the Boston Birth Cohort over a sixteen-­year period, the Black and Hispanic w ­ omen who w ­ ere expecting had lower folate levels and higher rates of folate insufficiency compared with the white w ­ omen.67 In theory, the cost of prenatal vitamins (which varies widely, from pennies to dollars per day) would be a moot point—­under the Affordable Care Act (ACA), insurers are required to cover maternity care, including folic acid and/or a prenatal multivitamin. But this alone does not ensure access or wherewithal. Some plans require a doctor’s prescription—­which involves not only the means to schedule and attend a prenatal appoint­ ment but also—­and this is even more infuriating—­a positive pregnancy test. By the time a w ­ oman has a positive pregnancy test in hand, it is already almost too late to achieve any protective benefits of a folic acid supplement. Coverage is a start, but it only begins to fill in the gaps in in­equality in prenatal care. Such inequities are likely one reason why medicine might regard pre­ natal vitamins as a stand in for folic acid supplements. The prenatal care clinical guidelines at the University of Michigan typify this perspective: “routine use of prenatal multivitamins is not recommended as they have not been shown to improve pregnancy outcome, although they offer a con­ ve­nient source of folic acid.” 68 I understand the rationale, but the logic is still somewhat flawed from my perspective. If it’s about one ­simple ques­ tion, what makes it easier to ask w ­ omen about prenatal multivitamins than about a folic acid supplement? If it’s a compliance issue, why would doc­ tors trust that ­women are taking prenatals but not folic acid alone? * A mong all American adults, minorities and individuals with lower levels of educa­ tion are less likely to consume supplements compared with white Americans and ­people with more years of schooling.

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One impression that kept coming up again and again in my research was the idea that multivitamins might not be demonstrably advantageous to infant or maternal outcomes, but neither are they evidently harmful. As Harriet Hall, a physician who helped found and writes for the blog Science-­Based Medicine, recently exclaimed, “­there is no good evidence to support the routine use of multivitamins . . . ​but t­ here is no good reason not to use them. If doctors recommend them, they should be honest about the uncertainty of the evidence and let their patients participate in the decision.” 69 In an interview with Time magazine, Dr. Scott S­ ullivan, the director of maternal and fetal medicine at the Medical University of South Carolina, said the same. No harm, no foul.70 Perhaps that is true, but it belies the broader perspective. One pos­si­ble reason that we are so accepting of prenatal multivitamins (even without evidence) combines economics with some just-­in-­case reasoning and dis­ tinctly American ideals of consumption—­prenatals are generally no more expensive than folic acid alone. Why not get more? Judging by their be­hav­ior, many American consumers are primed and willing to believe in the sensational—­t hat vitamins have the capacity to protect, to soothe, to calm, to energize, to alleviate the complaints of every­ day life. And it is no surprise that manufacturers are equally ready and willing to deliver. With billions of dollars on the t­ able and a steadily rising demand from consumers, is it any won­der that developers are churning out evermore niche supplements with increasingly sophisticated advertis­ ing and design at an alarming clip? The internet is replete with specialty prenatal vitamins and prenatal vitamin “roundups” touting products that sometimes cost upward of $50 per month (and some prescription prena­ tal multivitamin supplements have price tags in the hundreds of dollars), all of which might be grossly unnecessary. A generic folic acid supplement that would last through an entire pregnancy costs roughly six bucks. Most of all, the concept of nutritional insurance, constructed more than a ­century ago, is still alive and well. Perhaps it even thrives all the ­ omen are not more so during pregnancy. Even though many American w

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malnourished or suffering from deficiencies, prenatal vitamins are an easy way for us to be “better safe than sorry.” Trying to isolate singular defi­ ciencies among all pregnant ­women could be time consuming, expen­ sive, and exhausting—­for doctors and w ­ omen alike. Researchers still ­a ren’t sure ­whether some circumstances might warrant prenatal multivi­ tamin supplementation: veganism, vegetarianism, multiple-­gestation preg­ nancies, certain racial backgrounds. But even ­these hedges, as far as I can tell, are not grounded in critical investigation or conclusive evidence. Instead, they flow from the nutritional-­insurance-­policy reasoning, which may or may not have any credence.71 With patients emanating from all dif­fer­ent circumstances and wildly varying dietary habits, maybe prena­ tals are, simply, simpler. At the end of this I am left disillusioned with nutrition science and frus­ trated with a culture of blind faith. Through my efforts to come to terms with gulping down my prenatal tablet e­ very eve­ning, I know only a ­little more for certain than I did to begin with: to be watchful of oversupple­ mentation, to doubt grandiose claims, to be wary of reducing nutrition to a science, and to keep my expectations in check. I am confronted with the plain real­ity that beyond folic acid—­and maybe iron or vitamin D, depend­ ing on who you ask—­t here exists no clear evidence demonstrating bene­ ficial outcomes for vitamin supplements for most w ­ omen in the United States. But I still ­can’t shake my habit. I still ­can’t bring myself to trade in the ­whole indefinite gamut for the one substance I can rest assured might ben­ efit my ­future child. Despite my better judgment and my best efforts, I fall victim to the same faulty, speculative logic that has beguiled Americans for almost a hundred years. I accept the unproven, I take the insurance. I hope it provides.

chapter 2

•

Endure

For such a universal hardship, morning sickness is almost completely obscure. No one knows for certain why pregnant ­women experience it, what ­causes it, why it’s correlated with better pregnancy outcomes, or what to do about it. I began thinking about morning sickness even before I became preg­ nant, at the urging of a close friend who wanted some answers. Unbe­ knownst to me, her timing was perfect. She told me that she read online that low magnesium was the overlooked cause of morning sickness. Her sources suggested spraying magnesium oil on your skin and taking mag­ nesium bath soaks (Epsom salt baths), and she wanted to know w ­ hether ­there was any truth to t­ hese purported cures. Even more, was t­ here any harm in them? I am a wary consumer of online instruction; the internet is replete with morning sickness theories and advice—­some are rational, but many more are misplaced. I found almost no credible information about using mag­ nesium in any form for relief from nausea and vomiting, although it is sometimes used (despite a dearth of data) for ­later complications such as preeclampsia.1 One 2016 article in Nutrition Reviews made the case that many pregnant ­women do not consume the recommended daily intake of magnesium, and that a low-­dose magnesium supplement “could be

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safely recommended to pregnant w ­ omen in general,” but it was hardly compelling, especially given the authors’ own admission that the “require­ ments of magnesium in pregnancy are not well understood.”*,2 While I cannot comprehend promoting unproven, self-­styled, or “natu­ ral” remedies at large, I do comprehend the desperation driving w ­ omen to consume them. (Plus, when did a nice bath ever hurt anyone?) Morn­ ing sickness is loathsome, and even the most reputable scientific sources shed ­little light on the topic. When I set out to learn about morning sick­ ness, I discovered a ­great deal, but came up with hardly anything satisfying to pass on to my friend. Thanks to my friend’s timely question, though, I’ve begun my intellec­ tual quest for morning sickness solutions and answers well in advance of my own indisposition. My research has me hyper-­tuned-in to my e­ very sensation. Before t­ here is nausea, I notice my appetite shift. Food moves out of my purview. Once a central component of my daily life and rou­ tine, a source of excitement and anticipation and plea­sure, food becomes a distant consideration. I am indifferent. I am a listless eater. The absence of hunger is unsettling, like the calm before the storm. How surreal it is, too, to want to feel sick. I eagerly await any outward sign of the life growing inside me. I grope for the slightest sensation of nau­ sea, then won­der if I am conjuring non­ex­is­tent symptoms, falling victim to my own ­mental trickery like some kind of ex­pec­tant hypochondriac. The cold I am battling, courtesy of my husband and son, ­doesn’t make this guessing game any easier.

Morning sickness occurs all over the globe, in Eu­rope and Australia, in India and Israel, in Japan and Nepal and Tanzania. The rate varies from nation to nation, ranging from as low as 35 ­percent to almost 90 ­percent,

* The authors noted that ­women should not exceed the upper limit of 350 mg/day, and that most prenatal vitamins contain magnesium.

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with a worldwide average of roughly 66 ­percent. In the United States, most pregnant w ­ omen—­around 80 ­percent—­suffer from morning sickness, and between a third and a half vomit. Nausea typically commences between the fifth and seventh weeks of pregnancy. More precisely, research shows that most ­women begin feeling sick at around thirty-­nine to forty days of gestation, just a day or two before the six-­week mark.3 It usually lasts a ­little longer than a month, although it can last much longer.4 When I wake up on day forty-­two, I feel like I have a mild hangover. The next ­couple of days I feel like I have a more punishing hangover. A cup of coffee is manageable, and I am fine, but I do not usually feel like this. Miss Clavel’s famed words from the ­children’s book Madeline stay with me: “Something is not right!” And yet I second-­guess my own com­ plaints. Maybe I’m imagining ­t hings; maybe this is just my cold from last week. Maybe I am no dif­fer­ent from anyone e­ lse. I take a closer look at my prenatal vitamin; it has a ­little bit of magne­ sium. I swing by Trader Joe’s and pick some up. I cringe at the checkout as the cashier hands me the receipt.

Morning Sickness Management: Mapping the Terrain The current terrain for addressing morning sickness (including ­whether it even needs addressing in the first place) is murky. Dif­fer­ent answers emanate from dif­fer­ent crowds, and t­ here exists ­little conclusive data. Dietary counsel is typically the first line of defense against nausea and vomiting: eat first ­t hing in the morning, eat small meals, eat frequently throughout the day, consume ­simple, easily digested carbohydrates, avoid high-­fat foods. Some ­women find t­ hese strategies helpful, but for o ­ thers they are fruitless. Th ­ ere certainly ­isn’t much evidence that they alleviate nausea.5 ACOG guidelines recommend taking some vitamin supplements before conception, and also suggest a combined vitamin B6 or vitamin B12 plus doxylamine (an antihistamine frequently used to alleviate

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allergy symptoms) therapy as the first line of treatment if s­ imple dietary adjustments fail.6 A 2016 JAMA: Journal of the American Medical Association review highlighted t­hose therapies that outperform a placebo: a  hodgepodge mix of supplements, over-­the-­counter medicines, and prescription drugs (ginger, vitamin B6, antihistamines, metoclopramide, pyridoxine-­doxylamine, and ondansetron). The evidence for acupres­ sure and acu­punc­ture was unclear. Overall, though, the review found that the evidence for all the therapies was lacking and low quality.7 This scarcity stems at least in part from the legacy of medical interventions to treat morning sickness in the past. Medicine began to experiment with more “legitimate” (read: phar­ma­ ceu­ti­cal) interventions in the mid-1900s. Some of them backfired, result­ ing in dire consequences for individual w ­ omen and families as well as drastic repercussions for research into pregnancy. Indeed, the results have profoundly impacted the scope of prenatal medical research—­and our cul­ tural approach to it. In medicine, “iatrogenic illness” refers to an illness or condition actu­ ally caused by medical intervention, and one of the most devastating examples involved a drug called thalidomide. The drug, introduced in Germany in the late 1950s, was a sedative, marketed as a safe sleep aid for all populations. It was a major success, and with booming sales was quickly exported to dozens of countries. ­Because thalidomide helped alleviate nausea, physicians began prescribing it for morning sickness. Shortly thereafter, they recognized that it was lethal for fetuses: world­ wide, some 10,000 fetal deaths w ­ ere attributed to thalidomide. Among the surviving fetuses, exposure to the drug was associated with (and, as it turned out, directly caused) catastrophic irreversible birth defects. Many babies exposed to thalidomide ­were born with a rare congenital abnormal­ ity called phocomelia, a condition in which limbs are stunted or absent—­ “flipper like.” Thalidomide’s effects are so potent in utero that even a single dose—­one pill—­could wreak havoc on a fetus. Before its consequences ­were apparent and it was pulled from the market, hundreds of pregnant

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­women in the United States took thalidomide; hundreds of families’ lives ­were shattered. At the same time (and for de­cades prior), doctors w ­ ere prescribing a synthetic estrogen first produced in the late 1930s—­diethylstilbestrol (DES)—as a preventative for pregnancy loss and complications (the drug was believed to correct for one perceived cause of miscarriage—­low estrogen levels). But DES did not prevent miscarriage (or anything e­ lse), and its lived consequences ­didn’t become apparent for decades—­not ­until ­women who had been exposed to it in utero started to develop an extremely rare form of vaginal cancer (clear cell adenocarcinoma) in startling numbers. By 1971, the evidence was incontrovertible, and the FDA released a bulletin advising doctors to discontinue DES in preg­ nancy; but 5 to 10 million m ­ others and babies had already been exposed. Before the thalidomide disaster, many Americans believed that the pla­ centa effectively filtered out anything that could potentially harm a fetus, but thalidomide constituted heartbreaking proof that the placenta is no impenetrable barrier. If just one dose of something could be so destruc­ tive, what other dangers might be lurking? The thalidomide crisis—­ immediately followed as it was by the revelations involving the perils of DES—­sent shock waves through the medical profession and American ­ ere terrifying, and they also tarnished medical society. The prospects w authority. The effects are still reverberating. On the heels of ­t hese two disasters, other routine treatments and pro­ visions for pregnant w ­ omen came ­under scrutiny. Case reports of cleft lip and cleft palate with antihistamine use (again, antihistamines constitute a class of drugs used to treat allergy symptoms and motion sickness) dur­ ing pregnancy surfaced. T ­ rials found no evidence of causality, but the FDA ordered that antihistamine labels carry a warning for pregnant w ­ omen. ­After continued research exonerated antihistamines, the FDA allowed for the label’s removal in 1979.8 In fact, in light of what happened with thalidomide and DES, the pro­ cess of getting a drug approved became much more rigorous in general in

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the 1970s—­a nd so did the rules about who could participate in clinical ­ omen, and their fetuses, ­trials. Specifically, the potential risks to pregnant w ­were simply too g­ reat to count them in. New FDA guidelines mandated that researchers exclude “premenopausal females capable of becoming pregnant” from clinical ­t rials. This language—­even ­women capable of becoming pregnant—­effectively excluded all ­women of childbearing age, not just pregnant ­women. As a group, ­women ­were practically sidelined from clinical research altogether.9 The wording stressed the importance of protection—­i mplying that pregnant w ­ omen needed it. Indeed, pregnant ­women ­were tagged as a “vulnerable” population, a paternalistic identification threatening ­women’s equal autonomy. Clinical t­ rials enroll participants on a voluntary basis; the individuals are informed about the study and then elect to participate. Medicine trusts and accepts that adults are capable of making such decisions—­weighing risks against pos­si­ble beneficial outcomes—­but that confidence does not extend equally. In excluding potentially pregnant ­women from clinical ­trials (by default), medicine conveyed that it did not, in fact, trust ­women to do the same. All of this has been a prob­lem for numerous reasons. In the first place, as we learned, excluding w ­ omen from medical research has come at a real cost: we lack evidence on how best to treat ­women. In real­ity, the exclusion of w ­ omen has not protected them but left them vul­ nerable: “an emerging consensus suggests that routine exclusion of preg­ nant ­women from research participation leaves ­t hese w ­ omen and their fetuses vulnerable to potentially greater harm from the lack of rigorous scientific evidence of the safety of medi­cations and other interventions that are already being used or avoided in pregnancy.”10 We have, for example, a dearth of data on phar­ma­ceu­ti­cals and preg­ because men and nancy. This poses obvious safety risks, especially ­ ­women metabolize drugs differently—­and pregnant ­women metabolize drugs differently still. The 4 million American ­women who become preg­ nant ­every year do not suddenly stop needing treatment for under­lying

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health conditions; an estimated 4 ­percent of them need additional treat­ ment for chronic gestational conditions such as hypertension or diabetes, and more still suffer psychiatric symptoms that could benefit from treat­ ment. In 2013 in the United States, an estimated 64 ­percent of pregnant ­women ­were prescribed at least one medi­cation, but the real­ity is that we lack information on how ­phar­ma­ceu­ti­cals—­even “everyday” drugs fre­ quently prescribed—­work in and affect the pregnant body. In 2014, one report assessed that a mere 1  ­percent of studies on drug metabolism offered data on pregnancy.11 Indeed, all but about a dozen drugs are pre­ scribed “off-­label” during pregnancy, meaning that they are not techni­ cally approved for use specifically during pregnancy. ­Here, then, is yet another area where ­women come up short. The tide has been turning, however. In the 1990s, Congress and the National Institutes of Health (NIH) endeavored to begin to address this imbalance, directing that federally funded research proj­ects include ­women. A separate report from the Institute of Medicine recommended that ­women be “presumed eligible” to partake in studies rather than left out by default. The guidance turned the existing onus on its head, man­ dating that investigators justify excluding ­women, rather than the other way around. Such mandates yielded mea­sur­able change, such that by 2012 ­ ere ­women.12 some 57 ­percent of NIH study participants w In 2009, the NIH helped to launch the Second Wave Initiative, a research collaboration aimed at the inclusion of pregnant ­women in clin­ ical research, with the specific goals of improving understanding, treat­ ments, and outcomes for medical issues that arise during pregnancy. In 2014, the NIH spent $10 million to include more w ­ omen in studies; in 2019, new regulatory language reflected the recommendation from ACOG’s Committee on Ethics that pregnant w ­ omen be considered “medically com­ plex” rather than “vulnerable.”13 ­There have, in other words, been some real and admirable efforts aimed at narrowing the evidence gap; fresh voices advocating that ­women and pregnant w ­ omen receive fair and full repre­sen­ta­tion in the production of

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medical knowledge; and even some funding and regulatory commitments to meet the goal. The need is clear and even more urgent in light of recent health crises such as the H1N1 influenza outbreak and the emergence of Zika virus. But closing such vast gaps in knowledge does not happen swiftly, nor easily. (In 2008, one article described pregnancy as a “significant wild card in clinical management.”14 In 2016, another assessed that medical treat­ ment during pregnancy is often based on “informed guesswork.”15) It requires, too, a willingness. The examples of thalidomide and DES are haunting, and they have ­precipitated an understandable culture of mistrust and fear of taking medi­cations during pregnancy. They are excruciating reminders that the prospect of risk is not merely an abstract possibility; it is a palpable fear, a lived real­ity for so many victims. Even among ­women unfamiliar with ­these two specific episodes, their lessons—­warnings—­a re deeply entrenched. As journalist Nina Martin describes, “the ethical and scientific pendulum swung in the direction of extreme caution.”16 And in large part, ­t here it has remained. Experts say that “research with pregnant w ­ omen can be done and it can be done ethically.” But I won­der how many pregnant ­women would agree. I won­der if I do. I see poles—­ramifications, security—on both sides of the aisle. In one sense, the reasons to exclude pregnant ­women from research are the very same reasons to include them. I understand the need for change—­desire to be part of it—­even while I sit ­here think­ ing, Not me. “In some cases,” advocates say, “it’s just a m ­ atter of gathering ‘low ­hanging fruit’—­opportunistically but systematically collecting data.”17 Gathering and analyzing data for be­hav­iors that are already happening anyway sounds like a reasonable start, no? I spend some time on Google, and a­ fter an hour I am submitting a survey to a study investigating life­ style and fertility data. I never even need to leave my desk. I am well

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aware that the contribution is a drop in the bucket—­but how ­else are we ever g­ oing to fill it up?

Despite some advances in inclusion, then, American ­women continue to look with skepticism on pharmacological treatments of any kind during pregnancy (with good reason), and medicine continues to harbor a cer­ tain amount of “therapeutic nihilism” regarding treating a ­whole host of pregnancy symptoms.18 And the shortfall in available information on drugs during pregnancy is ongoing: one group of authors described pregnant ­women as being functionally “orphaned” from the pos­si­ble ben­ efits of pharmacology—­including the possibility of alleviating morning sickness.19 In the dark wake of thalidomide and DES, other morning sickness ther­ apies became a point of contention. Bendectin, a phar­ma­ceu­ti­cal cocktail containing doxylamine and pyridoxine (vitamin B6), was first introduced in the United States in 1956, just a few years before thalidomide.* From that time u ­ ntil it was withdrawn from the market in 1983, more than 30  million American ­women used Bendectin—­a lmost 25  ­percent of ­ omen filed lawsuits alleging that Bendectin ­ regnancies.20 Hundreds of w p had caused defects. Facing years of litigation and millions of dollars in funding to defend over 300 lawsuits alleging damages, the manufacturer simply pulled the drug. Numerous studies at the time showed that Bend­ ectin posed no adverse risks to a fetus; in fact, ­women who took Bendectin actually had lower rates of birth defects.

* In its initial formulation, Bendectin also contained dicyclomine, a drug used to help alleviate unwanted gastrointestinal symptoms and upset stomach (it’s commonly prescribed to treat irritable bowel syndrome). Researchers removed dicyclomine ­a fter they determined that it was unnecessary—­women who received a version of Bendectin without dicyclomine fared just as well.

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In the years that followed the withdrawal of Bendectin from the U.S. market, hospitalizations of pregnant ­women for severe nausea and vom­ iting of pregnancy doubled; the International Federation of Gynecol­ogy and Obstetrics decried the repeal of Bendectin as “the worst example in history of ­women being denied medi­cation without a cause.”21 Similarly, the ACOG Ethics Committee cites the instance as “an example of undue caution that may be a response to the history of thalidomide.”22 The pyridoxine-­doxylamine combination has been more extensively studied than any other treatment for nausea in pregnancy, biomedical or other­w ise. The drug combination has been available in Canada in a delayed-­release form (Diclectin) for de­cades, but it’s not available in the United States. Instead, ­women in the United States who ­really want it are forced to “do it yourself,” by combining a Unisom sleep tab with a vita­ min B6 supplement. Doctors, too, are frustrated with the situation. “No other agent given in pregnancy,” explain obstetrician/gynecologists Jen­ nifer Niebyl and T. Murphy Goodwin, “has more conclusive safety data.”23 The next closest drug has less than 10 ­percent as much data as doxylamine-­ pyridoxine. Studies consistently show that this combination drug ther­ apy improves w ­ omen’s symptoms, outperforms a placebo, and does not carry safety risks.24 In 2013 the FDA approved Diclegis—­the same drug as Bendectin—­for morning sickness therapy, and it received an A rating—­the highest pos­si­ble classification for pregnancy. Many physicians continue to sing its praises, based on ample research into the drug’s safety and efficacy. Yet pyridoxine-­ doxylamine is now embroiled in yet further controversy. Several doctors are worried that the FDA’s approval of Diclegis was based on a flawed study from the 1970s, with missing data, so t­hey’ve ­stopped prescribing it.25 The debate is unresolved, but the history of phar­ma­ceu­ti­cal repercussions for pregnant w ­ omen and their babies is bubbling ­under the surface. Another modern option, ondansetron (Zofran), is similarly fraught. Originally used as an antinausea medi­cation for chemotherapy patients,

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ondansetron turned out to work very well against morning sickness. In clinical studies, it is a top performer and consistently outshines other phar­ ma­ceu­ti­cal agents.26 Based on several proj­ects and reviews, prac­ti­tion­ers mostly agree that ondansetron is safe and has few, if any, risks, but a c­ ouple of conflicting results have raised eyebrows.27 Recent reviews of ondansetron highlight that the most robust proj­ects validate ondansetron’s safety. A 2016 analy­sis summarized that “although the safety studies published to date pre­sent sometimes conflicting results, it appears that ondansetron [use] during pregnancy is generally safe and is very effective for treating nausea and vomiting in pregnancy. Some data suggest a mildly increased risk of cardiac septal defects, although this asso­ ciation is not consistent across studies. Given ondansetron’s demonstrated efficacy . . . ​its use should not be completely discounted.” To minimize risk, the researchers suggested that ondansetron not be a first resort; ide­ ally, they added, it could be avoided in the first 10 weeks’ gestation, when the fetal cardiovascular system is forming.28 But obstetricians’ widespread confidence in ondansetron cannot erase suspicions. When I get together with a close friend from college who hap­ pens to be an obstetrician, I ask him what he thinks. “We have ­things that work,” he says. But he also tells me that his wife has suffered miserable morning sickness throughout all six of her pregnancies, and despite his urging, she remains wary. She’s never taken even a single dose of ondansetron—or anything ­else for that ­matter. For her, any risk is too high. Although medicine offers ­women some options, they clearly are not universally efficacious—or e­ lse they place ­women in the position of mak­ ing “choices” that feel like unnerving trade-­offs. Many ­women are still skeptical of this kind of treatment. Who can blame them? A 2015 Cochrane review directly announced that ­t here is a “lack of high-­quality evidence to back up any advice on which intervention to use . . . ​generally effects ­were inconsistent and l­ imited.”29 Experts admit: “no evidence-­based guide­ lines exist” for managing morning sickness.30

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Medicine’s previous attempts to treat w ­ omen for morning sickness are precisely the reason why so many ­women are so wary of anything that offers them relief.

Theories of Causation It is hardly surprising that treatment modalities have been so variable and in­effec­tive, ­because the cause or ­causes of morning sickness are definitively unknown. It’s very difficult to treat a condition without knowing anything about its origins. The foremost theories about the source of morning sick­ ness relate to pregnancy hormones and natu­ral se­lection. One prevalent concept for explaining morning sickness is that it is the consequence of mounting pregnancy hormones, especially h ­ uman chori­ onic gonadotropin (hCG). The concomitant timing of nausea and vomit­ ing with the rise and fall of hCG in early pregnancy is suspicious, but the correlation is perplexing. Scientists have no proof that pregnancy hor­ mones cause nausea and vomiting. Thousands of ­women whose bodies produce hCG during pregnancy experience no feelings of illness. And although conditions traditionally associated with elevated hCG levels, such as multiple gestations, tend to have higher rates of (worse) morning sick­ ness, the association is not always true. A separate hypothesis seeks to explain morning sickness without ­necessarily identifying its under­lying biological c­ auses. The premise is evo­ lutionary: that nausea and vomiting during pregnancy have an “adaptive significance,” protecting ­women and their embryos from potentially dam­ aging foods and substances. The theory holds that sensations of illness—­ ­ omen from consum­ and common food aversions they cause—­prevent w ing foods that might harm a fetus (such as alcohol, caffeinated beverages, and meats or strongly flavored vegetables that might carry toxins or micro­ organisms, especially if ­t hey’ve gone bad or are eaten undercooked). In turn, t­ hose foods most ­women who experience morning sickness can tolerate—­g rains, bland plant-­based foods—­tend not to pose potential

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health risks. By this explanation, morning sickness is functional, a utili­ tarian affliction. It is the body at work, inelegantly but valiantly defend­ ing the immunosuppressed pregnant w ­ oman and her fetus. This idea, introduced around 1940 as the “embryo protection hypothesis,” has since become a sophisticated evolutionary argument. It is an in­ter­est­ ing proposition. Morning sickness does not occur in other mammals, presumably ­because h ­ umans have an incredibly more diverse diet by comparison. It also coincides with organogenesis, the weeks when an embryo’s organs are forming and it is most vulnerable. Widespread food aversions—­meat, veg­ etables, alcohol—­happen to also be foods and substances that, especially in the past, could harm an embryo if spoiled, contaminated, or improp­ erly cooked. Common foods craved—­simple grains and carbohydrates—­ pose ­little risk. Socie­ties with higher intakes of trigger foods like meat and milk tend to have higher rates of morning sickness, while socie­ties whose traditional cuisines do not feature animal foods tend to have lower rates. Plus, ­women with morning sickness are statistically less likely to suffer a miscarriage.31 But this proposition is not necessarily airtight. Morning sickness is not necessary for or definitively predictive of a healthy pregnancy and birth. Plenty of expecting ­mothers who experience no symptoms go on to have perfectly healthy babies, just as plenty of expecting m ­ others who do have symptoms experience loss. Some scholars (and expecting w ­ omen) who are critical of this theory point out that many of the foods repugnant to ­pregnant w ­ omen, such as vegetables, are beneficial to a growing embryo. Indeed, researchers have documented that consuming such foods endan­ gers neither fetus nor ­mother.32 This seems irrelevant, however, given that the theory’s premise is entirely adaptive—­a much more convincing coun­ terpoint would be to prove that t­ hese foods and substances w ­ ere not harm­ ful in the past. As anthropologist Ivy Pike explains, modern studies examining morning sickness take place in Western cultures, where nutri­ tion is not typically a life-­or-­death m ­ atter; if anything, overnutrition is a

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bigger prob­lem. “This is clearly not the environment of our evolutionary past,” she says.33 Furthermore, if we accept the evolutionary argument—­t hat morning sickness plays a protective role for the fetus—­what does this imply about treatment? Should w ­ omen seek relief from a malady that evolved to safe­ guard the life growing inside them? Some scholars do question ­whether treating nonsevere morning sickness is actually a good t­ hing. Perhaps eliminating nausea and vomiting, they speculate, might be worse than suf­ fering them.34 It raises a valid question—­whether morning sickness should be cured. Americans, perhaps, might be more prone to believing that it should, given our expectations that medicine bestow us with magic bullets as well as our expectations that pregnant w ­ omen continue to “do it all.” But maybe we’d be better off thinking of morning sickness as part and parcel of normal pregnancy, something that need not be righted. ­There may be some appeal to such a practical perspective, but it cer­ tainly lacks compassion, especially when cultures around the world, midwifery practices, and even the WHO all offer at least suggestions for alleviating morning sickness. ­There is something validating in this, in respecting pregnant ­women’s nausea and vomiting as worth remedying. And treating morning sickness “does not lead to worse pregnancy out­ comes. If anything, the opposite is true,” explains Amy Kiefer, a scientist who now blogs about pregnancy research.35 One t­hing is for certain: t­here is no straightforward explanation. The likely-­ but-­ wholly-­ unsatisfying, possibility is that morning other, more-­ sickness has many and varying ­causes—­that it is a syndrome with multiple pos­si­ble (and prob­ably interacting) origins, not one singular pathway.36 That the real cause of morning sickness has continued to escape gen­ erations of physicians and scholars makes its treatment all the more elusive. ­These theories each have merit, but they are relatively new explanations. In the past, moderate conceptions of morning sickness mingled with more perverse approaches.

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Nausea and Vomiting of Pregnancy: Then and Now, Mind and Body One ­thing is clear: w ­ omen have been experiencing morning sickness for thousands of years. It is documented in the ancient writings of Hip­ pocrates, the humoral works of the Re­nais­sance period, the earliest obstetric texts from the nineteenth c­ entury, and twentieth-­century medi­ cal journals. Soranus, a physician who practiced in the Roman Empire, described an ailment affecting pregnant ­women: a sickness that began around 40 days’ gestation and lasted for many weeks. (Among his many prescriptions: a one-­day fast, a full-­body rub-­down with “soft linen,” hot baths, “a l­ittle weak wine,” light exercise, reading out loud, and danc­ ing.)37 In the late 1700s, a medical text on midwifery explained that “the first complaint attending pregnancy is the nausea and vomiting which in some ­women begins soon a­ fter conception and frequently continues till the end of the fourth month.” Bleeding was recommended.38 In the 1800s, as they attended more pregnant w ­ omen, physicians became more interested in nausea and vomiting during pregnancy. In large part, they continued to interpret it in terms of bodily balance, as “the body rid­ ding itself of . . . ​‘evil humors.’ ” Obstetricians thought vomiting itself both prevented an excess of blood and helped relieve ­women of nausea. They thus frequently relied on purgatives and emetics (substances that trigger vomiting), a scourge that would make modern prac­ti­tion­ers cringe. In his 1858 Manual of Obstetrics, William Tyler-­Smith recommended that w ­ omen be “puked occasionally with warm w ­ ater, chamomile tea, or a mustard emetic.” But many doctors also held that nausea and vomiting in preg­ nancy ­were the result of basic anatomical changes—­stretching and flexing ­here, constrictions or excess pressure ­there—or vari­ous uterine abnormali­ ties. They occasionally recommended sedatives (including opium) for relief, as well as rest and dietary advice (eat sitting upright, consume bland foods), or uterine repositioning procedures. More often, though, doctors took no action—­why intervene on a normal, healthy reaction? Regardless

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of what they believed to be the cause of nausea and vomiting in pregnancy, most doctors did consider its presence normal—­“a ­thing that must be.”39 For their part, literate ­women wrote of the miseries of morning sick­ ness (and sometimes their desire to alleviate it—­advice lit­er­a­ture and let­ ters reveal that ­women turned to numerous cordials and concoctions for relief), but they also regarded it as an ordinary, and even favorable, aspect of pregnancy. In fact, as Rachael Russell shows in Nausea and Vomiting: A History of Signs, Symptoms and Sickness in Nineteenth-­Century Britain, most pregnant w ­ omen in the past ­were quite accepting of nausea and vom­ iting, such that their attitudes colored medical ideas about it. (Pregnant ­ ere of course individual—­women internalized the ­women’s experiences w experience differently—­but most written rec­ords suggest a certain con­ tented ac­cep­tance of the condition. Compared to a typical ­woman in the twenty-­first ­century, ­t hese ­women spent much more of their lives preg­ nant, but generational wisdom taught t­ here was ­little to be done about morning sickness.) In other words, doctors in the nineteenth c­ entury seem to have largely ­adopted pregnant ­women’s tolerance for nausea and vom­ iting, framing them as customary in pregnancy.40 Indeed, advice lit­er­a­ture and doctors alike considered nausea and vom­ iting one of the first signs of pregnancy, so common that their absence was more unsettling than their regrettable impacts. This helps explain at least one reason why many nineteenth-­century ­women believed nausea and vomiting ­were “beneficial to pregnancy.” In an era when w ­ omen did not have access to any kind of laboratory pregnancy testing, much less a home testing device, nausea and vomiting ­were practical indicators of conception, “a clear sign” of pregnancy. Although it can now be easily detected by any layperson, pregnancy was once a skillful diagnosis, and ­women’s sensations of nausea and vomiting played an impor­tant role. Fur­ thermore, ­women’s experiences taught them that “a sick pregnancy is a safe one.” Remarkably, they thought sickness prevented miscarriage (then-­ called a “spontaneous abortion”). “­Women and their doctors . . . ​agreed that the occurrence of sickness proved the health of both baby and

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­mother.” As such, pregnant w ­ omen infrequently sought treatment for nausea or vomiting, and doctors infrequently imposed it.41 Nineteenth-­century doctors typically employed practical descriptors to discuss vari­ous prob­lems at hand. In this case, they used labels such as “nausea and vomiting of pregnancy,” “nausea and vomiting in pregnancy,” or “pregnancy vomiting.” By the mid-1800s, a new phrase—­“morning sickness”—­had surfaced, becoming “almost vernacular” by the 1850s. Many con­temporary physicians opposed the expression and derided it as sense­ less. In 1892, one M.D. candidate wrote in his dissertation that the term morning sickness was “unfortunate and unmeaning.” 42 Alas, the tag endured. This is fascinating considering the twenty-­first ­century campaign to extinguish the phrase “morning sickness” and replace it with the unwieldy—­but undoubtedly more accurate—­label “nausea and vomiting of pregnancy,” or NVP. (Pregnant ­women everywhere know the colloqui­ alism is painfully false; morning sickness is not confined to the morning. It is around-­the-­clock, likened by one group of researchers to the unremit­ ting nausea that accompanies chemotherapy treatment.43) In a sense we might say that the linguistic shift from morning sickness to NVP in the 2000s (at least in formal medical lit­er­a­ture) is less a step forward than it is a regression to the late-1800s descriptors. Backtracking has its benefits. But not always. Pity the ­woman suffering from extreme morning sickness around 1900, when some physicians began to adopt the theory that NVP—or at least, some cases of it—­were the physical symptom of psychiatric imbal­ ance, a female neurosis. As it went, a w ­ oman might suffer from NVP because her body was subconsciously, psychosomatically rejecting her fetus. Nausea and vomiting w ­ ere thus a “symbolic rejection of the pregnancy.” More broadly, doctors suggested that certain ­women ­were increasingly vulnerable to “excessive” NVP based on their nerves.44 Although this hysteria explanation could be applied to NVP generally, it w ­ asn’t necessarily a­ dopted across the board; instead, it was often reserved for the most severe instances of NVP. That designation alone—­severe

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NVP—­illustrates that doctors saw the near-­universal symptoms of nau­ sea and vomiting in pregnancy as falling across a spectrum, where intense severity could be indicative of pathology. It was a subjective distinction, but physicians speculated that violent NVP was a kind of extreme mani­ festation of “normal” NVP. They denoted t­ hese most intense cases—­about one in a thousand—as “pernicious vomiting of pregnancy,” or sometimes hyperemesis gravidarum, and said such cases ­were clearly distinct from the typical vomiting of pregnancy for both longer duration and intensity. Where they rarely saw the need to intervene for “regular” NVP, severe NVP was another story.45 Despite their subjective barometers, physicians often regarded the dis­ tinction as clear-­cut: “it is a definite, well-­recognised, and unmistakable disease,” explained one doctor in 1922.46 In fact, identifying a pathologi­ cal level of vomiting in pregnancy contributed to making moderate NVP “normal” or expected. At the time, the cause of pernicious vomiting was no dif­fer­ent than that of normal nausea and vomiting of pregnancy: “some neurosis allied to hysteria.” It was just . . . ​more so. Although ­t here was some discussion of toxemia and carbohydrate deprivation, as well as a loyal following to the uterine position hypothesis (that the uterus was situated “wrongly”), many physicians ascribed to the hysteria view, that pernicious vomiting of pregnancy was “always of neurotic origin.” 47 In the most extreme of cases, when a ­woman’s life was at stake, one option was to terminate the pregnancy. But a frequent line of treatment involved inspired psychiatric approaches, ranging from psychotherapy sessions, to solitary confinement, to forced feedings, to “suggestion.” 48 According to adherents, “suggestion” basically entailed talking a ­woman out of her severe sickness, which had only arisen ­because she expected it. It was all in her head. To the question of “what is suggestive treatment?” one doctor replied, In my practice it is a very s­ imple ­matter, necessitating merely a certain elementary knowledge of psy­chol­ogy and some moral courage. First of

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all I get the patient into [the] hospital . . . ​for ­t hese cases do not respond as satisfactorily when treated at home. . . . ​If I ­can’t get her into [the] hospital I get her into a room by herself and exclude from this room all old ­women. . . . ​Having got the patient into [the] hospital—or its best substitute—­the vomit bowl is kept away from her. If she wants to vomit she is told to vomit into the bed and when she does vomit the nurse is instructed not to be in too ­great a hurry to change her. . . . ​If she has any idea that an abortion—­which she may desire—is to be done she is firmly disabused of that idea . . . ​I do not make a practice of explaining ­things to the patient herself, but instead give my ­orders to the nurse in the patient’s hearing; and I find a certain curtness of manner works to advantage. Ordinary food is brought to the patient by the nurse at the regular meal hours and put before her as though we ­were quite convinced that the patient could keep such food down. She is never asked if she thinks she can keep some nourishment down; the nourishment is placed before her; she is told to eat it and assured that she ­w ill keep it down. . . . ​No visitors are allowed near the patient; no fuss is made over her; and the nurse is instructed to leave her to herself as much as pos­si­ble.49

Such protocol was apparently so effective (according to the male doctors who wrote about it) as to be considered further proof of the hysterical origins of NVP, be it normal or severe. Pernicious vomiting of pregnancy could be “instantaneously s­ topped,” described Arthur Hurst in The Lancet, “by the best form of psychotherapy—­explanation and persuasion.” The therapy was most effective when a w ­ oman was isolated, so as not to be “suggested” back into her illness. If the w ­ oman died, Hurst explained, “the [doctor’s] suggestion has not proved sufficiently power­f ul, prob­ably ­because the patient was not first made to believe with certainty that it would cure her.”*,50 The doctor who wrote the above description said that * A fter the 1940s, when medicine gained a better understanding of electrolyte bal­ ance, hyperemesis gravidarum decreased sharply as a cause of maternal mortality. In the 1930s, in Britain, it caused 159 deaths per million births; by the 1950s, it caused only three per million. T ­ oday, hyperemesis gravidarum is rarely lethal.

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he used this “suggestive method of treatment for all cases of vomiting in pregnancy, including the pernicious type,” with 100 ­percent success.51 In some ways, t­ hese nettlesome notions have been incredibly per­sis­tent. They have evolved. In the 1960s, investigators trying to refute the psychiatric explanation for morning sickness pointed to—­without a trace of irony—­marital sta­ tus as useful evidence against the “fetal rejection” theory.52 But (male) doc­ tors did not cease flirting with the prospect of psychiatric causation. One physician theorized, in 1968 in the American Journal of Obstetrics and Gynecol­ogy, that ­t here might be something to the psychiatric theories: “­there seems ­little doubt that psychiatric ­factors must be implicated,” he estimated, in a large proportion of severe morning sickness cases. He cited a high incidence of “­mother dependence” in patients with nausea, based on the evidence that many of them ­either moved home with their ­mothers or vice versa during their sickness. (Their husbands ­were largely absent.) He suggested that his fellow obstetricians don their counselor caps to “casually” ask patients about their personal lives and emotions. It is unclear what he thought they should do with their findings.53 ­Others explained that NVP occurred b ­ ecause w ­ omen w ­ ere unable to “cope with the vari­ ous stresses of being pregnant and converted this stress into physical symptoms.”54 In 1975, one author wrote that morning sickness was a phys­ ical experience but that the “more severe forms are often indicative of psychological conflict.”55 Even in the twenty-­first ­century, psy­chol­ogy still ­factors into the medical perspective on NVP.56 This is maddening. It is offensive, infuriating, insulting. But what if ­t here might be something to it?

The Placebo Effect Nausea is a subjective experience. It is difficult to describe (how do you describe feeling nauseous without using the word “nausea”?), and chal­ lenging to assess. Other symptoms share the slippery nature of nausea,

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pain and depression being the two prominent parallels. Each is fraught with a certain skepticism of authenticity. Their “real­ity” has been, and con­ tinues to be, a subject of debate. Pain, for instance, can be deserving or undeserving. And context is pivotal—­pain might be judged as real, false, trivialized, or exaggerated depending on the time, place, individual in pain, and individual judging the pain. Race, gender, age, and personal his­ tory all ­factor into our perceptions about pain’s “legitimacy.”57 To be in pain is to be questioned. As we have seen, NVP is very common. As far as scholars can tell, it always has been. Its ubiquity does lend it a certain validity, but this does not change the fact that NVP is still a fundamentally subjective affliction, vulnerable to the same kinds of doubts and uncertainties that color simi­ larly widespread conditions such as pain and depression. Doctors have devised ways to try to mea­sure the unmea­sur­able. They have scales, surveys, and inventories. Even ­t hese are evasive. How do we know if one person’s “5” is equal to another person’s “5”? How do we know that our own “5” is the same as it was yesterday? The reigning con­temporary scoring system for mea­sur­ing NVP is called the pregnancy-­unique quan­ tification of emesis and nausea: PUQE. It was devised in the early 2000s by Motherisk, an organ­ization that provides resources, information, and help regarding pregnancy and birth to hundreds of thousands of ­women. PUQE is a s­imple questionnaire consisting of three questions about the past twenty-­four hours: (1) how many hours have you felt nauseated? (2) how many times have you vomited? (3) how many times have you dry ­ ese questions probe at quantitative answers—­“real” numbers. heaved?58 Th Tests like the PUQE play a critical role in studies that explore subjective phenomena ranging from nausea to pain to irritable bowel syndrome to  depression, and despite their myriad prob­lems, they can be very revealing. Ted Kaptchuk has been studying t­ hese exact conditions for de­cades. And he’s working—­tirelessly and patiently—to persuade the medical estab­ lishment that it needs to take the placebo effect seriously. For still being

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in its infancy, the science of the placebo effect is remarkably compelling. Once disregarded as futile agents by which genuine medi­cations ­were deemed effective, placebos are emerging as conceivable treatments in their own right. Kaptchuk is at the helm of this work. In the 1970s he returned to the United States from Macau with a degree in Chinese medicine. He opened his own acu­punc­ture practice in Cambridge, Mas­sa­chu­setts, in 1976, in an area so replete with nontraditional healing outfits it was known as “quack row.” Kaptchuk’s clients w ­ ere healing with such rapidity that it made him scratch his head. He’s been investigating the placebo effect ever since. Despite his hippie air and unconventional background, Kaptchuk is a meticulous, data-­driven researcher working in one of the most esteemed halls of the acad­emy on the planet: Harvard University. His work has drawn the attention—­and sometimes the ire—of respected prac­ti­tion­ers across the globe. Kaptchuk helped to open the first and only interdisci­ plinary center for studying the placebo effect (affiliated with Beth Israel Deaconess Medical Center and Harvard Medical School) in 2011. It’s called the Program in Placebo Studies and the Therapeutic Encounter (PiPS). He and his team are paving the way in the budding field of placebo studies, and their work is difficult to ignore. Studying the placebo effect can be a tricky endeavor. Scientists need to be wary of unusual confounding ­factors. For one ­t hing, ­people might be genet­ically predisposed to the placebo effect (the nascent science of study­ ing genomic influences on the placebo effect is called “the placebome,” and looks for ge­ne­tic markers that might be associated with elevated ­ eople generally tend to improve responses to placebos).59 Additionally, p or return to normal over the course of illness—­a phenomenon known as “regression to the mean”—­which could account for some of a placebo’s effectiveness. In other words, it might appear that a placebo has “worked” when in fact an illness has simply run its course. The use of placebos also raises prickly bioethical questions, especially as researchers are devising all kinds of clever mechanisms to study them.

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Their creativity makes fake pills look archaic. Researchers have performed fake acu­punc­ture using retractable ­needles, sham brain surgeries, and fictitious arthroscopic operations. So far, their mock interventions have yielded outcomes on level with the ­actual treatments—­a stunning revela­ tion when you think about it. But it’s not entirely clear w ­ hether t­ hese kinds of conclusions, astonish­ ing as they are, tell us more about the power of the placebo effect or the futility of the treatments the placebos w ­ ere mea­sured against. Let us briefly consider the sham knee surgery example: in a randomized controlled trial of 180 patients with osteoarthritis in their knees (published in 2002 in the New ­England Journal of Medicine), the participants in the study ­were assigned to ­either receive standard surgical treatments or a simulated ­ hole layout of tools in the oper­ procedure—­including real incisions, the w ating room, a surgeon pretending to perform the procedure, and all the same pre-­and postoperative protocols. They ­really sold it. ­After months of recovery and continued rehabilitation, the patients who’d had ­actual surgical procedures “­were not better” off than the patients who’d had fake surgery—­measured by both pain relief and knee function.60 It is not clear what exactly we should make of this—­that a placebo can “work” as well as an a­ ctual surgery? Or that the traditional surgical treatments ­here are not quite up to snuff? In other words, are ­these pretenses actually healing? And are they even ethical? Furthermore, the efficacy of the placebo effect could call into question our entire framework for mea­sur­ing medicine’s effects—­the double-­blind randomized controlled trial. Placebos w ­ ere previously considered to be naught, a baseline mea­sure­ment for assessing interventions. If placebos exert genuine effects, what does that mean for the current paradigm of evidence-­based medicine?* * Evidence-­based medicine is defined as a purposeful and conscious effort to deter­ mine medical standards of practice and implement clinical decision-­making using the best evidence available.

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Wherever you stand on the ethics of fraudulent interventions among randomized t­rials, the research makes a power­ful case that placebos “work.” As a group of scholars described in the American Journal of Bioethics in 2015, “research findings over the last de­cade leave us no option but to accept the biological validity” of placebo effects and “to acknowl­ edge that they are integral to routine care.” 61 Indeed, in many cases placebos work as well as the real deal, performing comparably to costly prescription drugs and interventions. Studies show that placebos can instigate real change, in both subjective and objective markers, and they work best on symptoms regulated by the brain. None of the experts would suggest that a placebo could shrink a tumor, but they have a wealth of evidence to show that a placebo can influence mea­sur­able vitals such as heart rate and blood pressure, as well as symptoms like pain, depression, nausea, anxiety, or fatigue, and even may reduce Parkinson’s symptoms. The possibilities of the placebo are stunning. We still do not understand exactly how placebos work, but research is showing that the placebo effect is no s­ imple by-­product of a sugar pill. Instead, the placebo effect is a complex mesh of effects, a web. Placebos are not just proof of cognitive bias—­they actually generate vis­i­ble biologi­ cal and neurological effects. They succeed through an intricate series of neurological responses, involving neurotransmitters like dopamine and endorphins, emotions, expectations, and desires. In one study comparing acu­punc­ture to sham acu­punc­ture, the patients’ beliefs and expectations about acu­punc­ture’s benefits had more bearing on their improvement than ­whether or not they actually received acu­punc­ture. “Thus,” the reviewers describe, “it did not r­ eally ­matter ­whether the patients actually received the real or the sham procedure. What mattered was ­whether they believed in acu­punc­ture and expected a benefit from it.” 62 Put simply, it appears that patients’ inclinations to heal ­factor into the placebo complex. So do l­ ittle details. The color of a pill can influence its effectiveness for treating dif­fer­ent conditions, for example. Placebos perceived to cost more work better than less expensive ones. Bigger pills tend to be more effec­

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tive than smaller ones. Two pills work better than one. Brand name pills outperform generics. Injections beat pills. It is clear that invoking the ben­ efits of the placebo effect may require that we consider a host of contex­ tual circumstances. Signals traditionally associated with health care or healing—­a doctor’s visit, a ritual of treatment—­combine to cue the body and the mind to improve. In some studies, ­these prompts alone have actu­ ally induced the placebo effect before any placebo was even rendered. Even ­people who know they are taking a placebo report improvements compared with no treatment. This bears repeating: in studies conducted on irritable bowel syndrome and migraines, the study participants who ­were informed that they w ­ ere in the placebo arm of the trial still experi­ enced benefits. “ ‘­People associate the ritual of taking medicine as a posi­ tive healing effect,’ says Kaptchuk. Other work has demonstrated that ­ eople know they are taking it. ‘Even if Valium only mitigates anxiety if p they know it’s not medicine, the action itself can stimulate the brain into thinking the body is being healed.’ ” 63,* Put another way, “placebo effects can be produced by suggestions.” 64 Placebo effects can be produced by suggestion. Well, that is in­ter­est­ing.

Alternatively, several unconventional remedies for NVP have grown in popularity since 2000, partly b ­ ecause pregnant w ­ omen continue to worry (justly so) about taking phar­ma­ceu­ti­cals, partly ­because medicine has still not identified a clear-­cut cause or solution to NVP, and partly ­because “complementary” or “alternative” medicine has become so trendy. But ­t hese strategies are not implicitly superior to traditional biomedical ther­ apies. James Hamblin, the health editor for The Atlantic, details the flawed * Beyond the standard documentation of the placebo effect—­positive improvement—­ science has uncovered other intriguing findings that undergird the power of place­ bos. Study participants report experiencing the pos­si­ble negative side effects of medi­ cations when they receive placebos: the “nocebo effect.”

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logic ­behind the very idea of complementary or alternative medicine: “alternative medicine,” he writes, “is itself a strange notion, in that t­ here are ­really only three kinds of medicine: medicine that is proven to work, medicine that is proven not to work, and medicine that has not been con­ clusively studied.” 65 As Hamblin suggests, to a certain extent, the concept of “alternative medicine” ­doesn’t even make sense. This abstraction is becoming more apparent in research on NVP. Amer­ icans are more apt to perceive “alternative” therapies as “natu­ral,” and therefore as somehow more safe or effective (and less risky). ­These options, however, “are less rigorously tested and regulated than phar­ma­ceu­t i­cal remedies.” 66 Doctors are understandably frustrated with this situation—­herbal sub­ stances and alternative treatments are being sold to the public as natu­ral and safe without any scientific basis. Home-­styled remedies are not stud­ ied for safety or efficacy, nor are they regulated and standardized by the FDA or any other governing body, as conventional medicines and phar­ ma­ceu­ti­cals are. Furthermore, ­there are mechanisms to track adverse reac­ tions to prescription drugs, but ­there are no requirements about reporting such events for nonprescription substances. “­Women have chosen herbal products that have no safety rec­ord over available safe prescription prod­ ucts, prob­ably ­because of their erroneous belief that natu­ral is the same as safe,” explained a group of researchers in Pharmacotherapy in 2006.67 Some physicians even think ACOG should stop recommending ginger, the most studied alternative therapy for NVP, to pregnant patients.68 ­Others simply point out that abstaining from phar­ma­ceu­ti­cals at all costs in pregnancy “may cause more harm than good.” 69 Still, t­ here is some tentative evidence that some of the so-­called alter­ native therapies may benefit w ­ omen suffering from NVP, though none of them are a slam dunk. All ­things being equal, ­t here simply i­sn’t enough research to ­either prove or disprove ­whether they work.70 Some of the most studied options include acu­punc­ture or acupressure, vitamin B6, and gin­ ger. Doctors disagree over which one boasts the best data.

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A reasonable assessment from a review study published in the American Journal of Obstetrics and Gynecol­ogy in the early 2000s noted that “the preponderance” of evidence on acupressure is positive, although it is far from proven. Given their pos­si­ble effectiveness, affordability (a two-­pack of SeaBands costs about $10), lack of side effects, and overall safety (they carry virtually no risk), “acupressure bands,” they wrote, “are a treatment worth trying.”71 Reading all of this, I am wondering why I ­didn’t try sport­ ing a SeaBand when I was pregnant two years ago. ­There’s no guarantee it works, but t­ here d ­ on’t seem to be any down sides. Other studies suggest that taking a multivitamin before conception might help prevent morning sickness, but this is only helpful if you have had time to plan and prepare, plus it ­isn’t determined.72 Several proj­ects indicate that vitamin B6, one-­half of the successful doxylamine-­vitamin B6 therapy, can work well on its own. Vitamin B6 supplements are easy to find and may be helpful; however, ­because the “upper tolerable limit” for adults (the most that can be safely consumed) is 100 mg daily and most prenatal vitamins already contain B6, it’s impor­tant to monitor one’s over­ all daily intake.73 This raises a crucial point. Vitamins are not innocuous. Excessive con­ sumption of vitamin A, for example, is linked to birth defects. Indeed, much of the work on nonpharmaceutical options for alleviating NVP sig­ nals that we just are not positively sure about safety. Maximum dosages, treatment duration, and pos­si­ble interactions are unknown. Studies suggest certain therapies are safe, but they cannot know for sure.74 Ginger is the darling of the “alternative” therapies. Several recent stud­ ies and reviews have determined that it “may be an effective treatment choice” for NVP.75 A 2005 review of four randomized controlled t­ rials looking at ginger (in daily doses of 1 gram) reported no adverse outcomes, and ginger fared well compared with a placebo. “In summary,” the author wrote, “ginger is a safe and effective treatment option . . . ​and comparable ­ omen, the par­ with vitamin B6 in effectiveness.”76 In a 2003 study of 120 w ticipants in the experimental group who received ginger reported less

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nausea than a placebo group, although the placebo group did experience improvement.77 A meta-­a nalysis in 2014 reiterated ­these conclusions, stating that ­women who took 1 gram of ginger daily for a minimum of four consecutive days ­were five times more likely to have decreased symptoms.78 But ­here’s the kicker: in all ­t hese ­trials and review studies, the ­women in placebo groups also reported notable improvements. In one of the gin­ ger studies, 70 ­percent of the w ­ omen who took ginger reported feeling better—­and 50 ­percent of the ­women who took a placebo also reported feeling better.79 The discrepancy is noteworthy, of course; many more ­women who took ginger felt better than did ­women who took nothing. But still, a full half of ­women who received a placebo felt its effects. In a study ­ omen (49 ­percent) assessing doxylamine-­v itamin B6, sixty-­four of 131 w receiving the drug asked to continue using the medi­cation, and forty-­one of 125 ­women (33 ­percent) receiving the placebo asked to continue its use.80 Again, the drug was clearly more effective, but the placebo still helped one-­ third of the w ­ omen feel improvement. For both alternative treatments and traditional biomedical treatments, some options are significantly more effective than a placebo, but placebos can “work.”81 No one has set out yet to investigate the placebo effect during preg­ nancy.82 It is in­ter­est­ing, if not aggravating, that the placebo effect comes to life in almost e­ very study examining a morning sickness treatment. Yet maybe it ­shouldn’t be. The field of placebo studies undergirds ­t hese find­ ings, contextualizes them to the point of enhanced understanding.

When my husband cautiously offers me a cup of coffee in the morning, and I have to gulp before muttering, “No thanks,” I think, “Can I suggest myself out of nausea?” W ­ ere the nineteenth-­century doctors who cruelly tried to “suggest” ­women out of their nausea and vomiting inadvertently onto something? Is ­there any room for the sway of suggestion—­the power of the placebo—in NVP?

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Let us be clear: the nineteenth-­century physicians who swore by sug­ gestion ­were way off base. Besides their protocol being inhumane, degrad­ ing, and sexist by modern standards, they also missed the mark with their justifications for inflicting suggestion on ­women. They thought NVP was all in the head—­a hysteria produced by physical and emotional stress. To them, NVP was not “real.” Suggestion worked by trumping female neurosis. The science of placebo studies does no such ­thing. None of the research­ ers at the forefront of the work on placebos would suggest that their patients’ symptoms (such as chemotherapy-­induced nausea, migraines, or Parkinson’s symptoms) are feigned or purely psychological. Quite the opposite—­t hey are genuine symptoms, and their sufferers deserve relief. Placebo research demonstrates that subjective symptoms such as pain or ­ e’ve only barely nausea are highly complex manifestations, and that w begun to understand them. The effectiveness of the placebo effect forces us to take symptomology seriously, not dismiss it. At the same time, the science of the placebo effect highlights that the mind plays a critical role in health, in healing, and in recovery. Desire, expectations, belief—­these attitudes all have bearing on the placebo effect. To maximize the possibility of improvement from a placebo, you need to r­ eally expect that it w ­ ill help, believe that it can bring comfort, want it to allay your symptoms.

I am not so sure this can work for me. Th ­ ere is a tiny part of me that is waiting for—­maybe even hoping for—­nausea. The morning I wake up feel­ ing pretty chipper, I am groping for nausea like a well child desperate for a sick day. Nineteenth-­century w ­ omen appreciated NVP for what it communi­ cated to them: that they ­were pregnant and that their pregnancy was pro­ gressing well. They had a hunch that NVP was a good sign, and they w ­ ere right—­modern science validates their premonition.

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Researchers began exploring the relationship between morning sick­ ness and pregnancy outcomes in the mid-­twentieth ­century. Early work in the 1960s hinted that a lack of morning sickness might be associated with higher rates of “spontaneous abortion”—­t he con­temporary nomen­ clature for miscarriage.83 Doctors’ observations continued to suggest as much. In a study published in 1986, researchers announced that w ­ omen who experienced no nausea symptoms “experienced a significantly greater proportion of nonviable pregnancy outcomes (fetal death).”84 By 2001, a piece in The Lancet quoted evolutionary biologist Samuel Flaxman saying that “­every study that has examined the relationship between normal NVP and miscarriage has found that w ­ omen with NVP are less likely to miscarry than ­women who do not experience it.”85 (Still, as Flaxman himself notes, “the majority of w ­ omen that do not express NVP carry their pregnancies to term.”86) Similar data continue to emerge. A 2014 meta-­analysis of ten research proj­ects between 1992 and 2012, for example, concluded that ­women with NVP have fewer miscarriages.87 Summarizing recent evidence, science blogger Amy Kiefer explains that ­women who have NVP by about seven weeks’ gestation have only about a third the risk for miscarriage as w ­ omen without any symptoms by the same time. ­After eight weeks, she writes, “a lack of morning sickness pre­ dicts higher chances of a miscarriage.”88

So can the placebo effect work for w ­ omen with NVP? Maybe, I think. Prob­ably. If and when I begin feeling worse (I can make it through a wearisome hangover just as well as the next person), I w ­ ill try to put my faith in some­ thing, some ritual. As the days pass, I become increasingly desperate to feel any semblance of normalcy. On the Tuesday just ­after I turn seven weeks, I begin taking ginger, once mid-­morning and once in the early eve­ning. By Friday, I am feeling much better. The next week I see even more improvement. I leave

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town to be with ­family and celebrate my ­brother’s wedding during my tenth week of pregnancy—­which should be the pinnacle of any illness—­ and I am feeling pretty darn good. I gorge on aperitifs and wedding cake with no regrets. I won­der why I feel so well. Has morning sickness simply run its course? Or is it the ginger? Or the placebo effect? Or is it all just in my head? The real­ity is that t­ here is no magic bullet for NVP; t­ here never has been, and t­ here likely never w ­ ill be. Maybe the placebo is the next best ­ omen’s approach to morning sickness ­thing. At the end of the day, most w in the twenty-­first c­ entury seems to be l­ ittle changed from the 1800s and 1900s: stay the course, wait it out.89 Endure.

chapter 3

•

Grow

An obstetrician who trained at Johns Hopkins University once wrote that during pregnancy “the dominant metabolic forces are ­t hose which ­favor growth.”1 That was in 1919, yet I am witness to t­ hese forces e­ very day—­ when I look in the mirror, when I get (un)dressed, when I climb the stairs to my second-­floor apartment, when I hoist my son up from his crib, carry my groceries, turn around, stand up quickly. If t­ here is anything consis­ tent about pregnancy, it is this: growth. Even while I try to be buoyant and realistic about the fact that I am growing—it is a good sign, ­a fter all—­I find it difficult to embrace. I am reluctant; my soul resists my unrecognizable constitution like the foreign body it has become. I am militant about my diet and the foods I consume, and pregnancy does not change this. I try to shrug off my strict outlook ­toward my own figure, but old habits die hard. Recasting one’s own body image is never an easy task, pregnant or not. I am steeped in a culture where scales are fraught, weight is private, and growth is discouraging. Id ­ on’t own a scale, and I almost never weigh myself. But over the course of my pregnancy, I step on the scale thirteen times. Each time, I admit, I am anxious. I somehow feel as though I pay so much and too ­little atten­ tion to my expansion. I am si­mul­ta­neously preoccupied and unoccupied. How much should I grow? How much should I gain? How much should I care? 62

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Mostly, I eat how I always did, a ­little more. I am incapable of suppress­ ing hyperbolic eye rolls when p ­ eople tell me “­you’re eating for two now”; I shake my head, tell them my husband is “drinking for two now.” Where did such an idea even originate?

Lesson from the Past: ­D on’t Eat for Two Medical and lay lit­er­a­ture have been rebutting the common saying that pregnant ­women should “eat for two” for at least 150 years. Century-­old snippets refuting the eat-­for-­two saying sound familiar, if a ­little awkward, even t­ oday. From the late 1800s onward, advice manuals and guidebooks aimed at pregnant ­women have urged that “the idea is erroneous that it is well ‘to eat for two p ­ eople.’ ”2 One 1890s text, colorfully entitled Parturition without Pain: Code of Directions for Escaping from the Primal Curse (authored by physician Martin Luther Holbrook), stated that the need to eat for two during pregnancy was “a thorough delusion.”3 Continuing throughout the entire twentieth c­ entury, pregnancy writ­ ers worked to debunk the popu­lar myth. Early 1900s guidebooks set out to correct the “false notion” that pregnant ­women should eat for two, advising instead that additional food was hardly necessary during preg­ nancy (and certainly not necessary in the first half of pregnancy).4 “­There is no foundation,” asserted Claude Edwin Heaton in a 1935 maternity care book, “for the old belief that the pregnant ­mother must eat for two.”5 In a 1949 piece in The Pennsylvania Medical Journal, J. Robert Wilson stated that “the ancient belief that the pregnant patient must ‘eat for two’ has no basis in fact. Additional dietary needs during pregnancy,” he explained, “are only slightly greater than for the non-­pregnant w ­ oman.” 6 “Eating for two does not mean that you should eat twice as much food as before,” cau­ tioned the 1950 Parents Book issued by the New York Bureau of Maternal and Child Health.7 Virtually ­every book I was able to look at that touched on prenatal weight gain conveyed that eating for two was a regrettable and misguided

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piece of advice. Pregnancy was no cause to consume anything beyond the ordinary, never mind reach for second helpings.8 Put simply, American writers and health professionals seem to have been working to expose the notion that pregnant ­women should eat for two as a misconception for hundreds of years. Which begs the question— if medicine never endorsed the “eating for two” meal plan, what did it rec­ ommend in terms of prenatal weight gain?

Checking Growth Medicine may have been (and still is) united in its disavowal of eating for two, but it agreed on l­ ittle ­else about weight gain during pregnancy. From the late 1800s onward, advice to pregnant ­women about how, when, what, and how much to eat changed constantly. ­There has never been any last­ ing uniform answer to the question of how much weight ­women should gain, ideally, during a normal, healthy pregnancy. As we have already begun to see, the science of nutrition is both intricate and complex; thus in some ways it is no surprise that medicine’s understanding of nutrition during pregnancy has always been lacking. And yet the extent of this void is still remarkable. Amid medical lit­er­a­ture on prenatal nutrition, ­t here is a clear pattern of belief—­which runs directly ­counter to the notion of eating for two—­ dating back to at least the mid-­late 1800s: a pregnant ­woman need not eat much more (if any more at all), except perhaps t­ oward the very end of her pregnancy. In the nineteenth c­ entury, commentators rarely mentioned aggregate weight gain in terms of numbers. Before scales became common ­house­hold items, perhaps such quantification simply was not a widespread consideration. Instead, physicians and advice writers discussed prenatal physical growth without numerals. They mostly believed that pregnant ­women should continue eating as they typically ate. “In normal pregnancy t­ here is no indication for a special diet. You should eat the foods you are accus­

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tomed to and enjoy, provided a well-­balanced diet is taken,” wrote Heaton.9 As a m ­ other’s manual from the Michigan Department of Health put it, “the ­woman who is eating correctly anyway, ­will not have to vary her diet during pregnancy.” (Except, it added, to make it more laxative and to avoid indigestion.)10 ­We’ll come back to ponder this ideology more in the next chapter, but it’s worth mentioning ­here ­because it laid the foundation for modern medicine’s initial deliberations on gestational weight gain. At the heart of turn-­of-­t he-­century ideas about weight gain during pregnancy was the broad notion that pregnant ­women did not need to eat much more or dif­ ferently than anyone e­ lse, especially given the prevailing sentiment that many Americans ate too much to begin with. “The fact is more likely,” described Dr. Holbrook, “to be the seeming paradox that enough for one is too much for two.”11 Over the course of the first half of the 1900s, as the origins of modern prenatal care emerged in the United States, a­ ctual numbers began to fig­ ure into conversations about pregnancy and nutrition. Over time, taking down a ­woman’s weight became part of the routine prenatal visit, and keeping figures low became increasingly impor­tant. By midcentury, it was standard to mea­sure a pregnant ­woman’s weight at ­every visit, at least partly as a strategy to limit gain.12 One doctor reflected that in the 1950s, prenatal examinations ­were centered on the weigh-­in.13 Specific numbers vary from source to source, but u ­ ntil around 1950 most authorities suggested that prenatal weight gain max out at no more than twenty pounds, give or take.14 In the 1920s, ideal gains ­were ­limited to about fifteen pounds—­mostly in attempt to facilitate smoother l­abors and deliveries, but also to “preserve the ­woman’s figure ­after birth.”15 The lower the gain, the better. For the most part, medicine maintained, if not intensified, this strict advice throughout the ­m iddle of the twentieth ­century. Physicians expressed that prenatal weight gain should not exceed the weight of the tangible physical additions to a pregnant w ­ oman’s body, such as the fetus,

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uterus, and extra blood and plasma volume—­a ll of which amounts to approximately fifteen to eigh­teen pounds.16 Eigh­teen pounds was a com­ mon upper limit for growth, although some doctors ­were willing to stretch that slightly higher.17 Some physicians considered a weight gain range in the low twenties normal, but they often documented gains into the ­middle or upper twenties as “excessive.”18 The 1966 edition of Williams Obstetrics, a classic teaching text, summarized that it was “essential” to keep weight gain ­under 25 pounds, but preferable to limit it to just 15.19 Even if ­there w ­ ere slight variations between numerical weight gain rec­ ommendations, the idea that weight gain during pregnancy needed to be restrained was an almost universal, and imperative, standpoint among practicing physicians. “A strict diet regimen is essential in most cases,” expressed one research group in its article “Control of Weight Gain in Pregnancy.”20 The sentiment that pregnant ­women did not need any extra food or calories—­and instead needed to vigilantly control their caloric intake—­ proliferated in this “era of stringent dietary restriction.”21 Physicians reg­ ularly resorted to drastic mea­sures to assist with the goal of minimal weight gain. In one trial, doctors ­limited w ­ omen’s daily intake to just 1,000 calories. When such mea­sures to curb growth failed, many doctors doled out diuretics or phar­ma­ceu­ti­c als. Dexedrine and Benzedrine, both amphetamines now prescribed to treat symptoms of attention defi­ cit hyperactivity disorder (ADHD), w ­ ere one such option.22 The medical impetus to control weight during pregnancy was an urgent one, and ­whether they fell back on phar­ma­ceu­t i­cals or not, doctors tended to be insistent about minimizing weight gain. “I suspect a fair number of our patients are made quite miserable throughout their pregnancy,” observed one obstetrician, “by our zeal in stressing this phase of prenatal care [weight gain].”23 At the same time, though, other physicians took issue with severe lim­ itations and the mea­sures enacted to achieve them. They ­were equally as concerned about excessive restriction as they ­were excessive gain, and they

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advised their patients differently. Some moderates left ­women to their own devices when it came to weight. One doctor, in 1949, expressed that “at pre­ sent I feel that a g­ reat deal of undue emphasis is attached to the subject of weight gain during pregnancy.” Continuing on, he implored his colleagues to remember the “basic princi­ple that we are treating individuals rather than conditions in our maternity practice and wide fluctuations from so-­ called normal patterns can often be observed with complacency.”24 Ten years l­ater, one maternal and child health professor at the University of Pittsburgh intimated the same: “the routine, rigid restriction of a preg­ nant ­woman’s diet is inappropriate and unwise, and places an unfair emo­ tional strain on the mother-­to-be. Doctors should base diet advice on the specific nutritional needs of the individual patient, not on arbitrary scales and charts.” Explaining that dietary restriction could be harmful, Dr. Sam­ uel Wishik observed that “pregnancy is no time for weight control mea­ sures,” even for overweight ­women.25 This was the minority opinion, though. The predominant viewpoint was that pregnant w ­ omen desperately needed to minimize their weight gain; and although vari­ous technical reasons w ­ ere cited, it’s difficult to think that sexist ste­reo­t ypes ­didn’t ­factor in on some (prominent) level. One of doctors’ chief arguments in f­ avor of dieting during pregnancy was that ­doing so helped limit newborns’ size, therefore facilitating easier ­labors and deliveries. The idea was that eating “in the proportion of two persons,” as opposed to one, would result in a larger baby and thus make ­ ill soon ­labor more difficult.26 (But this is a misapprehension, as we w see.) Another prob­lem was toxemia—­now known as preeclampsia or eclampsia. The other reason, which is virtually never discussed, is that doctors assumed that pregnant ­women, as with adults in general, ­were not very good at regulating their food intake. Even in the 1800s, physicians w ­ ere partly worried about prenatal weight gain ­because it was, simply, weight gain. Modern medicine has almost always been concerned with overeat­ ing. Holbrook, the nineteenth-­century author who derided the idea of

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eating for two as an “absurdity,” explained that p ­ eople “almost always eat too much,” and “habitually take more food than is strictly required for the demands of the body.”27 On paper, it would seem that pregnant ­women ­were no dif­fer­ent, but again, I find it hard to escape from the con­temporary gendered assumptions of the time, that w ­ omen ­were not equally compe­ tent or in control.

I was a fastidious eater during my first pregnancy, and I gained twenty-­ eight to thirty pounds. To me, ­t hese additions felt like they w ­ ere just happening, and would go on happening, regardless of anything I did. Not that I was trying too hard—­exactly the opposite: I was eating almost exactly as I always had. And I grew, quite a bit. Given that my body seems preordained to become heavier during pregnancy—­despite my hardly altered food consumption—­I’m curious about w ­ hether ­women actually followed (or w ­ ere able to follow) the strin­ gent guidelines set forth in previous generations. The thought of keeping my weight gain to just fifteen to eigh­teen pounds strikes me as completely ludicrous. Was this normal? It seems like maybe. ­There appears to have been at least some level of disconnect between what medicine was promoting as the “ideal” prena­ tal weight gain and what pregnant ­women ­were actually gaining. Even doctors who ­were adamant that ­women keep their weight gain in the teens ­were still cognizant of a dif­fer­ent real­ity. Medical articles regularly acknowledged a much higher typical weight gain range than the recom­ mended limits. Indeed, obstetricians themselves ­were the first to admit that “normal” and “ideal” prenatal weight gain ­were not necessarily one and the same. The very physicians who advised a fifteen to twenty pounds gain at most registered average gains among their ­actual patients between twenty to twenty-­five pounds. For example, a physician in 1919 estimated that his patients’ prenatal weight gain averaged about thirty pounds, ranging from as ­little as ten to

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fifteen pounds in some cases to as much as forty to fifty pounds in ­others.28 In an international 1944 review of nineteen studies encompassing nearly 12,000 patients, the average weight gain was around twenty-­four pounds.29 Two years ­later, in a study involving 567 cases, the average maternal gain was twenty-­one pounds (the range spanned from −3 pounds to +48 pounds).30 In 1963, one article identified twenty to twenty-­four pounds as “normal” for prenatal weight gain but observed that some 20 ­percent of ­women typically exceeded that range.31 A 1969 piece described twenty-­four pounds as the average gain but noted wide variation (the authors also men­ tioned that gaining thirty pounds or more was beyond excessive and constituted a “danger level”).32 A 1970 piece stated that 23.5 pounds was average.33 In the mid-1960s, electronic data pro­cessing allowed for more compre­ hensive, wide-­scale analy­sis. One proj­ect looked at maternal weight gain and complications in almost 90,000 pregnancies. Among the 12,500 ­women who ­were pregnant for the first time and gave birth at forty weeks, the average gain was twenty-­two pounds. But the authors who reviewed the data explained that “uncomplicated patients may gain a wide variety of weight with impunity.” Hence, they said, “a clinically useful concept of ‘normal weight gain’ could not be determined.” Still, they defined the “ideal” weight gain range—­with the lowest rates of adverse events—as just sixteen to twenty pounds. As they concluded, “no ‘normal weight gain’ during pregnancy can be defined and . . . ​t he ‘ideal weight gain’ is around 18 pounds.”34 As ­these authors implied, averages can be misleading—­they come with standard deviations. Take the first major study to document average pre­ natal weight gain—­t he international proj­ect from the 1940s. It found that the average prenatal weight gain was twenty-­four pounds. But the stan­ dard deviation was 10.8 pounds—­meaning that most w ­ omen (about two-­ thirds) might, based on the study’s results, be expected to gain between thirteen and thirty-­five pounds.35 As one group of obstetricians intimated in 1975, “the wide range of weight gain in pregnancy compatible with a

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normal outcome is astonishing—­from a loss of more than 5 pounds to a gain of more than 50 pounds.”36 In the 1980s, researchers who reviewed data from thousands of pregnancies argued that even a very small weight gain—of five to ten pounds—­was not necessarily problematic. It seemed that favorable pregnancy outcomes could be expected for w ­ omen with a broad range of weight gain.37

Gaining Permission Up ­until 1970, the overwhelming rhe­toric among U.S. obstetricians was that w ­ omen and doctors should work to curb weight gain during preg­ nancy as much as pos­si­ble. Th ­ ose stringent limits relaxed a­ fter 1970, how­ ever, when a National Academies of Science National Research Council (NRC) report implicated pregnancy weight gain restrictions in the nation’s abysmal infant mortality rate. The NRC expressed that attempts to restrict pregnancy weight gain ­were effectively contributing to the nation’s high number of low-­birth-­weight infants and high infant mortality rates. Instead of protecting w ­ omen and babies, in other words, the NRC report implied that doctors’ widespread habit of trying to prevent pregnant ­women from gaining weight was harming them.38 It compared dietary restriction during pregnancy to “a form of relative starvation” and encour­ aged pregnant w ­ omen to “eat to appetite.”39 All in all, the NRC’s nutrition panel recommended that w ­ omen strive for a normal gestational weight gain of twenty to twenty-­five pounds.40 In the wake of the NRC report, the upper limits for pregnancy weight gain recommendations stretched to (and then beyond) twenty-­five pounds, and anx­i­eties about weight swung in the opposite direction. Rather than focusing on too much weight gain, the increasing births of underweight babies stirred mounting social and cultural concerns about insufficient ­ omen weight gain.41 The NRC report changed the conversation: pregnant w needed to gain weight, not restrict it. The new mindset percolated through­ out the de­cade, and it marked a major turning point, a clear break from

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the harsh limits set in the past. Where the prob­lem had once been gain­ ing too much, it was now gaining too l­ ittle. Through the 1970s, medical lit­er­a­ture increasingly picked up this new framework for gain. In the ­middle of the de­cade, ACOG amended its guidelines, permitting that twenty to thirty pounds was “normal.” 42 Some texts even permitted thirty-­five pounds.43 New laws mandated that diuret­ ics labels alert pregnant w ­ omen not to take them.44 Williams Obstetrics began warning prac­ti­tion­ers about the dangers—­rather than the merits— of severe dietary limitations.45 By the 1980s, attempting to restrict weight gain during pregnancy was a backward notion—it was taboo, an unhealthy deprivation. Normal weight gain advisories w ­ ere higher than ever before; thirty pounds would never have been advised just a generation prior.46 To my mind, this turnabout is astonishing. New York Times health reporter Jane Brody repeated findings from a major study affirming the “widespread practice of obstetricians of encouraging maximum weight gain during pregnancy.” 47 Indeed, the standard of practice, already by the early 1980s, was to encourage a gain of twenty to thirty pounds or more to “optimize the chances for a successful pregnancy outcome.” 48 Obstetri­ cians trained in the 1970s and 1980s thus learned a very dif­fer­ent set of standards regarding prenatal weight gain than their se­niors.

To a certain extent, the more liberal ideology ­toward prenatal weight gain in the 1970s was prob­ably an instance of medical recommendations shift­ ing to align with public health realities. American men and w ­ omen alike weighed more, on average, in the 1970s and beyond than they did in pre­ vious de­cades. As Peter Stearns writes in his book Fat History, during the 1960s and 1970s, standard mea­sure­ments for ­women’s dress sizes increased, life insurance policy standards w ­ ere rewritten, and seats in the Los Ange­ les Colosseum w ­ ere widened. Between 1960 and 1980, weight gain went up 3 ­percent among white ­women, 7 ­percent among Black ­women, 6 ­percent

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among white men, and 28 ­percent among Black men. “Then,” Stearns says, “the late 1980s and early 1990s broke the scales with an unpre­ce­dented surge. The average American adult gained eight pounds between 1985 and 1995.” 49 In this context, perhaps it is not very surprising that the relaxed guide­ lines for prenatal weight gain appear to have met a ready audience: w ­ omen started to gain more weight during pregnancy. Averages ­rose from about twenty pounds (or the low twenties) to 26.5 pounds, and then higher. In one study of ­women who became pregnant in Madison, Wisconsin, the average prenatal gain before 1971 was eleven to twenty pounds; ­after 1971, most ­women gained twenty-­one to thirty pounds.50 In a 2000 study documenting that ­women have been gaining more weight, on average, during their pregnancies since 1970, the authors explained that “crude data clearly show that ­after weight-­gain recommen­ dations ­were liberalized, t­ here was an increase in the [averages] of both pregnancy weight gain and infant birth weight.”51 In a 2013 review account­ ing for more than 68,000 ­women on five continents, the average gesta­ tional weight gain was twenty-­five to thirty-­five pounds.52 Clearly, medical recommendations about weight gain for pregnant ­ omen have deviated from them through­ ­women have not been gospel. W out history, and the prevailing norms governing body weight and physique have likely been equally, if not more, power­f ul than any professional guidelines. But the changes in what medicine perceived as “normal” or “healthy” weight gain for pregnant ­women over time did contribute to the conversation.

New Guidelines, Old Debate In 1990, the Institute of Medicine (IOM), a private nonprofit research group established by the National Academies of Science in 1970, released new recommendations for gestational weight gain. They w ­ ere specifically devised with the intent of reducing the incidence of low-­birth-­weight

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babies in the United States, and thus reflected a belief, at least in theory, that maternal weight gain—­low or high—­was linked to infant birth weight.53 The IOM guidelines gave researchers some benchmarks to work with, but the evidence undergirding them was less than ideal.54 Instead of a blanket weight gain range, the 1990 guidelines advised individualized recommendations based on ­women’s prepregnancy weight, delineating target weight gain ranges by body mass index (BMI).* For ­women with a normal BMI, gaining twenty-­five to thirty-­five pounds was considered appropriate; underweight ­women w ­ ere advised to gain twenty-­ eight to forty pounds; overweight ­women should gain fifteen to twenty-­five pounds; and obese ­women (defined as having a BMI of 30 or higher) w ­ ere instructed to gain at least fifteen pounds. ACOG a­ dopted the IOM par­ ameters in 1993.55 One of the experts who served as chairman for the IOM committee observed that “in a sense, this brings health recommendations in line with what is actually happening.”56 Almost immediately, critics harangued the guidelines for being too liberal, besides being grounded in “weak” evidence and relying on “obser­ vational studies that are a swamp of c­ auses, effects, confound­ers, and epi­ phenomena.” One article in The Lancet encapsulated many of critics’ fears, stating that the guidelines constituted a “potentially harmful policy . . . ​ [and] an inappropriate response.” They charged that the IOM recom­ mendations “encourage[d] overnourishment in all pregnancies” and would “feed the current epidemic of obesity in industrialized nations.” Essentially, t­ hese authors considered the liberalized weight gain guidelines a “misguided” attempt to solve the prob­lem of low birth weights. “We are at a loss,” they concluded, “to understand the logic of encouraging mil­ lions of ­women to overeat during pregnancy.”57 In the twenty-­first ­century, physicians continued to pour criticism on ­t hose same guidelines for failing to account for dramatic increases in the

* Body mass index is calculated using an individual’s weight, mea­sured in kilograms, and height, mea­sured in meters. The formula is kg/m2.

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prevalence of prepregnancy obesity (since 1990, t­ hese rates have risen by at least 70 ­percent; already by 2010 some 20 ­percent of ­women who became pregnant fell into the obese category). Many doctors wanted the guide­ lines to (1) incorporate an upper limit, rather than merely a minimum, for obese w ­ omen, and (2) stratify the BMI groupings even further, with obe­ sity subgroups. ­Others took issue with the guidelines’ under­lying assump­ tion that low birth weight was an outcome of insufficient maternal weight ­ omen, published in gain.58 A 2007 study of more than 300,000 Swedish w Obstetrics and Gynecol­ogy, suggested that the “optimal” weight gain ranges ­were much lower than t­ hose proposed by the IOM, with the highest gains for even the low-­BMI group topping out at just twenty-­two pounds. “­There have been discussions,” the authors noted, “about w ­ hether the IOM guide­ lines for weight gain are too high and contributing to the ongoing obesity epidemic.”59 Critics got one bit of what they wanted. In 2009, the IOM updated its pre­ natal weight gain guidelines with new specifics—­namely, more strict limita­ tions for the by-­then 27  ­percent of pregnant ­women who ­were obese.60 ­Under the new protocol, ­women who ­were obese when they became preg­ nant ­were advised to gain between 11 and 20 pounds, rather than “at least 15.” For singleton pregnancies, t­ hese ­were the 2009 IOM guidelines, strati­ fied by BMI: • BMI less than 18.5 (underweight): 28–40 pounds • BMI 18.5–24.9 (normal weight): 25–35 pounds • BMI 25.0–29.9 (overweight): 15–25 pounds • BMI 30 and above (obese): 11–20 pounds ACOG endorsed t­ hese guidelines, although they have been controversial. Indeed, many physicians still take issue with the IOM par­ameters for being too liberal, especially in the top two BMI categories of overweight and obese.61 Around the time of the 2009 IOM guidelines, researchers and clinicians launched efforts to minimize weight gain for obese pregnant w ­ omen to

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the point of zero pounds gained, or even a net loss.62 One multihospital consortium that convened in New York City to address the prob­lem of obesity during pregnancy even considered the utility of developing “spe­ cialized centers for obese w ­ omen” that would be equipped with a greater number of trained experts, more cesarean delivery rooms, and special equipment.63 Since the construction of the IOM guidelines, researchers have been trying to assess ­whether adherence to the guidelines actually improves maternal and fetal outcomes (or vice versa). So far, from what researchers can tell, it does. Weight gain outside the IOM par­ameters, especially far outside the IOM par­ameters, is correlated with more risks for ­mothers and babies, ranging from preeclampsia and infant birth weight issues to deliv­ ery interventions.64 So perhaps sticking to the guidelines might be advan­ tageous; but not that many w ­ omen adhere to the guidelines. Recent evidence from an international meta-­analysis of twenty-­three studies involving more than 1 million w ­ omen (published in JAMA in June 2017) indicates that just about one-­t hird of w ­ omen gain the recom­ mended amount of weight during their pregnancies; 23 ­percent gain less than recommended, and almost half gain more than recommended. Gaining weight outside the IOM guidelines—­regardless of prepregnancy BMI—­was indeed associated with adverse outcomes. According to the data, w ­ omen who did not gain enough weight w ­ ere at 5 ­percent higher risk for having a small-­for-­gestational-­age baby and for preterm birth (deliv­ ering before thirty-­seven weeks), and ­t hose risks ­were especially signifi­ ­ omen who also began their pregnancies underweight. On the cant for w flip side, pregnant ­women who gained too much weight had a 4 ­percent higher risk for having a large-­for-­gestational-­age baby and undergoing a cesarean delivery. ­These numbers may sound trivial, but they could amount to tens of thousands of events each year.65 ­Earlier proj­ects documented similar results. One review from 2013 found that only 17.5 ­percent of w ­ omen gained weight within the IOM recommendations, and that nearly 75 ­percent gained in excess of the

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recommendations. Based on the demonstrated elevated risks of hyper­ tensive prob­lems (10.9 ­percent higher), having a large-­for-­gestational-­age infant (6.4 ­percent higher), and needing a cesarean delivery (8.7 ­percent higher), the authors concluded that “collectively, the available lit­er­a­ture . . . ​ suggests that the public health implications of excessive weight gain dur­ ing pregnancy are potentially profound.” 66 But more work seems to indicate that gestational weight gain might just be a barometer for weight-­related prob­lems before or a­ fter pregnancy; pre-­ and postpregnancy weight, especially obesity, could ­matter more than ges­ tational weight gain.67 In other words, gestational weight gain might have more or less—or even no—­bearing, depending on a ­mother’s prepreg­ nancy weight status.68 In research as early as the 1990s, prepregnancy maternal weight began to emerge as an impor­tant determinant of healthy pregnancy outcomes, with “lean” and “normal” weight ­women having consistently better out­ comes and fewer adverse events than heavier ­women. (The New York Times chose to convey this research—­originally published in the New ­England Journal of Medicine—­under the dubious headline “Being Thin While Preg­ nant Is Seen as Best.” 69) Twenty-­first-­century research continues to direct attention t­ oward prepregnancy weight, and some researchers are calling for even more spartan recommendations for the highest-­BMI groups—­ limiting weight gain to just ten pounds or sometimes even recommend­ ing weight loss during pregnancy.70 But at this point, we have no data on this—­t here simply have not been any t­ rials. As Cochrane review authors noted, “­u ntil the safety of weight loss in obese pregnant w ­ omen can be established, ­there can be no practice recommendations for ­these ­women to intentionally lose weight during the pregnancy period.”71 For some w ­ omen, the increasing trend to begin pregnancy care ­earlier and ­earlier, before conception, is encouraging. For ­others, it is exasperating. Likewise, increasing research into postpartum weight patterns has shown that “problematic” gestational weight gain often correlates with

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postpartum weight retention.72 Furthermore, between-­pregnancy weight gain is associated with higher rates of gestational diabetes and hyper­ tension, cesarean delivery, and stillbirth.73 Although some of the mid-­ twentieth-­century research that supposedly documented t­ hese prob­lems looks seriously flawed—­one study, for example, calculated “permanent weight gain” based on ­women’s weight at their six week postpartum visits—­ investigators in the twenty-­first ­century are at least using more appropri­ ate postpartum mea­sur­ing points, ranging from thirty to fifty weeks a­ fter delivery. Still, the extent to which gestational weight gain influences a ­woman’s weight overall remains uncertain.74 Recently, this issue has broadened still more, as physicians and research­ ers are using epigenet­ics—­the science of gene expression modification and its ­causes—to link “excessive” prenatal weight gain not just to obesity in ­women, but also to their c­ hildren and the societal obesity epidemic. In line with the trend ­toward a focus on prepregnancy weight as more deter­ minant than prenatal weight gain, higher prepregnancy weight is associ­ ated with childhood markers of obesity such as BMI, total fat distribution, lipid levels, and insulin levels.75 Some studies indicate that obese ­women are nearly two times more likely to have a stillbirth than w ­ omen of nor­ mal weight, and that their babies are almost three times more likely to die in the first month of life.76 But ­t hese links are still tenuous. The evidence is much more clear that ­women who gain more weight while they are preg­ nant may go on to bear c­ hildren who are more likely to be overweight and have higher blood pressure in childhood, as well as more likely to develop diabetes, heart disease, and cancer as adults.77 Some critics (myself included) reproach ­these kinds of concerns as ­sexist, veiled contributions to biased standards of feminine beauty and slimness, a misplaced medical mechanism for controlling w ­ omen—­but dismissing them altogether is not a good option. If we discard concerns about postpartum weight retention as mere aesthetic bias, we risk losing sight of the pos­si­ble legitimate health ramifications—or benefits—­ associated with body weight. Disregarding “risk of weight retention” as

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an invalid concern associated with pregnancy weight gain ignores the escalating body of scientific knowledge indicating that weight does ­matter. And it risks ignoring w ­ omen—­myself included—­who do, for better or worse, care about minimizing their chances of retaining a few, or many, pounds ­after giving birth. Maybe it is an uncomfortable conversation, but I think we should have it. Doctors are. Th ­ ey’re comparing weight control during pregnancy with smoking cessation. Th ­ ey’re treating the special circumstances of preg­ nancy as an “opportunity . . . ​to break the cycle of obesity”—­just like quit­ ting tobacco.78 Of course this analogy should make us anxious, but exiting the conversation benefits no one. Obesity is not lung cancer, but plenty of evidence indicates that pregnancy can be an opportunity for change for the better.

Weighing In It does not look like the debate about “ideal weight gain” during pregnancy is ­going to be settled anytime soon. Society and medicine have considered pregnant ­women’s weight impor­tant (and sought to better understand it) for dif­fer­ent reasons at dif­fer­ent times—­clearly. But amid the change ­t here is also a shred of consistency. ­People have been asking the same questions for a very long time. What is normal? What is excessive? How impor­tant is prenatal weight gain? For whom? And beneath all this, ­there is the under­lying question: does it even ­matter? Research has swung back and forth on the question of w ­ hether mater­ nal weight gain is a determining f­ actor in fetal size, for example, since the nineteenth ­century. In the 1800s, doctors thought w ­ omen who gained less weight while they ­were pregnant gave birth to smaller babies, and they considered this desirable b ­ ecause they judged that birth would be easier (and safer) with smaller fetuses. (It did not hurt that this also aligned with the prevailing ideal of feminine beauty—­that w ­ omen be slender ­mothers.) ­Later, obstetricians who could rely on much safer birthing rooms and

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cesarean deliveries produced evidence indicating that smaller babies ­were, generally, less healthy than heavier babies. Thus, growing a smaller fetus was desirable in the late 1800s but was exposed as disadvantageous (­because it was associated with less healthy babies) in the twentieth ­century. But the ­actual empirical evidence about the connection between mater­ nal prenatal weight gain and fetal size has been all over the map, with some researchers attesting to their close (prob­ably causal) correlation and ­others contending that the association is a deception. That is, it is not at all clear that a w ­ oman who gains less weight w ­ ill have a smaller baby, or vice versa. In the de­cades around 1900, the correlation was widely accepted; then researchers challenged it. In 1935 one writer asserted that “­there is not the least bit of scientific evidence to show that you can have a smaller baby by restricting your diet.”79 In the 1940s, physicians disagreed about ­whether t­ here was any link between prenatal maternal weight gain and a baby’s birth weight. One review found that ­there was a “tendency for the average weight of the new­ born to increase as the ­mother gains more weight during gestation,” but that ­there was “no proportionate relationship between the two.” In other words, the authors found that ­t here was some relationship, but no direct correlation.80 Physician Samuel Meaker intimated the same in his book in 1956: “Does the total quantity of food consumed by a pregnant ­woman influence the size of her unborn baby? Only within very narrow limits.”81 During World War II, famine conditions in places like Leningrad and Holland created what researchers think of as “natu­ral experiments.” Pregnant ­women ­were forced to endure the direst circumstances, including severe malnutrition. According to retrospective research, ­t hese women—­ who consumed fewer than 1,000 calories daily—­gave birth to babies who weighed approximately 0.9 to 1.3 pounds less than average. Dif­fer­ent voices have painted this kind of evidence in dif­fer­ent ways—­some claim that the extreme nature of the conditions paired with modest weight defi­ cits are indicative that maternal weight gain cannot be blamed for the

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prob­lem of low birth weight. ­Others see the outcomes exactly the opposite.82 Answers to this question of how much maternal weight gain influences birth weight grew increasingly nuanced, if more divided, in the second half of the twentieth c­ entury.83 In 1962, Infant Care (a pamphlet produced by the U.S. ­Children’s Bureau) announced that “recent studies seem to show that the size of the baby is not closely related to his m ­ other’s diet.”84 In that same de­cade, one Obstetrics and Gynecol­ogy article suggested that t­here was a small correlation: “only about 2.5% of the maternal weight gained beyond 10 lb. can be demonstrated as additional fetal weight.” The next year, in the same journal, a separate research team concluded that a m ­ other’s prepreg­ nancy weight, weight gain, and baby’s birth weight ­were all strongly associ­ ated, but the exact nature of their association—in par­tic­u­lar, ­whether ­there was any cause-­and-­effect relationship, was still not clear.85 A piece in 1972 in Clinical Pediatrics stated that “­women who gain less in pregnancies tend to have smaller babies.” (Although, the author also qualified that the influence of pregnancy weight gain lessened as prepregnancy weight ­rose.)86 Other researchers in the late twentieth ­century also reported that prenatal weight gain and babies’ birth weights ­were highly associated—­one group of investi­ gators found them to have “an almost straight-­line correlation.”87 In the twenty-­first c­ entury, the exact nature of the relationship between prenatal weight gain and fetal growth is still undetermined. Recent evi­ dence does indicate that weight gain during pregnancy is at least related to fetal weight, and babies that are e­ ither too big or too small for their ges­ tational age can both be problematic. A reflective 2009 piece issued by the IOM asserted that evidence “links gestational weight gain directly with fetal growth, so that higher weight gain predicts large-­for-­gestational-­ age and lower weight gain predicts small-­for-­gestational-­age.” Epidemio­ logical evidence, the authors continued, consistently shows “a linear, direct relationship” between how much weight a m ­ other gains and how much her baby weighs at birth.88 Although, as researcher Emily Oster commented, the effects are small on an individual basis.89

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Put simply, studies have investigated the relationship between mater­ nal weight gain during pregnancy and birthweight multiple times over, in ­every de­cade since the late 1800s, and they have all reached dif­fer­ent con­ clusions. Furthermore, even the same conclusions have been used to dif­ fer­ent ends: the connection between maternal weight gain and fetal size, though tenuous, has been used to justify divergent perspectives and poli­ cies. In the 1970s, rising rates of low-­birth-­weight infants directly contrib­ uted to looser guidelines for prenatal weight gain. Twenty years l­ater, rising concerns about obesity directly contributed to the perspective that t­ hose guidelines had gone too far and needed to be constricted. In the last few de­cades, some researchers have suggested yet another twist—­that prenatal weight gain only affects birth weight for certain ­women. According to some studies, pregnancy weight gain correlates with birth weight among ­women with low to normal BMIs, but not among obese w ­ omen.90 I ­don’t know what to think about how my weight gain ­w ill influence my child’s birth weight. Maybe it w ­ ill, a l­ittle bit? Of course, birth weight is far from the only question researchers look­ ing into gestational weight gain have continually investigated. ­They’ve questioned w ­ hether maternal weight gain during pregnancy has any bearing on maternal or fetal complications, ranging from toxemia/pre­ eclampsia to delivery prob­lems. (Toxemia is the former nomenclature for preeclampsia, a serious late-­pregnancy condition whose symptoms include hypertension, excessive swelling, severe headaches, and vision prob­lems.) ­They’ve questioned what constitutes “ideal,” “insufficient,” or “excessive” weight gain. ­They’ve questioned how to counsel patients and what means they can safely employ t­ oward their ends. ­They’ve questioned—we all have questioned—­the very nature of this aspect so fundamental, so basic, as to be part of pregnancy: growth.

Weight gain during pregnancy might m ­ atter a ­great deal for m ­ others and babies. But then again, it also might not. As Aaron Caughey, the chair of

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the Obstetrics and Gynecol­ogy department at Oregon Health and Science University, emphasized in a fascinating 2017 editorial in JAMA, the research linking “inappropriate” gestational weight gain to adverse out­ comes is purely correlational. The correlations are strong and consistent, and they offer compelling reasons to accomplish healthier gestational weight gains (what­ever that means), but they remain associations—­which are powerless to tell us anything definitive about causation.91 History suggests that the lower and upper thresholds for weight gain in pregnancy are not static. It sounds obvious, but it is clear that the most contentious lines of debate about weight gain during pregnancy have fallen on the edges of the bell curve, where severe dietary restriction and exces­ sive weight gain lie. ­These are subjective categories, of course, with no clear demarcations, but ­women who gain a g­ reat deal of weight during preg­ nancy tend to have higher risks for certain adverse outcomes, as do some ­women who fail to gain much weight at all during pregnancy. I do know one ­thing, though: no medical evidence has ever indicated that pregnant w ­ omen should “eat for two.” Indeed, this has been one of the only unan­i­mous points of agreement about weight gain in pregnancy over time. Pregnant w ­ omen do not need to eat much more. (“Eating for two?” health economist Emily Oster asks in her wonderful book Expecting Better—­“you wish.”)92 Science has been trending t­oward the “less is more approach” for 150 years at least. As I confront the fluid data and numbers about how much weight to gain during pregnancy, I begin to won­der w ­ hether the amount of atten­ tion paid to gestational weight gain has eclipsed potentially more perti­ nent conversations about health and nutrition. Doctors have never been sure about exactly what constitutes “appropriate” weight gain during preg­ nancy, or how much to care about it. Accordingly, ­women have been sub­ ject to widely varying recommendations about how much weight they can acceptably gain during pregnancy, and while this is not implicitly troublesome—­medical recommendations change all the time—­I am still curious about the extent to which our focus on numbers contributes any­

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thing meaningful. Pregnant ­women’s bodies grow, and this inevitability lends to quantification: weight is ­simple to mea­sure and easy to track. But pounds are imperfect indicators of maternal or fetal health. Perhaps our culture’s proclivity to approach “pregnancy weight gain” as a discrete phenomenon inadvertently perpetuates the idea that pregnant ­women need to eat more, or eat for two. We have made pregnancy weight gain into a “­t hing.” I’m clearly guilty of this. Around the world, many professional midwifery practices do not see gestational weight gain as a top priority within prenatal care. Some mid­ wives are even so concerned about the pos­si­ble negative impacts of over­ discussing weight with pregnant w ­ omen that they have mixed feelings about relaying weight-­gain guidelines to them all.93 Indeed, across dif­fer­ ent health care settings, the counsel offered to pregnant w ­ omen about weight gain is discrepant—­t he messages vary by geography, patient pop­ ulation, and professional training, among other f­ actors.94 Even more arresting is the fact that regularly weighing pregnant ­women at prenatal appointments does not appear to actually influence maternal weight gain at all. (Perhaps this is one reason why many midwifery prac­ tices forego the routine weighing-in of their patients altogether.)95 What, then, is the point of the weigh-in in the first place? With this question in mind, I find something refreshing about the fin-­ de-­siècle idea that eating during pregnancy need not differ from any other time. “The appetite should be kept u ­ nder [control] in pregnancy as care­ fully as at any other time,” Dr. Emma Drake wrote in What a Young Wife ­Ought to Know.96 Dr. J. Morris Slemons, an early, highly esteemed expert in pregnancy, stated that “a diet which has previously been ample ­will like­ wise be sufficient throughout pregnancy.” 97 Dr. M. L. Holbrook announced that eating during pregnancy “should be—as, indeed, it should always be, ­ ese in moderation. It should be deliberate, and it should be cheerful.” 98 Th suggestions might have an off-­putting undercurrent (we ­will get to that in the next chapter), but I cannot help but find some appeal in their

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under­lying premise of continuity—­t heir implication that pregnancy need not usher in an altogether discrete approach to eating or calories or appe­ tites or growth. And I ­don’t think I am alone in that thought—­this very idea has recurred periodically in the medical lit­er­a­ture. In 1950, Williams Obstetrics stated that “in normal pregnancy the diet should be no more or less than that to which the patient has been accustomed.” 99 A 1956 parenting manual explained that “the same general princi­ples of balanced diet and weight control might be observed advantageously by nonpregnant w ­ omen, and also by men.”100 In a 1998 editorial in The Lancet, two authors stated, “we suggest that during gestation ­women need only follow the prudent diet endorsed in many national guidelines for the general population.” 101 Well, maybe it’s time to move on from numbers. My curiosity grows with my body.

chapter 4

• Eat

The first time I was pregnant, I chortled at the numerous apps and advice books that track the pro­gress of pregnancy with increasingly large foods week by week. In week five, a fetus is compared to a blueberry; in week eight, a raspberry; week thirteen, a lemon; by weeks forty to forty-­two, a watermelon. Even though I detest the association (why, I am not entirely certain, but presumably for the s­ imple reason that the entire ordeal is both inaccurate and juvenile) I still cannot help myself from checking the weekly updates my second time around. Each Monday, I secretly consult a few dif­fer­ent references, and pick my favorite. This week, my baby is as big as an onion. Or perhaps she is a pome­ granate, or a pear. An onion, I decide: savory and flavorful, pungent, effort­ ful yet revered in the culinary world, a stalwart staple in e­ very chef’s pantry. I am embarrassed to admit that I partake in this ritual—­sheepish as I sit writing the words, detailing my engagement in this meaningless calen­ dric marker, superficial and wanting. Yet e­ very week I find myself perusing the options and comparing my unborn ­daughter to a fruit or vegetable. I am sorry, ­little one—­I know you are better than this. Recently, media outlets have released a spate of similar lists meant to retaliate against the food analogies—­paperclips and sponges, hair bows 85

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and smart devices, loofahs and kettlebells—­but t­ hese are equally frivolous, equally senseless. And they h ­ aven’t resonated in the same way, h ­ aven’t had any apparent lasting power. And so I ask myself: why am I—­and evidently tens of thousands more ­women—­a mused at the prospect of mea­sur­ing pregnancy via—of all ­t hings—­fodder? Pregnancy narratives and advice books, textbooks and manuals, mem­ oirs and pamphlets, inevitably package food and gestation so intimately that it can, at times, feel like to be pregnant is to think about food, to con­ template eating. To be an eater. In food, we find common ground, we pregnant w ­ omen. And also com­ bat, combustion, nerves. ­Every pregnant ­woman carries with her a story about food: how she “thought twice” about eating some forbidden ingredient; how she stood para­lyzed in one aisle or another at the grocery store, uncertain and waver­ ing, hurriedly surfing her iPhone for a definite answer to some former minutiae; how she suffered through a coworker or even a stranger ques­ tioning her order at the corner market or local coffee shop; how her ­mother or grand­mother waved off one guideline or another as ludicrous; how she accidentally ate something she “­shouldn’t have” only to awaken in the ­middle of the night, terrified that she may have inflicted some harm upon her unborn child. They all run together. Or maybe that’s just me. In some ways, food is every­thing to pregnancy—it gives nourishment and strength and growth even while it submerges us in the icy w ­ aters of trepidation; it both agitates and remedies, instigating and easing queasi­ ness and upset stomachs; it relieves hunger, but toys with the appetite like a cat with a mouse; it fuels companionship and segregation alike. I think of all this—­somewhat bitterly, I admit—­every time I say “no thanks”—to a glass of wine, an extra cup of coffee, an oyster or sprouts or fine bleu cheese. Better not.

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Pregnancy is a time when w ­ omen—so entrenched in a culture that places slenderness at the center of the t­ able of femininity that I remember one ­woman writing about her ecstasy at the prospect of eating a banana (a banana!) without feeling guilty a­ fter she became pregnant—­might uniquely savor food, enjoy and take delight in its pleasures, s­ imple and complex. But we also uniquely fear it, fret over it, e­ very bite an agonizing balance of risk versus reward, chances and probabilities. What to Expect When ­You’re Expecting teaches the “best odds diet,” a less-­t han-­intuitive eating plan with an irksome name. In food, w ­ omen can always find reproach. For most of recorded medical history, the majority of discussions about healthful eating during pregnancy did not in fact revolve around health at all. Instead, conversations have focused on the h ­ azards foods pose, the apparently disordered and unsightly dietary mutations that accompany pregnancy (such as nausea, cravings, or swings in appetite), the delinea­ tion of rules to live by. Expecting w ­ omen w ­ ere at once problematic, fickle, perilous, as well as power­f ul, nurturing. Maternal. If we are what we eat, then motherhood begins long before birth.

Wait Wait . . . ​­D on’t Eat That! ­People have been telling pregnant ­women for thousands of years that what they eat could affect their unborn c­ hildren. In the ancient Western world, leading physicians like Hippocrates and Galen contended as much, cau­ tioning that dietary “­mistakes” ­were a prime cause of miscarriage. (Both writers failed to offer any details regarding what constituted such “­mistakes.”) Plato famously stated that “­children s­ houldn’t be made in bodies saturated with drunkenness.” In the ancient East, prominent doc­ tors like Caraka and Susrata warned that eating “too much or too ­little” food, or feeding an “addiction” to a certain food, could harm or kill a growing fetus; they devised precise dietary blueprints for each month (or

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sometimes even each week) of pregnancy. In the ­Middle Ages, pregnancy “regimens” addressed food consumption.1 And in the modern era, since at least the ­middle to late 1800s, advice writers have proclaimed that a pregnant ­woman’s diet is enormously impor­tant. Diet was one area pregnant w ­ omen needed to attend to “reli­ giously,” with “exacting” attention, they said.2 Indeed, dietary advice abounded in pregnancy health manuals in the West, emphasizing the importance of eating in moderation while also enumerating preferred foods to eat and ­t hose to avoid. Above all ­else, advice writers stressed the imperative of keeping the pregnant body in balance.3 And what e­ lse could threaten to the tip scale as perfectly as food?* In Amer­i­ca, t­ here is a long history of telling pregnant ­women what and how to eat. We may take it for granted that eating during pregnancy is somehow dif­fer­ent, more involved—to the point that many w ­ omen t­ oday seek out dietary advice as soon as they become pregnant, almost automati­ cally, as a ritual. But it’s grating, on some level, to think that w ­ omen sud­ denly need special help ­doing something ­they’ve done their entire lives—­ eat—­t he moment they become pregnant. In the nineteenth and twentieth centuries in the United States, the way a ­woman ate was an impor­tant aspect of her femininity—­a signifier of her class, her beauty, her refinement, her self-­control. At the turn of the twen­ tieth ­century, the ideal fash­ion­able w ­ oman was slender and trim, as frag­ ile as she was demure. Along with increasing access to exotic and foreign foods, thanks to the Industrial Revolution and urbanization, the act of eat­ ing itself became increasingly significant. “Eating correctly,” explains historian Joan Jacobs Brumberg, emerged as “a new morality.” ­Daughters

* In this chapter, I am less interested in rooting out “the truth” ­behind any par­tic­u ­lar dietary advice or recommendations about one food or another (thankfully, o ­ thers have already done this, most notably economist Emily Oster in her wonderful book Expecting Better) than I am in meditating on the intensity and polarity of ideas about food and eating throughout pregnancy.

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learned from their m ­ others to eat “delicately,” to keep their desires in check, and to approach the culinary ­table with caution. To exhibit dietary restraint was to abide by one pillar of womanhood.4 The slighter the appetite, the more frail the ­woman, the better she was—­not simply more attractive or appealing, but actually better. Pregnant w ­ omen then (as now) w ­ ere not exempt from the reigning cul­ ture of food. Indeed, dietary considerations w ­ ere paramount to a healthy pregnancy. In subsequent de­c ades, and into the twenty-­fi rst ­century, pregnant ­women, sometimes visibly distinct, continued to be sized up, assessed for how they manifested (or did not) their femininity. Perceptions of excess fat remained loaded with moral overtones—­variously equated with laziness, a lack of willpower, ­mental disturbance, sloth. My point is this: it is impossible to consider the ideological or physical role of food in pregnancy without also considering the broader context of ideals of femininity, motherhood, and domesticity as they relate to food. Con­temporary thinking about food and pregnancy has always been char­ acterized by a grating duality. Consider, for example, the pregnant w ­ oman’s appetite. The perspective articulated in the ­middle to late 1800s that pregnant ­women’s appetites are “capricious” has not changed very much in 150 years. The notion that pregnant ­women are volatile eaters, that they yo-yo back and forth between being insatiable and indifferent, wolfish and mousy, was and is entrenched in American culture.5 And it aligns quite closely with even longer-­standing historical perspectives that femininity itself (and what is more feminine than carry­ing a child?) carries within it the power of procreation but also the potential to be corrupting, unbridling. Even—­ especially—to a fetus. Pregnant ­women all around the globe, among dif­fer­ent cultures, expe­ rience food cravings, although the phenomenon seems more common in the United States, where between 50 and 90 ­percent of pregnant ­women report experiencing a specific food craving at some point during their

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pregnancies.* Interestingly, Americans in general are familiar with food cravings (in one study described in the journal Appetite, 97  ­percent of  ­women and 68  ­percent of men reported experiencing them), but American culture treats pregnancy cravings with a certain manner of exceptionalism.6 Scientists do not have a neatly packaged biological answer to the ques­ tion of why pregnant ­women (or ­humans, generally) experience food crav­ ings. They doubt it’s strictly hormonal, although hormones almost certainly play a role. It’s very common for taste sensitivities to shift during preg­ nancy (how many ­women stop drinking coffee, for example, ­because they simply “­don’t care for it anymore” while they are pregnant?), and the sen­ sory changes that contribute to such altered food preferences likely do stem from hormonal upheaval, but the link is tentative, an implication.7 The hypothesis that a food craving arises from a specific nutritional deficiency—­a popu­lar idea colloquially, at least—­a lso seems unlikely ­because most of the most commonly craved foods during pregnancy are unlikely to bridge major nutrient gaps (what deficit would choco­late fill?), and many of the most nutrient-­dense foods tend to fall low on the list of cravings (although I confess that I find myself salivating at the thought of sautéed kale ­here and ­t here). Researchers also note that if the “nutritional deficits” hypothesis was all t­ here was to it, we would expect cravings to increase progressively over the course of pregnancy, as fetal nutritional demands grow, but that is virtually never the case.8 Nor is it the case that pregnant w ­ omen necessarily share in their spe­ cific food cravings or fears. Around the world, pregnant w ­ omen learn to embrace and be wary of dif­fer­ent foods depending on cultural norms, reli­ * It is fascinating that ­women in dif­fer­ent socie­ties tend to crave dif­fer­ent foods. In Amer­i­ca, the most common cravings are for sweets, dairy products, and starchy foods; in Japan, more ­women long for rice; in Tanzania, pregnant ­women crave meat and mangos; and many languages and cultures ­don’t have a perfect translation for the concept of a “food craving” at all. Furthermore, research suggests that (among American ­women) cravings can shift over the course of a pregnancy, with urges for savory foods more common in the first trimester, urges for sweet foods at their peak in the second trimester, and urges for salty foods increasing in late pregnancy.

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gious beliefs, and generational wisdom. In some parts of Africa, pregnant ­women are not allowed to consume eggs or milk; in West Bengal, some fruits are feared as a cause of miscarriage; in Ethiopia, pregnant w ­ omen avoid honey, oranges, and pineapples.9 Clearly, it is not uncommon for one culture to prize the very foods another warns against (and vice versa). In Japan, pregnant w ­ omen avoid spicy foods but crave rice and consume sushi regularly—­while in the United States, most w ­ omen learn to avoid sushi. According to traditional Chinese medicine, pregnant w ­ omen need to avoid foods with yin qualities, including “cold foods” like ice cream, watermelon, or banana as well as “wet-­hot” foods such as shrimp, pineapple, or mango—­ again, foods many American ­women relish (or crave, at least anecdotally). Such cultural food edicts may appear harmless, but they are not.10 In the first place, food restrictions internationally often target w ­ omen, and pregnant w ­ omen especially. In developing nations or resource-­poor communities, food taboos can have damaging effects. In many parts of Sub-­Saharan Africa, for example, the foods pregnant ­women are forbid­ den from eating happen to be some of the most nutrient-­dense food sources available to them (including meat, fish, eggs, and legumes). As two scien­ tists observed, cultural food taboos are “one of the ­factors contributing to maternal undernutrition during pregnancy.”11 (Of course, in the United States, medicine tends to be more concerned with the opposite prob­lem.) In the United States, numerous food taboos mingle with certain fatalis­ tic cultural impressions about pregnancy cravings. Perhaps the perception that pregnancy is a time of “exemption,” a culturally sanctioned intermis­ sion from the prevailing norms of be­hav­ior, may contribute. Interestingly, this notion of disinhibition—­that “pregnancy is a time when one does not need to feel accountable for one’s food intake”—­coexists (not without prob­ lems) with its polar opposite: that pregnancy is a time for other-­worldly consciousness and attention, a time to abide by the imperative to eat well as scrupulously as ever.12 Pregnancy cravings—­and contrary interpretations of their occurrence—­ appear to be as ubiquitous historically as they are geo­graph­i­cally. In the

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past, many writers indicated that denying the so-­called “longings” of preg­ nancy could be harmful to a fetus; yet equally as many opined that giving in to the longings of pregnancy was also harmful. Thus, most advice regarding pregnancy cravings was ­either conflicting or ­else tempered and confusing. Take this observation, for instance, from Eutocia: Easy Favorable Child Bearing, a Book for All W ­ omen (1866): “if t­here are longings, and reason ­favors indulgence, it is well to heed them; but reason must control; for much harm may be done by foolish gratification of t­ hese whims.”13 Other writers described cravings as a symptom, typically of some under­lying ­disturbance—­“a strong self-­controlled w ­ oman is not troubled by longings,” one w ­ oman wrote. “Hence should she desire a t­ hing that it ­will be difficult to get, let her exercise reason, and good judgment in the denial, and the longing ­will not trou­ble her.”14 For their part, most medical writers did attempt to sideline both of ­these perspectives—­that caving in to or rejecting cravings was necessarily deleterious—­a nd instead asserted that “­t here is no valid scientific evi­ dence” that indulging or resisting cravings had poor outcomes.15 But the notion that a pregnant w ­ oman’s appetite—­and figure—­needed to be sur­ veilled and suppressed manifested in other ways. Maternity clothes, devised amid the growth of consumer culture in the early 1900s, promised to slim and camouflage the unattractive changes that accompanied the pregnant body. Indeed, maternity wear’s founda­ tional purpose was to minimize the pregnant body, to disguise it. For most of the twentieth ­century at least, maternity clothes contributed to the evolution of the “modern pregnant w ­ oman”: a glowing, cheerful, impec­ cably well-­g roomed and well-­d ressed and well-­made-up w ­ oman. Even while maternity clothes enabled many ­women to move and work and be in public anew, more comfortably—­helped make pregnancy an appropri­ ate sight and topic in casual conversation (where it had once been taboo and unbecoming to even mention in print newspapers)—­t hey nonethe­ less contributed to the idea that the course of pregnancy was more about

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controlling it, reining it in, radiating an ethereal “glow” than it was about nurturing anyone, m ­ other or baby.16 Threats to that entire proj­ect could emanate from even the unlikeliest of sources. Violations lurked everywhere, and none of the senses was safe from outside influence. In the de­cades on ­either side of the turn of the twentieth ­century, many Americans believed that a ­woman could some­ how mark her child (especially unfavorably) in utero, w ­ hether by experi­ encing or witnessing something frightful or unpleasant (such as seeing a person with a physical disability) or by eating certain foods. The theory of maternal impressions, or maternal markings, as it was called, was wide­ spread, and many w ­ omen feared the possibility of unusual encounters. A typical story involves a pregnant ­woman who, strolling through her gar­ den one eve­ning, saw a snake looking at her. The incident haunted her, and she went on to give birth to a baby with “no bony structure to give it uprightness and strength,” a slithery reminiscence of the foreboding snake.17 Amid the mounting advice lit­er­a­ture on pregnancy (along with rising literacy rates) in the 1800s, ­women could read about the true signs of “Great-­Bellies” and all the t­ hings that imperiled their babies’ lives and health. At the top of doctors’ compiled lists of pos­si­ble c­ auses of miscar­ riage and “deformity” w ­ ere myriad “unwomanly” activities (witnessing vari­ous forms of apparently “inappropriate” public entertainment, for example) and elevated emotions, including “inordinate sexual excitement” and “disgusting tastes.” Throughout the South, many Americans believed that foods consumed during pregnancy could influence a baby’s skin color, a con­ve­nient explanation for curiously dark-­or light-­skinned babies in a region awash with racial tensions and sexual assault. Balance and moderation in all ­t hings ­were central to preventing mis­ carriage, doctors stressed. They advised expecting w ­ omen to get rest, stay home, and exhibit serenity; they described pregnancy as a tenuous, deli­ cate state that could be easily upended by even “the smallest of ­things.”

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“Every­thing must be ‘just right,’ ” they buzzed.18 Many Americans believed that a fetus could see, hear, and feel every­t hing its ­mother saw, heard, and felt, which made it vulnerable and exposed.19 If such unpredictable epi­ sodes as sighting a snake, feeling sexual arousal, or experiencing a s­ imple mood swing might cause a miscarriage or an abnormality, what ­were ­women to think about what they put into their bodies? Perhaps in food they saw some modicum of control. By the 1920s, more and more professionals w ­ ere refining the picture, sifting out the “real” from the i­magined ­hazards. Most of them combat­ ted the concept of maternal impressions as erroneous: “Do not believe for a moment that anything you do, think or see can ‘mark’ or deform your baby,” clarified one writer.20 Another physician explained that “the only way in which a ­mother can mark her baby is in giving it a health body and a healthy mind. . . . ​A m ­ other does this by . . . ​above all, keeping a sane ­wholesome point of view on life.” And by eating properly.21 Then, as now, advice about what to eat varied wildly, and directives w ­ ere often contradictory. Some writers derided bread as aggressively as if it ­were poison; o ­ thers said it was fine. Some texts extolled the benefits of grains or eggs or meat or fish or soup, while o ­ thers spurned the same foods as deleterious, dangerous even. A single bite could encompass health or ­hazard, possibility or risk—it just depended whom you asked. Many ­women ­were advised to eat foods that would aid with constipa­ tion and “keep the bowels f­ree,” especially fruits and vegetables. Diges­ tive comfort was a frequent consideration: “you must,” directed Carol Van Blarcom in 1922, “constantly guard against overeating, constipation and indigestion of any kind.”22 Interestingly, too, many advice books warned against stimulants and intoxicants. No alcohol, no tea, no coffee. Some­ times, authors mentioned the dangers such substances posed to the fetus, but under­lying t­ hese specific directives was also the fact that it was con­ sidered improper for a ­woman to consume ­these t­hings, especially alcohol.

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­Women ­were understood to be more vulnerable to the vicelike grip of alcohol—­more liable to “contract the liquor habit”—­and their collective weakness was only exaggerated all the more during pregnancy. Thus, even though several authors mentioned the presumed danger alcohol posed to a developing fetus, it is impossible to read the strictures against alcohol during pregnancy in isolation—­and it simply was not considered appro­ priate for w ­ omen of means to drink at the turn of the ­century. Equally impor­tant as what to eat when pregnant at the turn of twenti­ eth ­century was the question of how to eat. Slowly, for one ­thing. Advice writers ­were adamant that ­women eat their food at a snail’s pace and chew ­every bite thoroughly. (Truly, doctors and advice-­dolers harped on the importance of “mastication”—­chewing—­with amusing dedication.) ­Women should eat in moderation, at regular hours, with “clock-­like regularity”; eating “should be deliberate, and it should be cheerful.”23 Cheerful! What a t­ hing to tell an expecting ­woman! Diet, as anything e­ lse, should be “governed by common sense in e­ very event,” wrote Dr. Emma Drake in What a Young Wife ­Ought to Know.24 I cannot help but smile at ­t hese buoyant directives: be wise, be sensi­ ble, be regular and methodic, be cheerful. They unwittingly lift my spir­ its, at least. Some physicians and birth attendants believed that a ­woman’s diet could chart the course for childbirth—­t hat an ideal diet might pave the way for a seamless and painless delivery. So they devised prescriptive dietary regimens aimed at just that. One such regimen urged w ­ omen to eat only fruits—­“the fruit diet,” it was called—­w ith the express belief that ­doing so would result in an effortless birth. The premise was that a w ­ oman who ate foods “­free from earthy and bony ­matter” would supposedly avoid pain and danger during childbirth. The more ripe the fruit, and the less of any other foodstuffs she consumed, the better. Bread and pastries w ­ ere strictly off limits.25 (Bread was a problematic food for vari­ous reasons, but it was expressly prohibited in the fruit diet for the fact that it “contains

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the ele­ments of bone,” presumably suggesting that it would cause a fetus to grow too well and therefore introduce pain during delivery.)26 Adherents to the fruit diet could consult any number of advice texts to ascertain which foods had the least “earthy m ­ atter”—­and w ­ ere thus ideal to consume—­and which foods packed it in (wheat had the most, followed by other grains and beans). Some spices and condiments w ­ ere safe—­honey, sugar, butter, oil, vinegar, and alcohol—­while ­others ­were “all earthy”: salt, cinnamon, pepper, nutmeg, ginger, cocoa, and coffee. Even w ­ ater—­t he only acceptable beverage according to the fruit diet—­should, ideally, be distilled before drinking to “purify it” from earthy ­matter.27 The diet, one proponent boasted, “has been successful universally.”28 Advice writers also harbored strong feelings about the importance of milk consumption; in fact, they w ­ ere rather obsessed with it. Milk in vir­ tually any form was “commended” for its untold healthful properties.29 Numerous pregnancy advice texts recommended that during the second half of pregnancy (when it was acceptable for ­women to eat slightly more than they normally ate) milk was the ideal dietary supplement. “Milk,” praised Mrs. Max West in a widely disseminated pamphlet, “is especially valuable in the diet of pregnancy, since milk not only contains all the ele­ ments of a perfect food, but it is valuable for stimulating the kidneys.”30 Milk-­drinking during pregnancy was impor­tant in its own right, but it was also crucial for simply establishing the habit of drinking milk so that ­women might continue drinking copious amounts of milk beyond birth and well into the postpartum period. In the 1910s, the U.S. Depart­ ment of Agriculture partnered with the National Dairy Council to pro­ mote milk-­d rinking among all Americans—­fi rst among ­children (in schools) and then among adults. Public health campaigns ­were ubiquitous, conducted in magazines, radio advertisements and songs, plays, posters, school field trips. They all sang the health benefits of milk, pushing American ­children and then their parents to drink milk, drink more milk, drink milk with meals, to grow, to be healthy, to build strong bones. The campaigns worked: milk consumption skyrocketed in the United

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States during the 1920s and 1930s, and the pregnancy lit­er­a­ture apparently bought in.31 If, like me, a pregnant w ­ oman e­ ither did not or preferred not to drink milk, she was urged to consume it anyway: “­every effort should be made to cultivate the taste for milk, for ­t here is no other one food so indispens­ able to the ­mother of a nursing baby.”32 Consuming only milk for several hours ­after ­labor was also thought to help with nursing, for reasons at once both obvious and painfully misguided. In the late 1800s, one popu­lar rem­ edy for a handful of complications of pregnancy (and especially for pre­ eclampsia) was the so-­called milk diet, which was (like the fruit diet), essentially exactly what it sounds like: a diet composed exclusively of milk. (I squirm just to think of this.) The therapy was held in high regard for some time.33 Doctors ascribed to other diets, too, “for the definite purpose of dimin­ ishing the bulk of the fetus . . . ​so as to allow its passage through a narrow pelvis.” One popu­lar regime, championed by Dr. Ludwig Prochownik, himself famous for conducting the first scientific study on diet and preg­ nancy in 1899, included a breakfast of coffee and a biscuit or bread with butter; a lunch (“dinner”) consisting of some meat, an egg, or fish with scant sauce, some green veggies cooked in fat, a salad, and cheese; and a supper of the same, plus some bread and butter. ­Women ­were not to consume ­water, soups, potatoes, puddings, sugar, or beer (though they could drink some red wine).34 Strangely, Prochownik’s diet also only advised a maximum of 500 milliliters of fluids throughout the day—­just ­under seventeen ounces. As I glance at my desk, cluttered with w ­ ater glasses, tea mugs, and empty seltzer cans, I feel parched just thinking about such a restriction. (Some of Prochownik’s colleagues, however, would pre­ sumably be pleased at my fluid intake b ­ ecause not every­one agreed with his regimen; indeed, ­others recommended “abundant fluids” throughout pregnancy.) By around 1920, such prescribed, restrictive programs as the fruit diet or the milk diet ­were beginning to fall out of fashion (although, as we

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know, doctors maintained the urgent advice to restrict weight gain gen­ erally), in part due to the emerging science of nutrition. A ­ fter the isolation of individual vitamins and minerals in the early 1900s, and the discovery that they could be implemented as therapies for diseases of deprivation (such as scurvy—­a lack of vitamin C, or rickets—­a lack of vitamin D), the science of nutrition became more fash­ion­able. Researchers and fledgling government organ­izations worked together to establish new bound­a ries and norms, popularizing terms such as “calories,” devising recommended daily allowances, and identifying foods based on their fat, protein, and car­ bohydrate breakdowns. Endeavors to apply nutrition science to gestation, however, suffered from a lack of coordination between formal medicine and nutrition researchers (who w ­ ere more likely to be laboratory researchers than prac­ ticing physicians). Unfortunately, the disconnect did not erode over the course of the 1900s. To wit: one team of obstetricians’ observation from the 1970s—­that “unfortunately, the physician’s knowledge of nutrition, in general, is deficient ­because formal instruction in nutritional princi­ples in most medical schools is absent or cursory”—­remains largely true.35 In fact, t­ here has been increasing recognition that the chasm between nutri­ tion and medicine is far deeper than previously thought, afflicting virtually all branches and specialties of practice, not just obstetrics and gynecol­ogy. In 2019, JAMA assessed that “nutrition education in medical school is rudimentary, at best, and ­limited for the duration of gradu­ate medical education for many specialties.” It suggested integrating nutritional edu­ cation into medical training to confront the serious deficits in clinical knowledge and practice nationwide.36 All of this is to say that—as far as I can tell—­pregnant w ­ omen during ­every era in modern American history have been forced to sift through conflicting, confusing, and irritating advice about what and how they should eat during their pregnancies, and we have often heard it emanat­ ing from ill-­informed (if well-­meaning) sources. My own frustrations feel unique—­particular to the convergence of the digital age and modern med­

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icine with the democ­ratization of information and feminism—­but per­ haps they are not so special. Our ­mothers and grand­mothers and great-­g randmothers alike ­were faced with choices about what to eat while they ­were pregnant. Though they likely approached the acquisition and preparation and consumption of food very differently than any of us, is it so hard to think that they, too, ­were forced to decide which—of many—­stipulations they would accept, which to discard as ill-­founded?

In the early twenty-­fi rst ­century, dietary advice for pregnant w ­ omen remains as volatile and contradictory as ever. Consume a Mediterranean diet to decrease the chances of gestational diabetes. Avoid fish. Consume fish. Abstain from alcohol and caffeine. Imbibe infrequently. Eat no deli meat, unpasteurized cheese, or anything that has been contaminated with listeria in the last thirty years.37 The standard information sheets in ­every obstetrics/gynecol­ogy office across the United States are as dizzying as a carousel, as precise as an algebraic proof. Advice books about what to eat crowd out the pregnancy sections in bookstores; radio shows and blogs and podcasts detail the advantages and disadvantages of this or that dietary philosophy, food group, “superfood,” or micronutrient. We are deluged. And yet we who are expecting are still left groping for more. Perhaps we simply need better information. Accessible information. And prob­ably so does every­one ­else. To be certain, numerous medical writers approach nutrition in preg­ nancy with a modicum of moderation and reason. Some prac­ti­tion­ers say that detailed dietary “rules” are not necessary during pregnancy and that adherence to par­tic­u­lar dietary constraints bears ­little effect on pregnancy outcomes in the industrialized world. The message—­a refreshing one, I think—­has always been t­ here to see for t­ hose who choose to see it: “­Simple, not strict, rules govern the diet,” exclaimed Dr. Joseph DeLee,

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the obstetrician with the dubious distinction of popularizing the use of forceps during childbirth in the 1800s.38 “The food of a pregnant ­woman does not differ materially from any diet which is found to contain the proper amount of nutrition,” wrote Susanna Cocroft in 1906. The widely read manual Prenatal Care, issued by the U.S. ­Children’s Bureau, similarly stated that “a pregnant ­woman may safely follow the dictates of her appetite as to the choice of her food.”39 J. Morris Slemons, the famed obstetrician-­ author of The Prospective ­Mother, coolly explained that “­there is no diet specifically adapted to the state of pregnancy; the prospective ­mother may exercise the same freedom as anyone ­else in the se­lection of food.” 40 We are hardly wanting for information, no, but I do think we are wanting for guidance. And, I think, we seek the same t­hing our great-­ grandmothers sought: control in the face of the unknown. In a torrent of guidelines and recommendations on every­t hing we do, we grasp at the wind. And the breezes carry echoes from the past. Science now affords us new ways of imagining in “maternal impressions”: the “fetal origins hypoth­ esis” proposes that the environment a m ­ other fashions for a fetus in utero has the ability to “permanently program the structure and physiology of her offspring.” According to ongoing research, traumatic experiences, extreme stress, environmental exposures, and even a ­mother’s emotional state—­besides known toxins and teratogens (substances that can harm a fetus)—­can impact fetal development and even ge­ne­tics. The fetus is “impressionable.” 41 We accept that what we consume can expose a fetus to risks. But we also hope—or worry—­that by choosing to eat certain foods we might have the power to shape or mold an unborn baby—to influence her taste buds, fine-­tune her palate already in the womb, affect her metabolism.42 In food lies some ele­ment of the centuries-­old fearfulness of maternal markings—­ the dread and the promise of impressions, reconfigured. In some ways, the way a pregnant w ­ oman approaches food is a win­ dow into her perspective on pregnancy in general. Eating while pregnant

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is ­either as normal and harmless (“natu­ral”) or as extraordinary (hazard­ ous, risky, replete with pos­si­ble danger) as pregnancy itself. It just depends on whom you ask. ­There are ­those of us who see food as a healthful, normal part of life—­ pregnancy included—­and do not so much fear its pos­si­ble risks as delight in its mysteries. ­There are ­others of us, though, who look at the breakfast plate, the lunch bag, the dinner t­ able, the supermarket and the café, and see nothing but risks to modify, components to parcel and manage and carefully monitor. A friend reminds me that in food we sense the “illu­ sion of some control.” ­ atter: pregnancy is as ter­ And perhaps this ­really is the crux of the m rifying as it is phenomenal, at once both precarious and fragile as well as resilient and timeless. It obscures. And as we drown in information and evidence and advice and guidelines, the very act of eating emerges as one familiar ­t hing. It becomes one pos­si­ble slice of solace and comfort, one sliver of self-­sovereignty, one bite of power­f ul influence. And so we eat. In fear, in joy, in doubt, and in hope. We consume.

chapter 5

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Watch

I have an early ultrasound scan to establish gestational age and confirm that my pregnancy is “­v iable.” Although I am baffled by this decision—­ because I am certain of the exact date I conceived (from using ovulation predictor kits)—­I readily submit to the procedure. I am terrified for this scan even while I yearn to have it. I count down the days, time is distorted; my appointment arrives abruptly. With my husband and son sitting next to me, I gaze desperately at the flat-­screen monitor suspended before me, watching as my own uterus shifts into focus. And ­t here it is—­one small blob with a tiny-­but-­ unmistakable flicker off to one side. My ­v iable intrauterine pregnancy is confirmed. Seeing this puts me at ease. All is well. And precisely ­because all is well, I cannot help but won­der: did we need to see that? New questions march through my mind. When is an ultrasound r­ eally necessary? How have obstetricians used ultrasounds in the past? How are they using them now? A ­couple of months l­ater, I’ve pushed t­hese ­matters deep into the recesses of my mind, as I anticipate my “anatomy scan”—­t he hour-­long ultrasound appointment nearly all pregnant ­women look forward to about halfway through their pregnancies. It is a complete anatomical exam of 102

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the fetus, producing estimated lengths and weights, foretelling gender, detecting abnormalities. I impatiently await the anatomy scan. The nights leading up to it, I am fitful and restless. I dream that instead of life, my body harbors death—­ cancer. Why am I so anxious? My appointment is a dose of pure joy. It energizes me, reminds me of every­thing my pregnancy w ­ ill bestow. I am alive in a dim-­lit room, my eyes glued to the screen stretched t­ oward me from the ceiling. I w ­ ill the blur it transmits to shift into focus. And it does. I see a baby girl; unbelievably, I can already tell that she looks like her ­brother. I watch her fan her fin­gers, gulp fluid, stretch her legs, bend at her spine. She is alive, and she is ­here. She is with me. The power to witness life before birth is an awesome, stunning tech­ nological accomplishment. How did we realize this capacity? And what is its legacy?

The Beginnings of Obstetric Ultrasound, in Brief The history of obstetric ultrasonography is relatively short, dating back only about fifty years. Ultrasound itself is no ­simple machinery; it’s quite a complicated technology. The apparatus shoots high-­f requency sound waves (ultrasonic waves) into bodily tissue. ­Those waves (we ­can’t hear them) rebound off the body and bounce back. The echoes created in this process—­called echolocation—­t hen construct a physical repre­sen­ta­tion: the ultrasound image.1 Like many medical technologies, the origins of diagnostic ultrasound lay in the military-­industrial complex. The foundations ­were laid during World War I, and scientists subsequently applied ultrasound devices—­ originally used to surveil ­enemy forces—to ­human bodies. The first machines used on p ­ eople drew from sonar and radar devices and produced images so rudimentary they would be unintelligible to any twenty-­fi rst c­ entury onlooker.

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The research was a slog, and the first application in pregnancy occurred with a lapse in oversight in the mid-1950s. One of the physicians who partook in the development of ultrasound at a hospital in the United King­ dom noticed that a par­tic­u­lar nurse had an uncanny penchant for guessing the exact position of a fetus’s head with astonishing accuracy. Eventually it came out that the nurse, Marjorie Marr, had been using the investigatory ultrasound machines in the wee hours of the morning, before any super­ visors arrived. She had taught herself to read the outputs (no small feat given the crude depictions the first ultrasounds produced). N ­ eedless to say, more formal investigation into the pos­si­ble role of ultrasound in pregnancy followed on the heels of Marr’s impropriety.2 In 1958, The Lancet ran the first article describing diagnostic obstetric ultrasound. A brief, dry piece, it hardly foreshadowed the animation to come.3 In the 1960s, when the public first encountered images of the fetus, Americans ­were mesmerized. In 1965, Life magazine ran its famous cover story featuring photos depicting ­human development spanning from con­ ception through twenty-­eight weeks’ gestation. At the time it ran, the Life piece was stunning. Never before had Americans witnessed such a depiction of fetal development. The photos w ­ eren’t ultrasounds, but they ­were truly awesome.4 At the time, ultrasound technology was still utterly primitive compared to ­today. The scanners ­were enormous, towering over patients at eight feet tall. Most took up about a third of the room, and interpreting their pro­ ductions required extensive training and practice. Only the most highly skilled experts could reliably decipher prenatal scans. Americans teased that the Diasonograph was a “Dinosaurograph.”5 In the 1970s, t­hose Stone Age, static repre­sen­ta­tions improved sub­ stantially with the development of real-­time ultrasound. The enhanced images revolutionized the prenatal scan. Real-­time ultrasounds produced real-­time images—­t he “videos” we are accustomed to ­today that allow us to see a fetus move or swallow, watch its heartbeat flicker.6 The new scan­ ners “demo­cratized” obstetric ultrasound; with enhanced resolution,

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updated technology, cheaper prices, and greater ease of use, prenatal scans w ­ ere no longer confined to a minority of providers and patients. By the 1980s, real-­time scans w ­ ere routine, typical components of prena­ tal care.7 Doctors hailed the prenatal scan as an extraordinary advance in the field. “I c­ an’t emphasize enough what an absolute major breakthrough diagnostic ultrasound has been,” Dr. Harold Fox beamed at a symposium in 1982. It meant doctors could conduct an examination on a fetus. They could pinpoint gestational age, locate abnormalities, track fetal growth and development.8 The possibilities ­were far-­reaching and exhilarating. So exhilarating, in fact, that ultrasound use burgeoned hastily. The authors of a controlled trial in the early 1980s in the United Kingdom observed that programs w ­ ere introduced “without firm evidence of ben­ eficial effects.”9 The “question of risk still hovers over routine prenatal use of ultrasound,” as a report in JAMA put it in 1982.10 In the United States, a consensus panel on Ultrasound Imaging in Pregnancy for the National Institutes of Health concluded that available evidence did not allow for any consensus “that routine use of ultrasound examinations for all pregnan­ cies improved perinatal outcome or decreased morbidity or mortality.” It demanded more research and declined to make any recommendations for routine screens. ­There simply was not enough data—on efficacy or safety—­ the panel stated.11

The Question of the Routine Scan Digging a ­little deeper, it’s clear that o ­ thers w ­ ere harboring doubts about ultrasound, too. “The effectiveness of ultrasound is widely questioned,” explained one group of doctors in 1988.12 For the most part, doctors agreed that ultrasound could play a valuable role in prenatal care in certain situations. That is, ultrasound was useful when it was “medically indicated.” But doctors differed in their opinions regarding w ­ hether ultrasound should be a routine component of all pregnancies.

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By the mid-1980s, a number of t­ rials looking into prenatal ultrasounds ­were in the works. Some of them suggested that routine ultrasound yielded improvements—­lower rates of induction for being overdue and fewer num­ bers of low birth weight babies. But in most studies the benefits w ­ ere “marginal.” And some results suggested that w ­ omen who had routine scans ­were more likely to be admitted to the hospital. A 1985 review assessed that studies had failed to “demonstrate adequately the usefulness of imaging ultrasound as a screening procedure for all pregnant ­women.”13 By the end of the 1980s t­ here was a clear consensus that prenatal ultra­ sounds ­were beneficial when deemed necessary, but ­there remained “con­ siderable uncertainty” about their routine deployment. And many t­ rials reported conflicting results, which clouded medicine’s foggy perspective even further.14 Some investigations around 1990 added considerably to the evidence pool, but by then ultrasound had already been so widely accepted and implemented into obstetric practice that it was virtually impossible to study a true “no ultrasound” group against a group set to receive scans. For example, Obstetrics and Gynecol­ogy published one of the first random­ ized controlled ­trials on ultrasound in pregnancy. In it, one group of ­women had a single scheduled ultrasound (ideally, conducted between ten and twelve weeks’ gestation), and the control group received normal pre­ natal care. Ultimately, the investigators concluded that ultrasound con­ ferred no benefits. However, ­because standard prenatal care did call for ultrasound on occasion (when “medically indicated”), the w ­ omen in the control group had a considerable number of ultrasound scans. Among the 413 w ­ omen in the “usual care” group, almost a quarter had an indication that had called for a scan.15 In an even larger trial released around the same time, the Helsinki Trial (involving more than 9,000 ­women), 77 ­percent of the control group had at least one ultrasound at some point in time. The average number of scans in the control group was 1.8 per w ­ oman; in the study group it was 2.1. (That trial documented a benefit from ultrasounds, attributed to higher detec­

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tion of anomalies.) Without discounting that evidence from the Helsinki Trial contributed to medical understanding, the study’s inability to cir­ cumscribe a “no treatment” group is illuminating. By this time, ultrasound was so woven into the fabric of prenatal care as to be conventional—it was uncommon not to receive a scan.16 For its size and its methods, not to mention its provocative conclusions, the RADIUS trial (Routine Antenatal Diagnostic Imaging with Ultra­ sound) in the early 1990s made quite a splash. It was a huge proj­ect, designed to test ­whether routine ultrasound in all pregnancies conferred any bene­ fits over using ultrasound only when doctors perceived some specific reason to perform one. The investigators studied more than 15,000 ­women at mul­ tiple locations across the United States, comparing a routine ultrasound screening group against a control group that only had screenings when indicated. They looked for differences related to all kinds of adverse out­ comes, including gestational age at delivery, birth weight, preterm delivery, and perinatal mortality. The researchers found no significant differences in any of the outcomes they assessed: babies and m ­ others fared the same in both groups. The only perceptible difference was that the ­women slated to receive routine ultra­ sounds had a higher rate of major fetal anomalies diagnosed in compari­ son with the ­women who received normal care (35 ­percent versus 10 ­percent detection rate, respectively)—­but the improved diagnostic rate did not translate into any meaningful benefits. The increased likelihood of find­ ing an abnormality in utero, in other words, did not reduce the likelihood of adverse outcomes. Instead, the most pertinent distinction between the groups, as researchers snidely remarked, was that the screening group had a substantially higher use of ultrasounds—­and higher bills to show for it.17 But again, the details of the study are revealing: among the control group, 45 ­percent of ­women had a sonogram. (The average number of scans in the control group was 0.6 compared with 2.2 in the study group.)18 The authors of the RADIUS trial said that the technique was “widely applied in high-­and low-­risk pregnancies,” and this was despite the fact that e­ very

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randomized controlled trial to date (eight in sum) had failed to show a benefit. To be clear, the RADIUS trial and its conclusions w ­ ere contentious. Some physicians critiqued the study’s design and disputed the authors’ interpretations of their results, saying their conclusions could not “be taken at face value.” It is fascinating, indeed, that proponents and detrac­ tors of routine ultrasound screening both deployed the RADIUS study as evidence in support of their position.19 Regardless, t­ hese proj­ects suggest that prenatal ultrasounds became so customary so rapidly that doctors strug­g led to study their effects. As a result, through the 1990s, doctors continued to debate the merits of rou­ tine ultrasound without coming to any firm point of agreement. Medical committees tasked with settling the ­matter waffled, just as they had in the 1980s. Take the conclusions of a panel in Norway, for example, which determined that “the medical utility of ultrasound screening, as opposed to examinations of pregnant ­women referred on the basis of clinical indi­ cations, has not been demonstrated,” yet it still went on to recommend a routine scan (at seventeen weeks).20 In the United States, ACOG refrained from recommending routine screening but explained that “­there is no uni­ form support for this stance.”21 One middle-­ground approach some physicians favored was that pro­ viders should routinely offer prenatal ultrasounds—­and discuss their theoretical benefits and risks—­with patients. This idea was steeped in eth­ ics. Not offering ­women prenatal scans, proponents said, “systematically eliminated the autonomy of pregnant ­women,” partly b ­ ecause it restricted access to both diagnostic information and the option of abortion given that information. Even more damning, they condemned physicians who expressed reticence about routine prenatal ultrasounds for contributing to “paternalistic denial of impor­tant information to pregnant ­women with­ out any convincing ethical or scientific justification.” Furthermore, they continued, “this denial of routine ultrasound makes a mockery of obstet­

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ric ethics and the clinical practice of obstetrics.”*,22 (Of course, this posi­ tion was not entirely without irony b ­ ecause w ­ omen still needed a trained expert to interpret the results of a scan for them.) Advocates branded this strategy “prenatal informed consent for sonog­ raphy,” or PICS. They made the case that a patient’s preferences to have an ultrasound should constitute a new “patient-­based” indication for a pre­ natal scan.23 And of course, research supports what many of us presume to be true: pregnant w ­ omen desire ultrasounds.24 With the question of routine scans still unresolved in the medical arena, and patient expectations mounting, doctors continued working to pin­ point the exact benefits prenatal ultrasounds conferred. By the turn of the twenty-­fi rst ­century, physicians enjoyed a slightly more nuanced understanding of the potential returns: ultrasounds regularly helped refine pregnancy dating, depicting a more accurate gestational age that often helped reduce interventions for being postterm l­ater on; they facilitated ­earlier detection of multiples pregnancies; sadly, they also helped diagnose loss.25 ­These advantages enjoyed wide ac­cep­tance for the most part, but the extent to which ultrasounds ­were able to help effectively diagnosis fetal abnormalities was the subject of much debate. Proj­ects went back and forth in their determinations on this m ­ atter, but as ultrasound technology continued to improve, and sonographers and physicians gained more experience reading scans, evidence increasingly leaned t­oward the conclusion that prenatal ultrasounds enhanced diag­ nostic capabilities. In a long-­term proj­ect in Spain spanning from the 1970s through the 1990s, accurate detection of fetal malformations skyrocketed * Doctors had other reasons to bristle at the prospect of routine scans: malpractice suits ­were on the rise. Prenatal ultrasounds did help physicians determine impor­tant prob­lems in utero, but they also heightened w ­ omen’s expectations. According to sur­ vey responses from a group of obstetricians and gynecologists in the U.S., malprac­ tice claims related to ultrasound use increased by a ­factor of more than 3.5 just over the course of the 1980s; the most frequent cause of lawsuits was errors in detecting fetal anomalies.

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from less than 20 ­percent to higher than 96 ­percent. The rates w ­ ere not so impressive everywhere, with global data indicating that accurate detec­ tion often varied quite widely, from less than 10 ­percent in some areas to as high as 84 ­percent in o ­ thers, but many physicians still came down in ­favor of scans for diagnostic purposes. Even so, they routinely cautioned that a clean scan “does not provide absolute assurance that a fetus is defect f­ ree.”26 While the value of ultrasound for screening purposes was (and remains) a subject of debate, relatively few physicians seem to have seriously chal­ lenged its utility. Although many malformations did not necessarily ben­ efit from therapy or intervention, for the most part doctors agreed that ­earlier awareness and information regarding anomalies is beneficial for both doctors and families. (They noted some tangible benefits, such as immediate transfer to a neonatal intensive care unit for babies in need, but also acknowledged that simply knowing about a pos­si­ble defect is valu­ able in its own right.) The issue also raised questions about therapeutic abortion; but again, a majority of the published medical lit­er­a­ture con­ veyed that gaining knowledge of an anomaly was advantageous and contributed to informed decision making.27 And yet ­there are considerations. The ramifications of a potential mis­ diagnosis (an erroneous diagnosis, a false-­positive result, or a false-­negative result) is one.28 Another is a phenomenon health professionals call over­ diagnosis, which occurs when a provider locates a “real” abnormality, but the finding does not actually benefit the patient. It happens often in screen­ ings (it’s most well-­documented in screenings for breast cancer and pros­ tate cancer), and it risks leading to overtreatment as well, in the form of unnecessary medical care. As one group of pediatricians explained in an article entitled “Overdiagnosis: How Our Compulsion for Diagnosis May Be Harming ­Children”: “a single test can give rise to a cascade of events, many of which have the potential to harm.” Given that ­there are already some concerns about overdiagnosis in prenatal sonography, this is some­

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thing to think about. We tend to think of screenings like ultrasounds as harmless, but they may not be so.29 Cost is an additional consideration. In the early 1990s, investigators determined that the average ­woman received 1.6 ultrasounds during her pregnancy. With roughly 4 million pregnancies annually and ultrasound scans costing approximately $200 each, they calculated that the overall cost of prenatal scans to the U.S. health care system was roughly $1 billion per year (never mind the opportunity cost of hours spent conducting, reading, and undergoing the scans).30 Given that in 2015 the average preg­ nant w ­ oman had more than five scans over the course of her pregnancy, the fiscal burden that prenatal ultrasound scans may represent has grown considerably. Of course, if ­t hese scans are beneficial for ­women and babies—­which they may be in a multitude of ways—­t hen the costs of prenatal ultra­ sound are well worth it. But we seem to have given up on even asking the question.

Prenatal Ultrasounds in the Twenty-­First ­C entury Most American ­women take it for granted that they w ­ ill have an ultra­ sound scan, but the role of ultrasounds—­again, especially routine scans— in prenatal care is still a somewhat vexatious issue. Respected medical associations do not sanction uniform policies. The World Health Organ­ ization recommends one “early” scan—­before 24 weeks—to estimate ges­ tational age, check for anomalies, identify multiples, and “improve a ­woman’s pregnancy experience.”31 Cochrane reviewers reaffirm this pol­ icy, citing evidence that a routine scan before twenty-­four weeks’ gesta­ tion yields some benefits.32 Many Eu­ro­pean medical organ­izations recom­ mend routine ultrasounds. The National Institutes of Health, ACOG, and the American Institute of Ultrasound in Medicine all recommend targeted screening of w ­ omen with medical indications, but not universal, routine

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scans—­although ACOG (somewhat confusingly) advises patients to expect at least one scan during pregnancy.33 In truth, ­t hese kinds of par­a meters allow for individual professional discretion, as the University of Michigan’s “Guidelines for Prenatal Care” imply: “routine use of screening fetal ultrasound in low-­risk ­women has not been demonstrated to improve long-­term outcome. Nonetheless, offer­ ing ultrasound imaging is reasonable.”34 Surveying the lit­er­a­ture, some of the best evidence for ultrasound’s ­ omen, benefits comes from first-­trimester dating scans.35 For most w dating is one of the first tasks tended to in prenatal care. The standard mechanism for dating a pregnancy—­for more than 200 years—­has been based on a ­woman’s last menstrual period (LMP). Named for a German obstetrician in the early 1800s, “Naegele’s rule” dictates that a pregnancy lasts 280 days calculated from a ­woman’s LMP. Thus, a ­woman’s esti­ mated due date is exactly forty weeks from the first day of her LMP. In some ways, this dating method has stood the test of time, but it suffers from many flaws. Many ­women d ­ on’t know or remember the exact date of their LMP, and ­others who think they do are often mistaken. (One clue that patients often make cognitive errors is the fact that ­women tend to overreport their LMP date as day one, five, fifteen, and twenty in any given month.) The math also assumes that e­ very w ­ oman, without fail, has a perfectly timed twenty-­eight-­day cycle where ovulation occurs on day fourteen, ­every month. Of course, such menstrual clockwork is illusory.36 This is where ultrasounds come into play. ­Because ­t here is so much ­human error built into menstrual cycle dating, physicians and ­women can turn to early ultrasound scans for enhanced accuracy. And this is no triv­ ial piece of information—­dating is crucially impor­tant. A few days can make a big difference in reducing postterm induction, for example, or classifying a fetus as “growth restricted.” Despite its seeming simplicity, accurately dating a pregnancy is one of the most valuable tasks in prena­ tal care.

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In the interest of accurate dating, it is becoming increasingly custom­ ary for obstetricians to perform early ultrasounds (in the first trimester) to establish gestational age and an estimated due date; another impetus is to confirm a v­ iable, intrauterine pregnancy. Most often, this is done via transvaginal ultrasound, and it is far more reliable and exact than LMP dating, providing a win­dow of ±5 days for gestational age.37 (Second tri­ mester scans are slightly less accurate, giving a win­dow of about ±8 days for gestational age.) The 2017 ACOG Committee Opinion on pregnancy dating asserts that ultrasonography in the first trimester is “the most accu­ rate method to establish or confirm gestational age.”38 I had a transvaginal scan for both my pregnancies—to both confirm viability, to see a gestational sac implanted in my uterus, with heart activ­ ity, and to determine timing. Both times, I was lucky. We w ­ ere lucky. All was well—­is well. And precisely ­because all is well, I ­can’t help but won­ der: did we need to see it? Meeting with the nurse afterward I was reminded again of the sometimes-­absurd nature of prenatal guidelines. She told me that the prac­ tice would stick to “manual” dating, based on Naegele’s rule and my LMP, despite the fact that the calculations based on an ovulation predic­ tor kit and the ultrasound I had just received—­which, again, is “the most accurate method to establish or confirm gestational age,” according to ACOG—­both indicated other­wise. They identically pointed to a separate gestational age and estimated due date. I remain dumbstruck by this. The ­ atters. Besides, why rely on difference is small—­just four days—­but this m lesser intel? Maybe I s­ houldn’t be so surprised, though. Am I not d ­ oing the same? For the most part, ­women like me have embraced ­t hese opportunities, taken advantage of the win­dow into pregnancy ultrasound offers. Indeed, it’s impossible to discuss prenatal ultrasounds without taking into con­ sideration their extensive popularity among ­women and families. For many ­women, prenatal ultrasounds have profoundly altered the experi­ ence of pregnancy itself, both physical and psychological.

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The evidence on “bonding” is in­ter­est­ing. In the past, some physicians hypothesized that the ultrasound experience was so power­f ul as to stim­ ulate behavioral changes among pregnant ­women. Specifically, doctors suggested that ex­pec­tant ­mothers who saw their babies on an ultrasound ­were often “strongly affected” by the experience and ­were even more likely to stop smoking (and thus deliver heavier, healthier babies).39 Some—­but not all—­research similarly imparted that ultrasounds enhanced “maternal-­ fetal bonding.” 40 Cochrane review authors have called this premise into question, determining that no reliable evidence as such exists for this assertion, but the idea that ­women might be stimulated to improve their lifestyle be­hav­iors ­after witnessing a baby via ultrasound does not, to me at least, seem all that far-­fetched. In fact, other studies have bolstered this idea by alluding to the fact that ultrasounds that transmit negative results—­ abnormality—­can impact maternal feelings of connection with a fetus.41 Yet feminist scholars have critiqued the prenatal ultrasound as another cog in the wheels of the industrial birth machinery. Ultrasounds replaced ­women as translators of their own bodies, supplying (mostly male) doc­ tors with “objective” views of the fetus and female body that upstaged ­women’s direct testimonies. It d ­ oesn’t help that ultrasounds grew to become conventional in the generation ­after childbirth moved primarily into the hospital. Furthermore, b ­ ecause it portrays the fetus as a sover­ eign being, in the hands of prolife proponents the ultrasound has become a po­liti­cal weapon.42 Indeed, ultrasound scans facilitated an entire new patient population—­ fetuses. With the ultrasound, write Malcolm Nicolson and John Fleming in their book Imaging and Imagining the Fetus, “the developing ­human being became, for the first time in its history, a clinical entity, a patient in its own right.” 43 This is certainly reflected in the rhe­toric from the Eunice Kennedy Shriver National Institute of Child Health and H ­ uman Develop­ ment; an expert panel in 2006 concluded that “­every fetus deserves” to have an examination via ultrasound.44

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The Safety Question Physicians are virtually unanimously confident in the safety of prenatal ultrasound scans, and it is not my aim to contest their overwhelming con­ sensus. But I confess myself disappointed that “the safety question” has hovered so quietly over the use of ultrasound since its first applications in pregnancy. Even pregnant ­women have posed few questions, pressed for even fewer answers, regarding the use of ultrasound. Given that it was introduced barely a generation ­a fter thalidomide and diethylstilbestrol (DES), this rattles me. Researchers have had a theoretical basis for safety concerns for de­cades. Ultrasound waves produce both heat and cavitation—­a pro­cess whereby air ­bubbles (when exposed to sound waves) swell and then shrink—in bodily tissue. Doctors mea­sure ­t hese effects using a “thermal index” and a “mechanical index.” 45 And t­ hey’ve learned that frequent ultrasound exposure can impact animals ranging from rats to monkeys.46 We also know that at very high levels, ultrasound waves are capable of inflicting ­ on’t know the exact damage on h ­ uman tissue.47 The prob­lem is that we d threshold.48 It is somewhat disconcerting to read how per­sis­tently unsure medicine has been about ultrasounds in pregnancy over time. In 1982, medical lit­ er­a­ture frequently admitted that the risks associated with obstetric ultra­ sound w ­ ere decidedly unknown. Evidence was “reassuring,” physicians noted.49 A de­cade ­later, the message sounded similar: “currently ­there is no documented evidence of risk of damage to the fetus.”50 But the ugly truth, in the words of one obstetrician, was that—­even in 1993, when ultra­ sounds w ­ ere extensively integrated into prenatal care—­“­there have been no controlled ­t rials in h ­ umans designed specifically to investigate the safety of the ultrasound.”51 That would change in the years to come, but experts are still calling for further study to establish the safety of ultra­ sounds in pregnancy.52

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Medicine seemed reasonably sure that ultrasound did not impact infants in the immediate term, but they could hardly speak to its long-­term effects. As some of the babies from the first major clinical ­trials studying prenatal ultrasound scans grew into childhood, t­ hose c­ hildren once again became the subjects of scientific study. Researchers consistently found no apparent associations with brain development, school per­for­mance, and cognitive mea­sures (and this remains true still t­ oday), but one strange finding warrants mention. Follow-up studies showed that eight-­and nine-­year-­old ­children who had been exposed to ultrasound in controlled ­trials the previous de­cade in Nor­ way had curiously high rates of left-­handedness.53 The concern with this unusual outcome was that ultrasound waves may have slightly affected the pro­cess of neuronal migration in utero—an impor­tant step in the develop­ ment of the central ner­vous system whereby cell neurons move into their proper placement in the brain.54 (The pro­cess starts as early as the second month of pregnancy.) Physicians have never reconciled t­ hese results—­ “debate continues,” wrote a research team in The Lancet in 2004, “about findings that suggest a pos­si­ble increase in non-­right-­handedness in boys, resulting in lingering uncertainties about potential effects on the developing ­ ere left-­or right-­ brain.”55 (The issue, as it ­were, was not ­whether c­ hildren w handed, but rather ­whether ultrasounds had any influence on the neurologi­ cal development that governs handedness.) But with only this isolated mea­sured effect, doctors have never placed too much weight on the finding. More recent longitudinal studies have been reassuring, detecting no significant differences between ­children exposed to ultrasounds (from eigh­teen weeks onward) and c­ hildren who w ­ ere not, across a wide variety of mea­sures including speech, language, be­hav­ior, and neurological devel­ opment. Yet in some ways, t­ hese proj­ects only offer hamstrung evidence, ­because the machinery and technology have already changed so much. Most of the studies that buttress the safety of in utero ultrasound ­were car­ ried out on the now-­outmoded equipment used more than two de­cades ago. Thus, it is no surprise that some doctors still insist that we need to

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undertake more studies to assess any “potential bio-­effects” of prenatal ultrasound scans.56 It has been exceedingly difficult to study the safety of prenatal ultra­ sounds. With rampant technological turnover, virtually universal appli­ cation, widely varying skill levels among sonographers, and sweeping faith in the safety of scans, discerning any pos­si­ble harms has been problem­ atic indeed. And that is not even addressing some deeper-­rooted issues about ­whether the armament of information that ultrasound provides might actually engender prob­lems or spark unnecessary interventions. In the twenty-­first ­century, questions about the safety of prenatal ultra­ sound seem mostly sequestered, regarded as though outlandish. I am self-­ conscious about my own desire to interrogate obstetric ultrasound’s safety. Reticence feels regressive, backward. Perhaps that is why I only find doubts expressed in the outlying corners of medical lit­er­a­ture. “Of all the applications of diagnostic ultrasound used t­ oday, exposure of the embryo in the first trimester prob­ably represents the greatest cause for concern of potential risk,” wrote Stanley Barnett in the specialist publication Seminars in Ultrasound.57 That was in 2002. But one prevalent proposal betrays the under­lying ambiguity about pre­ natal ultrasound’s safety: the As Low as Reasonably Achievable (ALARA) concept. It acknowledges the dearth of data on the safety and risks of pre­ natal ultrasonography, but stresses that its benefits warrant continued use. Given current data, supporters say, relinquishing ultrasounds would be more harmful than continuing to employ them. ALARA presses that we minimize fetal exposure to ultrasound as much as we can—­conducting fewer scans and reducing session lengths—­while still capitalizing on ultra­ sound where it makes sense or serves a purpose.58 This approach, even if not referenced as such, enjoys widespread approval. ACOG endorses it, as does the American College of Radiology and the American Institute of Ultrasound in Medicine. Threats to a fetus are only theoretical, but phy­ sicians nevertheless agree that minimizing ultrasound exposure is wise practice.59

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In light of this, it is disturbing that a new commercial ultrasound industry—­with no formal medical ties—­has cropped up. In 2004, the FDA issued a warning about in­de­pen­dent ultrasound centers opening in shop­ ping centers. Using the latest equipment, t­hese outfits conduct three-­ dimensional ultrasound sessions lasting thirty to forty-­five minutes and offer customers “keepsake videos” of their appointments for between $125 and $250. As the FDA warning conveys, ­t hese enterprises are extremely concerning. ­Here, ultrasounds serve no medical purpose, are conducted by untrained employees, and entail lengthy exposure times—­they are per­ formed casually, for personal preference. Ultrasound is a form of energy, the FDA cautions, and it has the potential to affect a fetus. “Modern equip­ ment,” the advisory stated, “can produce intensities that are eight times higher than ­t hose produced by equipment used 10 years ago.” Asked to comment on the situation, Dr. John Seed offered this chilling reflection: “although t­ here is no proof that ultrasound is damaging, ‘we used to think that about x rays too.’ ” 60 Used within the medical sphere, practicing obstetricians are mostly unworried about ultrasounds, and they are correct to point out that we have no evidence suggesting it impacts growth or development. Five de­cades of clinical use suggest we have absolutely no reason to be con­ cerned. Yet it is still difficult to entirely disregard the safety question, especially when esteemed medical organ­izations continue to articulate caveats that “safety cannot be presumed” or “ultrasound energy delivered to the fetus cannot be assumed to be completely innocuous.” 61 Such con­ cerns underline the need to abide by the ALARA precept, all the more so given the hazy nature of our ideas about ultrasound’s benefits. I remain curious about ­these questions but am well aware that, in some ways, my skepticism is merely an exercise in futility: when my doctor calls for a scan, I secretly relish the chance to visit with my unborn child. Given that “millions of fetuses have now been insonated in utero, and many extensive trawls for adverse effects have yielded no convincing evidence

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of harm,” it certainly seems reasonable that medicine “cautiously regard” prenatal ultrasound as safe, when it is used conservatively.62

Ultrasounds and the Phenomenon of Rapid Adoption Historically, the evidence on prenatal ultrasound has fashioned something of a quagmire. On the heels of its first applications in obstetrics, ultrasound use proliferated swiftly. Rapid technological improvements rendered yes­ terday’s data obsolete before physicians could even make sense of it; and ­women, for their part, increasingly came to expect, and demand, prena­ tal scans. “Given its increasing availability,” one group of authors observed in 2000, “screening prenatal sonography runs the risk of becoming the de facto standard of care without supportive clinical evidence.” 63 Put another way, data suggest that “prac­ti­tion­ers in the United States have de­cided, in spite of the lack of consensus about the efficacy of routine ultrasound screening, to make such screening their standard of care.” 64 Doctors’ thinking with regard to ultrasound has evolved subtly in the past four de­cades, but it appears to have been at least as greatly influenced by patients and culture as by scientific evidence. It is no surprise that most ­women enjoy ultrasounds—by most assessments, this s­ imple fact has played a role in the rapid adoption of routine prenatal ultrasound screen­ ing in developed countries. The exact extent to which w ­ omen’s fondness for scans has influenced their trajectory is impossible to parse, of course, but no one would deny that patients’ widespread appreciation for scans has affected medical perspectives and practice. Yet the reasons ­women tend to cite for desiring scans do not align with medical indications, and this detail raises bothersome questions.65 How much should patients’ preferences f­actor into medical decision making? Does patient autonomy encompass the right to a procedure such as a pre­ natal ultrasound? Where do we draw the lines between popu­lar demand and therapeutic value?

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Since the 1990s, the number of ultrasounds performed per preg­ nancy has risen steeply. In the mid-1990s, the average number of scans was about 1.5; in the early 2000s, it was roughly 2.5; by 2014, the aver­ age pregnant ­woman underwent 5.2 scans over the course of her preg­ nancy. As a 2015 Wall Street Journal piece highlighting t­ hese increases underlined, American ­women are getting many more ultrasounds per pregnancy than are technically recommended. This expansion is not confined to the United States, and it is unrelated to maternal risk ­factors.66 Doctors are unsure how to account for t­ hese changes, but they are likely multifactorial. Some explanations point to “nonclinical ­factors,” such as “the practice of defensive medicine, the desire to reassure a patient that her pregnancy is progressing normally, patient demand and even the ‘entertainment’ value of seeing one’s fetus.” 67 ­Others look to broader trends: a team of Canadian physicians explains that the proliferation of prenatal ultrasound is “consistent with a growing body of evidence suggesting that some health interventions most beneficial to high-­risk individuals are fre­ quently directed at apparently low-­risk populations. This ‘treatment-­risk paradox’ has been described for statin therapy [medi­cations that lower cholesterol levels] in high-­risk el­derly patients . . . ​[and] serves as a test case of a rapidly proliferating diagnostic technology. As such, it is a microcosm of a much bigger phenomenon that may be occurring with many other diagnostic imaging tests.” 68 Indeed, the rapid adoption and proliferation of ultrasounds in clinical practice is far from unique in medicine. The translation of scientific tech­ nologies into medical care is accelerating, writes Scott Gottlieb in Forbes. The pace of medical “pro­gress” is changing—­shrinking. Medicine is adapt­ ing science and technology at a “breakneck speed,” Gottlieb observes, and the “results are so convincing, and the benefits so seductive, that the resulting treatments . . . ​a re readily and widely ­adopted across clinical practice.” 69

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The ­future of ultrasound in prenatal care is far from obvious, but—­and I write this sardonically—it is likely not g­ oing anywhere fast.

In spite of myself, I see my own pregnancy reflected in this phenomenon: I have become a statistic. I am a low-­risk patient with a low-­risk pregnancy, and yet I have five scans between the time I conceive my ­daughter and the time she is born into the world. I think back to my first pregnancy, count­ ing, and realize I had five scans then as well. I am the average. Even as I review the rapid proliferation of ultrasonography as a cus­ tomary component in prenatal care in the United States, and even as I read about the theoretical concerns regarding safety and bristle at the real fis­ cal costs of overuse, I worry that my own concerns about our society’s widespread ac­cep­tance of prenatal ultrasound are, in fact, merely the result of my own deep-­seated biases against unnecessary medical interventions. And so, despite the lingering doubts I harbor about their necessity, I secretly brighten each time my doctor puts in an order for a scan. I take plea­sure in each of ­these meetings and easily forget my suspicions. To me, ­every scan marks a point of demarcation—­before and a­ fter. I am well aware of the irony that an in­de­pen­dent technological intervention, wielded by a complete stranger, bestows a newfound sense of connection with my own being, but I ­don’t need any evidence to tell me that ­t hese teasers bring me closer to the life growing within me. They bond me as they ground me. Like so many other ­women, I delight in this. I savor the chance to see my child, to feel so intimately connected to a person I feel so impossibly, absurdly removed from. To watch what is hiding in plain sight.

chapter 6

•

Move

On the cusp of my third trimester, a fresh wave of exhaustion crashes over me. My once avid daily exercise habit becomes a chore, another task to check off my list. I continue to work out, but each session is a painful reminder of just how ­little my pregnant body is capable of. ­Running is mis­ erable; jumping is out of the question; twists and stretches unthinkable. Where I was once lithe and limber and able, I am now confined, restricted. My body disobeys me. And yet I am resolute that I am still fully capable. I modify every­thing I do, but I continue to do it. Despite my fatigue, I still crave the activity and the release exercise offers me. When p ­ eople tell me to slow down, I roll my eyes. I am straddling a divide: torn between my desire to stay active, experi­ ence every­thing I love about physical activity, bask in the satisfaction it brings me, and my creeping inclinations—­entirely foreign to me—to col­ lapse, to relax, to give it all up. The movement I feel from within guides me. A ­little girl is kicking and pushing against me constantly, intermittently; somehow, her spasmodic activity grounds me. I choose to follow her lead.

In a 2016 piece in The Atlantic, writer Julie Beck explained that her “gut reaction” to the prospect of exercise during pregnancy was that it “seems 122

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risky.”1 She is not alone in her intuition—­t he idea that exercise might be hazardous for pregnant w ­ omen is pervasive in American society. Th ­ ere appears to be a good deal of confusion about the issue. As of 2014, only about 16 ­percent of pregnant w ­ omen in the United States w ­ ere exercising in accordance with ACOG guidelines, which suggest engaging in “moderate-­ intensity exercise for at least 20–30 minutes per day on most or all days of ­ omen surveyed for a study pub­ the week.”2 In 2016, a majority of rural w lished in the International Journal of Childbirth Education conveyed inac­ curate or confused understandings about exercising during pregnancy.3 In a 2010 survey of physicians and certified nurse-­midwives in Michigan, a surprisingly high number of prac­ti­tion­ers conveyed outdated informa­ tion to their patients, with 64  ­percent of respondents urging pregnant ­women to “limit their activity intensity based on a suggestion that has not been applicable for several years.” 4 Pregnant ­women who continue to exer­ cise hear—­from medical professionals and from friends and ­family—­t hat they should “be careful” or “take it easy.” Smart ­women like Julie Beck think instinctively about exercise as “risky.” Where did this kind of appre­ hension originate? Why are we so ner­vous about the prospect of exercising during pregnancy?

Historical Perspective American w ­ omen have long been taught to be cautious about physical exertion during pregnancy. Historically, medical ideas and recommenda­ tions regarding exercise during pregnancy have sprung almost entirely from social and cultural ideologies and biases.5 The trend has, in many ways, continued into the twenty-­first ­century. In the United States, medical recommendations about activity during pregnancy have been skewed and patronizing. Prior to 1900, doctors advised privileged upper-­class w ­ omen to maximize time spent idly, while working-­class w ­ omen frequently had no choice but to remain busy and active throughout their pregnancies.6 Even worse, slave ­women ­were

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expected to continue back-­breaking manual l­abor throughout their pregnancies.7 Even ­after slavery ended, race, class, and gender norms continued to powerfully shape ideas about physical activity during pregnancy. The “cult of true womanhood” valorized passive femininity—­t he ideal ­woman was white, fragile, and delicate; her body was a symbol of her prosperous, sed­ entary life. By contrast, lower-­class ­women and ­women of color typically depended on their bodies daily, and their physical appearance often betrayed their physical ­labor.8 Pregnancy was a continuation of t­ hese starkly divergent norms. Wealthy white ­women ­were advised to maintain their inactive lifestyles. Idleness was a signifier, a source of pride, for elite ­women, and pregnancy was a confining condition. Considered inappropriate or impolite for the likes of refined citizens, pregnancy was obscured, if not concealed, within upper-­ class homes. Vis­i­ble pregnancy was improper, and the topic itself was taboo. Many newspapers considered pregnancy an off-­limits topic (even for advertisers), too scandalous to mention. And yet working-­class ­women continued to engage in physical work, often outside the home, through­ out their pregnancies, for the ­simple reason that they had to. Nonetheless, the Victorian impetus to conceal pregnancy and pregnant bodies seems to have been incredibly enduring.9 ­These impressions ­were guided by social class and etiquette rather than evidence, much less individual preferences, and the dominant medical rec­ ommendations during the 1800s ­were that (white) pregnant w ­ omen rest, as much as pos­si­ble.10 This may not be too surprising, but it is paradoxical—­ because many medical writers also believed that working-­class w ­ omen’s physical l­ abor (i.e., work) helped explain their ste­reo­t ypically smoother deliveries compared with the experiences of wealthier ­women. Around 1900, however, a subtle shift began. Some (though not all) physicians, working to attract expecting patients, increasingly began to address pregnancy as a normal condition rather than a pathology. This revision carried a fresh message about activity: pregnant ­women could,

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for the most part, carry on with their normal lives.11 Physicians typically suggested that pregnant w ­ omen stay moderately active but cautioned against anything that might put too much strain on a ­woman’s body—or her mind. They also not-­so-­subtly implored pregnant ­women to keep up with their ­house­work. In his 1902 Manual of Antenatal Pathology and Hygiene: The Foetus, leading Scottish obstetrician J. W. Ballantyne contended that a pregnant ­woman should “take sufficient exercise to keep her body in health.” But he warned that “excessive exertion”—be it through bicycling, walking, golfing, dancing, or housework—­“should be forbidden.” (And Ballantyne—­renowned for his willingness to train w ­ omen in medical pro­ fessions such as midwifery—­admired a Swiss piece of legislation that apparently prohibited ­women in their final month of pregnancy from any kind of hard manual l­ abor, instead mandating rest.)12 In 1912, The Prospective ­Mother announced that “what a w ­ oman can h ­ andle depends on what she was ‘accustomed to,’ ” but insisted that idleness, above all other t­ hings, was most “unfavorable to comfort and health during pregnancy.” The author, J. Morris Slemons, further advised that “­every prospective [­mother] should occupy herself with congenial work and fitting diversions.”13 (Not sewing, though: sewing machines ­were “emphatically forbidden.”14) Dr. Joseph DeLee’s prominent The Princi­ples and Practice of Obstetrics, published in 1913, announced that pregnant ­women needed to avoid “vio­ lent exercise” as well as “jolts, ­r unning, sudden motions, lifting ­g reat weights, ­going up and down stairs quickly, ­horse­back riding, cycling, rid­ ing over rough roads, golf, tennis, dancing, and swimming.” DeLee, famous for pioneering the widespread use of forceps during childbirth (an intervention that caused far more harm than good), also stated that it was literally impossible for a pregnant w ­ oman to build a strong muscular sys­ tem. “This should have been done before,” he admonished.15,* * DeLee and ­others w ­ ere also adamantly opposed to sex during pregnancy. As DeLee explained, the topic was “of g­ reat importance,” as t­ here w ­ ere “many reasons for for­ bidding coitus during gestation.” Among them was a perceived risk of abortion or

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The basic premise was that pregnant ­women should “get enough exer­ cise” but avoid anything “violent.”16 For most, this meant walking and, most importantly, chores. Indeed, prac­ti­tion­ers unanimously agreed (quite passionately) that pregnant w ­ omen could and should continue to perform their ­house­hold duties as usual. How trite. J. Morris Slemons was thus not alone in his belief that the “existence of pregnancy by no means requires the abandonment of domestic duties.”17 But perhaps DeLee put it most bluntly: “house­work is desirable.”18 This kind of traditionalist, patriarchal advice mostly continued through the twentieth c­ entury. Generally speaking, pregnant w ­ omen w ­ ere “treated as though they had an illness.” They w ­ ere instructed to “relax, avoid stren­ uous exertion and even bending or stretching, for fear they would stran­ ­ hildren’s Bureau exclaimed gle or squash the baby.”19 In 1949, the U.S. C that pregnant w ­ omen could maintain h ­ ouse­work and gardening activities, could go for walks up to one mile at a time, and could swim from time to time.20 Most books in the 1940s proclaimed something similar, allowing that pregnant ­women could continue their ­house­work or go for a stroll, but by and large discouraging sports activities.21 Medical textbooks up through the 1960s and even into the 1970s announced that “pregnancy is not a good time to exercise” (although, again, they still permitted walking).22 In the m ­ iddle of the twentieth c­ entury doctors began to publish numer­ ous articles on prenatal exercises, but they ­were not conceiving of exercise in our modern sense of the word. Rather, ­t hese writers w ­ ere document­ ing initial forays into what readers w ­ ill likely recognize as prenatal classes. Their efforts ­were, in many ways, laudable—­they sought to prepare expect­ miscarriage, the possibility of overtaxing a w ­ oman’s already-­strained “nerve energy” with the “ner­vous shock” brought on by intercourse, an apparent infection risk (“a real danger”), and the example of animals, who “do not copulate when the female is preg­ nant.” DeLee noted that “the danger” of sex was elevated during the first three months, when many ­women ­weren’t yet sure they ­were pregnant, and the final three months. Best practice, he said, was to avoid intercourse entirely.

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ing ­women for childbirth and often to imbue them with some mea­sure of confidence or positivity leading up to delivery. Some of the pioneers in this movement remain well-­k nown figures even several de­cades ­later: Grant­ ley Dick-­Read, an early advocate for “natu­ral” (unmedicated) childbirth and author of the renowned book Childbirth Without Fear, and Fernand Lamaze, whose famous Lamaze breathing techniques are still featured in many childbirth preparation courses.23 The exercises that men like this introduced in prenatal classes included deep breathing, relaxation, Kegel exercises, pelvis tilting, and posture—­ all in the name of preparation for childbirth. When sessions did incorpo­ rate more traditional “exercise,” it sometimes took the form of physical work such as “polishing the floor on hands and knees.” One enthusiast further noted that it was crucial that “the obstetrician himself should ­ omen in a supervise the exercise class.”24 Picturing a group of pregnant w maternity ward in London circa 1950 scrubbing the floors in unison ­under the careful guidance of a male obstetrician, I d ­ on’t know w ­ hether to chuckle or cringe. Cringe, I think. Medical advice up through the 1960s was incredibly warped by gender ideals. It was, frankly, sexist: stay active, but not too active; take rest, but not at the cost of a clean, well-­kept home. Pregnancy may have been a time for ­women to ease up a ­little bit, but it was no excuse for shirking on chores, errands, and appearances. Doctors advised ­women to avoid “unwomanly” activities and carry on with their “feminine” work in the home. Any prenatal exercises w ­ ere exclusively designed to prepare aw ­ oman’s body for l­ abor and delivery—­childbirth was the finish line. When Michael Bruser published, in 1968, an article entitled “Sporting Activities during Pregnancy” in the prominent journal Obstetrics and Gynecol­ogy, it was a harbinger of changing times. Bruser observed that most obstetrics texts offered l­ittle more than generic advice about using common sense to avoid overexertion when it came to exercise during preg­ nancy, but he had more fundamental questions. “Is ­t here any reason why a pregnant w ­ oman should avoid fatigue?” he asked. Bruser was doubtful,

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so he sang a dif­fer­ent tune: t­ here was no reason pregnant ­women needed to restrict their exercise u ­ ntil very late in pregnancy. They could “perform adequately”—­w ith some handicaps (balance, for one)—up through eight months, he said, ­a fter which “­simple awkwardness” would suffice to implicitly limit their capabilities.25 Amid his revolutionary questions and suggestions, Bruser ended up recommending, rather ironically, that w ­ omen trust their own judgment. His advice—­which was aimed at athletes rather than recreational exercis­ ers, who w ­ ere a “rare breed” in the 1960s—­a llowed for continued partici­ pation so long as w ­ omen ­were comfortable. The message, with its vague references to ­women’s comfort and best judgment, was in some sense a continuation of the exact kind of vacant, “common sense” advice Bruser had hoped to c­ ounter. But by allowing that pregnant w ­ omen could exhaust themselves if they so desired, he was turning the older worldview on its head. Bruser’s willingness to question the very premise of overexertion as a risk—­“the notion that fatigue is harmful has never been proved,” he said—­marked a clear turning point.26 And it came at an impor­tant moment in time, when both society and scientific medicine ­were beginning to take legitimate interest in exercise as a component of health.

Move for Health Exercise has a long, in­ter­est­ing medical history. It was one of the princi­ ple components of ancient Greek and Roman medicine, considered a staple of bodily health. Indeed, Hippocrates and Galen both pointed to physical activity as an impor­tant marker of an individual’s health and one of the most basic f­ actors in formulating medical prescriptions. With the under­lying belief that illness resulted from one or more imbalances in the body, most ancient Western medicine was grounded in attempts to balance or recalibrate the six “non-­naturals,” one of which was motion/

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rest, or exercise.* Perhaps the fundamental cornerstone of ancient medical practice was carefully ascertaining and then adjusting a person’s “regi­ men”: his diet and exercise habits. Suggested revisions ­were highly indi­ vidualistic, taking into account a dizzying array of f­ actors ranging from individual constitution and appearance to local climate, weather, and even dreams. ­These princi­ples, including the primacy of achieving bal­ ance through regimen, held sway for thousands of years, essentially domi­ nating medical scholarship up u ­ ntil the 1800s. The first inklings of exercise in the “modern” sense of the word emerged in the late 1800s, in the context of widespread concerns about the deterio­ rating effects of civilization and urbanization on the nation’s young men. The “muscular Chris­tian­ity” movement touted the spiritual, moral, and physical benefits of exercise. To combat perceived moral failings and phys­ ical weakness, reformers started opening fitness centers all around the country: YMCAs. For the most part, ­t hese spaces ­were only available to men. Not surprisingly, they ­were initially met with skepticism, not just ­because the male-­only, sometimes-­nude properties made p ­ eople uncom­ fortable. The idea of exercise on its own—of actively working to exert and shape the body—­was largely considered, frankly, nuts. To exercise was to mark one’s self as dif­fer­ent—­odd at best, possibly subversive at worst.27 Around the same time, a small group of physicians started to proclaim the health benefits of vigorous exercise (for men). They formed the Amer­ ican Association for the Advancement of Physical Education, and worked to spread their gospel. “Let it be understood,” Dr. J. William White (a leading researcher and surgeon from Philadelphia) wrote in Lippincott’s maga­ zine in the 1880s, “that the main object and idea of exercise is the acquire­ ment or preservation of health.”28 Briefly, then, modern medicine appeared to consider exercise as a promising arena of study and practice in the late

* The ­others ­were: air, diet, sleep/wakefulness, excretions and retentions (the work­ ings of the digestive system), and “passions of the mind.”

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1800s. But in the wake of germ theory, the rise of laboratory science, and a scathing exposé of medical education in the early 1900s known as the Flexner Report, American medical schools quickly reinvented them­ selves in an effort to reclaim any ele­ment of prestige.29 In the pro­cess, they placed a premium on the hard sciences. Whereas medicine in the 1800s had been skeptical of mainstream science, medicine in the 1900s embraced it. And “physical education” was not a hard science. Exercise was not medicine.30 As medicine discarded exercise, burgeoning numbers of schools and universities a­ dopted it by way of sports and “phys ed.” Athletics moved into the traditional education system and was quickly couched as a way to “educate through the physical” while si­mul­ta­neously benefitting the nation’s health. Well, men’s health. White men’s health.31 Indeed, you ­wouldn’t read much about ­women exercising in the first half of the twentieth c­ entury. You would read about “reducing,” the con­ temporary terminology for dieting. Beginning in the 1920s, ­women started working to reduce their figures, mostly through dieting but also through other channels, some of which had the trappings of exercise. “Slenderiz­ ing salons” and “figure control rooms” equipped with a variety of reduc­ ing machines attracted female clientele interested in slimming down. Touting big effects with minimal exertion (no need to change your dress or remove your high heels!), most of ­t hese contraptions used vibrations to shake targeted body parts and “dissolve fatty tissues” to “eliminate inches.” ­These distinctly female centers w ­ ere popu­lar nationwide and stood in stark contrast to the male-­centric gyms that actually promoted physi­ cal exertion.32 In the postwar era, ideas about physical fitness w ­ ere steeped in Cold War efforts to showcase American superiority. Exercise science blossomed, and one group of researchers announced that “the lack of exercise among American youth was ‘a serious deficiency comparable to a vitamin defi­ ciency.’ ” Alarmed, President Dwight Eisenhower founded the President’s Council on Youth Fitness, elevating physical fitness and activity to a

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national ­matter.33 (This is the group that instituted the infamous, and hated, Presidential Fitness Challenge in ­middle and high schools across the country, assessing students on their capacity to perform pull-­ups, sit-­ ups, shut­t le runs, sprints, softball throws, and a standing broad jump.) Other politicians also pointed to physical fitness as a national status symbol. Shortly ­after he was elected president in 1960, John F. Kennedy warned Americans that the nation was becoming “soft,” mentally and physically—in Sports Illustrated, no less. He renamed Ike’s committee to incorporate all age groups and avowed that it would “promote exercise and fitness for Americans of all ages.” But exercise was still somewhat strange and “uncool,” even for men; among ­women, despite widespread attention to physical appearance and mounting anx­i­eties about body image, exer­ cise was a rarity.34 Building on e­ arlier research conducted at the Harvard Fatigue Labo­ ratory in the 1930s and 1940s though, new work began to explore exercise as a scientific field in its own right. And epidemiological researchers started to link inactivity—­a lack of exercise—­w ith a host of chronic conditions, including heart disease. Before long, studies ­were tying exercise and phys­ ical fitness to improved health: individuals with higher activity levels had lower rates of disease, better overall health, improved m ­ ental well-­being, and longer life spans.35 Responding to this outpouring of research in the 1970s, esteemed organ­izations such as the NIH, the American Heart Association, and the CDC began paying attention to the connections between health and exer­ cise as well. Prestigious journals such as the Journal of the American Medical Association and the New E ­ ngland Journal of Medicine published papers on the clinical implications of exercise science. In 1979, the U.S. Sur­ geon General called for an “attack on chronic disease” through exercise and nutrition. Exercise became, in short, a credible consideration within the medical sphere.36 And some of the long-­standing assumptions about exercise began to slowly fall away. Exercise started to become popu­lar, and the stigma

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surrounding it began to erode. The 1970s saw exercise become not just a pillar of primary health care but also a recognizable, acceptable pastime in the United States. Jogging, no longer the sole preserve of professional runners (or weirdos), emerged as a widespread recreational pursuit that promised to deliver cardiovascular health benefits. A “new era of fitness promotion” ensued: exercise became trendy, appealing, marketable.37 And yet exercise remained primarily a man’s game. For a time. Second-­wave feminists of the 1960s and 1970s fought for w ­ omen’s equal access and inclusion across multiple sectors of society, including politics, employment, w ­ omen’s health and reproductive rights, f­ amily dynamics, gender expectations, and sexuality.* They challenged social norms in vir­ tually e­ very arena—­and fitness was no exception. W ­ omen had power­f ul, strong bodies, too, feminists said, and ­women had the right to participate in exercise and athletics on equal ground. One outcome of ­these efforts was Title IX, the watershed legislation that prohibited sex discrimination in federally funded schools, including in athletics participation. Dating back to the nineteenth c­ entury, “physical fitness” and exercise had been loosely associated with politics via disagreeable theories about their poten­ tial to improve the nation’s “stock,” but in the hands of feminists, exercise was patently po­liti­cal.38 Take Jazzercise, for example. Jazzercise was one of the most popu­lar, and enduring, challenges to this reinvented separation of spheres. It was conceived by a ­woman, designed for ­women, marketed to w ­ omen. And it resonated. Imbued with messages of joy, poise, and self-­confidence, the program offered an entirely fresh take on exercise itself. Moving out­ side of the traditional male-­dominated exercise space (the gym), Jazzercise

* The first-­wave feminist movement, in the early 1900s, focused predominantly on securing the right to vote for w ­ omen. It culminated in the passing of the Nineteenth Amendment to the Constitution in 1920. Although it was a monumental landmark, in practice, equal voting rights did not extend to all American ­women equally; Black ­women across the nation remained disenfranchised for de­cades thereafter.

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classes promoted dancing and togetherness u ­ nder the rubric of aerobic fitness and sisterhood. The program addressed fitness from a w ­ oman’s perspective, and it was wildly successful. By 1984, Jazzercise was the sec­ ond biggest franchise nationally (Domino’s Pizza was the largest), with a revenue of $40 million, 350,000 students, and 2,700 trained teachers (nearly all w ­ omen).39 But Jazzercise, like many woman-­centered exercise regimens, was not uniformly feminist. It walked a fine line between being progressive and conservative. One w ­ oman exclaimed that Jazzercise taught her that her body was something she was supposed to try to control: “It was the first time I realized I was supposed to work on my body . . . ​to look how I d ­ on’t naturally.” 40 In this way, Jazzercise, and other programs like it, mixed messages of female liberation and strength with more traditional, confining ideals of feminine beauty. “The feel-­good fitness language that Jazzercise birthed,” says fitness history expert Natalia Petrzela, “blended newly empowering affirmations with old beauty directives that prized a thin and conventional sort of prettiness.” 41 Some critics derided the aerobics movement at large, including the rapid expansion of workout videos, as “promoting a ‘pas­ sive femininity.’ ” 42 This duality is, in many ways, endemic to w ­ omen’s fitness culture. It is ubiquitous in the world we inhabit. Jazzercise was hardly the point of ori­ gin, but it looms large. And I’m curious. I visit the official Jazzercise web­ site. Despite myself, the workout does look fun. I enter my postal zip code to check for a class near me, but ­there are none within twenty-­five miles. Disappointed, I turn to YouTube. I ­can’t find any recent full-­length classes, but I find something better: a handful of VHS tapes from the 1980s some­ one has uploaded. Perfect. They are all bright leggings and leotards, hair bows and poufy bangs, big chipper smiles and over-­the-­top narration. I modify many of the moves— I cannot extend my torso to the side and snap (more like heave) myself back upright without falling over, and I have to focus an inordinate amount of

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my attention on not peeing—­but I am still huffing and puffing ­after twenty minutes. My body is un­co­or­di­nated and burdensome, burgeoning. I decide to revisit Jazzercise a­ fter the baby comes. Maybe.

Exercise Returns By the end of the 1980s, exercise was not only cemented as a legitimate component of medical health and well-­being, it was a public movement. This was a true revolution—­exercise had become not only a newly profes­ sional and legitimate science, but it also had emerged as a mass-­market industry, a hobby, a pursuit. Workout videos became an enterprise in their own right, and aerobics sessions w ­ ere a staple. Jane Fonda’s famous vid­ eotape from 1982 sold 17 million copies.43 (It’s also available on YouTube and is equally as incompatible with my pregnant body as Jazzercise.) Exercise routines for e­ very faction of society—­including pregnant w ­ omen—­abounded.44 Prenatal exercise regimens proliferated so widely, in fact, that doctors grew concerned about them. Most programs ­were developed by nonphysicians, and they made untenable claims about how physical fitness would ease l­ abor and delivery.45 Even jogging during preg­ nancy piqued professional curiosity. In 1981, the Journal of the American Medical Association ran a story about a ­woman who ran four miles daily throughout her seventh pregnancy. She was the subject of a formal aca­ demic pre­sen­ta­t ion at the annual meeting of the American College of ­ oman’s sustained jogging warranted Sports Medicine.46 The fact that this w formal comment among medical professionals illustrates just how unac­ customed they ­were to seeing w ­ omen continue to exercise while they w ­ ere pregnant. (By comparison, it is difficult to imagine that professionals ­today would consider this situation worthy of special discussion.) Amid the budding national exercise craze and the increasing visibility of exercising pregnant ­women, medicine and society took up the relation­

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ship between exercise and pregnancy outcomes with renewed interest. According to one analy­sis, two “schools of thought” emerged: one con­ servative and the other liberal. Conservatives, predominantly physicians, ­were more likely to recommend “a restrictive, cautious approach” to preg­ nant ­women. By contrast, active pregnant ­women themselves saw no det­ riments to their activity and argued that exercise was a boon to their pregnancies.47 For ­those who harbored any concerns, ­there ­were two broad questions. The first was acute—­were t­ here any immediate prob­lems that resulted dur­ ing exercise for a m ­ other or a fetus? The second was chronic—­were ­there any broad negative outcomes of exercising on the course of a pregnancy or a birth? Some of the first work conducted on t­ hese questions took place with animals. Th ­ ose studies seemed to point to some potential risks, such as reduced maternal blood flow (which could be problematic if it caused a reduction in adequate blood supply to the uterus) and lower birth weights.48 But ­human research indicated other­wise. Small-­scale studies in the 1980s concluded that exercise did not impact fetal weight; they found that any effects on maternal blood flow or fetal heart rate ­were ­limited to exercise sessions, ­were minor, and had no vis­i­ble consequences.49 So in the short-­ term exercise did elicit subtle acute changes, but they ­were not evidently harmful. And in the long-­term exercise appeared to offer benefits. Then ­people started asking more specific questions. How hard could ­women work out? For how long? What kinds of exercises and activities could they pursue? As researchers dug into t­ hese inquiries, they increas­ ingly determined that vigorous or strenuous exercise posed no prob­lems—­ and might in fact be advantageous. One 1987 study, for example, looked at nearly 850 ­women split into four groups: a control group (no exercise), a low-­exercise group, a medium-­exercise group, and a high-­exercise group. Across all three exercising groups, physical activity had no negative out­ comes for m ­ others or babies. Their cesarean delivery (C-­section) rates ­were

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actually inversely correlated with higher exercise intensity, and the high-­ exercisers gave birth to babies with the highest Apgar scores (a numerical scale for mea­sur­ing newborn health). “Pregnancy outcomes,” the research­ ers concluded, “­were more favorable in the exercise groups, particularly the high-­exercise group.”50 Armed with some (albeit minimal) research, ACOG levied a formal opinion. In 1985, the organ­ization released its first-­ever guidelines on exer­ cising during pregnancy, formally approving of exercise among pregnant ­women. Given the scarcity of research, its recommendations ­were rela­ tively cautious. Pregnant ­women ­were advised to limit their maximum heart rates to 140 beats per minute, restrict strenuous activity to no more than fifteen minutes, and keep their core body temperatures below 100.4 degrees Fahrenheit.51 In 1994, ACOG amended its guidelines, ­doing away with the heart rate restriction and time limitations. (Raul Artal, one of the leading experts in the field, has repeatedly explained that the heart rate limitation had “no scientific value.”52) In 2002, another revision asserted that “pregnant ­women are now encouraged to follow general adult recom­ mendations” for physical activity.53 At the end of 2015, ACOG released new guidelines, which stressed that exercising during pregnancy carries very ­little risk. The group suggested that all pregnant w ­ omen without complications may partake in aerobic and strength training exercises for the duration of their pregnancies. The advisements from international groups have been similar. Furthermore, breaking with its own previous guidelines, ACOG began to encourage w ­ omen to start exercising during pregnancy, even if they h ­ adn’t previously.54 ­Women who w ­ ere exercising vigorously before they became pregnant also gained “permission” to continue with their same workouts, provided they felt up for it.55 (One piece of the original guidelines that research has continually substantiated is the advisement that pregnant ­women keep their core body temperatures u ­ nder about 102 degrees Fahrenheit, because elevated core body temperatures, especially in the first trimester, have been correlated with neural tube defects.56)

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Allowing that the pregnant body often demands numerous exercise modifications, ACOG’s general message is that exercise prescriptions for pregnant ­women should essentially be “the same . . . ​as t­hose recom­ mended for the general population.”57 With regard to exercise, pregnant ­women can work out just like every­body e­ lse. If they want to. Th ­ ese days, medical experts are telling w ­ omen to “forget about heart rate”: walking is safe, ­running is safe, intense exercise is safe.58 To be clear, pregnancy does entail physical changes that seriously impact exercise capabilities. Aside from the obvious (a growing figure, weight gain, a shifting center of balance), pregnancy also produces dramatic revi­ sions to the entire cardiovascular system: an increased blood volume (of up to 50 ­percent), a heightened resting heart rate (by fifteen to twenty beats per minute), and increased cardiac output (the amount of blood the heart pumps through the body’s vasculature in one minute). The respiratory sys­ tem is affected, too—­pregnant w ­ omen have a decreased lung capacity, limiting their “oxygen availability” and thus their capacity to endure vigorous aerobic exercise.59 (This is one reason for the colloquially popu­ lar “talk test,” which suggests that ­women can exert themselves but not beyond the point at which they can still talk and carry on a conversation comfortably.) In other words, science provided evidence that the Victorian Era cus­ toms and “social wisdom” encouraging pregnant w ­ omen to avoid physi­ cal activity ­were misguided (besides misogynistic and racist). At the pre­sent, the evidence clearly shows that exercising during pregnancy car­ ries no increased risks for the fetus or for the ­mother.60 It also has no docu­ mented associations with miscarriage or premature ­labor.61 Exercise offers many of the same overall benefits for pregnant ­women as it does for the general population—­improving physical fitness, helping with weight management, and improving mood. (Regarding weight, exer­ cising while pregnant only helps a l­ittle—­just as outside of pregnancy. A 2014 meta-­analysis showed that exercising while pregnant lowered prena­ tal weight gain by about 2.2 pounds on average.)62

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It also carries benefits par­t ic­u ­lar to pregnant ­women, ranging from decreasing their risk of gestational diabetes and hypertension to helping with typical maladies of pregnancy such as back pain, constipation, blad­ der control, varicose veins, and heartburn.63 Some ­women have reported that a quick bout of exercise (just three to five minutes) relieved their morning sickness symptoms.64 New York Times contributor Gretchen Reynolds wrote about a fascinating study in which mice whose ­mothers had run while they w ­ ere pregnant grew up to run more themselves—­t hey “had literally been born to run,” she quipped. The study, as Reynolds describes, “hint[s] at the possibility that to some extent our w ­ ill to work out may be influenced by a ­mother’s exercise habits during pregnancy, and begin as early as in the womb.” 65 Even more provocatively, recent research shows that being physically active during pregnancy might reduce a w ­ oman’s chances of having an instrumental or cesarean delivery. In a systematic review of randomized controlled t­ rials (published in 2014 in the American Journal of Obstetrics and Gynecol­ogy) encompassing more than 3,300 w ­ omen in sixteen stud­ ies, the authors found that “­women in exercise groups had a significantly lower risk of cesarean delivery.” 66 Importantly, only one of the studies included in the review actually offered any indication about the circum­ stances of cesarean deliveries, meaning most did not rec­ord or explain why the cesareans had occurred. This is a huge f­actor b ­ ecause many ­women elect to have cesarean deliveries ahead of time. Still, the num­ bers are hard to ignore—­really hard to ignore, actually. Exercise pro­ grams ­were shown to potentially lower the risk of cesarean delivery by about 15 ­percent. As the authors noted, this possibility “is of huge clini­ cal significance . . . ​a nd likely [is] difficult to obtain by any other single intervention.” 67 More recently, in 2017 a report in the same journal (with the chipper title “Exercise in Pregnancy!”) exclaimed that “­there is no intervention that we as providers can recommend to pregnant w ­ omen as impressive in its significant impact on so many maternal and perinatal outcomes.” The

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authors denounced the “myth that exercise might be harmful in preg­ nancy,” saying that the evidence “destroys” it.68

In keeping with recent medical recommendations, the media promotes exercise during pregnancy, with reasonable evidence-­based exceptions (such as pregnancy complications and hot yoga). Sometimes it sends mixed messages (“the real ­hazard,” warns one website, “is inactivity”), or it patronizes ­women by belittling the manifold obstacles to exercise that pregnancy imposes.69 And, of course, unbridled exercise promotion runs the risk of taking ­t hings too far—in a fast-paced world where pregnant ­women are unreasonably expected to “do it all,” exercise becomes just “one more t­ hing.” And sometimes we do need to take a rest. We are all, it seems to me, working against de­cades of ingrained cul­ tural and ideological conventions relegating pregnant w ­ omen to inactiv­ ity or domestic work. ­There are, of course, exercise modifications pregnant ­women should make, as well as some activities pregnant ­women prob­ably should avoid altogether (such as scuba diving or contact sports), but the ongoing scholarship should be reassuring to ­women who wish to remain active during their pregnancies. The recommendations I heard when I was pregnant w ­ ere to simply do what felt comfortable, safe, and good, based on my own intuition. Of course, this was welcome advice. But the unfortunate real­ity—­which applies to so much of the evidence-­ based pregnancy advice available t­oday—is that e­ ither it’s not meeting the right audience or it’s unrealistic for ­women to enact. Many ­women are not hearing the messages about the benefits of exercise during pregnancy; and even for ­t hose who do, exercise requires time, social support, and sometimes equipment or other resources such as a computer, internet access, physical space, childcare. In the 1980s, widespread access to VHS exercise tapes fueled the exer­ cise movement and brought the benefits of exercise to many who could

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not afford the time or money to attend group classes. In the new millen­ nium, when drop-in fitness classes frequently cost between $15 and $25, online videos and streaming ser­vices make similar promises, but t­ hese initiatives are still far from truly demo­cratizing the fitness industry. For myriad reasons, many ­women are unable to take advantage of ­these resources. Formal surveys suggest that less than half of pregnant ­women exercise at all; more are not exercising “enough.”70 Especially in underprivileged communities, pregnant w ­ omen are less likely to exercise and also are less likely to be aware of the health benefits exercise promises.71 And such disparities are not unique to the pregnant population. In the first two de­cades of the twenty-­first ­century, we have witnessed an explosion of growth in the fitness and wellness sectors. As of 2019, the exercise industry was worth $27 billion. But its benefits have not reached all Americans equally. As historian Natalia Petrzela explains, “Amer­i­ca is indeed experiencing a ‘wellness revolution,’ but it is so socioeco­nom­ ically constrained that it is literally laughable to imagine it including the poor.” Healthy living, she says, is a luxury increasingly available only to the more privileged classes in society, rather than a universal ­human right.72 Perhaps I should not be so proud of myself. Many ­women and policy makers (besides academics) are wary, if not critical, of the ACOG exercise recommendations for being overbearing. Especially given their explicit connections with “excess” maternal weight gain and the obesity epidemic, and in light of reigning perceptions of the ideal female figure—­a slim one—it is impossible to entirely dismiss the idea that pregnancy exercise advice continues to stem from cultural and social norms. Of course it does: physical exertion remains vaguely con­ nected to an “easier” l­ abor and delivery and more rapid postpartum weight loss; “common sense” still reigns; w ­ omen’s magazines still reference chores and child care as forms of exercise; pregnant bodies still need to be kept in control.

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Sometimes it is difficult to parse the medical benefits of exercise in preg­ nancy from the aesthetic expectations.73 In the twenty-­first ­century, Americans still revere a svelte femininity, applaud physical activity and believe in the gospel of exercise, and we still harbor vestiges of dated ideas about pregnant w ­ omen keeping up their looks—­and every­t hing ­else.74 I know this. I see the prob­lems. And yet I am still a faithful disciple. And so I keep moving.

chapter 7

•

Sleep

I am a stomach sleeper, so I count myself grateful for each night I am still able to slowly, cautiously turn over and relax onto my belly. Gradually, rolling becomes a pro­cess. Once mindless and automatic to the point of being unnoticeable, shifting my body in the ­middle of the night becomes a deliberate, careful undertaking. Around nineteen weeks, I begin to dread that my stomach-­sleeping days w ­ ill soon be over. I tire early; I need to get up to pee an average of twice each night; I wake constantly to shake off pins and ­needles in my fin­gers and hands; I rarely feel fully rested. My husband begins his cardiology fellowship at the beginning of my second trimester, and his grueling call schedule introduces a new hurdle: the middle-­of-­the-­night page. Thanks to his beeper, my already far-­fetched hopes of a sound night’s sleep become even more elusive, slipping away into the horizon like a tempting mirage. Some call nights are quiet, but ­t hose are unusual. His first night on call, my husband arrived home from work at 1:15 a.m., settled into bed, and then was paged to go back to the hospital fifteen minutes ­later. He returned home at 5:00 a.m., and he had to leave again half an hour ­later. We compared it to a typical night with our son when he was a newborn—­predictably, ste­reo­t ypically wearying. We laughed together. The humor wears off quickly.

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A month or so l­ ater, ­after a night punctuated by pages and phone calls ­every forty-­five minutes, a realization dawns on me. In five months, that pager is g­ oing to be waking up a newborn baby—­and its nursing, ener­ vated m ­ other as well. Between the baby and my husband’s pager, I can barely stand the thought of it. What are we ­going to do? What am I ­going to do?

I remember when I called each of my grand­mothers to tell them I was pregnant with my son. My maternal grand­mother was so elated (and surprised—­she thought I had opted to forego childbearing entirely) that she screamed with excitement for a few minutes straight. I cannot think of that “conversation” without smiling. My paternal grand­mother’s response led to a more typical exchange. She had been pregnant twenty-­ one times. I had the luxury of taking at-­home pregnancy tests, but in an era before ­those w ­ ere available, the w ­ omen of my grand­mothers’ generation detected their pregnancies differently. Some of them went to the doctor for a “rab­ bit test,” a now-­heinous-­sounding procedure whereby a urine sample was injected into an animal’s bloodstream (in addition to rabbits, frogs, mice, and rats w ­ ere also used) to observe its effects on the animal’s reproductive organs ­after it was dissected. (If the animal went into heat, vis­i­ble through a swollen reproductive tract, the test was considered positive.) It took mul­ tiple days for the (only sometimes accurate) results to come in. ­Others continued to rely on the more traditional signs and symptoms: a missed menstruation, swollen breasts, nausea. My grand­mother said she always knew when she was pregnant based on one t­ hing: how unbelievably, over­ whelmingly tired she was. Early pregnancy especially has long been associated with oppressive levels of exhaustion. J. Morris Slemons’s The Prospective M ­ other, pub­ lished in 1912, noted that “­women complain that they tire easily early in

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pregnancy, even from t­ hings they used to do very easily.”1 That sounds familiar. ­Today, exhaustion and fatigue are classic symptoms of early pregnancy, and science gives us one clue as to why: hormones. The physical changes that accompany pregnancy powerfully impact sleep, in both quality and quantity. During the first trimester, surges of progesterone lead to exces­ sive daytime sleepiness and intense feelings of fatigue for many ­women, and also often cause sleep “fragmentation” at night. Along with nausea and vomiting of pregnancy and other physical changes such as an increased blood supply and oxygen demand, the first trimester is distinguished for the extreme tiredness it engenders. If utter exhaustion is the hallmark of the first trimester, then insom­ nia, restless sleep, and frequent waking are stamps of the third trimester. An expanding abdomen would make sleep difficult enough on its own, but the added pressure it places on the bladder and diaphragm, frequent heartburn, swollen feet, and hormonal changes, not to mention the psy­ chological and emotional stress that comes with anticipating childbirth and motherhood, all comprise additional hurdles standing in the way of a solid night’s rest. (Oxytocin, the hormone responsible for triggering uter­ ine contractions, also typically peaks overnight, and might be a cause of fragmented sleep.)2 Estimates vary, but evidence indicates that sleep disturbance during pregnancy is widespread. A National Sleep Foundation poll in 1998 reported that 87 ­percent of w ­ omen had more disturbed sleep while they ­were pregnant compared with any other time in their lives.3 Between 29 and 76 ­percent of w ­ omen experience poor sleep quality during pregnancy, with 14 to 17 ­percent reporting that they experience insomnia symptoms.4 By the end of pregnancy, one study determined, more than 97 ­percent of ­women wake up in the ­middle of the night an average of 3.11 times, which lasts up to twenty minutes per incident.5 We may know something about the extent to which sleep is lacking during pregnancy, but our ability to overcome the prob­lem is less than

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impressive. The robust pregnancy advice lit­er­a­ture that confronts pregnant ­women ­today offers up countless suggestions for how to sleep well during pregnancy—­nap when you can! ask your partner for a gentle back mas­ sage at bedtime! use a body pillow!—­but such tips and tricks have yet to yield any noticeable improvements. This seems to be on trend for at least the past hundred years, if the first professional medical texts on pregnancy are any indication. Most of ­these early works w ­ ere released around the turn of the twentieth ­century, and several of them counseled expecting ­women on sleep. In the early 1900s, many writers ­were expressly concerned with sufficient ventilation—­fresh air in the bedroom was considered a baseline ingredient for a good night’s sleep. Prenatal Care (the U.S. C ­ hildren’s Bureau pamphlet first distributed ­ omen not in 1915) took this piece of advice a step farther by counseling w only to sleep with their bedroom win­dows open, but also to sleep outside—­ year-­round. (The author did allow that this might not be pos­si­ble in the North due to the “severity of the winters” ­there.)6 Historical remedies for insomnia centered on vari­ous herbs and sub­ stances; poppy and alcohol w ­ ere favored prescriptions before other, more intense sedatives ­were ­adopted. In 1901, Lydia Pinkham, an entrepreneur famous for developing and aggressively marketing her own patented tonic, recommended expecting ­women cut back on caffeine and take warm foot­ baths to temper sleeplessness (a footbath “makes the circulation more evenly distributed,” she said). She also suggested, true to form, that for the “very best results” ­women should use her very own Lydia E. Pinkham’s Vegetable Compound, “­because of its g­ reat nerve tonic properties.”7 Slemons, for his part, advised exhausted ­women to “yield” and nap, even “in spite of advice to the contrary which older w ­ omen are apt to give.”8 He identified some bedtime rituals to encourage sleep: a warm bath, warmed sheets (what a luxury!), a small glass of heated milk. He also described an early form of mindfulness and meditation therapy, border­ ing on self-­hypnosis: repeat and concentrate—­“I am getting sleepy, I am ­going to sleep.” According to Slemons, most prenatal insomnia resulted

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from “a faulty frame of mind.” ­Women simply needed to amend that, he explained. In order to sleep well, “the prospective m ­ other must stop think­ ing when she retires.” Stop thinking. She “must be able to banish worries, regrets, and fore­ bodings; she must have confidence in what­ever method she employs. She must convince herself that she can sleep, or at least that it makes no difference if she cannot.”9 This does not sound so easy to me. (Shy of recom­ mending ­women opt for a dif­fer­ent life, in 1912 Slemons did note one other pos­si­ble remedy for sleeplessness, although he said it was “rarely ­ ere a common remedy for sleep necessary”: narcotics.10 In fact, opiates w prob­lems through the 1800s.11) It is hardly surprising that a well-­established (white) male physician in the early 1900s would tell a pregnant patient that her inability to sleep was all in her head (remember morning sickness?), or that she should simply set aside her worries, stop fretting . . . ​stop using her brain. That even if she failed to sleep well, she could always make up for it the following day or night.12 Yet this kind of detached advice still abounds in the twenty-­first ­century, where it seems all the more unrealistic. Advice lit­er­a­ture—­some of it crafted by ­women—­still suggests that pregnant w ­ omen relax, rest when they can, sleep in, take it easy, pamper themselves, or splurge on self-­care indulgences like pedicures. But what about ­women who have real concerns—like financial constraints—­and are inundated with informa­ ­

tion about how they should “be pregnant”? What about working ­women? What about ­mothers? As author Zoe Heller wrote in the New Yorker in 2018, much of the sleep hygiene advice directed ­toward the broader public “leaves the misleading and slightly infuriating impression that sleep is a life-­style choice, a ­free resource, available to all who care enough to make it a priority.” And yet so many are unable to prioritize sleep. Some of the most consistent cor­ relations with insufficient sleep are low-­income homes, shift work, food

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insecurity, and minority racial status, she explains.13 I would add parents to that list.

The Medicine of Sleep Medical writers have periodically, if not consistently, remarked on sleep since the time of Hippocrates, who believed that sleep was a telling marker of health and a staple prescription for well-­being. In “Aphorisms,” he writes that “in what­ever disease sleep is laborious, it is a deadly symptom.” In a separate work, “On Dreams,” Hippocrates expounds on the importance of dreams: “the signs that come in sleep . . . ​have an impor­tant influence upon all ­things,” he writes. Hippocratic physicians believed that sleep was a time of complete rest, when the body shut down and disconnected. It took thousands of years for scientists to correct this mistaken perspective. In the 1800s, sleeplessness was considered a sort of individual blemish, a symptom of personal failing. ­Those who strug­gled with sleep understood that they themselves ­were the root of the prob­lem. And if the cause was personal, so too w ­ ere the pos­si­ble solutions: rise ­earlier, physically exert yourself more during the day, take a warm bath in the eve­ning. Most rem­ edies centered on exercise and open air.14 Modern medicine’s twentieth-­century explorations into sleep ­were fit­ ful, with the so-­called dawn of sleep science r­ eally emerging in the 1950s and 1960s. William Dement first documented and explained the stages of sleep, including rapid-­eye movement (REM) sleep, in the 1950s. He went on to found the first sleep clinic at Stanford University, and other clinics proliferated in the 1970s. Newly established professional socie­ties, journals, and sleep centers proclaimed that sleep science was a serious branch of medicine. Researchers studied sleep phases, cycles, and patterns, chart­ ing the bound­a ries of their new specialty. They fine-­tuned their under­ standings of sleep cycles and stages and documented clinical sleep disorders such as sleep apnea, narcolepsy, and restless leg syndrome.

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They emphasized that sleep was critical to health. But it ­wasn’t ­until far more recently that medicine started to listen. In fact, w ­ e’re only just begin­ ning to become attuned to the global effects of chronic, everyday sleep deprivation. On the eve of the third de­cade in the twenty-­first ­century, ­there is an outpouring of attention to sleep and its profound importance to h ­ uman health. Reflecting on this extensive new body of work showing how cru­ cial sleep is to health and well-­being, comedian Amy Poehler, in her hilar­ ious book Yes, Please, wrote, “I now read articles about how ­great sleep is and how impor­tant it is and I cry ­because I want it so bad and am so mad at how ­great every­one ­else seems to be at it.” For individuals struggling to sleep well, the new science of sleep is indeed upsetting. “The impact of chronic sleep loss and sleep related dis­ orders can be seen in virtually ­every key indicator of public health,” one team of researchers explained: “mortality, morbidity, work per­for­mance, accidents and injuries, functioning and quality of life, f­ amily well-­being, and health care utilization.”15 Sleep deprivation is now a major subject of coverage in popu­lar media outlets, industry and policy debates, and pro­ fessional lit­er­a­ture. A lack of sleep has been tied to negative effects on learning and cognitive functioning, declines in metabolism, breakdown in social relationships, decreased workplace productivity, decreased ­mental and physical health, and higher mortality. No won­der Amy Poehler is crying. Americans are sleeping less, and reportedly worse, since the early 1900s. Over the course of the twentieth ­century, sleep time in the United States ­ e’ve decreased by a whopping 20 ­percent.16 In just the past four de­cades, w started sleeping 1.5 to 2.0 hours less per night on average, and more of us are sleeping less than six hours per night.17 It is dismaying, too, that historically, some 75 ­percent of sleep research has been conducted only on men; herein lies yet another arena in which data on ­women are sorely lacking.18 Recent work has indicated that “Amer­ ican ­women may be bearing more of the burden of sleep deprivation than

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men,” based on evidence showing that ­women suffer larger gaps between the sleep they need and the sleep they get. As ­women have moved into the workplace in greater numbers, many of us have not relinquished our responsibilities at home—­often just the opposite. Sleep has suffered a blow on many American w ­ omen’s priority lists, and as a result is frequently mourned as a distant luxury.19 For all Americans, declines in sleep have stemmed from many dif­fer­ ent ­factors, ranging from social and environmental changes related to industrialization (such as artificial light and factory work), urbanization and suburbanization, alterations in work habits and employer expecta­ tions, to the connectivity of the digital age. The rise of shift work, too, has had profound effects for the more than 20 ­percent of Americans our soci­ ety relies on to conduct work at night (across dif­fer­ent industries); their work patterns have been wreaking havoc with their natu­ral sleeping patterns.20 Their work comes at a cost. Nighttime shift work has obvious implications for sleep, and other pro­ fessional pathways are similarly notorious for the extent of sleep depriva­ tion they demand throughout gradu­ate education, training, and c­ areer advancement. Loss of sleep is endemic among doctors, for example. Although recent policies have capped “duty hours” for young doctors (lim­ iting the number of hours they can work consecutively as well as the total number of hours they can work in a week), some programs knowingly and routinely disregard t­ hese without shame. I know many physicians-­in-­ training who (along with their colleagues) are frequently expected to dis­ obey work-­hour limitations and to knowingly misreport the number of hours they spend in the hospital. It’s simply part of their work culture. And ­t here are no such limits to even violate for attending physicians, who also suffer from sleep deprivation disproportionately compared with the gen­ eral population, a thought that is frankly terrifying in light of work showing that excessive tiredness is comparable to intoxication.21 Indeed, William Dement himself has derided the medical establish­ ment’s “almost willful ignorance about the dangers of fatigue.” What is

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particularly dangerous, he explains, is how alert someone who is brutally tired can feel. ­Because the body’s response to a loss of sleep is arousal, we can fool ourselves into thinking I’m fine.22 But we are not fine. And even seemingly minor sleep loss can accumu­ late over time—­what researchers call “sleep debt.” Sleep debt is stubborn and difficult to pay off; it is easy to accrue and near-­impossible to pay back. This is the exact prob­lem that plagues me. When it comes to sleep, pregnancy pre­sents a classic economic dilemma: supply can never meet demand. It drives me crazy when ­people tell me to “sleep while you can!”— as if I might be able to amass a vast storage of sleep hours and make with­ drawals l­ ater on. Pregnant ­women are excellent at building up sleep debt, and powerless to prepare for its continued, often exponential escalation ­after childbirth. Dement, for one, appreciates this prob­lem, and has even proposed that we consider treating pregnancy as a sleep disorder in itself. He urges us to encourage pregnant ­women to nap to help make up for some of their lost sleep. “I hope ­every w ­ oman who reads this book,” he wrote in The Promise of Sleep, “­w ill rise up and demand that the sleep prob­lems related to childbearing and ­women generally be recognized as part of the male neglect of ­women’s health prob­lems.”23 Yet virtually none of the popu­lar lit­er­a­ture on sleep hygiene and sleep health addresses pregnancy, or even parenthood. Both topics ­were absent from the index of one of the most popu­lar recent publications explicating the significance of sleep, for example. What should we make of the fact that the book explores sleep’s connection to fertility (sleep deprivation can impact male and female fertility levels) and fetal sleep but ignores mater­ nal sleep and parenthood?*,24 * Researchers studying fetal sleep report that a fetus spends the vast majority of each day (twenty-­one to twenty-­t wo hours) in utero asleep. Over the course of pregnancy, a fetus w ­ ill spend increasing amounts of time in REM sleep, reaching about nine hours per day in the third trimester and twelve hours per day in the final week before birth. Indeed, good sleep is critical for healthy fetal brain development—to the extent that disturbing fetal or neonatal REM sleep carries consequences. Some studies have

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Parents are almost universally sleep deprived. One recent proj­ect in Germany—­a nation with many more parental support systems built into its policies than the United States—­concluded that parents ­don’t regain their prior levels of sleep duration and satisfaction (from before pregnancy) for six years a­ fter childbirth. Although the impact was more pronounced among first-­time parents, if you happen to have more than one child t­ hese years could ­really add up. And, surprise: ­mothers (especially nursing ­mothers) feel the effects more than ­fathers.25

Sleeping Pregnant Researchers d ­ on’t r­ eally have a solid grasp on what constitutes “normal” or healthy sleep during each trimester, but they do have reason to believe that crappy sleep is characteristic of pregnancy. In one proj­ect analyzing responses from more than 2,400 ­women, 75 ­percent of w ­ omen reported poor sleep quality and 100 ­percent said they experienced frequent night wakings. As the study’s authors concluded, “­women experience poor sleep across pregnancy, and . . . ​a substantial proportion of pregnant w ­ omen do not get adequate sleep.”26 Many w ­ omen experience sleep disturbances differently over the course of their pregnancies. Ste­reo­typically, the first trimester is characterized by extreme exhaustion and increased sleepiness, and the third trimester is characterized by frustration with falling and staying asleep. (The second trimester evades such standards, and many w ­ omen report fewer sleep prob­lems during the ­middle months of their pregnancies; however, the sec­ ond trimester is also the least well studied when it comes to sleep, and it may be that ­women simply experience fewer changes in disturbed sleep

found a correlation between abnormal sleep (a lack of REM sleep in par­tic­u ­lar) and autism. Interestingly, one of the ways researchers are working to mea­sure and explain the negative effects of alcohol exposure in the womb and through breastmilk lies in sleep: alcohol notoriously impedes REM sleep, so pregnant or nursing ­women who consume alcohol might be tampering with their babies’ sleep states.

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during the second trimester.) ­These trends are not merely anecdotal: studies suggest that sleep becomes progressively more disturbed ­until the final trimester, when insomnia rates reach levels more than twice as high compared with e­ arlier in pregnancy.27 It is encouraging that t­ here has been a burst of attention to sleep in pregnancy in the last c­ ouple of de­c ades, but prior to the twenty-­fi rst ­century the topic of sleep in pregnancy was, if anything, a general con­ sideration rather than a concerted item of interest. Some obstetric texts mentioned sleep in the mid-1900s, but the references tended t­ oward tra­ ditional wisdom and ­were mostly unhelpful. A typical note, found in the 1962 edition of the Combined Textbook of Obstetrics and Gynecol­ogy, stated, “Sleep is sometimes disturbed in the ­later months of pregnancy in w ­ omen other­w ise well, ­either ­because of general discomfort, fetal movements or endocrine disturbances.”28 The first published article to explore sleep in pregnancy came out in the American Journal of Obstetrics and Gynecol­ogy in 1968. It was mostly descriptive, documenting electroencephalography sleep patterns (EEGs, which monitor brain activity during sleep) in late pregnancy. But it also found that pregnant w ­ omen took twice as long to fall asleep, experienced many more (and longer) night awakenings, and spent less time in slow-­ wave sleep than control subjects. As the authors described it, “the over-­ all sleep pattern observed in gestation seemed similar in some re­spects to insomnia.”29 Sleeping during pregnancy, in other words, is akin to sleep­ ing with insomnia. The features of this inaugural proj­ect are intriguing for more than t­ hese conclusions, however. The authors also found that sleep, though pro­ foundly altered in pregnancy, tended to “normalize” within a ­couple of weeks of giving birth. ­Here’s how they made the determination: their study, conducted at the University of Florida among just seven white, middle-­ class ­women aged twenty-­t wo to thirty years old, had the participants hooked up for EEG recordings just prior to their bedtimes for three con­ secutive nights during late pregnancy, immediately a­ fter delivery, and then

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again in the postpartum period. (The w ­ omen w ­ ere asked to refrain from alcohol and coffee prior to testing.) During the recordings immediately a­ fter birth, the authors explained that hospital staff kept their routine practices, such as taking vital signs, to an absolute minimum while the ­women ­were sleeping. In addition, “the 2 a.m. feeding was eliminated” (strict infant feeding schedules ­were not uncommon at the time), and newborns w ­ ere kept in the nursery between 10:00 p.m. and 6:00 a.m. so that they would not interrupt their ­mothers’ sleep and interfere with the sleep recordings. Although the authors appeared dumbfounded by their subjects’ sud­ den and impressive sleep recovery right ­after birth, it is no won­der they found that sleep normalized a­ fter delivery—­t he newborns ­were not t­ here to wake their ­mothers up! Of course, no scientist would embark on this kind of trial ­today, not least ­because of the evidence pointing to the ­benefits of m ­ others and newborn babies “rooming in” and feeding on-­demand.30 Nonetheless, the authors called attention to sleep disturbance in pregnancy—­their publication granted the prob­lem newfound legitimacy as a complaint of pregnancy and an area of research. They chastised pre­ vious writers for casting aside sleep prob­lems as “minor complications” and instead advocated that sleep changes during pregnancy be taken seri­ ously. Using the insomnia analogy, they specified that pregnant w ­ omen took longer to fall asleep, woke more frequently, and slept less overall than nonpregnant controls. They also exhibited drastic reductions in REM sleep, a common pattern among depressed patients—­a finding about which the researchers w ­ ere understandably “very concerned.”31 They sug­ gested that sleep symptoms might be useful in indicating patients “in greatest need of special care.”32 It has taken nearly half a ­century, but scientists and doctors are now on the cusp of d ­ oing just that. Between 1968 and 1998, only twenty more articles on sleep and preg­ nancy ­were published, a paltry number given the extent of sleep distur­ bances during pregnancy. Most of them w ­ ere less than revealing, too, given

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their design and small sample sizes. “We are no closer to understanding the implications of altered sleep patterns on . . . ​­women’s health out­ comes than we ­were when it was originally questioned 30 years ago,” Kath­ ryn Lee wrote in a review in 1998. Disappointed with the lack of pro­gress, Lee still noted that research findings showed that pregnant w ­ omen and ­mothers suffer from a notably greater lack of sleep than nonpregnant ­women and childfree ­women.33 As we begin to perceive the prevalence of ­mental health diagnoses sur­ rounding pregnancy—an estimated one in seven American w ­ omen suf­ fers from anxiety or depression while she is pregnant, and postpartum depression affects roughly one in ten ­women—­the relationship between sleep and m ­ ental health in pregnancy is also starting to become more apparent. But the research is perched precariously atop centuries of patterns in medical history of treating pregnant w ­ omen as unstable, hyper­ emotional, and even deranged beings. If medicine perceived w ­ omen gen­ erally as capricious and impressionable (it did), pregnant ­women ­were all the more so. For thousands of years, doctors have treated the female reproductive system as pathological and fearsome. In ancient Egypt, medical writings attributed virtually any symptoms in w ­ omen to the uterus. In ancient Greece, the uterus was perceived as animalistic, a live being ­housed within a ­woman’s body. The infamous “theory of the wandering womb” held that this animate creature could move around a w ­ oman’s body and wreak havoc. Symptoms ranging from shortness of breath to coughs or joint pain could result from the womb’s mischievous be­hav­ior, and the best ways to address such symptoms entailed taming the womb and luring it back into its proper position in the body. One prominent solution for manipulating the womb and anchoring back in its rightful place was to “satisfy” it, with ­either sexual intercourse or pregnancy. This theory, absurd as it may seem, had a lasting influence on medical understandings of the female body through at least the M ­ iddle Ages. The Greek word hysteron, “movement of the uterus,” also gave us the term hys-

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teria, a broad and variable categorical label used for hundreds of years to capture a host of diverse symptoms. Female hysteria (a redundant phrase prior to the turn of the twentieth ­century—­hysteria was implicitly femi­ nine for most of the historical rec­ord) was considered a bodily malfunc­ tion, explained in terms of female anatomy and sexuality. In the 1800s, the medical perspective on the ­causes of hysteria shifted ­toward the ner­ vous system, and around 1900 doctors and psychiatrists also began to argue that hysteria was neurological.34 Sigmund Freud, who famously argued that hysteria—­increasingly referred to as neurasthenia in the 1900s—­was not unique to ­women alone, also believed that hysteria in ­women resulted when they ­were not pregnant and ­were childless. In virtually e­ very society and time period, w ­ omen who bucked social norms—­whether through stepping into public spaces, defying their roles as ­mothers, neglecting marriage, or flouting social conventions (includ­ ing practicing medicine)—­have been especially vulnerable to charges of being hysterical. The term hormone, coined in 1905, helped pave the way for dif­fer­ent kinds of discussions surrounding w ­ omen’s anatomy, childbearing, and “hysteria” in the twentieth c­ entury, but in some ways endocrinology merely provided new rhe­toric for old conversations.35 As Amy Koerber argues in her fascinating book From Hysteria to Hormones, “hormones have allowed scientists to move away from theories of the womb as the main motivator of ­women’s be­hav­iors, but researchers have not abandoned the basic pre­ sumption that appears in ancient texts—­namely, that w ­ omen are moti­ vated by something inside themselves that they cannot control, whereas men control themselves through rationality and the male brain.”36 If this sounds like a dated reference, it is not: the hysterical pregnant ­woman is very much still alive in the twenty-­first c­ entury. We can see her in countless movies, tele­vi­sion sitcoms and dramas, and even in the pages of supposedly helpful books like What to Expect When Y ­ ou’re Expecting. American culture continues to second-­guess pregnant ­women’s motiva­ tions, rationality, and intellectual capacity. As Monica Hesse argued in a

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2019 Washington Post piece entitled “What We D ­ on’t Know about How a Uterus Works Is ­Going to Hurt Us All,” “we are collectively terrible at talking about reproduction. Especially when it comes to pregnant bodies. We’ve got to do better.” The fraught tradition of medically conflating vague symptoms of hys­ teria, ­women’s reproduction, and pregnancy itself makes it all the more pressing that we approach w ­ omen’s symptoms seriously. One relevant arena garnering overdue attention from medicine and society is postpar­ tum depression: it appears that sleep might play an impor­tant role in screening for, or possibly even minimizing the risk of, postpartum mood disorders, just as sleep researchers first proposed in 1968. Yet, as with pregnancy and hysteria itself, medicine’s historical expla­ nations of the relationship between sleep deprivation in pregnancy and depression manifest in similarly bigoted (if colorful) language. Doctors have long described the frequent coexistence of “psychosis” and insom­ nia in ­women. In a robust conversation published in The Lancet in 1896, a group of physicians enumerated different kinds of insanity that occur during pregnancy and the postpartum period. They found many. (My favorite: “insanity of l­abor,” which could be e­ ither “hysterical and tran­ sient” or “more lasting and permanent.” A close second: one doctor’s sug­ gestion that “insanity might be the first sign of conception.”) Th ­ ere was general agreement that insanity, though—­especially in the postpartum period—­was strongly tied to insomnia. “Active, miserable sleeplessness,” they concurred, was characteristic of puerperal insanity.37 Con­temporary research confirms the power­f ul links between sleep, mood, and clinical depression. Research suggests that higher levels of sleep disturbances in late pregnancy are associated with a higher likelihood of depressive symptoms in the postpartum period.38 And in the postpartum period, w ­ omen with higher levels of depressive symptoms also report higher levels of sleep disturbance. “Sleep prob­lems,” put simply, “are pro­ spective risk f­ actors for increases in depressive symptoms during preg­ nancy.” The same is true in the postpartum period.39

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And more and more authors are pointing to sleep as a promising new arena for health interventions during pregnancy. Incorporating sleep hygiene into the prenatal care protocol, in other words, could help both improve pregnant ­women’s health and experiences (and in turn, infant health) and potentially function as a screening tool for identifying ­women at a higher risk for postpartum depression.40 Merely asking pregnant ­women about their sleep quality might help health professionals better find and attend to prenatal and postpartum depression.41 One program in ­Canada offered expecting m ­ others a sleep education intervention that entailed an initial consultation with a nurse (covering sleep hygiene, relaxation, strategies for increasing sleep, and infant sleep) as well as written information and followup phone calls e­ very week for five weeks. Compared with a control group, the ­women who received the intervention reported sleeping almost an extra hour each night a­ fter their babies w ­ ere born.42 Given the severity and prevalence of postpartum depression, being aware of its potential correlations with sleep could be one ave­nue for improving the ways we identify, support, and treat w ­ omen who are e­ ither at risk for or suffering from postpartum depression. But that is just the tip of the iceberg. In the last de­cade alone, a wealth of research has linked sleep disturbance during pregnancy to a host of adverse maternal and neonatal outcomes. In composite, they paint an alarming picture. Poor sleep in pregnancy has been linked to hyperten­ sion, gestational diabetes, preeclampsia, premature birth, cesarean deliv­ eries, and depression. At this point, all of ­these links are just that: links. Experts can only identify the correlations, and they are not entirely cer­ tain as to how poor sleep quality during pregnancy might potentially cause any of ­these adverse outcomes. But they do believe it’s “biologically plau­ sible” for sleep to play a causative role. One prominent explanation is that a chronic loss of sleep leads to stress and abnormal inflammatory reac­ tions, which can impact the course of pregnancy.43 Sleep (like nutrition) is a tricky t­ hing to study. Researchers are forced to rely on imperfect data—­many studies depend upon subjective mea­sure­ments

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such as self-­reports, questionnaires, survey results, and sleep diaries. Other tests such as polysomnography and actigraphy (two kinds of sleep tests) offer more quantifiable data, but they are expensive to operate and have other downsides. They ­aren’t perfectly accurate, and they also demand that study participants sleep in aty­pi­cal environments (sleep laborato­ ries), which might influence their sleep. One common solution employed to overcome this hurdle is to have the participants come in for sleep record­ ings on multiple consecutive nights and throw out the data from the first night. Presumably this helps, I suppose, but sleeping in a lab is never g­ oing to be the same as sleeping at home.44 Perhaps we should simply rely on both kinds of evidence for the best results, as many proj­ects do. But researchers often find stark differences between data: their subjects’ accounts ­don’t necessarily line up with their technical recordings. What are they to do when t­ hese two forms of evi­ dence conflict? To a certain extent, we might say that it ­doesn’t ­matter—­despite varia­ tions, both kinds of evidence uniformly signal that sleep is indeed impacted during pregnancy and beyond. Sleep disruptions during pregnancy are “inevitable,” one team of scientists announced.45 The specifics are no more encouraging. Pregnant ­women who sleep less than 6.25 hours per night are at a higher risk for gestational diabetes.46 Pregnant ­women with insomnia or sleep apnea diagnoses are 30 and 40 ­percent more likely to deliver preterm, respectively. Estimates suggest that internationally ­these statistics could influence pregnancy outcomes for more than 2,000 w ­ omen.47 Another study found that expecting ­mothers who got less than six hours of sleep per night w ­ ere 4.5 times more likely to undergo a cesarean delivery and had longer l­abors (by nine hours) than t­ hose who slept a minimum of ­ atters all the more, t­ here seven hours nightly.48 (And then, complicating m is the 2019 proj­ect that found that ­women whose sleep was not disrupted enough ­were more likely to have stillbirths. The authors reported that extended “undisturbed sleep” and a lack of night awakenings ­were “asso­

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ciated with late fetal demise.” Disrupted sleep, said investigator Louise O’Brien, “appears to be protective” against stillbirth.49) It seems that if pregnant w ­ omen should be ­doing anything “for two,” it might be sleeping. And yet, for this pregnant w ­ oman at least, that seems unfeasible to the point of being absurd. I won­der if disturbed sleep might have served any evolutionary pur­ pose, and if anthropology has anything to teach us about sleep loss dur­ ing pregnancy. I realize, as my due date inches closer on my calendar, that I am waking up roughly e­ very two to three hours—­which is exactly how often I expect to be waking up with my d ­ aughter, once she is born. Is my body in some way preparing for what’s ahead? Just shy of turning thirty-­five weeks, my sleep begins to deteriorate—­ fast. I strug­gle to fall asleep, despite the fact that my ­whole being aches with exhaustion. I wake frequently; I am uncomfortable; I am restless. My mind races. If I was tired before, I am depleted now. I google the Pittsburgh Sleep Quality Index (PSQI) to take the test and see how I fare. “A total score of ‘5’ or greater is indicative of poor sleep qual­ ity,” the rubric announces. The average score during pregnancy is a 6.07.50 I score a 7. As if that tells me anything new. I decide I need more information, so I search for a sleep tracking app on my smartphone, against my own better judgment. I download the top-­ rated app—it is supposedly the most sophisticated t­ hing available in this format. The first night I set it up, I sleep terribly—­I swear I’m awake from 3:00 a.m. ­until my alarm goes off. I toss and turn in bed, stewing over how tired I am, a sense of defeat creeping over me as the light edges in around my curtains. I expect a failing score for my first foray into sleep tracking. Instead, the app congratulates me on a “good night!” and scores me at an 86 out of 100. What? Maybe I was sleeping a­ fter all? I spend the rest of the day talking myself out of any hint of exhaustion. Two nights ­later, I sleep like I ­haven’t in weeks—­I d ­ on’t wake up a single time. Foolishly proud of myself, giddy at my exceptional slumber, and thinking I aced my own experiment, I reach for my phone to check my

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analy­sis: 89. L ­ ater in the week, I sleep unremarkably and wake up antici­ pating some mediocre score akin to t­hose I’d been averaging. Instead, I earn a 48. ­After just a few nights, I become disgruntled, spiteful even, of the app. I think ­there must be something wrong with it. I redouble my setup efforts, I follow ­every piece of the instructions—­I fine-­tune its placement, move my white noise machine to a separate spot in the room, move my son’s monitor across to other side of the bed. This app, I think definitively, is not capturing the real­ity of my (lousy) sleep. I feel like it’s snickering at me and my concerns. It’s fickle. Admittedly, my iPhone app is hardly the most state-­of-­the-­art technol­ ogy, but this is the best that would be available for most w ­ omen. On aver­ age, we ­aren’t enrolled in clinical t­rials, we ­don’t have the resources to consult sleep experts, we d ­ on’t have the time or wherewithal to self-­reflect so extensively on sleep. Even knowing my system is flawed, ­every time I look at my sleep-­tracking history the disconnect between my perceived experience and the sonar reading of my nighttime breath and movements exasperates me. To a certain extent, this is an exercise in futility. I­ sn’t it ironic, a­ fter all, that this app designed to help facilitate better sleep—to improve my sleep quality and experience—­demands that I throw some of the most basic tenets of sleep hygiene out the win­dow? Where I had once neglected my phone ­after dark, I now flit through bits of advice before bed (“Put screens away,” I read) and gain a new bedside partner. I look at it first ­t hing when I wake up. I won­der about it when I wake in the m ­ iddle of the night. And then I question its calculations. What kind of evidence about sleep carries the most weight? My own qualitative perceptions of how I have slept and how fatigued I am, or quan­ titative data? Thinking this over on a walk in my neighborhood, I decide to keep using my sleep tracking app for a while. I vow to reframe my attitude ­toward it. Perhaps I am sleeping better than I think. Or perhaps I am not.

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But I remember what I’ve learned about the placebo effect, and consider that if my phone wants to tell me I’m well-­rested, maybe I should listen. Maybe. The next few days my scores faze me for how dismally they say I’m sleeping, and then I delete the app altogether. I brace myself for the real­ ity that however poorly I am sleeping now, it w ­ ill only get worse in a m ­ atter of weeks. When my grand­mother calls me to ask how I’m ­doing, I tell her I’m ­doing well but feel exhausted and tired all the time. “Oh, honey,” she chuckles, “­you’re ­going to be tired the rest of your life.” I think she is prob­ ably right.

chapter 8

• Plan

Years ago, a mentor of mine joked that “if t­ here’s anything to know about Brittany, it’s that she likes to know what’s ­going on.” To some extent, of course, this rings true for every­one. But my desire to know what’s ­going on, what’s g­ oing to be ­going on, and every­t hing about what may or may not be ­going on now or in the ­future burns deep inside me, like fuel driv­ ing a locomotive engine across the tracks. I think if I had to describe myself in a phrase, this might sum it up: I need to know what is ­going on. My almost-­two-­year-­old son, who parrots my words so reliably that I some­ times feel as though being with him is like looking in a garbled mirror, frequently announces, deadpan, “OK: I have a plan.” Apparently, even a toddler can sense this about me. As I waddle over to look at our ­family’s calendar pasted to the refrig­ erator, cluttered with magnets and fin­ger paint scribbles, ultrasound scans and lists and handwritten reminders, I think about the weeks and month ahead, and my thoughts shift intently: birth itself is beginning to eclipse pregnancy. Having been through it once already, I feel as if I know pre­ cisely 1,000 ­percent more about what’s to come than I did as a first-­time m ­ other. And yet. And yet I cannot know what ­w ill happen. I cannot predict a single ­thing. I cannot have a plan. 162

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Or can I? Should I? I never documented a birth plan per se during my first pregnancy, but I had some very distinct ideas about what I thought I wanted to happen, what I was capable of, and how ­things would go. I conveyed ­those ideas to my obstetrician, who respected them and received them both thoughtfully and professionally. I like to think that my “intentions,” let us call them, w ­ ere not naive, that they came from a place of empowerment and education, careful reflec­ tion and forethought. And perhaps they did. But t­ here is no way I could have envisioned what it would be like when my ­water broke just before 11:00 p.m. one night a few days shy of my due date; no way I could have comprehended the depths of exhaustion my body would sink into a­ fter spending the entire night awake in one long, continuous fit of misery and loathing; no way I could have known that my body would laugh at the prospect of pounding contractions at regular intervals and instead direct my uterus to seize up and clench my entire body in painful spasms for minutes at a time, followed by sporadic, pathetically short, seconds-­long lapses. I could go on, but I’ll spare you the details. My story is hardly unique. By late the next morning, I had sharply deviated from my premeditated “plans,” presumably like so many other w ­ omen in the rooms alongside my own (and not without many tears and much doubt). Afterward, though: what a relief. In hindsight, it all seemed so clear, so right. ­Doesn’t it always? Afterward: if I’d had a written birth plan, something tangible to lash out at, I would have ceremoniously set it on fire and thrown it, crumpled and flaming, into a garbage pail. Not that anyone would have let me. Forget that plan. I had a new plan: have this baby. The feeling of satisfaction I experienced when I fi­nally—as I saw it—­ gave up, when I fi­nally abandoned my prearranged objectives, when I fi­nally cut myself some slack and gave myself permission to make a deci­ sion in that moment, to let every­thing I had walked in planning to do

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go—­at last—­well, that is forming the basis of new plans for delivery num­ ber two, I realize now, still gazing at my calendar. ­Here they are again—­intentions, ideas, blueprints. They must have unconsciously sprouted, and apparently have been germinating, this ­whole time, without my even knowing. Now, I recognize, ­here they are at the fore­front, clear as the ice crystals spiking down from the overhang outside my win­dow. I feel somehow that they are more valid, more sound, more legitimate, grounded as they are in my lived experience. But I know that is only a trick of the mind, a ploy on the senses. ­Because all births may be alike, but no two are the same.

Historian Judith Leavitt, an expert on the history of childbirth in Amer­ i­ca, explains in her book Brought to Bed how childbirth moved from the home to the hospital around the turn of the twentieth c­ entury. Prior to 1900, childbirth was a central, defining feature in w ­ omen’s lives—­some 85 ­percent of a married w ­ oman’s life was typically spent e­ ither pregnant or nursing. Indeed, the t­ rials and tribulations of bearing c­ hildren pro­ foundly ­shaped ­women’s personal lives and social roles.1 And childbirth was, for many, a fearsome event, a looming and ever-­ present “shadow.” Death imperiled ­mothers and their babies, as did the prospect of lasting physical debilities that could spring from complications such as tears or lacerations. (Even into the early 1900s, an estimated one ­mother died for ­every 154 births. Accounting for the statistic that the aver­ age ­woman gave birth approximately five times over the course of her life, it is more accurate to say that about one in thirty w ­ omen—3.3 ­percent—­could expect to perish in childbirth.) The dread of anticipated pain, too, was frightening. Yes, w ­ omen spent a good amount of time fretting childbirth, never forgetting the possibility of death, a ­family’s demise.2 ­Women withstood all this, Leavitt says, through the collective sharing of experiences, support, and woman-­centered cooperation. They made the

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ritual of birth, daunting and grim, into a shared bond, a pathway to com­ munion. And it was ­women who steered the ship—­t hey flocked to one another’s side to help a neighbor endure ­labor, to manage her delivery, to guide her through the postpartum period, and to help assume responsi­ bility for her domestic work. Birth was forbidding, yes, but so too was it social; w ­ omen feared it ­because they had such intimate knowledge and firsthand experience with it. Whereas up through the 1800s ­women themselves oversaw the pro­cess of birth, in the 1900s doctors took over the reins. The change happened gradually at first, with a small minority of w ­ omen with means in l­ imited geographic locations inviting physicians to attend their births, to bring their tools and their training and their drugs. Th ­ ese ­women expected their male guests, outsiders still to childbirth, to bring something to the t­ able, so to speak, to do something—­birthing w ­ omen had no need for merely another standstill witness. They wanted action, or ­else escape. Ah, yes, escape. Perhaps more than anything, this yearning s­ haped the early modern history of obstetrics: w ­ omen demanded of medicine that it release them from the pain of l­abor. They w ­ ere adamant: they sought out the doctors who had ether and chloroform and shut the door in the face of ­those who refused to administer them. Fanny Longfellow, the wife of Henry Wadsworth Longfellow, famously announced in 1847, a­ fter she was delivered of her third child by a dentist (the only practitioner she or her husband could find who agreed to administer an anesthetic), that ether was “certainly the greatest blessing of this age” and that she was “proud to be the pioneer to less suffering for poor weak womankind.” Her brother-­ in-­law joked to the renowned poet, “If you had asked your wife which she preferred, a boy or a girl, she would have replied, ‘I ­will take ether.’ ”3 As doctors took over, w ­ omen’s conversations about birth, once open and exuberant and alarmingly honest, turned to whispers. Victorian mores of morality and repression and censorship swept reproduction ­u nder the rug: silence and sequestering replaced chatter and tutelage. And laboring ­women, once anesthetized, ­were increasingly blind to their

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own experiences, knocked out entirely to their moment of transforma­ tion. The sentiment expressed by Dr. J. Herbert Claiborne, a practitioner in ­Virginia who took up anesthesia in accordance with its rapid adoption, is as enthralling as it is haunting: “Nothing gives me so much plea­sure as the promise of that Lethe [oblivion; from Greek myth] to the ex­pec­ tant ­mother when the fearful hour draws nigh, except the fulfillment of that promise, and her grateful expression of returning consciousness—­‘Is it indeed all over, and is my baby born?’ ” 4 If anesthesia was controversial or hesitantly applied during childbirth in the mid/late-1800s, by 1900 most physicians used it with scant reserva­ tion. But ether was not perfect, nor was chloroform; by the time the new anesthetic scopolamine was introduced in the early 1900s, ­women and doctors alike ­were waiting for it with outstretched hands, ready and ­eager. Doctors w ­ ere hesitant to use scopolamine at first; it sometimes caused dev­ astating side effects like fetal asphyxia, hemorrhage, and delirium and vio­lence (besides prolonged ­labor). But ­women clamored for it. They formed the Twilight Sleep Association and insisted that scopolamine, colloquially known as “twilight sleep,” be available to any ­woman who wanted it. The accounts of twilight sleep deliveries are bone chilling. Typically administered in conjunction with an opiate at intervals throughout ­labor, scopolamine altered consciousness and inhibited the mind. It did not relieve pain. U ­ nder the influence of twilight sleep, the laboring w ­ oman experienced the full, sharp, painful physicality of l­abor and delivery; what she lost was her sentience and her memory. With their ­mental facilities disabled, most ­women became violent, and their deliveries became so thoroughly turbu­ lent that hospitals devised special “beds”—­reminiscent of cribs or cages—to contain them. ­Women ­were frequently left alone, their screams and thrash­ ing ignored, for hours or however long it took.5 Birth became something that happened to w ­ omen, rather than something they did. If childbirth was already swiveling out of sight for w ­ omen, scopolamine rendered it completely invisible—­stole away any recollection of the expe­

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rience entirely. Its widespread use in the first part of the twentieth ­century poached a generation of ­women’s exposure to birth, leaving them with nothing to go on, no grasp on the final act in the play. All without ever easing their pain. Over the ensuing de­cades, in conjunction with major social and cul­ tural changes (especially urbanization, industrialization, and increasing— though starkly l­imited—­access to contraceptive devices), w ­ omen’s col­ lective, once-­intimate knowledge of ­labor and birth continued to fall away, to the point where many young ­women ­were left in the dark, ignorant of even the most basic ­matters regarding sexuality and reproduction. In her evocative and power­f ul account of the experiences of unwed ­mothers who ­were forced to surrender their babies in the mid-1900s, The Girls Who Went Away, Ann Fessler poignantly demonstrates that young American ­women ­were often left to figure ­things out for themselves when it came to sex education. Many of the ­women Fessler interviewed said that they only learned how conception occurred ­after they became pregnant, no one having taken the time to tell them “how it works,” w ­ hether at home or at school. One w ­ oman, who intimated that she “had no idea” how preg­ nancy tran­spired, intimated, “it’s borderline child abuse not to share this kind of information.” ­Others ­were kept in the dark throughout their entire pregnancies about childbirth, sometimes having no understanding of how their babies would emerge from their bodies ­until it happened in real time.6 Young, unwed ­mothers in the de­cades prior to Roe v. Wade may have been especially deprived of support and education, but a lack of familiar­ ity with childbirth was pervasive. By 1930, most births in the United States occurred in hospitals rather than in homes, and the sociality of pregnancy, of ­labor, of birth, of new motherhood had been shattered; the familiarity and solidarity of the previous c­ entury eroded, and w ­ omen w ­ ere stripped not only of their proximity to reproductive ­matters, but also of access to information about them. Conception, gestation, and delivery w ­ ere all cast ­under a new shadow, characterized not only by fear and trepidation but also by ignorance and inexperience.

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Where it had once been dismaying and ever-­present, birth became obscured. And how could any w ­ oman craft a plan for what she could not see?

In some ways, American ­women have spent the last ­century at least becom­ ing reacquainted with birth, trying to retrieve some shred of their for­ mer intimacy or (perceived) authority with the pro­cess. The history of birth plans is coupled with the histories of prenatal care and prenatal edu­ cation, ­women’s rights and feminism, the proliferation of hospitals and the availability of anesthesia. The prenatal care system as it exists in the twenty-­fi rst ­century was devised around the time that birth moved to the hospital, well over a ­century ago; in many ways, “prenatal care” was simply not feasible before the early 1900s. For one t­ hing, pregnancy testing had yet to be developed. How could doctors deliver care without being able to diagnose pregnancy early and easily? In 1834, a British professor at Guy’s Hospital (outside Lon­ don) drolly observed that “the most certain mode of knowing w ­ hether a ­woman be in a state of gestation or not is by waiting till the term of nine months is complete.” Plus, caring for ­women during pregnancy was a social endeavor, grounded in tradition and lifestyle advice—­not medical visits.7 The idea that pregnant ­women would habitually, regularly seek medical counsel or treatment would have seemed thoroughly alien, per­ haps even absurd.8 In conjunction with the changing locale of childbirth, other develop­ ments around 1900 sparked some changes. Progressive reformers called attention to the atrocious infant and maternal mortality rates in the United States and abroad: for ­every thousand live births, 100 babies died before they turned one, and some six to nine w ­ omen also lost their lives. Reform­ ers instigated a host of public health interventions—­ranging from clean­ ing up milk and ­water supplies, to proper sewage drainage, to routinizing

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handwashing in hospitals—­designed to help improve the abysmal infant and mortality statistics in the first few de­cades of the twentieth c­ entury.9 One major strategy for improving infant mortality (that followed on the heels of sanitary reforms) involved education. Reformers thought that part of the reason so many babies ­were perishing was ­because their ­mothers ­were ill-­informed or ill-­equipped to care for them properly. Thus, “experts”—in psy­chol­ogy, nursing, pediatrics, and public health—­began endeavoring to train ­mothers (especially foreign-­born m ­ others). They taught them about feeding, nutrition, domestic hygiene, and infant care practices ranging from bathing to dressing. And under­lying all of this teaching was the staunch belief that “correct” mothering heeded scientific advice and medical counsel. In order to properly raise c­ hildren, m ­ others needed medicine.10 (This was not an entirely unwelcome imposition—­ ­ others embraced medical direction, to the extent that many American m they expected and depended on medical guidance.11) Doctors replaced ­family members and friends as ­mothers’ principal advice-­givers. And their scope included ex­pec­tant ­mothers. Progressive Era maternal education campaigns entailed “convincing [­women] to follow a prescribed regimen during pregnancy and to make use of quality medical ser­vices.”12 But many of the programs had a l­ imited scope, focusing more intently on motherhood than pregnancy—­t hey itemized essential baby care necessi­ ties, taught expecting ­women how to prepare formula and bathe infants, and reviewed general ­matters of infant hygiene and care.13 Nevertheless, more and more, Americans came to regard pregnancy as a time that benefitted from—if not mandated—­medical supervision and management. They painted the ideal “modern” pregnant ­woman as an ebullient young (married and white) w ­ oman who upheld her domestic responsibilities throughout pregnancy and heeded her doctor’s advice.14 Efforts to reach increasing numbers of w ­ omen expanded. In 1901, the Instructive District Nursing Association began paying prenatal visits to some of the patients at the Boston Lying-­In Hospital; it was one of the first

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moves ­toward systematic prenatal care anywhere in the country. Within five years, the program encompassed all pregnant ­women, and its work helped notably reduce mortality. A few years ­later, in 1909, Mrs. William Lowell Putnam initiated an “ ‘experiment’ in intensive prenatal care,” also in Boston. Her proj­ect involved nurses visiting pregnant patients ­every ten days. The trial eventually blossomed into a long-­term clinic. In 1918, the Maternity Center Association in New York opened its doors; one ele­ment of its mission was to coordinate prenatal care across multiple sites in New York. Nurses in the program canvased entire neighborhoods, conducting home visits and convincing ­women to seek prenatal care. They screened for pregnancy complications and founded “Mothercraft clubs” that taught ­women about birth and newborn care. The proj­ect was incredibly success­ ful and helped firmly establish the pre­ce­dent of prenatal care as a v­ iable and worthwhile endeavor.15 In the mid-1920s, Mary Breckenridge founded the practice of nurse-­ ­ omen in rural east­ midwifery and began delivering care to expecting w ern Kentucky. Her growing team of nurse-­midwives offered care and instruction to ­women with historically l­ imited access to both, and relied on physicians as health con­sul­tants; again, maternal death rates decreased, and infant mortality among Breckenridge’s patients dropped to ­u nder 3 ­percent. By the following de­cade, physicians ­were increasingly roped into prenatal care via medical school curricula and hospitals, and pro­ fessionals ­were working to standardize and routinize pregnancy care nationwide.16 In the first intimation of hospital-­based prenatal care, doctors attend­ ing to pregnant ­women w ­ ere almost singularly focused on identifying preeclampsia symptoms (often referenced as toxemia) as early as pos­si­ ble, periodically testing ­women’s vitals for any signs of trou­ble (the “pre­ eclampsia model of care”). In time, physicians broadened their scope, but the under­lying concern with identifying abnormalities or complica­ tions of pregnancy remained a hallmark of the medical system of prena­ tal care.

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In the latter half of the twentieth c­ entury, certain ele­ments pushed back against that perceived focus on the pathology of pregnancy, as well as against the intimidating, drugged, routinized standards of childbirth that ­were typical in most hospitals. Numerous “alternative birth” movements materialized in the 1960s and 1970s, such as Grantly Dick-­Read’s Childbirth without Fear, Fernand Lamaze’s Childbirth without Pain, and Rob­ ert Bradley’s “husband-­coached birthing.” Invariably, t­ hese “natu­ral birth” movements (so-­called b ­ ecause they by-­and-­large promoted unmedicated birth) contained educational ingredients, focusing on delivering knowl­ edge and empowering ­women ­under the rubric of choice. Many of their goals aligned with ­t hose of the burgeoning ­women’s health movement—­ improved health care for w ­ omen, increased access to information, ques­ tioning the dominant (male) medical establishment, and promoting a f­eminist interpretation of health and health care—as well as the rise of health consumerism. Most of the alternative birth approaches offered classes throughout pregnancy, providing formal group instruction on the biology of birth as well as prescriptive childbirth techniques and practices. Some included films depicting l­ abor and birth, which often left power­f ul impressions on ­women (and their male partners, who ­were increasingly invited to join in). Collectively, ­these developments helped substantiate the custom of classroom-­based prenatal education as part of the experience of being pregnant in Amer­i­ca. And they markedly diverged from the type of pre­ natal classes that had begun proliferating in the early 1900s; their focus was on l­ abor management and birthing techniques rather than infant care and layettes.17 However, over the coming de­cades, explains sociologist Elizabeth Armstrong, “the ‘childbirth education’ spawned by alterna­ tive birth movements” collided with biomedical initiatives to reduce infant mortality rates, giving rise to the modern concept of “prenatal education.”18 The general notion of a “birth plan” was born during ­these de­cades, and it sprang up from a milieu of patient advocacy and informed consent,

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feminism and the ­women’s health movement, and a collective clamoring for the democ­ratization of information. Early devisers of birth plans ­were in some ways acting on antiestablishmentarian impulses, pushing back against the resounding medical authority over childbirth. In 1980, Penny Simkin, a physical therapist and childbirth educator, along with her colleague Carla Reinke, published one of the first pieces to formally document the concept of “the birth plan” in a pamphlet that reached audiences in the thousands. As they envisioned it, a birth plan was a way to foster informed decision making, communication, and coopera­ tion on behalf of ­women, families, and health prac­ti­tion­ers. Against criti­ cisms that the concept was preposterous, Simkin explained that she wanted birth plans to function as “a vehicle for trust and communication.”19 Many health professionals—­obstetrics was still dominated by mostly male physicians at the time—­were not receptive to their patients walking in with premeditated ideas about their upcoming ­labors and deliveries. ­Here is what one consulting pediatrician in the United Kingdom said in 1985: “A steady but growing trickle of strange ladies is infiltrating the sys­ tem and arriving in ­labour wards . . . ​w ith a familiar shopping list of demands telling doctors and midwives what to do. . . . ​­These patients tend to arrive, without warning, in the ­Labour Ward with their lethal shopping lists. . . . ​They are not entitled to tell doctors how to do their work. They are not entitled to ask us to lower professional standards and to jeopardise babies’ lives.”20 Perhaps in retaliation against this exact type of outlook, the WHO offi­ cially sanctioned birth plans in 1985, calling them a “top category of rec­ ommended practices for making pregnancy safer.”21 The announcement certainly helped the concept to gain some credence, and also demonstrates how, in many ways, the original conception of the birth plan was far from radical. Birth plans functioned as more of a corrective to de­cades of w ­ omen being left in the dark. They emerged as a pos­si­ble way to help condition expecting m ­ others (and f­athers) for what was to come, and they w ­ ere hardly dif­fer­ent from childbirth education classes. The pro­cess of devis­

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ing a birth plan was intended to implicitly help families prepare for the physical and emotional toll of childbirth, and to foster more open lines of communication between ­women, their partners, and health care providers.22 That is not exactly what happened. It is perhaps no secret that some providers have been unenthusiastic about birth plans.23 Some are openly hostile t­ oward them. And although health professionals who are wary of birth plans refer to a number of pos­ si­ble “issues”—­that a w ­ oman with a birth plan might be less apt to “go with the flow,” for example, or that her birth plan might include what they con­ sider “useless” information (specific background m ­ usic being a frequently cited example)—it is hard to side-­step the question of authority. A ­woman who devises a birth plan is a patient who is making premeditated deci­ sions about birth, may ask questions, or even disagree with her doctor. She wants to know what is g­ oing on and why. She embodies the possibility of a challenge to medical authority. Some physicians intimate that pregnant ­women are incapable of com­ posing scripts for childbirth b ­ ecause they are not trained in obstetrics. But such professional concerns have the trappings of retaliatory, defensive cries ­ nder threat from an underling, especially given that of an expert come u birth plans need not be planned scripts. Plus, many doctors say that it is only on the “rare occasion” that a patient’s birth plan includes potentially harmful choices.24 At the same time, some concerns are not entirely unfounded. It is appar­ ent that having a birth plan is not implicitly beneficial for expecting ­women. As one group of authors explained, it is not enough merely to have enacted a birth plan: “satisfaction is not just having a positive experience but the positive evaluation of that experience.”25 Furthermore, the inter­ net is replete with vacuous “birth plan checklists” that transform the pro­ cess of creation, the bringing of the plan into fruition—­which is by all accounts the most valuable component of any birth plan—­into a cut-­and-­ dried, surface-­level inventory, a rote indexing rather than a personal,

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instructional experience. And it is not unreasonable to imagine that birth plans could foster unrealistic expectations or potentially situate w ­ omen to experience a sense of failure and disappointment, since t­ hings often do not go as planned.26 ­There is plenty of compelling, if peculiar, evidence calling the overall efficacy of birth plans into question. It shocks me to read that childbirth education generally—­according to a Cochrane review—is not demonstrably advantageous in terms of birth outcomes. “Unfortunately,” the Cochrane team of authors wrote, “the effects of . . . ​education for childbirth or par­ enthood remain largely unknown.”27 Birth plans themselves do not seem to have any influence—­positive or negative—on the standard mea­sures for obstetric and neonatal outcomes, such as episiotomy, cesarean deliv­ ery, delivery interventions (including epidural rates), or Apgar scores.28 One study published in 2018 reported that “despite receiving care consis­ tent with their birth plan,” w ­ omen with birth plans w ­ ere actually less satisfied and felt less in control during childbirth compared with the w ­ omen who had no birth plans.29 That gives me pause. It is maddening, too, that we have some reason to believe that convey­ ing preferences about childbirth in a formal manner might actually back­ fire and lead to reduced communication between ­women and health staff. A number of studies suggest that when an expecting ­woman arrives at the hospital with a birth plan in hand—­especially if that birth plan is derived from a checklist and especially if that birth plan diverges from hospital/medical standards—­t he health care staff are less likely to take her seriously.30 Worse still is the possibility that “­women with birth plans might be receiving less support and encouragement throughout their ­labor” on account of “ ‘ irritation’ on the part of health care professionals.” Indeed, many studies describe that physicians harbor negative percep­ tions of ­women with birth plans, sometimes even anticipating poorer outcomes for ­t hose ­women or their babies.31 I ­don’t need to say that this is troublesome indeed.

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It has been difficult to objectively assess the value and outcomes asso­ ciated with birth plans. Some research demonstrates that birth plans clearly can have a positive effect on w ­ omen’s experiences with childbirth— by enhancing their understanding of l­abor and birth, empowering them to voice their desires and preferences, and improving communication between ­women and providers. Yet other studies have suggested that the advantages are so ­limited as to be insignificant, and still ­others actually ­ ere is, furthermore, a gap­ hint that they may have negative influences.32 Th ing, glaring prob­lem with trying to study birth plans: most ­women who devise birth plans are evidently “dif­fer­ent” from t­ hose who do not. W ­ omen with birth plans tend to, as a group, prefer deliveries with fewer interven­ tions. They also are generally older and more highly educated.33 With such stark demographic differences, it can be hard to parse any significant out­ comes reliably. One sure ­thing about birth plans is that they are controversial and often divisive; but the reasons for their being so polarizing are difficult to swal­ low. Indeed, it is hard to appreciate open opposition to the prospect of engagement. B ­ ecause ­isn’t that the aim, ­after all, to engage ­women? To pre­ pare them and hear them? Re­spect them? Across the research, numerous w ­ omen and academics hint that perhaps it is our terminology that is flawed: a birth plan conveys the illusion of con­ trol. What about a birthing “guide,” birth “preferences,” birth “wishes,” or birth “intentions”? they ask.34 It’s pos­si­ble that may help, I suppose. In part, it is precisely the origin story of birth plans that continues to make them so stigmatized—­they ­were conceived as a “backlash” against what many w ­ omen and providers considered to be the “over-­ medicalization” of pregnancy and birth. On some fundamental level they framed ­women’s reproduction as binary: natu­ral versus medicalized, ­woman versus man, patients versus doctors, laypeople versus specialists.35 Birth plans, in their original incarnation, intrinsically (and not unprob­ lematically) pitted expecting w ­ omen against medicine, and sadly the

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legacy has continued. Birth plans still risk setting ­women in opposi­ tion—to their doctors, to hospitals, and to themselves. Possessing a birth plan can isolate or socialize w ­ omen, depending on their pre­sent com­pany. As one expert said, though: “the e­ nemy is not the birth plan.”36 Nor is the w ­ oman who devises it. Nor is the provider uncertain of its utility at pre­sent. I identify with all of this, so much so that I am left predictably irreso­ lute about the ­whole concept. Except I do have one conviction: to each her own. ­Here is what I recognize now: I did have a birth plan for my son’s deliv­ ery two years ago. I just kept it “informal,” internal, unwritten. I spoke of it to my husband, my s­ ister, my obstetrician. But I never documented it and did not want it on the rec­ord. ­Because, I admit, I did not want to be one of “­t hose w ­ omen.” I did not want to ruffle any feathers. And I did not want to fail. Actually, though, I did fail, at least judging by certain standards. I did not stick to my plan. I caved in. I got an epidural. And I was happy about it, no less. I remember trying to decide—­yes or no, yes or no—­collapsed in a crumpled heap of indecision on the hospital gurney, crying and wishing more than anything that someone would give me the permission to say yes, to swerve off the road I had paved for myself, to crash-­land on shore. Or to just rest. Just for a few minutes. And then I remember breathing, release, gratitude, the steady regain­ ing of confidence. This was the effect that having a birth plan, however private, had for me: it left me with the preposterous sense that I needed someone ­else’s per­ mission to change course, to rewrite the script in my own play, when in real­ity all I needed was to treat myself with the same compassion I would a friend.

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Outside, the leaves have all fallen; they lie in heaps, dried out and turned a dull ugly brown, muddied beneath the slush and ice. A few blow in the wind, and my thoughts wander with them to the next season, the next autumn, when my ­family ­will sit down at the Thanksgiving ­table with four, rather than three. And I know that at the end of every­t hing, that is what ­really ­matters. I w ­ ill plan for that.

chapter 9

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Commence

As my due date nears, I become increasingly desperate to simply . . . ​not be pregnant anymore. I think of Nora Ephron’s famous quote: “If preg­ ­ ere I sit. nancy w ­ ere a book, they would cut the last two chapters.”1 And h Writing the last chapter in a pregnancy book. I adopt the refrain of full-­term ­women everywhere: I am ready to be done. I brush aside the glaring irony that in completing my pregnancy I ­will cross no finish line. Only pose at a new starting block. I become addicted to Google: I analyze due date statistics and read up on do-­it-­yourself ­labor induction methods. Old wives’ tales may make for entertaining stories, but they carry ­little, if any, evidence ­behind them. Nonetheless, I’m more than willing to give almost all of them a go. From the time I turn thirty-­nine weeks, I’m drinking a special tea blend from a local apothecary (eponymously named “get-­the-­baby-­out tea”); I’m munching on pineapple and dates; I’m cooking eggplant for dinner and dousing my salads in balsamic vinegar; I’m walking as much as the icy December streets (and my toddling two year old) allow; I’m having sex; I’m exercising. As I write, I’m perched atop a birthing ball. If I lived in any of the places home to restaurants famed for serving dishes that send ­women into ­labor, I would be booking my dinner reservation. What does any of it hurt?

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I draw the line at nipple stimulation and castor oil, though, which are actually the two do-­it-­yourself l­abor induction methods backed by the most empirical evidence. Nipple stimulation sounds s­ imple enough, but it only “works” when used extensively—as in several hours per day. Most ­women who take this pursuit seriously employ a breast pump. The way I see it, I w ­ ill be spending enough time with a breast pump in the months to come, so I have l­ ittle interest in spending my last few days of pregnancy attached to one. As for castor oil, it upsets the gastrointestinal tract to the extent that it triggers vicious diarrhea (and theoretically, in turn, uterine contractions); the only ­thing more anxiety-­provoking to me than ­labor and birth themselves are l­abor and birth with a massive case of diarrhea. No thanks. With ­every passing day, I become more distracted, more agitated, more restless. I tell myself I w ­ ill not get my hopes up. But I do. I cannot help myself from hoping, Maybe t­ oday. I call my friend Sarah, an obstetrics resident at the University of Mich­ igan, and beg her for advice. She laughs as she listens to all my attempts. “The ­t hing is,” she tells me, “­don’t you think we’d know by now if t­ here was actually something ­else like that that worked?” I am s­ ilent; this is not what I want to hear. “The only ­thing we know starts ­labor,” Sarah says, “is Pitocin.”

Induction in Medicine We do not yet fully understand the exact reasons why, when, or how l­abor begins—­the ­human body still retains some of its mysteries—­but we can paint with broad strokes. In the days and weeks prior to birth, a w ­ oman’s cervix begins to dilate and soften; the fetus situates itself facedown in the pelvis ­behind the cervix; the pituitary glands release surges of oxytocin, the hormone that stimulates contractions; and the placenta begins to release prostaglandins, hormone-­like substances that also fuel contractions. But

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­labor follows no logical sequence of progression. It cannot be predicted; it is not a neat equation.2 Long before the rise of modern medicine, ­women employed all kinds of creative, self-­styled strategies to bring on ­labor, and they had many and varied reasons for wanting to do so. Not surprisingly, most (male) physi­ cians’ suggestions read crudely. Hippocrates endorsed nipple stimulation to spur contractions, as well as mechanical dilation of the cervix. Like many of his ideas, including bloodletting, t­ hese ministrations had remark­ able staying power. Mechanical dilation of the cervix remained popu­lar for hundreds of years, continuing to be in vogue even into the nineteenth and twentieth centuries in the West. Indeed, Eu­ro­pean and American prac­t i­t ion­ers employed numerous monstrous-­looking instruments and contraptions in their efforts to dilate the cervix and begin ­labor. The Bossi-­type uterine dilator, with its “power­ful screw action” unleashed a­ fter the four-­pronged tip had pried the cervix apart, had a rep­ utation for being traumatic. Thankfully, it was discarded ­after only a few de­cades of use. But the De Ribes Bag—­a rubber bag with a silk outer sheath that was inserted through the cervix and pumped full of sterilized ­water—­was more widely accepted.3 Apart from such procedures and contraptions being so painful and scarring, they often introduced new sources of morbidity and mortality: germs. Before antibiotics, infection was a main cause of maternal death, and into the modern period infec­ tions ­were frequently introduced via doctors’ hands. Not ­every attempt to trigger ­labor was so gruesome, though. Many Western civilizations made use of a fungus—­ergot—to expedite the l­ abor pro­cess. Some suggested quinine. ­Others depended upon castor oil, the thick viscous substance I already know “prompts” the digestive system. And t­ hese ­were not merely old wives’ tales—­t hese ­were the sophisticated tools of formal medicine. Castor oil, for example, was solidified as cus­ tomary hospital practice a­ fter being published in medical lit­er­a­ture in the early 1900s, despite dubious evidence.4 Indeed, the oil-­bath-­enema method was something of a “time-­honored” medical ritual in obstetrics.5

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In the late 1800s, doctors identified and described pituitary extracts for the first time, relying on rabbits (the subjects) and cows (the source) for their research. They tinkered, isolating dif­fer­ent derivations, experimenting with vari­ous modes of administration, and documenting the physiologi­ cal effects they observed. Most applications caused a rise in blood pressure; one was a diuretic. Another caused uterine contractions.6 In h ­ umans, pituitrin extract caused more power­ful and prolonged con­ tractions than any other agent of induction, doctors said. Pituitrin’s out­ comes w ­ ere obvious, plainly apparent to even an untrained observer: “the naked eye effect of a single injection,” wrote W. Blair Bell in 1909, “is immediate and convincing.” 7 Other authors explained that pituitrin’s effects w ­ ere “always exceedingly striking . . . ​coming on or increasing force within a few minutes,” causing “storms of contractions.”8 Pituitrin’s influ­ ence was marked, precipitous; ­these doctors could see it working. None of them thought to ask ­women about their experience, though, much less to write down what they had to say. In all the historical medi­ cal lit­er­a­ture I read on induction, I could find no account, no description, that incorporated a ­woman’s perspective. Writing from the vantage of hindsight, in a time where anecdotal evidence on the heightened pain of ­ omen’s voices is l­abor induced by Pitocin abounds, the omission of w glaring. I begin to reminiscence, traveling back in time two years, almost to the day. I was lying on a cot, in ­labor and waiting to be checked into the hos­ pital as my unborn son, kicking then steadying, was ready at last to come into the world. I remember turning away from the monitor displaying my contractions, bracing and panting and tensing when they consumed me, crushing and erratic. I groped for each one to end. “Well, you certainly look like a ­woman in ­labor,” the resident joked. “Well, I’m trying ­really hard,” I laughed. I snap back to the pre­sent, my body stiff and rigid from the mere mem­ ory of (early) ­labor, and I ask myself: am I ­really ready to begin again? Then again, is anyone?

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The very first use of pituitary extracts in obstetrics, in 1909, described its utility for preventing postpartum hemorrhage. A ­ fter a ­woman was delivered of her baby and the placenta, doses of pituitary extract could cause her bleeding uterus to contract so tightly that it would cease bleed­ ing. (This is supposed to happen on its own, and the failure of the uterus  to contract a­ fter birth remains a frequent cause of postpartum hemorrhage ­today.) Given that postpartum hemorrhage was a grave occur­ rence at the time—­accounting for almost a quarter of maternal mortality cases, which ­were upward of 400 to 500 deaths per 100,000 live births—­ most obstetricians considered this discovery invaluable.9 (Recall that ­t hese maternal mortality rates w ­ ere per birth, and the average ­woman gave birth between five and six times over the course of her life. So the chances of death for any individual ­woman ­were magnified.) But obstetricians very quickly began to try the extracts ­earlier in the birthing pro­cess: during ­labor. Initially, the use of pituitary extracts was strictly ­limited to ­labor itself (rather than before ­labor began) and was predominantly confined to cases of toxemia (now called eclampsia) or preeclampsia, which frequently endangered a pregnancy and demanded a premature delivery. In fact, doctors w ­ ere adamant that pituitary extracts simply would not trigger ­labor, noting that their best uses ­were in the sec­ ond or third stages of ­labor, when doses would “rapidly [lead] to deliv­ ery.” When obstetricians used pituitary extracts, their goal was to time the administration as late in ­labor as pos­si­ble, but still prior to delivery.10 That would change over the course of the next few de­cades. By the 1910s, obstetricians on both sides of the Atlantic w ­ ere singing the praises of pituitary extract, saying that it would soon be in ­every obste­ trician’s “armamentarium.”11 “I would not willingly be without it,” one physician wrote.12 Indeed, pituitary extract was so widely written about that doctors developed “rules” for its use within just a few years.13 Even before scientists isolated the hormone in question—­oxytocin (from the Greek words for “sudden delivery” and “birth”)—in the 1920s, a number of companies brought pituitary extract preparations to market. Hoffman

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La Roche developed Pituglandol; another firm marketed Infundin; and Parke Davis developed Pituitrin, the most widely used blend.14 “Throw away your forceps and use Pituitrin,” the com­pany advertised.15 In 1915, a mere six years ­after its initial obstetric application, an article in the Journal of the American Medical Association announced that “pituitary extract is h ­ ere to stay.”16 But ­there ­were some who w ­ ere concerned with its safety. “It has no place in the normal case,” wrote Dr. J. K. Quigley. It “must,” he explained, “be used judiciously and with a due appreciation of the pos­si­ble dangers of so power­ful a uterine stimulant. This is the most impor­tant point.”17 By the 1920s, the lit­er­a­ture had mushroomed enough that t­ here was an ongoing, somewhat contentious, debate about the safety of Pituitrin for pregnant ­women.18 The dangers ­were real, stemming in the early years especially from a diversity in the potency of vari­ous preparations (which made systematiz­ ing doses impossible). One study in the early 1920s found that differences in concentrations varied by up to thirtyfold. In par­tic­u ­lar, pituitary extracts contained wildly fluctuating levels of vasopressors, which cause constriction in the blood vessels and elevate the heart rate. Lacking any method to reliably know the vasopressor content in any given dose of pitu­ itary extract, doctors w ­ ere unable to accurately assess a ­woman’s risk. The ­simple fact was that ­every ­woman responded differently to the substance. In ­these ways, Pitocin’s earliest incarnations w ­ ere highly unpre­ dictable, “erratic.”*,19 It was a volatile substance indeed. Before 1948, when the “Pitocin drip” (­later the “Pit drip”) was first intro­ duced, most doctors injected Pituitrin doses by hand; thereafter, continuous * The possibility of “pituitrin shock” was another concern. When pituitrin was adminis­ tered in combination with anesthetics (themselves virtually universally applied in child­ birth in the 1950s), it could apparently lead to serious respiratory or cardiovascular com­ plications: spasms, severely decreased heart rate, arrhythmias, even heart attack and death. (Given that doctors typically did dose Pituitrin in combination with other popu­lar phar­ma­ceu­ti­cals during ­labor and delivery, such as morphine and scopolamine—­“twilight sleep”—­it’s in­ter­est­ing that this was mentioned so infrequently.)

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intravenous administration (IV) became customary.20 Pitocin was the first synthetic version of the hormone oxytocin; by the 1950s, it had been systematized and purified, and its use was “almost standard practice.”21 Within less than a de­cade, IV Pitocin had already been integrated into prominent obstetrics textbooks.22 The IV drip was advantageous b ­ ecause it afforded doctors more con­ trol over the timing, dosing, and overall administration of Pitocin to a laboring ­woman. It offered them the ability to increase and decrease uterine contractions “at ­w ill.” And yet Pitocin remained controversial—­ widely relied upon in some areas and reserved as a last resort, “fraught with . . . ​danger,” in ­others.23 The risks—­fetal distress, deteriorating mater­ nal health, uterine rupture, hemorrhage—­were not insignificant, and it is likely they ­were amplified given that Pitocin was primarily applied in the most high-­risk cases (of eclampsia or preeclampsia). Countless obstetri­ cians warned that a patient dosed with Pitocin should never be without her doctor at her side. If the “worldwide interest” in the Pitocin drip was not deterred, it did remain—­for a very brief time—­restricted to certain select cases.24 As in the early de­cades of the 1900s, Pitocin was not, strictly speaking, regarded as a method for induction: it would not trigger l­abor. Instead, when doc­ tors set out to initiate l­ abor they typically used multiple methods in com­ bination, and they increasingly saw Pitocin as a promising adjunct. It was an aid, not a method in itself, for induction. For the most part, induction entailed a scripted series of interventions—it was a pro­cess rather than a moment. And instigating that pro­cess typically began with a membrane rupture. Membrane rupture is the medical term for when the amniotic sac that protects the fetus breaks—it is equivalent to the colloquial description of aw ­ oman’s “­water breaking.” It can happen e­ ither spontaneously or “arti­ ficially,” by a physician or midwife, and it has a long tradition in the his­ tory of induction. In modern medicine, a membrane rupture is classified as surgical—­a tactile procedure performed. But prior to antibiotics, a mem­

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brane rupture was risky to carry out—if it failed to trigger l­abor, t­here was a high risk of infection. This is why when a w ­ oman’s ­water breaks, most obstetricians would advise her to have her l­ abor induced if she d ­ oesn’t go into ­labor on her own, ­after a period of time. Thanks to the develop­ ment of antibiotics in the 1930s and 1940s, maternal complications and mortality related to ­things like infection and fever markedly improved, rendering many formerly life-­threatening procedures and illnesses far less dangerous. ­These weapons also contributed to a fresh perspective in the growing enterprise of birth. With a new arsenal and better fallback plans in the event of complications, obstetricians ­were more apt to undertake interven­ tions they previously had avoided, such as the use of forceps—­and mem­ brane sweeping (when a health care provider inserts one or two fin­gers into the cervix and “sweeps” around, with the intention of loosening the amniotic sac from the lower uterus). Still, even with the safety net antibiotics wove, surgical induction was hardly foolproof or universally safe. Furthermore, doctors constantly lamented the procedure for its being inefficient and unreliable as a trigger for ­labor. So they continued to pair it with other methods. And they ­were ready and e­ ager to welcome new pos­si­ble methods for induction. A ­ fter it was introduced in 1948, enthusiasm for the Pitocin drip caught like a con­ tagion, regardless of periodically published cautionary tales about “mis­ haps” following its use.25 In the 1950s, doctors attempting induction always began with a mem­ brane rupture—­sweeping “as wide as pos­si­ble.”26 Once they perceived that l­abor was in motion, they administered morphine and scopolamine, two sedative agents so power­f ul they infamously robbed a generation of ­women of any memory of having given birth at all. Once a ­woman was “­under the influence,” gradually, often even “unnecessarily” (as many of them freely admitted), physicians would add Pitocin to her already potent induction cocktail, often increasing the dose over time.27 This “­triple procedure”—­combining a membrane rupture, “full employment” of

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morphine and scopolamine as well as “other depressant drugs,” and an IV Pitocin drip—­was routinized in many locations.28 Much like in recent years, doctors disagreed over w ­ hether inductions ­were associated with higher rates of other interventions, including cesar­ ean delivery (C-­sections). Some physicians ­were adamant that induction reduced the likelihood of a cesarean delivery while ­others rebutted that induction was “without question associated with an inexcusable increase in complications” and was to blame for the rising number of cesarean deliveries.29 The disagreement stemmed from more than opposing interpreta­ tions of data. In part, ­t hese physicians ­were debating the philosophical nature of the relationship between modern medicine and childbirth. For some physicians, interventions and phar­ma­ceu­t i­cals represented a wel­ come extension of the birth pro­cess, a mechanism for augmenting natu­ral physiology.30 For ­others, inductive agents symbolized the hazardous nature of medical interventions in birth, be they “emotional or physical . . . ​mild or fatal.”31 The renowned natu­ral childbirth advocate Grantley Dick-­Read criti­ cized routinized inductions, for example, for being part of the “cult of interference” that endangered birth. The cult, he observed, “is more highly developed in the U.S.A. than in any other country in the world.”32 ­Others shared in his reflection, describing U.S. medicine as the most enthusiastic recipient of the Pit drip.33 “Article a­ fter article” in the U.S. medical press heralded successful, hassle-­free inductions via the Pitocin drip, complained one physician, while neglecting the risks entirely. “­There are ­those of us,” he said, “who have other views.”34 Despite ongoing safety debates, doctors continued to use Pitocin in the 1950s. In fact, they used it more and more frequently, enough so that doc­ tors soon carefully enumerated vari­ous prerequisites for induction. They haggled over the finer details, but all agreed in princi­ple that a w ­ oman needed to be at or near term and her cervix needed to be prepared—­soft, effaced, and partly dilated. A ­ fter the mid-1960s, doctors could use the

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“Bishop score,” introduced by Edward Bishop (an obstetrician in Phila­ delphia), to quantify a w ­ oman’s cervical “preparedness” for l­abor. The rubric accounted for vari­ous pelvic mea­sure­ments, and the overall score could range from 0 to 13: the higher the score, the more ready the cervix for birth. According to Bishop, induction was safest and most effective among ­women with a score of at least 9.35 In 1971, just a few years a­ fter Bishop introduced his cervical grading rubric, the first report of induc­ tion using Pitocin alone—­w ithout the surgical rupture of membranes—­ was published. The practice grew more common over the succeeding de­cades, so that by the latter half of the ­century Pitocin had replaced mem­ brane rupture as the primary mechanism for triggering l­ abor.36 During ­these years, induction rates swelled, rising in parallel with climbing indications for induction.37 Previously, in the late nineteenth and early twentieth centuries, the prospect of actuating l­abor had not been taken lightly. Induction was strictly reserved for the direst cases, when a ­woman’s life might be in danger. Sometimes t­ hese ­were instances of “abor­ tion,” the term used to describe coincidental fetal death or miscarriages late in pregnancy (­a fter the quickening, when a ­woman could feel fetal movement), rather than a purposeful termination of a pregnancy. (The word “abortion” only gained its modern meaning and connotation in the context of the late-1800s campaign to eliminate the widespread prac­ tice of “restoring the menses”—­terminating a pregnancy—­prior to the quickening.)38 Besides evacuating the womb of a deceased fetus, the other primary indication for inducing a ­woman’s ­labor in the de­cades surrounding the turn of the twentieth c­ entury was toxemia, t­ oday known as eclampsia. Eclampsia and its precursor, preeclampsia, are serious health conditions, characterized by acute swelling, abnormally elevated blood pressure lev­ els, and protein in the urine, among other symptoms. Untreated, the con­ ditions can lead to serious, life-­t hreatening complications for m ­ other and baby. ­There is no “cure”—­only cautious management or delivery. ­Today, the roughly 4.5  ­percent of American ­women diagnosed with preeclampsia

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are monitored carefully, the subjects of a fine balancing act between, on the one hand, allowing a pregnancy to continue for as long as pos­si­ble without jeopardizing the health of ­mother or baby, and, on the other, deliv­ ering the baby preterm. Doctors in the early 1900s expressed some other concerns—­women with a history of giving birth to large babies (other­wise described as ­women with “constricted pelvises”) and perceived fetal distress, for example—­but facilitating the delivery of a dead fetus and “treating” toxemia w ­ ere by far the two most impor­tant and well-­accepted rationales for inducing ­labor. ­After the introductions of Pituitrin, and especially the Pit drip, however, the grounds for induction expanded—­a lot. Fresh grounds for induction peppered the growing medical lit­er­a­ture, with a myriad of labels arising to describe any given phenomenon. “Post-­ date” pregnancies, for example, formed a sizeable new group of cases that could require induction. Doctors variably described such rationales: a “prolongation of pregnancy,”39 the interruption of pregnancy, “postmatu­ rity.” 40 “Inertia” was a separate category of concern: “in certain cases of inertia,” explained two enthusiasts, “some degree of control over the uter­ ine forces can be achieved” with the Pitocin drip.41 It is striking to observe how rapidly con­ve­nience, too, became a justifi­ cation for inducing ­labor. Considering the way physicians talked about it, con­ve­n ience was a widespread consideration by at least the 1950s.42 In a chapter on induction, one 1958 obstetrics textbook identified con­ve­nience as a “debatable indication” for induction, which often “appears unjusti­ fied in retrospect.” 43 The following year, writers in the Journal of the American Medical Association observed an “increased trend for elective induction” in New York City, noting that more than half of all oxytocin inductions citywide w ­ ere performed for elective reasons.44 Illuminating such developments, one group of physicians explained, in 1956, that l­abor could be induced in “any case in which the obstetrician deems ­labor justifiable.” 45 Judging from the escalating rates of induc­ tion in the latter half of the twentieth c­ entury, obstetricians across the

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nation deemed more and more cases justifiable. By the late 1970s, induc­ tion was getting “out of hand,” according to some. In G ­ reat Britain, the average national induction rate was 40 ­percent, with some areas reaching as high as 75 ­percent. In the United States, induction rates doubled between the late 1980s and 1990s. In her book Birth: The Surprising History of How We Are Born, writer Tina Cassidy cata­loged t­ hese de­cades as giving way to a “Pitocin epidemic.” 46 By the 1990s, Pitocin had become “one of the stars of the ‘cascade of intervention’ narrative of medicalized childbirth.” 47 Into the early twenty-­ first c­entury, with induction rates still climbing—to 20  ­percent, then 25 ­percent—­and elective induction gaining new visibility, concerns con­ tinued to mount. “Most w ­ omen just want to get their pregnancies over with,” Dr. Deborah A. Wing, an obstetrician at the University of South­ ern California, told New York Times health reporter Jane Brody. “They consider it abnormal if they go one day past their due date. They ­don’t real­ ize that the due date is merely a suggestion.” 48

The Dating Game Pregnant ­women ­today can determine their due dates easily, ­either man­ ually or with any number of “due date calculators” available online that automatically count 280 days from the first day of a ­woman’s last men­ strual period. This sounds ­simple enough, but anyone involved in the birthing pro­cess ­will tell you that the concept of a “due date” is acutely flawed. Indeed, doctors and midwives have taken issue with the misno­ mer for de­cades. Rather than a singular end point, they have explained time and again (apparently to no avail), ­there exists wide variability in the length of pregnancy for dif­fer­ent ­women and babies. First-­time ­mothers tend to be pregnant longer than ­women who’ve given birth previously; racial discrepancies in average pregnancy duration abound; and ultrasound technology suggests that the 280-­day standard (“Naegele’s rule,” named for the early-­nineteenth-­century German physician who documented the

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timing) might simply be three days off.49 Designating a single due date is not only inaccurate but also risks frequent misapplication, as we worry when the specific day comes and goes. The marker, in other words, has become a dubious target. And yet the deception has been enduring, holding generations of ­women tight in its grip. I cannot help but smirk at one doctor’s grumbling remarks from 1957: “we have been repeatedly confronted by normally sen­ sible ­women who seem to lose their good judgment when they believe their babies are overdue.”50 A colleague, writing in the same de­cade, exclaimed somewhat paternalistically that expecting w ­ omen “should not be told a definite date for ­labor. When it does not happen on the appointed day they become anxious. I usually give them a fortnight—­a week before and ­a fter term—­during which to expect the baby.”51 This has a certain appeal to it—­t hat of reason—­but it’s hard to envision “due fortnights” gaining much popularity. The moniker just d ­ oesn’t have the same ring to it. A due date. Perhaps it just needs a ­little alliteration . . . ​a fetal fortnight? No. Prob­ably not. Instead, we remain seduced by the idea—­now centuries old—­t hat we might be able to calculate and predict a single day for ­labor to commence. The concept is beguiling: the “due date,” proffering order to the unknown. Even well aware that I should discount it, I count down to my own “estimated date of delivery” dutifully, taking ­great (undue) satisfaction in ticking off each square on the calendar hanging in my kitchen. As the date nears, the rhythm of my life begins to pound, and I cannot tell ­whether its tempo speeds up or slows down; my meter is distorted by expectancy. “Prolonged pregnancy” emerged as one of the “first and foremost” indi­ cations for inducing l­abor during the 1950s. In that de­c ade, doctors ­worried that a prolonged pregnancy—­one that lasted more than forty-­ one weeks—­c arried fearsome risks, such as too-­large babies and fetal ­d istress during l­abor. Their main fear stemmed from the possibility of “disproportion”—­that a baby could grow too big to pass through its

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­mother’s birth canal. Induction, then, was a way to help “promote easy vaginal delivery of a healthy child of reasonable size without detriment to the ­mother.” Avoiding prolonged pregnancy was a de­cided advantage, many obstetricians said, and thus induction was a tool—­capable of improv­ ing neonatal and maternal health as well as contributing to lower rates of cesarean deliveries and mortality for both ­mothers and infants.52 By the end of the 1950s, induction at forty-­one weeks was routine in many hos­ pitals, and some practices induced any w ­ oman more than five days over­ due. Many locations had induction rates as high as 20 ­percent, and some had rates as high as 50 to 70 ­percent.53 But physicians who ­were willing to accept a more variable conception of a ­woman’s “due date” complicated the ­matter. Accounting for individ­ ual variation in gestation, they suggested, “­t here are no reliable criteria, clinical or anatomical, of post-­maturity.”54 With so many loopholes in the practice of manually dating a pregnancy, deciding when a pregnancy stretched into the category of being “prolonged” was not a ­matter of uni­ versal agreement. Indeed, before ultrasound technology became available, diagnosing postmaturity was a real challenge.55 Once improvements in ultrasound technology enabled first-­trimester dating scans (see chapter 5), ascertaining the expected due date became much more simplified and streamlined. And while an accurate estimated due date may at first glance appear a frivolous m ­ atter, it is in fact tremendously impor­tant from a medical per­ spective. At the end of pregnancy, a few days can make all the difference in making clinical decisions. Yes, the margins are significant in the world of obstetrics. When we track the pro­gress of pregnancy by trimesters, by months, by weeks, ­every day counts. Medical definitions can be fiddly ­t hings—­necessary, indeed, but so often too are they drowning in subjectivity. When does a pregnancy become ­viable? When does a fetus become ­v iable? When is a pregnancy complete? When is it overdue? And why are fetuses “due” to the world, anyway?

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­Today, one medical workaround for reclaiming the false promises of a due date is the notion of “full term.” A full-­term pregnancy (sometimes simply referred to as a term pregnancy) is a medically complete one—­a gestation fulfilled. But the original definition of a term pregnancy—­one lasting between thirty-­seven and forty-­t wo weeks—­agreed upon in the 1970s was somewhat arbitrary. (A delivery before thirty-­seven weeks was labeled preterm and a­ fter forty-­t wo weeks it was labeled postterm.)56 It is easy to see how such designations bear weight. Indeed, the implications are highly significant. If w ­ omen and doctors consider any “full-­term” pregnancy equal, and ­there is no harm in performing an induction, then why not induce at thirty-­nine weeks if every­one’s on board? Why not thirty-­eight? Or thirty-­seven? In 2013, physicians proposed a new classification system to better cap­ ture the nuances of timing a term pregnancy. “Early term” would refer to a pregnancy ending between thirty-­seven and thirty-­nine weeks; “full term” would apply to pregnancies lasting thirty-­nine to forty-­one weeks; and “late term” would apply to pregnancies ending between forty-­one and forty-­t wo weeks. Births at or beyond forty-­t wo weeks remained “post­ term.” The goal, said one obstetrician of the new gradations, was to appre­ ciate that “each week of gestation up to thirty-­nine weeks is impor­tant for a fetus to fully develop before delivery and have a healthy start.”57 (The author who presented t­ hese redefined term gradations noted that “given the known excess morbidity and mortality risk of delivery prior to thirty-­ nine weeks, it is essential not to undertake nonmedically indicated deliv­ ery before reaching this date.”58) But some doctors ­were concerned that this stratification was simply a new spin on an old prob­lem: flimsy bound­aries. “Is a 38 week 6 day preg­ nancy ­really dif­fer­ent from a 39 week 0 day pregnancy?” asked a group of colleagues in JAMA. “Is a 39 week 0 day gestation physiologically the same as a 40 week 6 day gestation?”59 The beginning of ­human life does not conform to medical dictionaries and encyclopedias so nicely. Yet we continue to rely on such sharp distinctions. ACOG and the Society for

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Maternal and Fetal Medicine both endorsed the new hierarchy for term pregnancies.60 How are we to make sense of such sharp distinctions, such precise edges, comingled with the overarching, more relaxed concept of a “due fortnight”? At the end of the day, some of t­ hese debates—­about the timing of preg­ nancy, about induction, about intervening on birth—­reflect a far deeper divide: who is a better obstetrician—­man or nature? Does the doctor know best? Or a ­woman’s body? Or a fetus? All the evidence in the world could never answer ­these questions neatly for us. Some professionals would likely say that the worldviews are incompatible—­historically (and po­liti­cally), this divide has been disas­ trously oversimplified: the medical, pathological, interventionalist perspec­ tive of doctors and modern medicine versus the evolutionary, feminist, holistic perspective of midwifery and natural-­birth advocates. But painting the debate as a battlefield with two opposing sides, clear enemies staking their claim to the contested territory, is a ­mistake (besides being inaccurate). Neither school of thought is implicitly right or wrong: medicine does not perceive ­every pregnant w ­ oman’s body as a ticking bomb, and midwifery does not deny the pos­si­ble health risks of carry­ing or catching babies. Fur­ thermore, t­ here is danger in the philosophy that the ­human body is “meant” or “not meant” to do anything. Evolution unfolds, but it does not make any promises; evidence exists, accumulates, but it cannot foretell. Yet that does not stop us from trying.

Induction T ­ oday The debates about induction—­ranging from delineating legitimate indi­ cations for having one, to its safety, outcomes, and associations with inter­ ventions and cesarean deliveries—­feel more recycled than new. But the conversation is gaining new life in light of recent findings. Many recent ­trials exploring induction have suffered fundamental methodological flaws, such as comparing induction at X number of weeks

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to spontaneous l­abor at X number of weeks. “This is a false comparison,” noted journalist Chelsea Conaboy, “­because w ­ omen cannot choose to go into spontaneous ­labor . . . ​The real choice that pregnant w ­ omen face is between inducing or continuing the pregnancy past [a certain] point.” (Or, as one doctor wryly put it: “Spontaneous l­ abor is not a clinical ‘strategy.’ ”) And ­women whose pregnancies continue ­until or beyond their due dates are ultimately more likely to need interventions.61 ­Because they looked at the situation as such, t­ hese studies w ­ ere “not . . . ​useful to guide clinical decision making.” 62 Newer proj­ects have sought to correct for t­ hese glaring shortcomings. In a major break from the past de­cades, data released in 2018 suggested that elective induction at thirty-­nine weeks—­with no medical indication—­ carried no adverse outcomes when compared with ex­pec­tant manage­ ment (which is essentially a “wait and see” protocol), and it was associ­ ated with a lower cesarean delivery rate. To anyone who had been paying attention, ­these results w ­ ere quite extraordinary, and indeed they ruffled some feathers. A Randomized Trial of Induction Versus Ex­pec­tant Management (the ARRIVE trial), as published in the New ­England Journal of Medicine, ran­ domized more than 6,000 w ­ omen at over forty hospitals to e­ ither receive an induction at thirty-­nine weeks—­for no apparent reason—or ­else receive ex­pec­tant management as their pregnancies progressed.* The cesarean delivery rate in the induction group was lower than in the ex­pec­tant man­ agement group (18.6 ­percent versus 22.2 ­percent, respectively). ­There ­were also no discernable increases in complications among the induction group, and for some outcome mea­sures the ­mothers and babies in the induction group actually fared better. The results, said Dr. Merielle Ste­ phens, “fly in the face of a lot of what we hold to be true, which is that inductions are interventions and can have bad outcomes.” 63 * Women enrolled in the study ­were randomly assigned during their thirty-­eighth week of pregnancy. Members of the experimental group ­were induced between thirty-­nine weeks and thirty-­nine weeks/four days.

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Instead of triggering a “cascade of interventions,” t­ hese data implied, elective inductions, if anything, carried lower risks than ex­pec­tant man­ agement. Furthermore, the ARRIVE trial results called into question the public health strategy of reducing inductions in order to reduce the rates of cesarean delivery. In truth, this was not entirely novel evidence in 2018. Multiple previ­ ous ­trials, reviews, and meta-­analyses had already begun to shed light on the false impression—­perpetuated not only through word of mouth but also in medical guidelines, textbooks, and professional orga­nizational materials—­that being induced necessarily heightened a ­woman’s chances of needing a cesarean delivery.64 But the ARRIVE trial was a landmark study, and in the same year it was released other publications buttressed its conclusions. A Cochrane review reported that induction was associ­ ated with a lower number of perinatal deaths and cesarean deliveries com­ pared with ex­pec­tant management (although it was associated with more assisted vaginal deliveries).*,65 Statistical analysts explained that elective induction at thirty-­nine weeks resulted in lower “population risks” com­ pared with ex­pec­tant management and induction at a l­ ater time, forty-­one weeks. Specifically, the investigators stated, elective induction of l­abor at 39 weeks resulted in a lower cesarean delivery rate, lower rates of mater­ nal morbidity, fewer stillbirths and neonatal deaths, and lower rates of neonatal mortality, all regardless of a ­woman’s cervical “readiness.” The sta­ tistics ­were striking, too: the cesarean delivery rates differed vastly, from almost 14 ­percent in induction groups to nearly 36 ­percent in ex­pec­tant management groups.66 Taken together, all this evidence has been contentious and divisive. It challenges the “obstetric man­tra” from previous de­cades that elective induction needlessly introduces new risks to expecting w ­ omen and their babies. Indeed, it suggests the opposite—­that elective induction might be * The review considered evidence from thirty t­ rials internationally (more than 12,000 ­women); induction was employed only at or beyond term, most often around forty-­ one weeks.

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“considered as one f­ actor in [a] comprehensive strategy to improve mater­ nal outcomes.” 67 In theory, and taken to the extreme, we could ask, why not induce all pregnant ­women at thirty-­nine weeks? Indeed, at the 2016 annual ACOG meeting, two physicians with opposing viewpoints on elec­ tive induction, Dr. Charles Lockwood and Dr. Errol Norwitz, “debated” this exact question in front of their colleagues. But the intended debate was instead a congenial conversation. Remarkably, both physicians reached the same, shocking conclusion: universal inductions at thirty-­nine weeks would protect both moms and babies—­pregnancy should end at thirty-­nine weeks.68 ­These new data may be making a splash in obstetric circles, but they have not changed any guidelines (yet). (ACOG currently recommends induction only for medical reasons, and still advises that induction be restricted to pregnancies at least thirty-­nine weeks “old,” with excellent dating, and w ­ omen with ripe cervixes.) And the vantage certainly does not seem to have made its way into w ­ omen’s conversations. I d ­ on’t hear anyone talking about it. When I hear friends and ­family speak about induction, it’s often layered with fear—­and a deep desire to avoid it. Many ­women’s impression of induction as a “leading culprit for excessive child­ birth” is, as Hilda Bastian suggests, “deeply rooted now.” 69 Mulling all of this over, ­running my hand over my extended belly as I pass the thirty-­nine-­week mark in my own pregnancy, it blows my mind to even think about the prospect of universal induction. What would sup­ port for it even look like? Would ­women welcome it with open arms? Or would they spurn it, another unwanted intervention? At times, I think, it feels tempting to wish that I might step away from it all, to somehow forget what I have learned, to wallow in unawareness. But discounting the seeming minutiae, the dates and definitions and timing, the evidence and the ­human bodies themselves, would leave us all in the dark. Doctors studying Pitocin in the ­middle of the twentieth ­century frequently observed its helpfulness in overcoming “uterine weak­

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ness” or “uterine inertia.”70 ­Others noted its utility for kick-­starting “slug­ gish” uteruses, or “treating ‘lazy or weak’ uterine action.”71 A point: the ways we choose to discuss and label ­women’s bodies bear real weight. ­These historical terms may seem laughable, but their legacy is carry­ ing on. Disparagements like this abound: a w ­ oman “stalls” in l­abor, her cervix can be “incompetent,” her cervical mucus can be “hostile.” Nor is such degrading verbiage necessarily unique to the medical sector. What does the midwife who professes that a ­woman’s body was “perfectly designed by nature” to bear c­ hildren or deliver vaginally say to the patient who is unable to conceive, or to the ­woman who recently had a cesarean delivery? Or to the ­woman who chose to have one? As Monica Hesse so powerfully points out in her piece in the Washington Post, our society’s collective (and willful) ignorance about how to talk about pregnancy and the pregnant body “­isn’t something to be laughed off.”72 As states across the nation debate the legality of abortion at vari­ous weeks into pregnancy, as physicians debate the evidence surrounding induction and interventions, as workers and workplaces negotiate the nature and duration of ­family leave policies, as pregnant and postpartum ­women grapple with the expectations placed on them and their bodies, and as individual families plan and prepare for a new f­ uture, the particu­ larities of pregnancy—­a nd the language we use to describe it—­become magnified in their significance. And of course, none of this evolves in a vacuum. “Another extremely impor­tant aspect of this subject ­matter,” wrote one team of researchers in 2018, “is: what do ­women want?”73 I am not certain this a question we can even answer. ­Women have been some of the primary ­drivers of elective induction, but of course they are not uniformly in support of easy access to it. Doctors and medicine have been lambasted for rising cesarean deliv­ ery rates (and even, historically, for relocating birth from the home to the hospital), but more nuanced research has shown that ­women have pushed

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for ­these kinds of changes—­a nd pushed back against them—as well. ­Women sought out hospitals; they demanded anesthetics; they asked about cesarean deliveries and elective inductions; they questioned obstetric rene­ gotiations and interventions; they have ­shaped the narrative, b ­ ecause they have been participants and d ­ rivers in all ­these conversations. So are we.

Edgy and emotional, I decide to go for a walk. You never know. Pacing through my neighborhood, I consider the historical authenticity of my own impatience, my readiness to play with homespun induction; I am reluctant to truly accept futility. My ventures, though they are fruitless, ground me somehow, linking me to both the past and the pre­sent. My mind suddenly swimming with medicine and lit­er­a­ture and poli­ tics and philosophy, I think of my ­mother, of my grand­mothers, carry­ing on. And I won­der: what ­w ill my ­daughter find waiting for her? Pregnancy is a construct, and yet it is not. My expanding form is ele­ mental, real, palpating from within. Each day, I notice my body growing, stretching; I try to ignore my sleeplessness; I feign distraction while I covet patience. The passing of time loses meaning, its units of mea­sure­ment sud­ denly impenetrable. I am hurried; I am suspended. I am waiting. ­Until I am not. And every­thing is reconceived.

Acknowl­edgments

It is never an author alone who brings a book to completion, and Carrying On is no dif­fer­ent. For the past four years, I’ve had the privilege to work alongside an amaz­ ing group of ­mothers. Thank you to my colleagues Meg Collins, Charlène Barkulis, Marissa Bader, Melissa Kresser, and Heather Reed—­I love ­every minute working with all of you. I am grateful to the University of New ­England, where I worked for a duration of the time I spent working on this book and had the opportu­ nity to develop medical history courses that gave shape to many of the ideas and questions within it. Many thanks to the incredible ­women who participated in my class on the history of pregnancy—­I hope the seminar was half as meaningful to each of them as it was to me. Special thanks as well to Elizabeth DeWolfe, Jennifer Tuttle, and Julie Peterson for your sup­ port, friendship, and exemplary work with young ­people. Thank you to the many w ­ omen, including my two amazing grand­ mothers, who gave their time to speak with me about their experiences and questions throughout their own pregnancies—­t heir generosity and openness strengthened this proj­ect in indescribable ways. Thanks also to Sarah Bell, Tina Hubbard, Cullen and Kelsey Clair, Andrew Clair and Jessica Cozzetta Clair, Dillon Gaines, Diane Stronach, Rachel Withers,

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Wendy Kline, David Stradling, and Isaac Campos, who all contributed to this proj­ect in one way or another. Tina Cassidy generously agreed to review drafts of this manuscript, and I believe the final version is far better for her having looked at it—­I am grateful not only for her input and expertise, but also for her pushing me to see the forest for the trees. My editor, Peter Mickulas, has been an enthu­ siastic supporter of this book from the first time I described it to him, and the final product owes much to his encouragement, feedback, and wise counsel throughout (besides his patience and good humor). My parents, Patty and Dan Clair, supported me in making a major life change while I was writing this book, and I think it might have floundered in limbo without their guidance. My ­mother also read ­every draft of ­every chapter multiple times over (and never failed to catch a ­mistake—if ­t here are any left, I blame her). Patty, your willingness to invest so much of your time in this book fills with me gratitude and appreciation. My ­family ­didn’t help me write this book, but they gave me every­t hing I needed so that I could. James and Mary—­you are the best. And Joshua, well, so are you. Lastly, Mary: Carrying On is for you.

Notes

notes to the preface 1.  Ann Oakley, The Captured Womb: A History of the Medical Care of Pregnant ­Women (Oxford: Blackwell, 1986), 37–38, 62; Leslie Reagan, Dangerous Pregnancies: ­Mothers, Disabilities, and Abortion in Modern Amer­i­ca (Berkeley: University of California Press, 2010), 7; Irvine Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800–1950 (New York: Clarendon Press, 1992), 279. 2.  Greg R. Alexander and Milton Kotelchuck, “Assessing the Role and Effec­ tiveness of Prenatal Care: History, Challenges, and Directions for ­Future Research,” Public Health Reports 116, no. 4 (2001): 307, https://­doi​.­org​/­10​.­1016​/S­ 0033​ -­3549(04)50052​-­3. 3.  Jon Tyson et al., “Prenatal Care Evaluation and Cohort Analyses,” Pediatrics 85, no. 2 (February 1990): 195–204; H. K. Atrash, “Not All Prenatal Care Is Appro­ priate Care,” Journal of the American Medical ­Women’s Association (1972) 50, no. 5 (October 1995): 144–146; K. D. Frick and P. M. Lantz, “Se­lection Bias in Pre­ natal Care Utilization: An Interdisciplinary Framework and Review of the Lit­er­ a­t ure,” Medical Care Research and Review 53, no. 4 (December 1996): 371–396, https://­doi​.­org​/­10​.1­ 177​/­107755879605300401. 4.  Dovile Vilda et al., “Income In­equality and Racial Disparities in Pregnancy-­ Related Mortality in the US,” SSM—­Population Health 9 (December  2019): 100477, https://­doi​.­org ​/­10​.­1016​/­j​.­ssmph​.­2019​.­100477; Eliana Dockterman, “U.S. Ranks Worst Developed Country for Maternal Health,” Time, May 5, 2015, http://­ time​.c­ om​/­3847755​/m ­ others​-­children​-­health​-­save​-­the​-­children​-­report​/;­ Elisabeth Rosenthal, “American Way of Birth, Costliest in the World,” New York Times, June 30, 2013, http://­w ww​.­nytimes​.­com​/2­ 013​/0 ­ 7​/0 ­ 1​/­health​/­american​-­way​-­of​-­birth​

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-­costliest​-­in​-­the​-­world​.­html; Peter G. Pryde, “Contemplating Our Maternity Care Crisis in the United States: Reflections of an Obstetrician Anesthesiologist,” Anesthesia and Analgesia 128, no. 5 (May 2019): 1036–1041, https://­doi​.­org​/1­ 0​.­1213​/­ANE​ .­0000000000004026; Molly M. Killion, “Maternal Mortality in the United States,” MCN: The American Journal of Maternal/Child Nursing 45, no.  4 (July  2020): 240–240, https://­doi​.­org​/­10​.­1097​/­NMC​.­0000000000000631. 5.  Pryde, “Contemplating Our Maternity Care Crisis.” 6.  World Health Organ­ization, Trends in Maternal Mortality: 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division (Geneva: World Health Organ­ization, 2015), http://­apps​.­who​ .­i nt ​/­i ris​/ ­bitstream​/­handle​/­10665​/­194254​/­9789241565141 ​_­eng​.­pdf; World Health Organ­ization, “Trends in Maternal Mortality in 2000–2017: United States of ­ ho​.i­ nt​/­gho​/­maternal​_ ­health​/c­ ountries​/u ­ sa​.­pdf. Amer­i­ca,” 2019, https://­w ww​.w 7.  Ester Bloom, “Amer­i­ca’s Pregnancy-­Care Paradox: Paying Ever More for the Same Bad Results,” The Atlantic, November 10, 2015, https://­w ww​.t­ heatlantic​.­com​ /­business​/­a rchive​/­2015​/­11​/­a mericas​-­pregnancy​-­care​-­paradox​-­paying​-­ever​-­more​ -­for​-­the​-­same​-­bad​-­results​/4­ 15032​/­; Eva Luo, “Contemplating Our Maternity Care Crisis in the United States: Reflections of an Obstetrician Anesthesiologist,” Anes­ rg​/­10​.­1213​/­ANE​ thesia and Analgesia 128, no. 5 (May 2019): 1036–1041, https://­doi​.o .­0000000000004026; Leana Wen, “I’m Pregnant. What Would Happen If I ­Couldn’t Afford Health Care?” NPR, Shots, March 11, 2017, https://­w ww​.n ­ pr​.o ­ rg​ /­sections​/­health​-­shots​/2­ 017​/0 ­ 3​/­11​/­519416036​/i­ m​-­pregnant​-­what​-­would​-­happen​-­if​ -­i​-­couldnt​-­afford​-­health​-­care. 8.  Adam J. Zolotor and Martha C. Carlough, “Update on Prenatal Care,” American ­Family Physician 89, no. 3 (February 1, 2014): 199–208. 9.  U.S. C ­ hildren’s Bureau, Prenatal Care (Washington D.C.: U.S. Government Printing Office, 1930); Oakley, The Captured Womb, 62, 65, 79; “Antenatal Clin­ ics,” The Lancet 214, no. 5528 (August 10, 1929): 295 [first published in vol. 2, no. 5528 (1929)], https://­doi​.­org​/­10​.­1016​/­S0140​-­6736(01)02191​-­2; Alex  F. Peahl, Roger  D. Smith, and Michelle H. Moniz, “Prenatal Care Redesign: Creating Flexible Mater­ nity Care Models through Virtual Care,” American Journal of Obstetrics and Gynecol­ogy 223, no. 3 (2020): 389.e1–389.e10, https://­doi​.­org​/­10​.­1016​/­j​.­ajog​.­2020​.­05​ .­029; Alex F. Peahl et al., “Right-­Sizing Prenatal Care to Meet Patients’ Needs and Improve Maternity Care Value,” Obstetrics and Gynecol­ogy 135, no. 5 (May 2020): 1027–1037, https://­doi​.­org​/­10​.­1097​/­AOG​.­0000000000003820; Alex Friedman Peahl et al., “A Comparison of International Prenatal Care Guidelines for Low-­R isk ­Women to Inform High-­Value Care,” American Journal of Obstetrics and Gynecol­ ogy 222, no. 5 (May 2020): 505–507, https://­doi​.­org​/­10​.­1016​/­j​.­ajog​.2­ 020​.­01​.­021. 10.  Peahl, Smith, and Moniz, “Prenatal Care Redesign.”

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61.  “Vitamin Supplementation in Pregnancy,” 81; Steer, “Is Vitamin D Supple­ mentation in Pregnancy Advisable?” 2143. 62.  ACOG, “Committee Opinion Number 495.” 63.  Duckworth, Mistry, and Chappell, “Vitamin Supplementation in Preg­ nancy,” 176; Sfakianaki, “Prenatal Vitamins.” 64.  Elliot Hannon, “Study Finds Multivitamins Are a Complete Waste of Money, Why Do We Keep Taking Them?” Slate, December 16, 2013, http://­w ww​ .­slate​.­com​/­blogs​/­t he​_­slatest​/­2013​/­12​/­16​/­a​_­medical​_­journal​_­on​_­multivitamins​ _­stop​_­wasting​_­your​_ ­money​.­html; Jane E. Brody, “Studies Show ­Little Benefit in Supplements,” New York Times, November 14, 2016, https://­w ww​.­nytimes​.­com​ /­2016​/­11​/­15​/­well​/­eat​/­studies​-­show​-­little​-­benefit​-­in​-­supplements​.­html; Eliseo Gual­ lar et al., “Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements,” Annals of Internal Medicine 159, no. 12 (December 17, 2013): 850, https://­doi​.­org​/­10​.­7326​/­0003​-­4819​-­159​-­12​-­201312170​-­00011; Longwood Seminars, “Food and Vitamins”; Price, Vitamania. 65.  Cohen, “Supplement Paradox”; Guallar et al., “Enough Is Enough,” 851. ­ omen Take Recommended 66.  March of Dimes, “Fewer Than Half of U.S. W Vitamins prior to Pregnancy, According to March of Dimes New Prenatal Health & Nutrition Survey,” September  19, 2017, https://­w ww​.­marchofdimes​.­org​/­news​ /­fewer​-­than​-­half​-­of​-­u​-­s​-­women​-­take​-­recommended​-­vitamins​-­prior​-­to​-­pregnancy​ -­according​-­to​-­march​-­of​-­dimes​-­new​-­prenatal​-­health​-­nutrition​-­survey​.­a spx; Elizabeth D. Kantor et al., “Trends in Dietary Supplement Use among US Adults from 1999–2012,” JAMA 316, no. 14 (October 11, 2016): 1464, https://­doi​.­org​/­10​ .­1001​/­jama​.­2016​.­14403. 67.  Tina L. Cheng et al., “Folate Nutrition Status in M ­ others of the Boston Birth Cohort, Sample of a US Urban Low-­Income Population,” American Journal of Public Health 108, no. 6 (2018): 799–807, https://­doi​.­org​/­10​.­2105​/­AJPH​.­2018​.­304355. 68.  Prenatal Care Guideline Team, “Guidelines for Clinical Care: Prenatal Care” (University of Michigan, December 2013), 12, http://­w ww​.­med​.­umich​.­edu​ /­1info​/F ­ HP​/­practiceguides​/­newpnc​/­PNC​.­pdf. 69.  Harriet Hall, “Prenatal Multivitamins and Iron: Not Evidence-­Based,” Science-­Based Medicine, February  2, 2016, https://­sciencebasedmedicine​.­org​ /­prenatal​-­multivitamins​-­and​-­iron​-­not​-­evidence​-­based​/­. 70.  Alice Park, “Do Pregnant W ­ omen R ­ eally Need a Multivitamin?” Time, July 12, 2016, http://­time​.­com​/­4402863​/­prenatal​-­vitamins​-­pregnancy​-­multivitamin​/­. 71.  Hovdenak and Haram, “Influence of Mineral,” 131; Sfakianaki, “Prenatal Vita­ mins”; Tara Haelle and Emily Willingham, The Informed Parent: A Science-­Based Resource for Your Child’s First Four Years (New York: TarcherPerigee, 2016), 6.

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chapter 2 ​—­ ​endure 1. Maria Makrides et  al., “Magnesium Supplementation in Pregnancy,” Cochrane Database of Systematic Reviews, no. 4 (April 4, 2014): CD000937, https://­ doi​.­org​/­10​.­1002​/­1 4651858​.­CD000937​.­pub2; Ragnar Rylander, “Treatment with Magnesium in Pregnancy,” AIMS Public Health 2, no. 4 (2015): 804–809, https://­ doi​.­org​/­10​.­3934​/p ­ ublichealth​.­2015​.­4​.­804. 2.  Lynne M. Dalton et al., “Magnesium in Pregnancy,” Nutrition Reviews 74, ­ uw018. no. 9 (September 2016): 550, 555, https://­doi​.­org​/­10​.­1093​/­nutrit​/n 3.  Amy Kiefer, “Morning Sickness & Miscarriage: How Much Does Nausea Lower Your Risk?” Expecting Science, March 11, 2016, https://­expectingscience​ .­com​/­2016​/­03​/­11​/­nausea​-­and​-­the​-­risk​-­of​-­miscarriage​-­how​-­much​-­does​-­morning​ -­sickness​-­lower​-­your​-­risk​/­; G. V Pepper and S. Craig Roberts, “Rates of Nausea and Vomiting in Pregnancy and Dietary Characteristics across Populations,” Proceedings of the Royal Society B: Biological Sciences 273, no.  1601 (October  22, 2006): 2676, https://­doi​.­org​/­10​.­1098​/­rspb​.­2006​.­3633; Paul W. Sherman and Sam­ uel M. Flaxman, “Nausea and Vomiting of Pregnancy in an Evolutionary Perspec­ tive,” American Journal of Obstetrics and Gynecol­ogy, Understanding and Treating Nausea and Vomiting of Pregnancy, 186, no. 5, Supplement 2 (May 2002): S190, ­ ob​.­2002​.­122593; M. A. Klebanoff et al., “Epidemiology of https://­doi​.­org​/­10​.­1067​/m Vomiting in Early Pregnancy,” Obstetrics and Gynecol­ogy 66, no.  5 (Novem­ ber 1985): 612–616. 4.  Tara Haelle and Emily Willingham, The Informed Parent: A Science-­Based Resource for Your Child’s First Four Years (New York: TarcherPerigee, 2016), 26. 5.  Mitzi Davis, “Nausea and Vomiting of Pregnancy: An Evidence-­Based Review,” Journal of Perinatal and Neonatal Nursing 18, no. 4 (December 10, 2004): 322, https://­doi​.­org​/­10​.­1097​/­00005237​-­200410000​-­00002. 6.  “Practice Bulletin No. 153: Nausea and Vomiting of Pregnancy,” Obstetrics and Gynecol­ogy 126, no. 3 (September 2015): 688, https://­doi​.­org​/­10​.­1097​/­AOG​ .­0000000000001048. 7.  Catherine McParlin et al., “Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy: A Systematic Review,” JAMA 316, no. 13 (October 4, 2016): 1392, 1398, https://­doi​.­org​/1­ 0​.­1001​/­jama​.­2016​.­14337. 8.  M. Kousen, “Treatment of Nausea and Vomiting in Pregnancy,” American ­Family Physician 48, no. 7 (November 15, 1993): 1280. 9.  Stephen J. Dubner, “Bad Medicine, Part 2: (Drug) ­Trials and Tribulations (Ep. 269),” Freaknomics, December 7, 2016, https://­f reakonomics​.­com​/­podcast​/­bad​ -­medicine​-­part​-­2​-­drug​-­trials​-­and​-­tribulations​/­.

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10.  Pamela Payne, “Including Pregnant ­Women in Clinical Research: Practi­ cal Guidance for Institutional Review Boards,” Ethics and ­Human Research 41, no. 6 (November 2019): 35–40, https://­doi​.­org​/­10​.­1002​/e­ ahr​.5­ 00036. 11.  Mary  C. Blehar et  al., “Enrolling Pregnant W ­ omen: Issues in Clinical Research,” ­Women’s Health Issues 23, no. 1 (January 2013): e39–45, https://­doi​.­org​ /­10​.­1016​/j­ ​.w ­ hi​.­2012​.­10​.0 ­ 03; Anne Lyerly, “Should Pregnant ­Women Be Included in Clinical ­Trials?” AAMC News, July 24, 2018, https://­w ww​.­aamc​.o ­ rg​/­news​-­insights​ /­should​-­pregnant​-­women​-­be​-­included​-­clinical​-­trials; Anne Drapkin Lyerly, Mar­ garet Olivia ­Little, and Ruth Faden, “The Second Wave: ­Toward Responsible Inclusion of Pregnant ­Women in Research,” International Journal of Feminist Approaches to Bioethics 1, no. 2 (2008): 5–22, https://­doi​.­org​/­10​.­1353​/­ijf​.­0​.­0047. 12.  American College of Obstetricians and Gynecologists Committee on Eth­ ­ omen ics, “Committee Opinion No. 646: Ethical Considerations for Including W as Research Participants,” Obstetrics and Gynecol­ogy 126, no. 5 (November 2015): e100–107, https://­doi​.­org​/­10​.­1097​/­AOG​.­0000000000001150; Lyerly, ­Little, and Faden, “Second Wave.” ­ omen”; ACOG Committee on Ethics, “Com­ 13.  Payne, “Including Pregnant W mittee Opinion No. 646.” 14.  Lyerly, ­Little, and Faden, “Second Wave.” 15.  Nina Martin, “Most Drugs A ­ ren’t Tested on Pregnant W ­ omen. This Anti-­ Nausea Cure Shows Why That’s a Prob­lem,” ProPublica, May 26, 2016, https://­ www​.­propublica​ .­org ​ /­a rticle​ /­m ost​-­drugs​-­not​-­tested​-­pregnant​-­women​-­anti​ -­nausea​-­cure​-­why​-­thats​-­a​-­problem. 16.  Martin, “Most Drugs.” 17.  Lyerly, “Should Pregnant W ­ omen.” 18.  J. S. Biggs, “Vomiting in Pregnancy: ­Causes and Management,” Drugs 9, no. 4 (1975): 303, https://­doi​.­org​/­10​.­2165​/­00003495​-­197509040​-­00007; Carolyn A. Lane, “Nausea and Vomiting of Pregnancy: A Tailored Approach to Treatment,” Clinical Obstetrics and Gynecol­ogy 50, no. 1 (March 2007): 101, https://­doi​.­org​/1­ 0​ .­1097​/­grf​.0 ­ b013e31802f178f. 19.  Gideon Koren et  al., “Effectiveness of Delayed-­Release Doxylamine and Pyridoxine for Nausea and Vomiting of Pregnancy: A Randomized Placebo Controlled Trial,” American Journal of Obstetrics and Gynecol­ogy 203, no. 6 (Decem­ ber 2010): 571.e3, https://­doi​.­org​/­10​.­1016​/­j​.­ajog​.­2010​.­07​.­030. 20.  Kousen, “Treatment of Nausea,” 1280; Jennifer R. Niebyl and T. Murphy Goodwin, “Overview of Nausea and Vomiting of Pregnancy with an Emphasis on Vitamins and Ginger,” in “Understanding and Treating Nausea and Vomit­ ing of Pregnancy,” special issue, American Journal of Obstetrics and Gynecol­ogy,

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186, no.  5, Supplement 2 (May  2002): S254, https://­doi​.­org ​/­10​.­1067​/­mob​.­2002​ .­122595. 21. Koren et  al., “Delayed-­Release Doxylamine,” 571.e1, quoted on 571.e5; Jennifer R. Niebyl, “Nausea and Vomiting in Pregnancy,” New ­England Journal of Medicine 363, no.  16 (October  14, 2010): 1546, https://­doi​.­org ​/­10​.­1056​/­NEJ​ Mcp1003896; Emily Oster, Expecting Better: Why Conventional Pregnancy Wisdom Is Wrong—­and What You ­Really Need to Know (New York: Penguin Books, 2013), 95; Jane E. Brody, “Shadow of Doubt Wipes Out Bendectin,” New York Times, June 19, 1983, http://­w ww​.­nytimes​.­com​/­1983​/­06​/­19​/­weekinreview​/­shadow​-­of​-­doubt​ -­wipes​-­out​-­bendectin​.­html. 22.  ACOG Committee on Ethics, “Committee Opinion No. 646.” 23.  Niebyl and Goodwin, “Overview of Nausea,” S254. 24.  Zina Levichek et al., “Nausea and Vomiting of Pregnancy. Evidence-­Based Treatment Algorithm,” Canadian ­Family Physician 48 (February 2002): 268–269, https://­w ww​.­ncbi​.­nlm​.­nih​.­gov​/­pubmed​/­11889884; Gideon Koren, “Treating Morn­ ing Sickness in the United States—­Changes in Prescribing Are Needed,” American Journal of Obstetrics and Gynecol­ogy 211, no. 6 (December 2014): 605, https://­ doi​.­org ​/­10​.­1016​/­j​.­ajog​.­2014​.­08​.­017; Martina  L. Badell, Susan  M. Ramin, and Judith A. Smith, “Treatment Options for Nausea and Vomiting during Pregnancy,” Pharmacotherapy 26, no. 9 (September 2006): 1279, https://­doi​.­org​/­10​.­1592​/­phco​ .­26​.­9​.­1273; Koren et al., “Delayed-­Release Doxylamine,” 571.e1, 571.e3, 571.e5; Niebyl, “Nausea and Vomiting,” 1546. 25.  Koren, “Treating Morning Sickness,” 602; Jacqueline Howard, “Morning Sickness Drug Called into Question,” CNN, January 4, 2017, http://­w ww​.­cnn​.­com​ /­2017​/­01​/0 ­ 4​/­health​/­diclegis​-­morning​-­sickness​-­drug​-­fda​/­index​.­html; “How Safe Is the Morning-­Sickness Drug Diclegis?” The Cut, July 20, 2015, http://­nymag​.­com​ /­t hecut​/­2015​/­07​/­how​-­safe​-­is​-­the​-­morning​-­sickness​-­drug​-­diclegis​.­html; Richard Harris, “Morning Sickness Pill Gets Second Look From Per­sis­tent Researchers,” ­ ealth​-­shots​/­2017​/­01​/­06​ NPR Shots, January  6, 2017, http://­w ww​.­npr​.­org​/s­ ections​/h /­508562318​/­morning​-­sickness​-­pill​-­gets​-­second​-­look​-­from​-­persistent​-­researchers. 26.  Lauren G. Oliveira et al., “Ondansetron Compared with Doxylamine and Pyridoxine for Treatment of Nausea in Pregnancy: A Randomized Controlled Trial,” Obstetrics and Gynecol­ogy 124, no. 4 (October 2014): 735–742, https://­doi​ .­org​/­10​.­1097​/­AOG​.­0000000000000479; Shaun D. Carstairs, “Ondansetron Use in Pregnancy and Birth Defects: A Systematic Review,” Obstetrics and Gynecol­ogy 127, no. 5 (May 2016): 878–883, https://­doi​.­org​/­10​.­1097​/­AOG​.­0000000000001388. 27. Björn Pasternak, Henrik Svanström, and Anders Hviid, “Ondansetron in Pregnancy and Risk of Adverse Fetal Outcomes,” New E ­ ngland Journal of Medicine

214

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368, no.  9 (February  28, 2013): 814–823, https://­doi​.­org​/1­ 0​.­1056​/N ­ EJMoa1211035; James P. Reichmann and Michael S. Kirkbride, “Ondansetron Use in Pregnancy and Ondansetron Use in Pregnancy and Birth Defects: A Systematic Review,” Obstetrics and Gynecol­ogy 128, no. 2 (August 2016): 409, https://­doi​.­org ​/­10​.­1097​ /­AOG​.­0000000000001548; Reichmann and Kirkbride, “Ondansetron Use.” 28.  Carstairs, “Ondansetron Use.” 29.  Anne Matthews et al., “Interventions for Nausea and Vomiting in Early Pregnancy,” in Cochrane Database of Systematic Reviews, no. 9 (September 8, 2015): CD007575, 3, https://­doi​.­org​/1­ 0​.­1002​/­14651858​.­CD007575​.­pub4. 30.  Laura A. Magee, Paolo Mazzotta, and Gideon Koren, “Evidence-­Based View of Safety and Effectiveness of Pharmacologic Therapy for Nausea and Vomiting of Pregnancy (NVP),” in “Understanding and Treating Nausea and Vomiting of Pregnancy,” special issue, American Journal of Obstetrics and Gynecol­ogy, 186, no. 5, Supplement 2 (May 2002): S256, https://­doi​.­org​/­10​.­1067​/­mob​.­2002​.­122596. 31.  Sherman and Flaxman, “Nausea and Vomiting,” S190, S191, S192, S193, S196; Pepper and Roberts, “Rates of Nausea,” 2676; Samuel M. Flaxman and Paul W. Sherman, “Morning Sickness: Adaptive Cause or Nonadaptive Consequence of Embryo Viability?” American Naturalist 172, no. 1 (2008): 54–55, 60, https://­doi​.­org​ /­10​.­1086​/­588081; Raj Persaud, “If Morning Sickness Is Associated with Fewer ­Miscarriages and Higher IQ Babies—­Should It Be Treated?” Huffington Post, Feb­ ruary 3, 2013, http://­w ww​.­huffingtonpost​.­co​.­uk​/­dr​-­raj​-­persaud​/­morning​-­sickness​ -­pregnancy​_­b​_­2237627​.­html. 32.  Judith E. Brown, Emily S. Kahn, and Terryl J. Hartman, “Profet, Profits, and Proof: Do Nausea and Vomiting of Early Pregnancy Protect ­Women from ‘Harm­ ful’ Vegetables?” American Journal of Obstetrics and Gynecol­ogy 176, no. 1 (Janu­ ary 1997): 180–181, https://­doi​.­org​/­10​.­1016​/­S0002​-­9378(97)80032​-­4. 33.  A. Pirisi, “Meaning of Morning Sickness Still Unsettled,” The Lancet 357, no. 9264 (April 21, 2001): 1272. 34.  Sherman and Flaxman, “Nausea and Vomiting,” S195; Persaud, “Morning Sickness.” 35.  Kiefer, “Morning Sickness & Miscarriage.” 36. Thomas Murphy Goodwin, “Nausea and Vomiting of Pregnancy: An Obstetric Syndrome,” American Journal of Obstetrics and Gynecol­ogy, in “Under­ standing and Treating Nausea and Vomiting of Pregnancy,” special issue, 186, no. 5, Supplement 2 (May 2002): S188, https://­doi​.­org​/­10​.­1067​/­mob​.­2002​.­122592. 37.  Denys V. I. Fairweather, “Nausea and Vomiting in Pregnancy,” American Journal of Obstetrics and Gynecol­ogy 102, no. 1 (September 1, 1968): 136–138, https://­ doi​.o ­ rg​/­10​.1­ 016​/­0002​-­9378(68)90445​-­6. 38.  Fairweather, “Nausea and Vomiting,” 138–139.

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39.  Rachael Russell, “Nausea and Vomiting: A History of Signs, Symptoms and Sickness in Nineteenth-­Century Britain” (PhD diss., University of Manchester, 2012), 135–136, 138, quote on 147, https://­w ww​.­escholar​.­manchester​.­ac​.­u k ​/­u k​-­ac​ -­man​-­scw:160923; Rachael Russell, “The Positive Side of Morning Sickness,” Well­ come Library: Researcher’s View, December 3, 2013, http://­blog​.­wellcomelibrary​ .­org​/­2013​/­03​/­g uest​-­post​-­the​-­positive​-­side​-­of​-­morning​-­sickness​/­. 40.  Russell, “Nausea and Vomiting,” 129. 41.  Russell, “Nausea and Vomiting,” chap. 4; Russell, “Positive Side.” 42.  Russell, “Nausea and Vomiting,” 138, quoted on 139. 43.  Renée Lacroix, Erica Eason, and Ronald Melzack, “Nausea and Vomiting during Pregnancy: A Prospective Study of Its Frequency, Intensity, and Patterns of Change,” American Journal of Obstetrics and Gynecol­ogy 182, no. 4 (April 2000): 935, 936, https://­doi​.­org​/­10​.­1016​/­S0002​-­9378(00)70349​-­8. 44.  Biggs, “Vomiting in Pregnancy,” 302; Lane, “Nausea and Vomiting,” 101; Russell, “Nausea and Vomiting.” 45.  Russell, “Nausea and Vomiting,” see chap. 4. 46.  C. Oldfield, “Pernicious Vomiting of Pregnancy,” The Lancet 199, no. 5149 (May 6, 1922): 917 [first published in vol. 1, no. 5149], https://­doi​.o ­ rg​/­10​.­1016​/­S0140​ -­6736(00)95620​-­4. 47.  Whitridge Williams is quoted on 528 of Arthur F. Hurst, “The Hysterical Nature of So-­Called Pernicious Vomiting of Pregnancy,” The Lancet 199, no. 5142 (March 18, 1922): 528–529 [first published vol. 1, no. 5142], https://­doi​.­org​/­10​.­1016​ /­S0140​-­6736(01)26208​-­4; Oldfield, “Pernicious Vomiting, 917; “Pernicious Vom­ iting of Pregnancy,” Journal of the American Medical Association 82, no.  5 ­ 2650310048020; “Per­ (February 2, 1924): 394–395, https://­doi​.­org​/­10​.­1001​/­jama​.­1924​.0 nicious Vomiting of Pregnancy,” Journal of the American Medical Association 54, ­ rg​/1­ 0​.­1001​/j­ ama​.­1910​.0 ­ 2550330036003; no. 7 (February 12, 1910): 538–538, https://­doi​.o Russell, “Nausea and Vomiting,” 155–161, 229–230. 48.  Hurst, “Hysterical Nature,” 528. 49.  H. B. Atlee, “The Treatment of the Pernicious Vomiting of Pregnancy,” Canadian Medical Association Journal 15, no. 4 (April 1925): 388–389, https://­w ww​ .­ncbi​.­nlm​.­nih​.g­ ov​/p ­ ubmed​/2­ 0315332. 50.  Hurst, “Hysterical Nature,” 529; Fairweather, “Nausea and Vomiting,” 146, 153. 51.  Atlee, “Pernicious Vomiting,” 388. 52.  P.  L.  C. Diggory and J.  S. Tomkinson, “Nausea and Vomiting in Preg­ nancy a Trial of Meclozine Dihydrochloride with and without Pyridoxine,” The Lancet 280, no. 7252 (August 1962): 371–372, https://­doi​.­org ​/­10​.­1016​/­S0140​ -­6736(62)90228​-­3.

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Science 345, no.  6203 (September  19, 2014): 1446–1447, https://­doi​.­org​/­10​.­1126​ /­science​.­345​.­6203​.­1446; Ted J. Kaptchuk and Franklin G. Miller, “Placebo Effects in Medicine,” New E ­ ngland Journal of Medicine 373, no.  1 (July  2, 2015): 8–9, https://­doi​.­org​/­10​.­1056​/­N EJMp1504023; “Power of the Placebo Effect,” Harvard Health, May  2017, http://­w ww​.­health​.­harvard​.­e du​/­mental​-­health​/­t he​-­power​ -­of​-­the​-­placebo​-­effect; Price, Finniss, and Benedetti, “Comprehensive Review,” 570, 576, 585. 64.  Price, Finniss, and Benedetti, “Comprehensive Review,” 585. 65.  James Hamblin, “­There Is No ‘Alternative Medicine,’ ” The Atlantic, Octo­ ber 2014, https://­w ww​.­t heatlantic​.­com​/­magazine​/­a rchive​/­2014​/­10​/­t here​-­is​-­no​ -­alternative​-­medicine​/­379342​/­. 66.  Matthews et al., “Interventions for Nausea,” 4. 67.  Badell, Ramin, and Smith, “Treatment Options,” 1283. 68.  Donald M. Marcus and Wayne R. Snodgrass, “Do No Harm: Avoidance of Herbal Medicines during Pregnancy,” Obstetrics and Gynecol­ogy 105, no. 5 (May 2005): 1119. 69.  Lane, “Nausea and Vomiting,” 104. 70.  Patricia Aikins Murphy, “Alternative Therapies for Nausea and Vomiting of Pregnancy,” Obstetrics and Gynecol­ogy 91, no. 1 (January 1998): 149, https://­doi​ .­org​/­10​.­1016​/­s0029​-­7844(97)00582​-­6. 71.  Joseph A. Roscoe and Sara E. Matteson, “Acupressure and Acustimulation Bands for Control of Nausea: A Brief Review,” in “Understanding and Treating Nausea and Vomiting of Pregnancy,” special issue, American Journal of Obstetrics and Gynecol­ogy 186, no. 5, Supplement 2 (May 2002): S246, https://­doi​.­org​/­10​ .­1067​/­mob​.­2002​.­122606; Badell, Ramin, and Smith, “Treatment Options,” 1284. 72.  Niebyl and Goodwin, “Overview of Nausea,” S253; Davis, “Nausea and Vom­ iting,” 321; Badell, Ramin, and Smith, “Treatment Options,” 1278. 73.  Davis, “Nausea and Vomiting,” 319. 74.  Mingshuang Ding, Matthew Leach, and Helen Bradley, “The Effectiveness and Safety of Ginger for Pregnancy-­Induced Nausea and Vomiting: A Systematic Review,” ­Women and Birth 26, no. 1 (March 2013): e26, e29, https://­doi​.­org​/­10​.­1016​ /­j​.w ­ ombi​.2­ 012​.­08​.­001. 75.  Michelle Wool­house, “Complementary Medicine for Pregnancy Compli­ cations,” Australian F ­ amily Physician 35, no.  9 (September  2006), 695, https://­ europepmc​.­org​/­article​/­med​/­16969438. 76.  E. Bryer, “A Lit­er­a­ture Review of the Effectiveness of Ginger in Alleviating Mild-­to-­Moderate Nausea and Vomiting of Pregnancy,” Journal of Midwifery and ­Women’s Health 50, no. 1 (January 2005): E2, https://­doi​.­org​/­10​.­1016​/­j​.­jmwh​.­2004​ .­08​.­023.

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77.  Karen E. Willetts, Abie Ekangaki, and John A. Eden, “Effect of a Ginger Extract on Pregnancy-­Induced Nausea: A Randomised Controlled Trial,” Australian and New Zealand Journal of Obstetrics and Gynaecol­ogy 43, no. 2 (April 2003): 139, 143, https://­doi​.­org​/­10​.­1046​/j­ ​.­0004​-­8666​.­2003​.­00039​.­x. 78.  Maggie Thomson, Renee Corbin, and Lawrence Leung, “Effects of Ginger for Nausea and Vomiting in Early Pregnancy: A Meta-­Analysis,” Journal of the American Board of F ­ amily Medicine 27, no. 1 (January 1, 2014): 115, https://­doi​.­org​ /­10​.­3122​/j­ abfm​.­2014​.­01​.­130167. 79.  Thomson, Corbin, and Leung, “Effects of Ginger,” 118. 80.  Koren et al., “Delayed-­Release Doxylamine,” 571.e3. 81.  H. S. Winters, “Antiemetics in Nausea, and Vomiting of Pregnancy,” Obstetrics and Gynecol­ogy 18 (December 1961): 755. 82.  Matok et al., “Characteristics of ­Women,” 559. 83.  Fairweather, “Nausea and Vomiting,” 146. 84.  Forrest D. Tierson, Carolyn L. Olsen, and Ernest B. Hook, “Nausea and Vomiting of Pregnancy and Association with Pregnancy Outcome,” American Journal of Obstetrics and Gynecol­ogy 155, no. 5 (November 1, 1986): 1017, https://­ doi​.­org​/­10​.­1016​/­0002​-­9378(86)90337​-­6. 85.  Pirisi, “Meaning of Morning Sickness,” 1272. 86.  Flaxman and Sherman, “Morning Sickness,” 60. 87.  Adrienne LaFrance, “The Protective Power of Morning Sickness,” The Atlantic, September 26, 2016, https://­w ww​.­t heatlantic​.­com​/­health​/­archive​/­2016​/­09​/­t he​ -­protective​-­power​-­of​-­morning​-­sickness​/­501551​/­; Elissa Strauss and Ruth Graham, “Morning Sickness Is No Fun for a Mom, but It May Be Good for Her Baby,” Slate, September 28, 2016, http://­w ww​.­slate​.­com​/­blogs​/­x x ​_­factor​/­2016​/­09​/­28​/­morning​ _­sickness​_­is​_n ­ o​_­f un​_f­ or​_ a­ ​_m ­ om​_­but​_­it​_m ­ ay​_­be​_ ­good​_­for​_­baby​.­html. 88.  Kiefer, “Morning Sickness.” 89.  T. Dougray, “Antihistamines in the Treatment of Nausea and Vomiting of Pregnancy: Report on a Clinical Investigation,” British Medical Journal 2, no. 4636 (1949): 1083, https://­doi​.­org​/1­ 0​.­1136​/­bmj​.­2​.­4636​.­1081.

chapter 3 ​—­ ​grow 1.  J. Morris Slemons, The Nutrition of the Fetus (New Haven, CT: Yale Univer­ sity Press, 1919), 7. 2.  E G. Cook, Eutocia: Easy Favorable Child Bearing, A Book for All ­Women, Health and Happiness for the C ­ hildren—­Home Treatment, and a Complete Manual for the House­hold (Chicago: Arcade, 1886), 55; Max West, Prenatal Care, Pub­ lication No. 4, Care of ­Children Series No. 1 (Washington, D.C.: U.S. C ­ hildren’s Bureau, Government Printing Office, 1915), 9.

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219

3.  Martin Luther Holbrook, ed., Parturition without Pain: A Code of Directions for Escaping from the Primal Curse (New York: M. L. Holbrook, 1891), 62. 4.  Emma F. Angell Drake, What a Young Wife ­Ought to Know (Philadelphia: Vir, 1901), 149; Susanna Cocroft, Motherhood: The Generative Organs, Their Purpose, and Derangements (Chicago: Headington, 1906), 115; West, Prenatal Care, 9; Slemons, Nutrition of the Fetus, 46; Carolyn C. Van Blarcom, Getting Ready to Be a ­Mother: A L ­ ittle Book of Information and Advice for the Young ­Woman Who Is Looking Forward to Motherhood (New York: MacMillan, 1922), 49; American Child Health Association, The Ex­pec­tant ­Mother in the House of Health (New York: American Child Health Association, 1924), 10. 5.  Claude Edwin Heaton, Modern Motherhood: A Book of Information on Complete Maternity Care: Prenatal—­Delivery—­Aftercare (New York: Farrar & Rine­ ­ athitrust​.­org​/­Record​/­009074496. hart, 1935), 19, https://­catalog​.h 6.  J. Robert Willson, “The Management of Excessive Weight Gain in Pregnancy,” Pennsylvania Medical Journal 52, no. 4 (January 1949): 384. 7.  New York State Department of Health Bureau of Maternal and Child Health, Parents Book, 1950, 11. 8.  Samuel R. Meaker, Preparing for Motherhood: A Manual for Ex­p ec­t ant Parents (Chicago: Year Book, 1956), 80, https://­a rchive​.­org​/­details​/­prepar­ing​ formoth00meak; Albert  W. Bauer, “Food and Posture during Pregnancy,” Lancet 279, no. 7242 (June 1962): 1268, https://­doi​.­org​/­10​.­1016​/­S 0140​-­6736(62)​ 92366​-­8. 9. Heaton, Modern Motherhood, 17. 10.  Michigan Department of Health, The Michigan M ­ others’ Manual (Lansing, 1926), 12. 11. Holbrook, Parturition without Pain, 64–65. 12.  M. M. Abitbol, “Weight Gain in Pregnancy,” American Journal of Obstetrics and Gynecol­ogy 104, no. 1 (May 1, 1969): 140–157, https://­doi​.­org​/­10​.­1016​/s­ 0002​ -­9378(16)34153​-­9. 13.  Ronald A. Chez, “Editorial: Weight Gain during Pregnancy,” American Journal of Public Health 76, no. 12 (December 1986): 1390, https://­doi​.­org​/­10​.­2105​/­ajph​ .­76​.­12​.­1390. 14.  D. S. Feig and C. D. Naylor, “Eating for Two: Are Guidelines for Weight Gain during Pregnancy Too Liberal?” Lancet 351, no. 9108 (April 4, 1998): 1054, https://­ doi​.­org​/­10​.­1016​/­S0140​-­6736(97)06261​-­2. 15.  B. F. Abrams and R. K. Laros, “Prepregnancy Weight, Weight Gain, and Birth Weight,” American Journal of Obstetrics and Gynecol­ogy 154, no. 3 (March 1986): 503, https://­doi​.­org​/­10​.­1016​/­0002​-­9378(86)90591​-­0. 16.  Willson, “Management of Excessive Weight Gain,” 384.

220

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17. Meaker, Preparing for Motherhood, 90; Bureau of Maternal and Child Health, Parents Book, 13. 18.  Ann Mullins, “Overweight in Pregnancy,” Lancet 275, no.  7116 (Janu­ ary 1960): 146, https://­doi​.­org​/1­ 0​.­1016​/s­ 0140​-­6736(60)90059​-­3; D. Craddock, “The Normal Weight Gain in Pregnancy: A Series from General Practice,” Journal of Obstetrics and Gynaecol­ogy of the British Commonwealth 77, no. 8 (August 1970): 729, https://­doi​.­org​/1­ 0​.­1111​/­j​.­1471​-­0528​.­1970​.­tb03599​.­x; L. O. Poidevin, “Weight Gain in Pregnancy,” Medical Journal of Australia 47(2) (August 27, 1960): 324, https://­ doi​.­org​/­10​.­5694​/­j​.­1326​-­5377​.­1960​.­tb68460​.­x. 19.  Abrams and Laros, “Prepregnancy Weight,” 503. 20.  S. Breslow et al., “Control of Weight Gain in Pregnancy: Double Blind Study of a Dieting Aid,” Clinical Medicine (Northfield) 70 (May 1963): 936. 21. Meaker, Preparing for Motherhood, 80; J. W. Simpson, R. W. Lawless, and A. C. Mitchell, “Responsibility of the Obstetrician to the Fetus. II. Influence of Prepregnancy Weight and Pregnancy Weight Gain on Birthweight,” Obstetrics and Gynecol­ogy 45, no. 5 (May 1975): 482; “New Dietary Yardstick,” New York Times, May 26, 1941. 22.  Willson, “Management of Excessive Weight Gain,” 385; Meaker, Preparing for Motherhood, 90–91; J. H. Bolton, “Certain Aspects of Weight Gain,” Medical Journal of Australia 45, no. 22 (November 29, 1958): 727; Breslow et al., “Control of Weight Gain.” 23.  Willson, “Management of Excessive Weight Gain,” 388. 24.  Willson, “Management of Excessive Weight Gain,” 388. 25.  “Diet Restrictions Termed Harmful to Unborn Child,” New York Times, October 15, 1958, https://­w ww​.­nytimes​.­com​/­1958​/­10​/­15​/­a rchives​/­diet​-­restrictions​ -­termed​-­harmful​-­to​-­unborn​-­child​.­html. 26. Holbrook, Parturition without Pain, 64; Simpson, Lawless, and Mitchell, “Responsibility of the Obstetrician,” 482; Abrams and Laros, “Prepregnancy Weight,” 503. 27. Holbrook, Parturition without Pain, 64–65, Dr. Bull quoted on 62. 28. Slemons, Nutrition of the Fetus, 7. 29.  I. Nyirjesy, W. M. Lonergan, and J. J. Kane, “Clinical Significance of Total Weight Gain in Pregnancy. I. Primipara,” Obstetrics and Gynecol­ogy 32, no. 3 (Sep­ tember 1968): 394; Craddock, “Normal Weight Gain,” 728. 30.  J. Klein, “The Relationship of Maternal Weight Gain to the Weight of the Newborn Infant,” American Journal of Obstetrics and Gynecol­ogy 52, no. 4 (Octo­ ber 1946): 580, https://­doi​.o ­ rg​/­10​.­1016​/­0002​-­9378(46)90122​-­6. 31.  Breslow et al., “Control of Weight Gain,” 931. 32.  Abitbol, “Weight Gain in Pregnancy,” 141, 144.

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221

33.  Craddock, “Normal Weight Gain.” 34.  Nyirjesy, Lonergan, and Kane, “Clinical Significance,” 391, 395, 396. 35. J. Pomerance, “Weight Gain in Pregnancy: How Much Is Enough?” Clinical Pediatrics 11, no. 10 (October 1972): 555, https://­doi​.­org ​/­10​.­1 177​/­0009​ 92287201101002. 36.  Simpson, Lawless, and Mitchell, “Responsibility of the Obstetrician,” 484. 37.  D. R. Tavris and J. A. Read, “Effect of Maternal Weight Gain on Fetal, Infant, and Childhood Death and on Cognitive Development,” Obstetrics and Gynecol­ ogy 60, no. 6 (December 1982): 692–693. 38.  Harold Schmeck, “Pregnant W ­ omen Advised to Gain,” New York Times, July  30, 1970, https://­w ww​.­nytimes​.­com​/­1970​/­07​/­30​/­a rchives​/­pregnant​-­women​ -­advised​-­to​-­gain​-­study​-­finds​-­limit​-­on​-­weight​-­can​-­be​.­html. 39.  A. Gormican, J. Valentine, and E. Satter, “Relationships of Maternal Weight ­ actors Gain, Prepregnancy Weight, and Infant Birthweight. Interaction of Weight F in Pregnancy,” Journal of the American Dietetic Association 77, no. 6 (Decem­ ber 1980): 662; Abrams and Laros, “Prepregnancy Weight,” 504. 40.  Schmeck, “Pregnant ­Women Advised to Gain”; Abrams and Laros, “Pre­ pregnancy Weight,” 504. 41.  Feig and Naylor, “Eating for Two,” 1054; Jane Brody, “Low Birth Weight Is Linked to Ills: British Study Cites Effects of Poor Fetal Nutrition,” New York Times, November  14, 1972, https://­w ww​.­nytimes​.­com​/­1972​/­11​/­1 4​/­a rchives​/­low​-­birth​ -­weight​-­is​-­linked​-­to​-­ills​-­british​-­study​-­cites​-­effects​-­of​.­html. 42.  Simpson, Lawless, and Mitchell, “Responsibility of the Obstetrician,” 484; Frances Cerra, “Weight Gain in Pregnancy: A More Tolerant Approach,” New York Times, October  19, 1979, https://­w ww​.­nytimes​.­com​/­1979​/­10​/­19​/­a rchives​ /­weight​-­gain​-­in​-­pregnancy​-­a​-­more​-­tolerant​-­approach​.­html. 43.  Jane Brody, “Feeding the Unborn: Some Diet Wisdom for Mothers-­to-­Be,” New York Times, November  28, 1979, https://­w ww​.­nytimes​.­com​/­1979​/­11​/­28​ /­a rchives​/­feeding​-­the​-­unborn​-­some​-­diet​-­wisdom​-­for​-­motherstobe​-­personal​ -­health​.­html. 44.  Cerra, “Weight Gain in Pregnancy.” 45.  Selma M. Taffel and Kenneth G. Keppel, “Advice about Weight Gain dur­ ing Pregnancy and ­Actual Weight Gain,” American Journal of Public Health 76, no. 12 (December 1986): 1396, https://­doi​.­org​/­10​.­2105​/­ajph​.­76​.­12​.­1396. 46.  Brody, “Feeding the Unborn”; Judith Wershil Hasan, “Of Pregnancy and Nutrition,” New York Times, October 21, 1979, https://­w ww​.­nytimes​.­com​/1­ 979​/­10​ /­21​/­a rchives​/­westchester​-­weekly​-­of​-­pregnancy​-­and​-­nutrition​.­html; Gormican, Valentine, and Satter, “Relationships of Maternal Weight Gain,” 662; Anna Quindlen, “The New Rules for Pregnancy,” New York Times, September 28, 1986,

222

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https://­w ww​.­nytimes​.­com​/­1986​/­09​/­2 8​/­magazine​/­t he​-­new​-­rules​-­for​-­pregnancy​ .­html; “What to Eat,” New York Times, September 28, 1986. 47.  Jane Brody, “Fetal Health: A New View Emerges,” New York Times, Febru­ ary 16, 1982, https://­w ww​.­nytimes​.­com​/­1982​/­02​/­16​/­science​/­fetal​-­health​-­a​-­new​-­view​ -­emerges​.­html. 48.  Tavris and Read, “Effect of Maternal Weight Gain,” 689. 49.  Peter N. Stearns, Fat History: Bodies and Beauty in the Modern West (New York: New York University Press, 2002). 50.  Barbara Abrams, Sarah L. Altman, and Kate E. Pickett, “Pregnancy Weight Gain: Still Controversial,” American Journal of Clinical Nutrition 71, no.  5 (May 2000): 1233s–1241, https://­doi​.­org​/­10​.­1093​/­ajcn​/­71​.­5​.­1233s; Gormican, Valen­ tine, and Satter, “Relationships of Maternal Weight Gain,” 664, 665, 666–667. 51.  Abrams, Altman, and Pickett, “Pregnancy Weight Gain.” 52.  Munim Mannan, Suhail AR Doi, and Abdullah A Mamun, “Association between Weight Gain during Pregnancy and Postpartum Weight Retention and Obesity: A Bias-­Adjusted Meta-­Analysis,” Nutrition Reviews 71, no. 6 (June 1, 2013): 346, https://­doi​.­org​/­10​.­1111​/­nure​.­12034. 53. Raul Artal, Charles  J. Lockwood, and Haywood  L. Brown, “Weight Gain Recommendations in Pregnancy and the Obesity Epidemic,” Obstetrics and  Gynecol­ogy 115, no.  1 (January  2010): 152, https://­doi​.­org​/­10​.­1097​/­AOG​ .­0b013e3181c51908; Rebecca F. Goldstein et al., “Association of Gestational Weight Gain with Maternal and Infant Outcomes: A Systematic Review and Meta-­ Analysis,” JAMA 317, no. 21 (June 6, 2017): 2208, https://­doi​.­org​/­10​.­1001​/­jama​.­2017​ .­3635. 54.  Julie Johnson et al., “Pregnancy Outcomes with Weight Gain above or below the 2009 Institute of Medicine Guidelines,” Obstetrics and Gynecol­ogy 121, no. 5 (May 2013): 969–975, https://­doi​.­org​/­10​.­1097​/­AOG​.­0b013e31828aea03. 55.  Artal, Lockwood, and Brown, “Weight Gain Recommendations,” 152; Feig and Naylor, “Eating for Two,” 1054; Associated Press, “Pregnant ­Women Can Gain More and Skip Vitamins, a Panel Says,” New York Times, June 7, 1990, https://­w ww​ .­n ytimes​ .­c om​ /­1990​ /­0 6​ /­0 7​ /­u s​ /­p regnant​-­women​-­can​-­gain​-­more​-­and​-­skip​ -­vitamins​-­a​-­panel​-­says​.­html; Janet C. King, “New National Acad­emy of Sciences Guidelines for Nutrition during Pregnancy,” Diabetes 40, Supplement 2 (Decem­ ber 1991): 151, https://­doi​.­org​/­10​.­2337​/­diab​.­40​.­2​.­s151. 56.  Institute of Medicine, Committee on Nutritional Status during Pregnancy and Lactation, Nutrition during Pregnancy: Part I Weight Gain: Part II Nutrient Supplements (Washington, DC: National Academies Press, 1990), http://­w ww​.­ncbi​ .­nlm​.­nih​.­gov​/­books​/­NBK235228​/­; Associated Press, “Pregnant ­Women Can Gain More.”

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57.  Feig and Naylor, “Eating for Two,” 1054–1055; J. W. Johnson, J. A. Longmate, and B. Frentzen, “Excessive Maternal Weight and Pregnancy Outcome,” American Journal of Obstetrics and Gynecol­ogy 167, no. 2 (August 1992): 353, 366, 369, https://­doi​.­org​/­10​.1­ 016​/­s0002​-­9378(11)91414​-­8. 58. Anemona Hartocllis, “Growing Obesity Increases Perils of Child­ bearing,” New York Times, June 6, 2010, https://­w ww​.­nytimes​.­com​/­2010​/­06​/­06​ /­health​/­06obese​.­html; Artal, Lockwood, and Brown, “Weight Gain Recom­ mendations,” 152. 59.  Marie I. Cedergren, “Optimal Gestational Weight Gain for Body Mass Index Categories,” Obstetrics and Gynecol­ogy 110, no. 4 (October 2007): 759, 763, https://­ doi​.­org​/­10​.­1097​/­01​.­AOG​.­0000279450​.­85198​.b ­ 2. 60.  Tara Parker-­Pope, “Study Urges Weight Gain Be Reduced in Pregnancy,” New York Times, May  28, 2009, https://­w ww​.­nytimes​.­com​/­2009​/­05​/­29​/­health​ /­research​/­29pregnant​.­html; Kathleen M. Rasmussen et al., “Recommendations for Weight Gain during Pregnancy in the Context of the Obesity Epidemic,” Obstetrics and Gynecol­ogy 116, no. 5 (November 2010): 1192, https://­doi​.­org​/­10​.­1097​/A ­ OG​ .­0b013e3181f60da7. 61.  American College of Obstetricians and Gynecologists, “ACOG Committee Opinion No. 548: Weight Gain during Pregnancy,” Obstetrics and Gynecol­ogy 121, no. 1 (January 2013): 210–211, http://­10​.­1097​/­01​.­AOG​.0 ­ 000425668​.­87506​.­4c. 62.  Roni Caryn Rabin, “New Goal for the Obese: Zero Gain in Pregnancy,” New York Times, December  15, 2009, https://­w ww​.­nytimes​.­com​/­2009​/­12​/­15​/­health​ /­15obese​.­html. 63.  Hartocllis, “Growing Obesity.” 64.  Yen N. Truong et al., “Weight Gain in Pregnancy: Does the Institute of Med­ icine Have It Right?,” American Journal of Obstetrics and Gynecol­ogy 212, no. 3 (March 1, 2015): 362.e1, https://­doi​.­org​/­10​.­1016​/­j​.­ajog​.­2015​.­01​.­027; Johnson et al., “Pregnancy Outcomes”; Tara Haelle and Emily Willingham, The Informed Parent: A Science-­Based Resource for Your Child’s First Four Years (New York: TarcherPerigee, 2016), 7. 65.  Centers for Disease Control and Prevention, “Weight Gain During Preg­ nancy,” updated December  7, 2020, https://­w ww​.­cdc​.­gov​/­reproductivehealth​ /­maternalinfanthealth​/­pregnancy​-­weight​-­gain​.h ­ tm; Goldstein et al., “Association of Gestational Weight Gain,” 2207, 2209, 2221–23; Rachel Shulman and Melissa Kottke, “Impact of Maternal Knowledge of Recommended Weight Gain in Preg­ nancy on Gestational Weight Gain,” American Journal of Obstetrics and Gynecol­ ogy 214, no. 6 (June 2016): 754.e1, https://­doi​.o ­ rg​/1­ 0​.­1016​/­j​.a­ jog​.­2016​.­03​.­021. 66.  Johnson et  al., “Pregnancy Outcomes,” 5–6; Kathleen  M. Rasmussen, Ann L. Yaktine, and Institute of Medicine, eds., Weight Gain during Pregnancy:

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Reexamining the Guidelines (Washington, DC: National Academies Press, 2009), 186; Meera Viswanathan et al., Outcomes of Maternal Weight Gain (Rockville, MD: Agency for Healthcare Research and Quality, 2008), https://­w ww​.­ncbi​ .­n lm​.­nih​.­gov​/­books​/­NBK38595​/­. 67.  Haelle and Willingham, Informed Parent, 8. 68.  M. E. Cogswell et al., “Gestational Weight Gain among Average-­Weight and Overweight ­Women—­W hat Is Excessive?” American Journal of Obstetrics and Gynecol­ogy 172, no.  2 (February  1995): 706, https://­doi​.­org​/­10​.­1016​/­0002​ -­9378(95)90598​-­7. 69.  Associated Press, “Being Thin While Pregnant Is Seen as Best,” New York Times, January 15, 1998, https://­w ww​.n ­ ytimes​.­com​/1­ 998​/­01​/­15​/­us​/b ­ eing​-­thin​-­while​ -­pregnant​-­is​-­seen​-­as​-­best​.­html. 70.  Artal, Lockwood, and Brown, “Weight Gain Recommendations,” 154. 71.  Christine M. Furber et al., “Antenatal Interventions for Reducing Weight in Obese ­Women for Improving Pregnancy Outcome,” Cochrane Database of Systematic Reviews, no.  1 (January  31, 2013 ): CD009334, https://­doi​.­org​/­10​.­1002​ /­14651858​.­CD009334​.­pub2. 72.  Mannan, Doi, and Mamun, “Association between Weight Gain,” 345, 346, 351; Rasmussen, Yaktine, and Institute of Medicine, Weight Gain during Pregnancy, 186. 73.  Nicholas Bakalar, “Having a Baby: Risk Seen in Weight Gain between Preg­ nancies,” New York Times, October 17, 2006, https://­w ww​.­nytimes​.­com​/­2006​/­10​ /­17​/­health​/1­ 7preg​.h ­ tml. 74.  Abitbol, “Weight Gain in Pregnancy,” 144; Rasmussen, Yaktine, and Insti­ tute of Medicine, Weight Gain during Pregnancy. 75.  R. Gaillard et al., “Maternal Weight Gain in Dif­fer­ent Periods of Pregnancy and Childhood Cardio-­Metabolic Outcomes. The Generation R Study,” International Journal of Obesity 39, no.  4 (April  2015): 677, https://­doi​.­org​/­10​.­1038​/­ijo​ .­2014​.­175. 76.  Hartocllis, “Growing Obesity.” 77.  Nicholas Bakalar, “On the Scales: Findings Challenge Guidelines for Weight Gain in Pregnancy,” New York Times, April 10, 2007, https://­w ww​.­nytimes​.­com​ /­2007​/0 ­ 4​/1­ 0​/­health​/­nutrition​/1­ 0scal​.­html; Rasmussen, Yaktine, and Institute of Medicine, Weight Gain during Pregnancy, 229. Jane Brody, “Weight Prob­lems May Begin in the Womb,” New York Times, September 7, 2010, https://­w ww​.n ­ ytimes​ .­com​/­2010​/0 ­ 9​/0 ­ 7​/­health​/0 ­ 7brody​.h ­ tml. 78.  Rabin, “New Goal”; Artal, Lockwood, and Brown, “Weight Gain Recom­ mendations,” 154. 79. Heaton, Modern Motherhood, 22.

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80.  Klein, “Relationship of Maternal Weight Gain,” 575, 577, 580. 81. Meaker, Preparing for Motherhood, 80. 82.  Artal, Lockwood, and Brown, “Weight Gain Recommendations,” 153; Bauer, “Food and Posture,” 1268; Brody, “Fetal Health,” 689. 83.  See, for example, N. J. Eastman and E. Jackson, “Weight Relationships in Pregnancy. I. The Bearing of Maternal Weight Gain and Pre-­Pregnancy Weight on Birth Weight in Full Term Pregnancies,” Obstetrical and Gynecological Survey 23, no. 11 (November 1968): 1003–1025. 84. ­Children’s Bureau, Prenatal Care (Washington, DC: U.S. Department of Health, Education, and Welfare, 1962), 22. 85.  K. R. Niswander et al., “Weight Gain during Pregnancy and Prepregnancy Weight. Association with Birth Weight of Term Gestation,” Obstetrics and Gynecol­ogy 33, no. 4 (April 1969): 489. 86.  Pomerance, “Weight Gain in Pregnancy,” 554–555. 87. Gormican, Valentine, and Satter, “Relationships of Maternal Weight Gain,” 665. 88.  Rasmussen, Yaktine, and Institute of Medicine, Weight Gain during Pregnancy, 228–229. 89.  Emily Oster, Expecting Better: Why Conventional Pregnancy Wisdom Is Wrong—­and What You ­Really Need to Know (New York: Penguin Books, 2013), 140–142. 90.  Abrams and Laros, “Prepregnancy Weight,” 506–508. 91.  Aaron B. Caughey, “Gestational Weight Gain and Outcomes for M ­ others and Infants,” JAMA 317, no. 21 (June 6, 2017): 2175, https://­doi​.­org​/1­ 0​.­1001​/­jama​.­2017​ .­6265. 92. Oster, Expecting Better. 93.  Jane C. Willcox et al., “Excess Gestational Weight Gain: An Exploration of Midwives’ Views and Practice,” BMC Pregnancy and Childbirth 12, no. 1 (Decem­ ber 2012), https://­doi​.­org​/­10​.­1186​/­1471​-­2393​-­12​-­102. 94.  Ashley Weeks et al., “Inconsistent Weight Communication Among Prena­ tal Healthcare Providers and Patients: A Narrative Review,” Obstetrical and Gynecological Survey 73, no. 8 (August 2018): 486–499, https://­doi​.­org ​/­10​.­1097​/­OGX​ .­0000000000000588. 95.  Shanna M. Fealy et al., “Weighing as a Stand-­A lone Intervention Does Not Reduce Excessive Gestational Weight Gain Compared to Routine Antenatal Care: A Systematic Review and Meta-­Analysis of Randomised Controlled T ­ rials,” BMC Pregnancy and Childbirth 17, no. 1 (2017): 36, https://­doi​.­org ​/­10​.­1186​/­s12884​-­016​ -­1207​-­2; D. L. Dimperio, B. H. Frentzen, and A. C. Cruz, “Routine Weighing dur­ ing Antenatal Visits.,” BMJ 304, no. 6825 (February 22, 1992): 460–460, https://­

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doi​.­org​/­10​.­1136​/ ­bmj​.­304​.­6825​.4­ 60; George T. H. Ellison and Mary Holliday, “The Use of Maternal Weight Mea­sure­ments during Antenatal Care. A National Sur­ vey of Midwifery Practice throughout the United Kingdom,” Journal of Evaluation in Clinical Practice 3, no. 4 (November 1997): 303–317, https://­doi​.o ­ rg​/­10​.­1046​ /­j​.­1365​-­2753​.­1997​.t­ 01​-­1​-­00007​.x­ . 96. Drake, What a Young Wife ­Ought to Know, 149. 97. Slemons, Nutrition of the Fetus, 46–47. 98. Holbrook, Parturition without Pain, 65. 99.  Taffel and Keppel, “Advice about Weight Gain,” 1396. 100. Meaker, Preparing for Motherhood, 93. 101.  Feig and Naylor, “Eating for Two,” 1055.

chapter 4 ​—­ ​­ eat 1.  Melitta Weiss-­Amer, “Medieval ­Women’s Guides to Food during Pregnancy: Origins, Texts, and Traditions,” Canadian Bulletin of Medical History, Decem­ ber 13, 2016, https://­doi​.­org ​/­10​.­3138​/­cbmh​.­10​.­1​.­5; Sara Dickerman, “Food Fright,” Slate, September 15, 2004, https://­slate​.­com​/­human​-­interest​/­2004​/­09​/­have​-­pregnant​ -­women​-­always​-­been​-­scared​-­by​-­food​.­html. 2. Carolyn  C. Van Blarcom, Getting Ready to Be a ­Mother: A ­Little Book of ­Information and Advice for the Young ­Woman Who Is Looking Forward to Motherhood (New York: MacMillan, 1922), 48; E.  G. Cook, Eutocia: Easy Favorable Child Bearing, A Book for All ­Women, Health and Happiness for the ­Children— Home Treatment, and a Complete Manual for the House­hold (Chicago: Arcade, 1886), 52. 3.  Victoria Glover, “ ‘To Conceive with Child Is the Earnest Desire If Not of All, ­ omen’: The Advancement of Prenatal Care and Childbirth in Early Yet of Most W Modern ­England: 1500–1770” (master’s thesis, ­Virginia Commonwealth Univer­ sity, 2018), 70–72, https://­scholarscompass​.­vcu​.­edu​/­etd​/­5694. 4.  Joan Jacobs Brumberg, Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease (Cambridge, MA: Harvard University Press, 1988), 136, 174. 5.  Robert Barnes and Fancourt Barnes, A System of Obstetric Medicine and Surgery: Theoretical and Clinical, vol. 1 (London: Smith, Elder, and Co., 1884), 216; Cheryl K. Lemus, “ ‘The Maternity Racket’: Medicine, Consumerism, and the Modern American Pregnancy, 1876–1960” (PhD diss., Northern Illinois Univer­ sity, 2011), https://­search​.­proquest​.­com​/­docview​/­894441403​/­abstract​/­94CBB​42​ B00​AB4074PQ​/1­ . 6.  Katie Fesler, “The Craving Brain,” Tufts Nutrition Magazine, Winter 2014, https://­now​.­tufts​.­edu​/­articles​/­craving​-­brain.

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7.  Natalia C. Orloff and Julia M. Hormes, “Pickles and Ice Cream! Food Crav­ ings in Pregnancy: Hypotheses, Preliminary Evidence, and Directions for ­Future Research,” Frontiers in Psy­chol­ogy 5 (September 23, 2014), https://­doi​.­org​/­10​.­3389​ /­f psyg​.­2014​.­01076. 8.  Orloff and Hormes, “Pickles and Ice Cream.” 9.  Victor Benno Meyer-­Rochow, “Food Taboos: Their Origins and Purposes,” Journal of Ethnobiology and Ethnomedicine 5, no. 1 (December 2009), https://­doi​ .­org​/­10​.­1186​/­1746​-­4269​-­5​-­18; Sreetama Chakrabarti and Abhik Chakrabarti, “Food ­ omen Living in a Rural Area Taboos in Pregnancy and Early Lactation among W of West Bengal,” Journal of ­Family Medicine and Primary Care 8, no. 1 (Janu­ ary  2019): 86–90, https://­doi​.­org​/­10​.­4103​/­jfmpc​.j­ fmpc​_ ­53​_­17; Gamuchirai Cha­ kona and Charlie Shackleton, “Food Taboos and Cultural Beliefs Influence Food Choice and Dietary Preferences among Pregnant ­Women in the Eastern Cape, South Africa,” Nutrients 11, no.  11 (November  5, 2019), https://­doi​.­org​/­10​.­3390​ /­nu11112668. 10.  Daniel Silas Adamson, “The Myths about Food and Pregnancy,” BBC News, March 25, 2015, https://­w ww​.­bbc​.c­ om​/­news​/­magazine​-­32033409; Ying Lau, “Tra­ ditional Chinese Pregnancy Restrictions, Health-­Related Quality of Life and Per­ ceived Stress among Pregnant W ­ omen in Macao, China,” Asian Nursing Research 6, no. 1 (March 1, 2012): 27–34, https://­doi​.­org​/­10​.­1016​/­j​.­anr​.­2012​.­02​.­005; Orloff and Hormes, “Pickles and Ice Cream.” 11.  Chakona and Shackleton, “Food Taboos.” 12.  Orloff and Hormes, “Pickles and Ice Cream.” 13. Cook, Eutocia, 55–56. 14.  Emma F. Angell Drake, What a Young Wife O ­ ught to Know (Philadelphia: Vir, 1901). 15.  J. W. Ballantyne, Manual of Antenatal Pathology and Hygiene: The Foetus (New York: William Wood, 1902), 473, http://­hdl​.­handle​.­net​/­2027​/u ­ c1​.­b3848934. 16.  Lemus, “Maternity Racket.” 17. Cook, Eutocia, 51. 18.  Shannon Withycombe, Lost: Miscarriage in Nineteenth-­Century Amer­i­ca (New Brunswick, NJ: Rutgers University Press, 2019), 47, 74–75, 79; Leslie Reagan, Dangerous Pregnancies: M ­ others, Disabilities, and Abortion in Modern Amer­i­ca (Berkeley: University of California Press, 2010), 7–9. 19.  Glover, “To Conceive with Child,” 56. 20.  Van Blarcom, Getting Ready to Be a M ­ other, 47. 21. Reagan, Dangerous Pregnancies, 10. 22.  Van Blarcom, Getting Ready to Be a M ­ other, 49.

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23.  Quote from M. L. Holbrook, ed., Parturition without Pain: A Code of Directions for Escaping from the Primal Curse (New York: M. L. Holbrook, 1891), 65; quote from Van Blarcom, Getting Ready to Be a ­Mother, 49; Drake, What a Young Wife ­Ought to Know, 149. 24. Drake, What a Young Wife O ­ ught to Know. 25. Cook, Eutocia; Holbrook, Parturition without Pain, 50–53. 26. Cook, Eutocia, 56. 27. Holbrook, Parturition without Pain, 53–56. 28. Holbrook, Parturition without Pain, 58. 29.  Joseph  B. De Lee, The Princi­ples and Practice of Obstetrics (Philadel­ phia: W.B. Saunders, 1913), 225–226, http://­hdl​.­handle​.­net​/­2027​/­nnc2​.­a rk:​/­13960​ /­t6349dh39. ­ hildren Series 30.  Mrs. Max West, Prenatal Care, Publication No. 4, Care of C ­ hildren’s Bureau, Government Printing Office, No. 1 (Washington, DC: U.S. C 1915). 31.  Harvey Levenstein, Fear of Food: A History of Why We Worry about What We Eat (Chicago: University of Chicago Press, 2012). 32.  Susanna Cocroft, Motherhood: The Generative Organs, Their Purpose, and Derangements (Chicago: Headington, 1906), 115; West, Prenatal Care, 9. 33.  L. G. Van Scoyoc, “Obstetrics: Milk Diet in the Albuminuria of Pregnancy,” American Observer, September 1885, 136–137; “International Congress of Gynecol­ ogy and Obstetrics,” The Lancet, October 17, 1896, 1124–1122. 34. Ballantyne, Manual of Antenatal Pathology, 472–474; Irene Hoesli, “Nutri­ tion in Pregnancy,” The Global Library of W ­ omen’s Medicine, April 2009, https://­ doi​.o ­ rg​/1­ 0​.3­ 843​/G ­ LOWM​.­10097; Van Blarcom, Getting Ready to Be a ­Mother, 50. 35.  J. W. Simpson, R. W. Lawless, and A. C. Mitchell, “Responsibility of the Obstetrician to the Fetus. II. Influence of Prepregnancy Weight and Pregnancy Weight Gain on Birthweight,” Obstetrics and Gynecol­ogy 45, no. 5 (May 1975): 484. 36.  Stephen Devries, Walter Willett, and Robert O. Bonow, “Nutrition Educa­ tion in Medical School, Residency Training, and Practice,” JAMA 321, no. 14 (April 9, 2019): 1351–1352, https://­doi​.­org​/1­ 0​.­1001​/­jama​.­2019​.­1581. 37.  Kashmira Gander, “Eating Mediterranean Diet During Pregnancy Could Cut Gestational Diabetes Risk: Study,” Newsweek, July  23, 2019, https://­w ww​ .­n ewsweek ​ .­c om​ /­e ating​-­mediterranean​-­diet​-­during​-­pregnancy​-­could​-­cut​ -­gestational​-­diabetes​-­risk​-­study​-­1450423; Rachel Weltzer Warren, “The Foods to Avoid When ­You’re Pregnant,” NYT Parenting, April 17, 2020, https://­parenting​ .­nytimes​.c­ om​/­pregnancy​/­​-­foods​-­to​-­avoid​-­when​-­pregnant; Nathan S. Fox, “Dos and ­Don’ts in Pregnancy: Truths and Myths,” Obstetrics and Gynecol­ogy 131, no. 4

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(April  2018): 713, https://­doi​.­org​/­10​.­1097​/­AOG​.­0000000000002517; Chelsea Conaboy, “Coffee, Sex And Sushi: An Evidence Update On Pregnancy Do’s And ­Don’ts,” CommonHealth, March 16, 2018, https://­w ww​.­wbur​.­org​/­commonhealth​ /­2018​/­03​/­16​/­evidence​-­dos​-­and​-­donts​-­pregnancy; Annie Behr, “The Scales Have Tipped on Fish and Pregnancy. Why ­Haven’t the Recommendations Caught Up?” Slate Magazine, May  20, 2017, https://­slate​.­com​/­technology​/­2017​/­05​/­pregnant​ -­women​-­should​-­eat​-­more​-­fish​-­not​-­less​.­html. 38.  De Lee, Princi­ples and Practice of Obstetrics, 225. 39. West, Prenatal Care, 8. 40.  J. Morris Slemons, The Nutrition of the Fetus (New Haven, CT: Yale Uni­ versity Press, 1919), 46. 41.  Annie Murphy Paul, Origins: How the Nine Months before Birth Shape the ­ ree Press, 2010). Rest of Our Lives (New York: F 42.  Hoesli, “Nutrition in Pregnancy”; Paul, Origins.

chapter 5 ​—­ ​watch 1.  Malcolm Nicolson and John E. E. Fleming, Imaging and Imagining the Fetus: The Development of Obstetric Ultrasound (Baltimore: Johns Hopkins University Press, 2013), 12, https://­muse​-­jhu​-­edu​.e­ zproxy​.­library​.­tufts​.e­ du​/­book​/­21079​/­. 2.  Nicolson and Fleming, Imaging and Imagining, 117. 3.  Nicolson and Fleming, Imaging and Imagining, 142. 4.  Moira Weigel, “How Ultrasound Became Po­liti­cal,” The Atlantic, January 24, 2017, https://­w ww​.­t heatlantic​.­com​/ ­health​/a­ rchive​/2­ 017​/­01​/­u ltrasound​-­woman​ -­pregnancy​/­514109​/­. 5.  S. Campbell, “A Short History of Sonography in Obstetrics and Gynaecol­ ogy,” Facts, Views and Vision in ObGyn 5, no. 3 (2013): 215, https://­w ww​.­ncbi​.­nlm​ .­nih​.g­ ov​/p ­ mc​/a­ rticles​/P ­ MC3987368​/­; Nicolson and Fleming, Imaging and Imagining, 167. 6.  Weigel, “How Ultrasound Became Po­l iti­cal”; Z. Papp and T. Fekete, “The Evolving Role of Ultrasound in Obstetrics/Gynecol­ogy Practice,” International Journal of Gynecol­ogy and Obstetrics 82, no. 3 (September 1, 2003): 340, https://­ doi​.­org​/1­ 0​.­1016​/S­ 0020​-­7292(03)00224​-­8. 7.  Weigel, “How Ultrasound Became Po­l iti­c al”; Campbell, “Short History of Sonography,” 219–220; Papp and Fekete, “Evolving Role of Ultrasound,” 341–342; Nicolson and Fleming, Imaging and Imagining, 232. 8.  Barbara Bolsen, “Question of Risk Still Hovers over Routine Prenatal Use of Ultrasound,” JAMA 247, no. 16 (April 23, 1982): 2196, https://­doi​.­org​/­10​.­1001​/­jama​ .­1982​.­03320410003001.

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9.  Leiv S. Bakketeig et al., “Randomised Controlled Trial of Ultrasonographic Screening in Pregnancy,” The Lancet 324, no. 8396 (July 28, 1984): 207, https://­doi​ .­org​/­10​.1­ 016​/S­ 0140​-­6736(84)90492​-­6. 10.  Bolsen, “Question of Risk.” 11.  Sturla Eik-­Nes et al., “Ultrasound Screening in Pregnancy: A Randomised Controlled Trial,” The Lancet 1, no. 8390 (June 16, 1984): 1347, https://­doi​.­org​/­10​ .­1016​/s­ 0140​-­6736(84)91834​-­8; Urban Waldenström et al., “Effects of Routine One-­ Stage Ultrasound Screening in Pregnancy: A Randomised Controlled Trial,” The Lancet 2, no. 8611 (September 10, 1988): 585, https://­doi​.­org​/­10​.­1016​/­S0140​-­6736​ (88)90636​-­8; B. Ewigman, M. LeFevre, and J. Hesser, “A Randomized Trial of Routine Prenatal Ultrasound,” Obstetrics and Gynecol­ogy 76, no. 2 (August 1990): 189; “Diagnostic Ultrasound Imaging in Pregnancy,” Consensus Development Conference Statement (National Institutes of Health, February 1984), https://­ consensus​.­nih​.­gov​/­1984​/­1984UltrasoundPregnancy041html​.­htm. 12.  Waldenström et al., “Effects of Routine One-­Stage Ultrasound,” 585. 13.  Bakketeig et al., “Randomised Controlled Trial,” 207, 210; Eik-­Nes et al., “Ultrasound Screening,” 1347; Waldenström et al., “Effects of Routine One-­Stage Ultrasound,” 585. 14.  Frank A. Chervenak, Laurence B. McCullough, and Judith L. Chervenak, “Prenatal Informed Consent for Sonogram: An Indication for Obstetric Ultraso­ nography,” American Journal of Obstetrics and Gynecol­ogy 161, no. 4 (October 1, 1989): 857, https://­doi​.­org​/1­ 0​.­1016​/­0002​-­9378(89)90735​-­7; “Periodic Health Exami­ nation, 1992 Update: 2. Routine Prenatal Ultrasound Screening. Canadian Task Force on the Periodic Health Examination,” CMAJ: Canadian Medical Association Journal 147, no. 5 (September 1, 1992): 629–630. 15.  Ewigman, LeFevre, and Hesser, “Randomized Trial,” 189, 191. 16.  A. Saari-­Kemppainen et al., “Ultrasound Screening and Perinatal Mor­ tality: Controlled Trial of Systematic One-­Stage Screening in Pregnancy,” The Lancet 336, no.  8712 (August  18, 1990): 389, https://­doi​.­org​/­10​.­1016​/­0140​-­6736​ (90)91941​-­3. 17.  Bernard  G. Ewigman et  al., “Effect of Prenatal Ultrasound Screening on Perinatal Outcome,” New ­England Journal of Medicine 329, no. 12 (September 16, 1993): 823–826, https://­doi​.­org​/1­ 0​.­1056​/N ­ EJM199309163291201; Michael L. LeFevre et  al., “A Randomized Trial of Prenatal Ultrasonographic Screening: Impact on Maternal Management and Outcome,” American Journal of Obstetrics and Gynecol­ogy 169, no. 3 (September 1, 1993): 488, https://­doi​.­org​/1­ 0​.­1016​/­0002​-­9378​ (93)90605​-­I. 18.  Ewigman et al., “Effect of Prenatal Ultrasound,” 821, 823.

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19.  LeFevre et al., “Randomized Trial,” 483; Steven H. Golde et al., “Correspon­ dence: Prenatal Ultrasound Screening and Perinatal Outcome,” New E ­ ngland Journal of Medicine 330, no. 8 (February 24, 1994): 570–571, https://­doi​.­org​/­10​.­1056​ /­nejm199402243300812; William J. Polzin and Kim Brady, “Routine Ultrasonog­ raphy in Pregnancy,” American Journal of Obstetrics and Gynecol­ogy 172, no. 1 (January 1, 1995): 242–243, https://­doi​.­org​/­10​.­1016​/­0002​-­9378(95)90133​-­7; Daniel W. Skupski et al., “The Impact of Routine Obstetric Ultrasonographic Screening in a Low-­R isk Population,” American Journal of Obstetrics and Gynecol­ogy 175, no. 5 (November 1, 1996): 238, 241, https://­doi​.­org​/­10​.­1016​/­S0002​-­9378(96)70019​-­4. 20.  “Periodic Health Examination, 1992 Update,” 628. 21.  Frank  A. Chervenak, Laurence  B. McCullough, and William  J. Ledger, “Advocacy for Routine Obstetric Ultrasound: An Essential Obligation in Con­ temporary Obstetric Care,” ACOG Clinical Review 1, no.  2 (March  1, 1996): 1, https://­doi​.o ­ rg​/­10​.­1016​/­S1085​-­6862(00)80001​-­1. 22.  Chervenak, McCullough, and Ledger, “Advocacy for Routine Obstetric Ultrasound,” 2, 4; E. O. Horger, and C. C. Tsai, “Ultrasound and the Prenatal Diagnosis of Congenital Anomalies: A Medicolegal Perspective,” Obstetrics and Gynecol­ogy 74, no. 4 (October 1989): 617, 619. 23.  Chervenak, McCullough, and Ledger, “Advocacy for Routine Obstetric Ultrasound,” 1–2; Chervenak, McCullough, and Chervenak, “Prenatal Informed Consent,” 857. 24.  M. B. Stephens, R. Montefalcon, and D. A. Lane, “The Maternal Perspective on Prenatal Ultrasound,” Journal of F ­ amily Practice 49, no. 7 (July 2000): 601–604; John J You et al., “Proliferation of Prenatal Ultrasonography,” CMAJ: Canadian Medical Association Journal 182, no. 2 (February 9, 2010): 143–151, https://­doi​.­org​ /­10​.­1503​/c­ maj​.­090979. 25.  Jeffrey M. Barrett and Jennifer Brinson, “Evaluation of Obstetric Ultraso­ nography at the First Prenatal Visit,” American Journal of Obstetrics and Gynecol­ ogy 165, no. 4 (October 1, 1991): 1002, https://­doi​.o ­ rg​/­10​.­1016​/­0002​-­9378(91)90458​-­4; L. Bricker et al., “Ultrasound Screening in Pregnancy: A Systematic Review of the Clinical Effectiveness, Cost-­Effectiveness and ­Women’s Views,” Health Technology Assessment 4, no. 16 (2000): iii, iv. 26.  Luís Flávio Gonçalves, Philippe Jeanty, and Joyce M. ­Piper, “The Accuracy of Prenatal Ultrasonography in Detecting Congenital Anomalies,” American Journal of Obstetrics and Gynecol­ogy 171, no. 6 (December 1, 1994): 610, 612, https://­ doi​.o ­ rg​/1­ 0​.­1016​/­0002​-­9378(94)90411​-­1; Jeffrey G. Boyle, “Letter: The Accuracy of Prenatal Ultrasonography in Detecting Congenital Anomalies,” American Journal of Obstetrics and Gynecol­ogy 173, no. 2 (August 1995): 667, https://­doi​.­org​/­10​

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1983): 392–393, https://­doi​.­org​/1­ 0​.­1056​/­nejm198302173080710; J. T. Grace, “Prena­ tal Ultrasound Examinations and Mother-­Infant Bonding,” New ­England Journal of Medicine 309, no. 9 (September 1, 1983): 561. 41.  Bricker et al., “Ultrasound Screening in Pregnancy,” iv; Ashraf F. Nabhan and Nasreen Aflaifel, “High Feedback versus Low Feedback of Prenatal Ultra­ sound for Reducing Maternal Anxiety and Improving Maternal Health Behav­ iour in Pregnancy,” Cochrane Database of Systematic Reviews 2015, no. 8 (2015): CD007208, https://­doi​.­org​/­10​.­1002​/­1 4651858​.­CD007208​.­pub3; Margaret E. Fur­ ness, “Reporting Obstetric Ultrasound,” The Lancet 1, no. 8534 (March 21, 1987): 675–676, https://­doi​.­org​/­10​.­1016​/­S0140​-­6736(87)90431​-­4; Nicolson and Fleming, Imaging and Imagining, 264–265; Fletcher and Evans, “Maternal Bonding.” 42.  Weigel, “How Ultrasound Became Po­liti­cal”; Andrew J. Hogan, “Mobiliz­ ing the Fetus: Julie Roberts, The Visualised Foetus; Malcolm Nicolson and John E. E. Fleming, ‘Imaging and Imagining the Fetus’,” Technology and Culture 55, no. 3 (August 8, 2014): 730–733, https://­doi​.­org​/­10​.­1353​/­tech​.­2014​.­0075. 43.  Nicolson and Fleming, Imaging and Imagining, 1. 44.  Uma M. Reddy et al., “Prenatal Imaging: Ultrasonography and Magnetic Resonance Imaging,” Obstetrics and Gynecol­ogy 112, no. 1 (July 2008): 155, https://­ doi​.­org​/­10​.­1097​/­01​.­AOG​.­0000318871​.­95090​.­d9. 45.  Bolsen, “Question of Risk,” 2195; Daniel Engber, “Are Sonograms Danger­ ous?” Slate, December 5, 2005, http://­w ww​.­slate​.­com​/­articles​/­news​_­and​_­politics​ /­explainer​/­2005​/­12​/­are​_ ­sonograms ​_­dangerous​.­html. 46.  J. P. Newnham et al., “Effects of Frequent Ultrasound during Pregnancy: A Randomised Controlled Trial,” The Lancet 342, no. 8876 (October 9, 1993): 890, ­ rg​/­10​.­1016​/­0140​-­6736(93)91944​-­H; Stanley B. Barnett, “Routine Ultra­ https://­doi​.o sound Scanning in First Trimester: What Are the Risks?” Seminars in Ultrasound, CT and MRI 23, no. 5 (October 1, 2002): 389, https://­doi​.­org​/­10​.­1016​/­S0887​ -­2171(02)90009​-­0; Kwan H. Ng, “International Guidelines and Regulations for the Safe Use of Diagnostic Ultrasound in Medicine,” Journal of Medical Ultrasound 10, no. 1 (January 1, 2002): 6–7, https://­doi​.­org​/­10​.­1016​/­S0929​-­6441(09)60017​-­5. 47.  Tanya Lewis, “5 Fascinating Facts about Fetal Ultrasounds,” Live Science, May  16, 2013, https://­w ww​.­l ivescience​.­com​/­32071​-­history​-­of​-­fetal​-­ultrasound​ .­html. 48.  Reddy et al., “Prenatal Imaging,” 150. 49.  Bolsen, “Question of Risk,” 2195. 50.  Barrett and Brinson, “Evaluation of Obstetric Ultrasonography,” 1005. 51.  Newnham et al., “Effects of Frequent Ultrasound,” 890. 52.  This sentiment is widespread in the lit­er­a­ture. See, for example, So­ma Mukherjee and Basky Thilaganathan, “The Diagnostic and Therapeutic Role of

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Ultrasound in Obstetrics,” Obstetrics, Gynaecol­ogy and Reproductive Medicine 20, no. 2 (February 1, 2010): 45, https://­doi​.­org​/1­ 0​.­1016​/­j​.­ogrm​.2­ 009​.­11​.­005. 53.  Marc  J. Keirse, “Frequent Prenatal Ultrasound: Time to Think Again,” The Lancet 342, no. 8876 (October 9, 1993): 878, https://­doi​.o ­ rg​/1­ 0​.­1016​/0 ­ 140​-­6736​ (93)91938​-­i. 54.  Barnett, “Routine Ultrasound Scanning,” 390. 55.  John P. Newnham et al., “Effects of Repeated Prenatal Ultrasound Exami­ nations on Childhood Outcome up to 8 Years of Age: Follow-up of a Randomised Controlled Trial,” The Lancet 364, no. 9450 (December 4, 2004): 2038, https://­doi​ .­org​/­10​.­1016​/­s0140​-­6736(04)17516​-­8; Engber, “Are Sonograms Dangerous?” 56.  Newnham et al., “Effects of Repeated Prenatal Ultrasound,” 2038, 2043; Kevin Helliker, “Pregnant ­Women Get More Ultrasounds, Without Clear Medi­ ­ regnant​ cal Need,” Wall Street Journal, July 17, 2015, http://­w ww​.­wsj​.­com​/­articles​/p -­women​-­get​-­more​-­ultrasounds​-­without​-­clear​-­medical​-­need​-­1437141219. 57.  Barnett, “Routine Ultrasound Scanning,” 387. 58.  Ng, “International Guidelines,” 5, 7. 59.  American College of Obstetricians and Gynecologists, “Practice Bulletin No. 175: Ultrasound in Pregnancy,” Obstetrics and Gynecol­ogy 128, no. 6 (Decem­ ber 2016): e241, https://­doi​.­org​/­10​.­1097​/­AOG​.­0000000000001815; Harriet Hall, “Are Prenatal Ultrasounds Dangerous?” Science-­Based Medicine, August 30, 2011, https://­sciencebasedmedicine​.­org​/­are​-­prenatal​-­ultrasounds​-­dangerous​/­; Ameri­ can College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, “Committee Opinion 656: Guidelines for Diagnostic Imaging during Pregnancy and Lactation,” Obstetrics and Gynecol­ogy 127, no 2 (2016):e75–80, https://­doi​.­org​ /­10​.­1097​/­aog​.­0000000000001316. 60.  Janice Hopkins Tanne, “FDA Warns against Commercial Prenatal Ultra­ sound Videos,” British Medical Journal 328, no. 7444 (April 10, 2004): 853, https://­dx​ .­doi​.­org​/­10​.1­ 136​/ ­bmj​.­328​.­7444​.­853. 61.  Skupski et al., “Impact of Routine Obstetric,” 233–234; Reddy et al., “Prena­ tal Imaging,” 150; ACOG, “Practice Bulletin No. 175.” 62.  Nicolson and Fleming, Imaging and Imagining, 260. 63.  Stephens, Montefalcon, and Lane, “Maternal Perspective,” 603. 64.  Siddique et al., “Trends in Prenatal Ultrasound Use,” 1134. 65. Stephens, Montefalcon, and Lane, “Maternal Perspective,” 603; Joan  G. Lalor and Declan Devane, “Information, Knowledge and Expectations of the Routine Ultrasound Scan,” Midwifery 23, no. 1 (March 1, 2007): 13–22, https://­doi​.­org​/­10​.­1016​ /­j​.­midw​.­2006​.­02​.­001; Eva Molander, Siw Alehagen, and Carina M. Berterö, “Routine Ultrasound Examination during Pregnancy: A World of Possibilities,” Midwifery ­ idw​.­2008​.0 ­ 4​.­008. 26, no. 1 (February 1, 2010): 23, 25, https://­doi​.­org​/­10​.­1016​/­j​.m

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66.  Siddique et  al., “Trends in Prenatal Ultrasound Use,” 1129; You et  al., “Proliferation of Prenatal Ultrasonography,” 143, 146; Helliker, “Pregnant ­Women.” 67.  You et al., “Proliferation of Prenatal Ultrasonography,” 146. 68.  You et al., “Proliferation of Prenatal Ultrasonography,” 146. 69.  Scott Gottlieb, “The Quickening Pace of Medical Pro­gress and Its Discon­ tents,” Forbes, June 17, 2015, https://­w ww​.f­ orbes​.­com​/­sites​/­scottgottlieb​/­2015​/­06​/1­ 7​ /­t he​-­quickening​-­pace​-­of​-­medical​-­progress​-­and​-­its​-­discontents​/­.

chapter 6 ​—­ ​move 1.  Julie Beck, “Exercise, for a Healthier Pregnancy,” The Atlantic, July 8, 2016, http://­w ww​.­t heatlantic​.­c om​/­health​/­a rchive​/­2 016​/­07​/­e xercise​-­for​-­a​-­healthier​ -­pregnancy​/­490424​/­. 2.  American College of Obstetricians and Gynecologists, “ACOG Committee Opinion No. 650: Physical Activity and Exercise during Pregnancy and the Post­ partum Period,” Obstetrics and Gynecol­ogy 126, no. 6 (December 2015): e135–­e142, https://­doi​.­org​/­10​.­1097​/­aog​.­0000000000001214. 3.  Dana M. Dillard, “Exercise and Pregnancy,” International Journal of Childbirth Education 31, no. 1 (January 2016): 9. 4.  Patricia W. Bauer, Clifford L. Broman, and James M. Pivarnik, “Exercise and Pregnancy Knowledge Among Healthcare Providers,” Journal of ­Women’s Health ­ rg​/­10​.­1089​/­jwh​.­2008​.­1295. 19, no. 2 (2010): 337, https://­doi​.o 5.  George F. Winter, “Evidence on Exercise in Pregnancy,” British Journal of Midwifery 23, no. 12 (December 2015): 844, https://­doi​.­org​/­10​.­12968​/­bjom​.­2015​.­23​ .­12​.­844; Danielle Symons Downs et al., “Physical Activity and Pregnancy: Past and Pre­sent Evidence and ­Future Recommendations,” Research Quarterly for Exercise and Sport 83, no. 4 (December 2012): 2, https://­d x​.­doi​.­org​/­10​.­1080​/­02701367​.­2012​ .­10599138; Bauer, Broman, and Pivarnik, “Exercise and Pregnancy Knowledge,” 335; Raul Artal and Susan Kelemen Gardin, “Historical Perspectives,” in Exercise in Pregnancy, ed. Raul Artal, Robert A. Wiswell, and Barbara L. Drinkwater, II (Baltimore: Williams & Wilkins, 1991), 1. 6.  Eilidh H. R. Macrae, “Risky or Relaxing? Exercise during Pregnancy in Brit­ ain, c.1930–1960,” W ­ omen’s History Review 24, no. 5 (September 3, 2015): 739–756, https://­doi​.­org​/1­ 0​.­1080​/­09612025​.­2015​.­1028212; Jean Rankin, Edith M Hillan, and Nanette Mutrie, “An Historical Overview of Physical Activity and Childbirth,” British Journal of Midwifery 8, no. 12 (December 7, 2000): 761, https://­doi​.­org​/­10​ .­12968​/­bjom​.­2000​.­8​.­12​.­8040. 7.  Michael P. Johnson, “Smothered Slave Infants: ­Were Slave M ­ others at Fault?” Journal of Southern History 47, no. 4 (November 1981): 510, https://­doi​.­org​/­10​.­2307​

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/­2207400; Deborah Gray White, Ar’n’t I a ­Woman?: Female Slaves in the Plantation South (New York: W.W. Norton, 1985). 8.  Rankin, Hillan, and Mutrie, “Historical Overview,” 762. 9.  Rankin, Hillan, and Mutrie, “Historical Overview,” 762; Pamela Shrock, “Exercise and Physical Activity during Pregnancy,” in Global Library of ­Women’s Medicine, 2008, https://­doi​.­org​/­10​.­3843​/­GLOWM​.­10098. 10.  Artal and Gardin, “Historical Perspectives,” 2. 11.  Elizabeth A. Burns, “A Historical Overview of Prenatal Exercise Practices” (master’s thesis, University of Wisconsin at La Crosse, 1988), 25. 12.  J. W. Ballantyne, Manual of Antenatal Pathology and Hygiene: The Foetus (New York: William Wood, 1902), 475, http://­hdl​.­handle​.­net​/­2027​/­uc1​.­b3848934. 13.  Josiah Morris Slemons, The Prospective ­Mother: A Handbook for W ­ omen during Pregnancy (New York: D. Appleton, 1912), 133, 132. 14. Slemons, Prospective ­Mother, 132. 15.  Joseph B. De Lee, The Princi­ples and Practice of Obstetrics (Philadelphia: W.B. Saunders, 1913), 227, http://­hdl​.­handle​.­net​/­2027​/­nnc2​.­ark:​/­13960​/­t6349dh39. 16.  H. B. Atlee, “Pre-­Natal and Post-­Natal Care,” Canadian Medical Association Journal 37, no. 6 (December 1937): 551; Burns, “Historical Overview,” 35. 17. Slemons, Prospective ­Mother, 132. 18.  De Lee, Princi­ples and Practice of Obstetrics, 227. 19.  Roni Caryn Rabin, “Ask Well: Is It Safe to Exercise during Pregnancy?” New York Times, March 20, 2016, http://­well​.­blogs​.­nytimes​.­com​/­2016​/­03​/­10​/­a sk​-­well​ -­pregnancy​-­and​-­exercise​/­; Shrock, “Exercise and Physical Activity”; Roger L. Hammer, Jan Perkins, and Richard Parr, “Exercise during the Childbearing Year,” Journal of Perinatal Education 9, no.  1 (2000): 5, https://­d x​.­doi​.­org​/­10​.­1624%2​ F105812400X87455. 20.  Downs et al., “Physical Activity and Pregnancy,” 3. 21.  Artal and Gardin, “Historical Perspectives,” 4. 22.  Rabin, “Ask Well: Is It Safe.” 23.  Artal and Gardin, “Historical Perspectives,” 3. 24.  “Value of Antenatal Exercises,” British Medical Journal 2, no. 4673 (1950): 280–281; Macrae, “Risky or Relaxing?” 25.  Michael Bruser, “Sporting Activities during Pregnancy,” Obstetrics and Gynecol­ogy 32, no. 5 (1968): 721–722. 26.  Bruser, “Sporting Activities,” 724–725, 722; Gina Kolata, Ultimate Fitness: The Quest for Truth about Health and Exercise (New York: Picador USA, 2004), 25. 27.  Some ­women did take up “purposive exercise” in the mid-1800s, but they ­were by far the minority. Natalia Mehlman Petrzela, “Homophobia at a CrossFit

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Is a Good Time to Recall That Gyms Have Always Been Gay Spaces,” Slate Magazine, June 20, 2018, https://­slate​.­com​/­human​-­interest​/­2018​/­06​/­crossfit​-­homophobia​ -­reminds​-­us​-­that​-­gyms​-­have​-­always​-­been​-­gay​.­html; Natalia Mehlman Petrzela, “Finding the Way from Cult of Fit to Culture of Fitness,” 24Life, August 9, 2018, https://­w ww​.2­ 4life​.­com​/­finding​-­the​-­way​-­from​-­cult​-­of​-­fit​-­to​-­culture​-­of​-­fitness​/­; Kolata, Ultimate Fitness, 36. 28.  Jack  W. Berryman, “Exercise Is Medicine: A Historical Perspective,” ­Current Sports Medicine Reports 9, no. 4 (2010): 2–3, https://­doi​.­org​/­10​.­1249​/­jsr​ .­0b013e3181e7d86d. 29.  Abraham Flexner, Medical Education in the United States and Canada: A Report to the Car­ne­g ie Foundation for the Advancement of Teaching, Bulletin No. 4. (New York City: Car­ne­gie Foundation for the Advancement of Teaching, 1910). The Flexner Report charged that American medical schools—­w ith lax admission and graduation standards, and vastly discrepant teaching and train­ ing practices that failed to adhere to scientific standards—­were not up to snuff. As a result, medical education grew more systematized and consolidated (and white and male), and also worked to align its curriculum much more closely with basic scientific princi­ples. 30.  Berryman, “Exercise Is Medicine,” 3; Kolata, Ultimate Fitness. 31.  Berryman, “Exercise Is Medicine,” 3–4. 32.  Natalia Mehlman Petrzela, “Weight Loss Salons and Reducing Machines,” Well+Good, September 1, 2015, https://­w ww​.w ­ ellandgood​.­com​/­good​-­sweat​/­weight​ -­loss​-­salons​-­reducing​-­machines​/­. 33. Kolata, Ultimate Fitness, 42–43. 34.  Berryman, “Exercise Is Medicine”; Natalia Mehlman Petrzela, “The Origins of Jogging in the U.S. for W ­ omen,” Well+Good, September 24, 2015, https://­w ww​ .­wellandgood​.­com​/­good​-­sweat​/­history​-­of​-­women​-­jogging​/­; Kolata, Ultimate Fitness, 43–44; Phil Edwards, “A Brief History of the Bizarre and Sadistic Presiden­ tial Fitness Test,” Vox, April 24, 2015, https://­w ww​.­vox​.­com​/­2015​/­4​/­2 4​/­8489501​ /­presidential​-­fitness​-­test. 35.  Berryman, “Exercise Is Medicine,” 4–5. 36.  Berryman, “Exercise Is Medicine,” 5. 37.  Mehlman Petrzela, “Origins of Jogging”; Kolata, Ultimate Fitness, 29–30, 48. 38.  Natalia Mehlman Petrzela, “Post-­Election Wellness Routines Get Po­liti­cal,” Well+Good, November  18, 2016, https://­w ww​.­wellandgood​.­com​/­good​-­advice​ /­wellness​-­and​-­politics​-­post​-­election​-­trump​/­. 39.  Natalia Mehlman Petrzela, “The W ­ omen ­behind the ’80s Aerobics Craze,” Well+Good, August  4, 2015, https://­w ww​.­wellandgood​.­com​/­good​-­sweat​/­1980s​ -­aerobics​-­instructors​-­jane​-­fonda​-­jazzercize​/­.

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54.  Raul Artal, “Exercise in Pregnancy: Guidelines,” Clinical Obstetrics and Gynecol­ogy 59, no. 3 (September 2016): 639–640, https://­doi​.­org​/­10​.­1097​/­grf​.­0000​ 000000000223. 55.  American College of Obstetricians and Gynecologists, “Exercise during ­ atients​/F ­ AQs​/E ­ xercise​-­During​ Pregnancy: FAQ,” July 2017, http://­w ww​.­acog​.­org​/P -­Pregnancy. 56.  Hammer, Perkins, and Parr, “Exercise during the Childbearing Year,” 6; Robert  W. Jarski and Diane  L. Trippet, “The Risks and Benefits of Exercise during Pregnancy,” Journal of ­Family Practice 30, no. 2 (February 1990): 185. 57.  Artal, “Exercise in Pregnancy: Guidelines,” 640; ACOG, “Committee Opin­ ion No. 650,” e135–­e142. 58.  Ron Artal quoted in Suzanne Schlosberg, “The Truth About Prenatal Exercise,” Fit Pregnancy and Baby, August 16, 2011; updated April 3, 2017, https://­ web​.­a rchive​.­org ​/­web​/­20180907024126​/ ­https://­w ww​.­fitpregnancy​.­com​/­exercise​ /­prenatal​-­workouts​/­truth​-­about​-­prenatal​-­exercise. 59.  Kari Bø et al., “Consensus Statement: Exercise and Pregnancy in Recreational and Elite Athletes: 2016 Evidence Summary from the IOC Expert Group Meeting, Lausanne. Part 1—­Exercise in W ­ omen Planning Pregnancy and ­Those Who Are Pregnant,” British Journal of Sports Medicine 50 (2016): 573, https://­doi​.­org​/­10​.­1136​ /­bjsports​-­2016​-­096810; ACOG, “Committee Opinion No. 650,” e136–­e137. 60.  Winter, “Evidence on Exercise in Pregnancy,” 844; Emma Lewis, “Exercise ­ amily Physician 43, no. 8 (August 2014): 541, https://­ in Pregnancy,” Australian F www​.­racgp​.­org​.­au​/­a fp​/­2014​/­august​/­exercise​-­in​-­pregnancy​/­; ACOG, “Exercise during Pregnancy: FAQ”; ACOG, “Committee Opinion No. 650.” 61.  Adrienne Parad, Elizabeth Leonard, and Lara Handler, “Exercise and Preg­ nancy Loss,” American F ­ amily Physician 91, no. 7 (2015): 437, https://­w ww​.­aafp​ .­org​/a­ fp​/2­ 015​/­0401​/­p437​.­html; Hammer, Perkins, and Parr, “Exercise during the Childbearing Year,” 5; Kari Bø et al., “Exercise and Pregnancy in Recreational and Elite Athletes: 2016/2017 Evidence Summary from the IOC Expert Group Meeting, Lausanne. Part 5. Recommendations for Health Professionals and Active ­Women,” British Journal of Sports Medicine 52, no. 17 (September 1, 2018): 1080–1085, https://­ doi​.­org​/­10​.­1136​/ ­bjsports​-­2018​-­099351. 62.  Iris Domenjoz, Bengt Kayser, and Michel Boulvain, “Effect of Physical Activity during Pregnancy on Mode of Delivery,” American Journal of Obstetrics and Gynecol­ogy 211 (October 2014): 401.e10, https://­doi​.o ­ rg​/­10​.­1016​/j­ ​.­ajog​.­2014​.0 ­ 3​ .­030; see also Carrie Nobles et al., “The Effect of an Exercise Intervention on Ges­ tational Weight Gain: The Be­hav­iors Affecting Baby and You (B.A.B.Y.) Study: A Randomized Controlled Trial,” American Journal of Health Promotion 32, no. 3

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January 18, 2019, https://­w ww​.­sciencedaily​.­com ​/­releases​/­2019​/­01 ​/­190118083200​ .­htm. 50.  Sedov et al., “Sleep Quality,” 172.

chapter 8 ​—­ ​plan 1.  Judith Walzer Leavitt, Brought to Bed: Childbearing in Amer­i­ca, 1750–1950 (New York: Oxford University Press, 1986). 2.  Judith Walzer Leavitt, “­Under the Shadow of Maternity: American W ­ omen’s Responses to Death and Debility Fears in Nineteenth-­Century Childbirth,” Feminist Studies 12, no. 1 (Spring 1986): 129–154, https://­doi​.­org​/­10​.­2307​/­3177988; Wal­ zer Leavitt, Brought to Bed. 3.  Jacqueline Wolf, Deliver Me from Pain: Anesthesia and Birth in Amer­i­ca (Baltimore: Johns Hopkins University Press, 2009), 13. 4.  Walzer Leavitt, Brought to Bed, 122. 5.  Walzer Leavitt, Brought to Bed. 6.  Ann Fessler, The Girls Who Went Away: The Hidden History of ­Women Who Surrendered ­Children for Adoption in the De­cades before Roe v. Wade (New York: Penguin Press, 2007). 7. Fessler, Girls Who Went Away, quote from 17, 11, 25, 29. 8.  Ann Oakley, The Captured Womb: A History of the Medical Care of Pregnant ­Women (Oxford: Blackwell, 1986), 2, 11. 9.  National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health, Centers for Disease Control and Prevention, “Achievements in Public Health, 1900–1999: Healthier ­Mothers and Babies,” CDC Morbidity and Mortality Weekly Report 48, no. 38 (October 1999): 849–858, https://­ www​.­cdc​.g­ ov​/­mmwr​/­preview​/­mmwrhtml​/­mm4838a2​.­htm. ­ others: Scientific Motherhood in the Nine­ 10.  Rima D. Apple, “Constructing M teenth and Twentieth Centuries,” Social History of Medicine 8, no. 2 (1995): 166–167, 174, https://­doi​.­org​/­10​.­1093​/­shm​/­8​.­2​.­161; Jacqueline H. Wolf, “  ‘ They Lacked the Right Food’: A Brief History of Breastfeeding and the Quest for Social Justice,” Journal of ­Human Lactation 34, no. 2 (May 1, 2018): 226–231, https://­doi​.­org​/­10​.­1177​ /­0890334418757449. 11.  Rima D. Apple, Perfect Motherhood: Science and Childrearing in Amer­i­ca (New Brunswick, NJ: Rutgers University Press, 2006), 2, 38–29, 55, 122. 12.  Richard Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality (Baltimore: Johns Hopkins University Press, 1990), 6, 100, 119, 122, 136, quote 220; Jacqueline Wolf, D ­ on’t Kill Your Baby: Public Health and the Decline of Breastfeeding in the Nineteenth and Twentieth Centuries (Columbus: Ohio State University Press, 2001), 26–27.

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13.  Cheryl K. Lemus, “ ‘The Maternity Racket’: Medicine, Consumerism, and the Modern American Pregnancy, 1876–1960” (PhD diss., Northern Illinois Univer­ sity, 2011), https://­search​.­proquest​.­com​/­docview​/­894441403​/­abstract​/­94CBB42​ B00​AB4074PQ​/1­ . 14.  Lemus, “Maternity Racket.” 15. Oakley, Captured Womb, 53–54; Judith  A. Maloni et  al., “Transforming Prenatal Care: Reflections on the Past and Pre­sent With Implications for the F ­ uture,” Journal of Obstetric, Gynecologic and Neonatal Nursing 25, no. 1 (Janu­ ary 1996): 17, https://­doi​.­org​/1­ 0​.­1111​/­j​.­1552​-­6909​.­1996​.t­ b02508​.­x; Lemus, “Maternity Racket.” 16.  Maloni et al., “Transforming Prenatal Care,” 18. 17.  Elizabeth M. Armstrong, “Lessons in Control: Prenatal Education in the ­ rg​/­10​.­2307​ Hospital,” Social Prob­lems 47, no. 4 (November 2000): 585, https://­doi​.o /­3097136; Joanne Motino Bailey, Patricia Crane, and Clark E. Nugent, “Childbirth Education and Birth Plans,” Obstetrics and Gynecol­ogy Clinics of North Amer­i­ca 35, no. 3 (September 2008): 497, https://­doi​.­org​/­10​.­1016​/­j​.­ogc​.­2008​.­04​.­005; Judith ­ addy: The Journey from Waiting Room to BirthWalzer Leavitt, Make Room for D ing Room (Chapel Hill: University of North Carolina Press, 2009), 142, 146, 149. 18.  Armstrong, “Lessons in Control,” 586. 19.  Penny Simkin, “Birth Plans: ­A fter 25  Years, ­Women Still Want to Be Heard,” Birth 34, no.  1 (March  2007): 49–50, https://­doi​.­org​/­10​.­1111​/­j​.­1523​-­536X​ .­2006​.­00126​.­x. 20.  Beverly Beech, “Challenging the Medicalisation of Birth,” AIMS 23, no. 2 (2011), https://­w ww​.­aims​.­org​.­u k ​/­journal​/­item​/­challenging​-­the​-­medicalisation​-­of​ -­birth. 21.  Yalda Afshar et al., “Birth Plans—­Impact on Mode of Delivery, Obstetrical Interventions, and Birth Experience Satisfaction: A Prospective Cohort Study,” Birth 45, no. 1 (March 2018): 43, https://­doi​.­org​/­10​.­1111​/­birt​.­12320. 22.  Tamara Kaufman, “Evolution of the Birth Plan,” Journal of Perinatal Education 16, no. 3 (January 22, 2007): 47, https://­doi​.­org​/­10​.­1624​/­105812407X217985. 23.  Simkin, “Birth Plans,” 50. 24.  Bailey, Crane, and Nugent, “Childbirth Education,” 507. 25.  Bailey, Crane, and Nugent, “Childbirth Education,” 505. 26.  Bailey, Crane, and Nugent, “Childbirth Education,” 504. 27.  Bailey, Crane, and Nugent, “Childbirth Education,” 498. 28.  Pedro Hidalgo-­L opezosa, Maria Aurora Rodríguez-­Borrego, and Maria Carmen Muñoz-­Villanueva, “Are Birth Plans Associated with Improved Mater­ nal or Neonatal Outcomes?,” MCN, The American Journal of Maternal/Child ­ b013e31827ea97f; Nursing 38, no. 3 (2013): 150–151, https://­doi​.­org​/­10​.­1097​/­NMC​.0

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­Bernie Divall et al., “Birth Plans: A Narrative Review of the Lit­er­a­ture,” International Journal of Childbirth 6, no. 3 (2016): 159, https://­doi​.o ­ rg​/­10​.­1891​/2­ 156​-­5287​.­6​ .­3​.1­ 57; Afshar et al., “Birth Plans,” 43; Shad H. Deering et al., “Patients Presenting with Birth Plans: A Case-­Control Study of Delivery Outcomes,” Journal of Reproductive Medicine 52, no. 10 (October 2007): 884–887. 29.  Afshar et al., “Birth Plans,” 43. 30.  Simkin, “Birth Plans,” 50; Bailey, Crane, and Nugent, “Childbirth Educa­ tion,” 504. 31.  Divall et al., “Birth Plans,” 160; Afshar et al., “Birth Plans,” 44. 32.  Afshar et al., “Birth Plans,” 47–48; Melissa Aragon et al., “Perspectives of Ex­pec­tant ­Women and Health Care Providers on Birth Plans,” Journal of Obstetrics and Gynaecol­ogy Canada 35, no. 11 (November 2013): 980, https://­doi​.­org​/­10​ .­1016​/­S1701​-­2163(15)30785​-­4. 33.  Divall et al., “Birth Plans,” 159; Hidalgo-­Lopezosa, Rodríguez-­Borrego, and Muñoz-­Villanueva, “Are Birth Plans Associated,” 150. 34.  Aragon et al., “Perspectives of Ex­pec­tant ­Women,” 980–981; Divall et al., “Birth Plans,” 163. 35.  Bailey, Crane, and Nugent, “Childbirth Education,” 504. 36.  Bailey, Crane, and Nugent, “Childbirth Education,” 504.

chapter 9 ​—­ ​commence 1.  Norah Ephron, Heartburn (New York: Vintage, 1996; first published in 1983), 44. 2.  Navneet Magon and Sanjay Kalra, “The Orgasmic History of Oxytocin: Love, Lust, and ­Labor,” Indian Journal of Endocrinology and Metabolism 15, Supplement 3 (September 2011): S156–­S161, https://­doi​.­org​/­10​.­4103​/­2230​-­8210​.­84851; Hilda Bas­ tian, “#GreatKateWait: Baby s Due, but Might Not Have Gotten the Memo,” Scientific American Blog Network, July 20, 2013, https://­blogs​.­scientificamerican​.­com​ /­a bsolutely​-­maybe​/­g reatkatewait​-­babys​-­due​-­but​-­might​-­not​-­have​-­gotten​-­the​ -­memo​/­. 3.  G. I. Benrubi, “­Labor Induction: Historic Perspectives,” Clinical Obstetrics and Gynecol­ogy 43, no. 3 (September 2000): 429–432; “Word of the Month: De Ribes Bag,” Midwives Chronicle, February 20, 2017, https://­rcmheritage​.­wordpress​ .­com​/­2017​/­02​/­20​/­word​-­of​-­the​-­week​-­de​-­ribes​-­bag ​/­; Luis Sanchez-­Ramos and Andrew M. Kaunitz, “Induction of ­Labor,” The Global Library of ­Women’s Medicine, April 2009, http://­doi​.­org​/­10​.­3843​/­GLOWM​.­10130. 4.  “The Induction of ­Labour,” British Medical Journal 1, no. 5081 (May 24, 1958): 1226.

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5.  I. B. Faris and B. Kahlenberg, “Intravenous Pitocin by the Drip Method in the Induction of ­L abour,” Journal of Obstetrics and Gynaecol­ogy of the British Empire 61, no.  1 (February  1954): 96, https://­doi​.­org​/­10​.­1111​/­j​.­1471​-­0528​.­1954​ .­tb07450​.­x. 6.  W. Blair Bell, “The Pituitary Body and the Therapeutic Value of the Infun­ dibular Extract in Shock, Uterine Atony, and Intestinal Paresis,” British Medical Journal 2, no. 2553 (December 4, 1909): 1610, https://­doi​.­org​/­10​.­1136​/­bmj​.­2​.­2553​.­1609. 7.  Bell, “Pituitary Body,” 1611. 8.  F. C. Harrison, “On the Use of Pituitary Extract in Obstetrics,” Archives of Internal Medicine 12, no.  3 (1913): 323, https://­doi​.­org​/­10​.­1001​/­a rchinte​.­1913​ .­00070030079008. 9.  Robert Allan, “The Use of Pituitary Extract in Obstetrics” (MD diss., Uni­ versity of Edinburgh, United Kingdom, 1914), 25, https://­w ww​.­proquest​.­com​ /­docview​/3­ 01173463​/;­ Irvine Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality 1800–1950 (New York: Oxford Univer­ sity Press, 1992), https://­doi​.­org​/­10​.­1093​/­acprof:oso​/9­ 780198229971​.0 ­ 01​.0 ­ 001. 10.  Harrison, “On the Use of Pituitary Extract,” 326; Allan, “Use of Pituitary Extract,” 21; J. K. Quigley, “Pituitary Extract in Obstetrics,” Journal of the Ameri­ rg​/­10​.­1001​/­jama​ can Medical Association 64, no. 15 (1915): 1222–1224, https://­doi​.o .­1915​.­02570410020008. 11.  “Use of Pituitrin in Obstetrics,” California State Journal of Medicine 9, no. 12 (December 1911): 490, https://­pubmed​.­ncbi​.n ­ lm​.n ­ ih​.g­ ov​/1­ 8735407​/­. 12.  Bell, “The Pituitary Body,” 1611. 13.  Harrison, “On the Use of Pituitary Extract,” 322. 14.  Allan, “Use of Pituitary Extract,” 11. 15.  Quigley, “Pituitary Extract in Obstetrics,” 1222. 16.  Quigley, “Pituitary Extract in Obstetrics,” 1222. 17.  Quigley, “Pituitary Extract in Obstetrics,” 1224. 18.  M. Pierce Rucker, “The Action of Pituitary Extract on the Uterus,” Journal of the American Medical Association 85, no. 21 (1925): 1637–1638, https://­doi​.­org​/1­ 0​ .­1001​/j­ ama​.­1925​.­02670210039012; Farquhar Matheson, “Pituitrin in ­Labour,” New Zealand Medical Journal 128, no. 1427 (December 18, 2015): 79, https://­assets​-­global​ .­website​-­files​.­c om​/­5e332a62c703f653182faf47​/­5e332a62c703f6e9892fd558​_­100​ -­Years1427%20(1)​.p ­ df. 19.  Faris and Kahlenberg, “Intravenous Pitocin,” 96; A. J. Wrigley, “The Place of Oxytocic Drugs before the Birth of the Child,” BJOG 66, no. 5 (October 1, 1959): 861, https://­doi​.­org​/­10​.­1111​/­j​.­1471​-­0528​.­1959​.­tb01934​.­x; M. Lesser and G. A. Eason, “Cardiac Arrest ­u nder Anaesthesia During Induction of ­L abour with ‘Pitocin’

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Drip,” British Medical Journal 2, no. 4879 (July 10, 1954): 80, https://­d x​.­doi​.­org​/1­ 0​ .­1136%2Fbmj​.­2.​ ­4879​.7­ 9; Allan, “Use of Pituitary Extract,” 17. 20.  H. M. Carey, “An Improved Technique for the Induction of L ­ abour,” Journal of Obstetrics and Gynaecol­ogy of the British Empire 61, no. 1 (February 1954): 59; Lesser and Eason, “Cardiac Arrest,” 79. 21.  Faris and Kahlenberg, “Intravenous Pitocin,” 96. 22.  G. W. Theobald, H. A. Kelsey, and J. M. B. Muirhead, “Pitocin Drip,” BJOG 63, no. 5 (October 1, 1956): 641, https://­doi​.­org​/1­ 0​.­1111​/­j​.­1471​-­0528​.­1956​.t­ b05543​.­x. 23.  Faris and Kahlenberg, “Intravenous Pitocin,” 98. 24.  Theobald, Kelsey, and Muirhead, “Pitocin Drip,” 641. 25.  “Induction of ­Labour,” in “Joint Annual Meeting, Toronto, 1955, Summary of Proceedings,” British Medical Journal 2, no. 4930 (1955): 45. 26.  Theobald, Kelsey, and Muirhead, “Pitocin Drip,” 644. 27.  Theobald, Kelsey, and Muirhead, “Pitocin Drip,” 645. 28.  Theobald, Kelsey, and Muirhead, “Pitocin Drip,” 655. 29.  G. Gordon Lennon and E. M. Edwards, “Induction of ­Labour,” British Medical Journal 1, no. 5084 (June 14, 1958): 1414; Edward H. Bishop, “Dangers Attend­ ing Elective Induction of ­Labor,” Journal of the American Medical Association 166, no. 16 (April 19, 1958): 1955, https://­doi​.­org​/­10​.­1001​/­jama​.­1958​.­02990160011003; T. J. Ryan, “On the Safety of the Pitocin Drip,” BJOG 65, no. 1 (February 1, 1958): 71–77, https://­doi​.­org​/­10​.­1111​/­j​.­1471​-­0528​.­1958​.­tb06211​.­x; J. Chassar Moir, “Discussion on the Place of Oxytocic Drugs before the Birth of the Child,” BJOG 66, no. 5 (Octo­ ber 1, 1959): 860–884, https://­doi​.­org​/­10​.­1111​/­j​.­1471​-­0528​.­1959​.­tb01935​.­x. 30.  Theobald, Kelsey, and Muirhead, “Pitocin Drip,” 654–655. 31.  Bishop, “Dangers Attending Elective Induction,” 1956. 32. Grantly Dick-­Read, “Induction of L ­ abour,” British Medical Journal 1, no. 5085 (June 21, 1958): 1478. 33.  Louis Goldman, “The Treatment of Inefficient Uterine Action with the Intra­ venous Oxytocin Drip,” BJOG 66, no. 3 (1959): 382, https://­doi​.­org​/­10​.­1111​/­j​.­1471​ -­0528​.­1959​.­tb02046​.­x. 34.  Wrigley, “Place of Oxytocic Drugs,” 857. 35.  Carolina Abboud, “ ‘Elective Induction of L ­ abor’ (1955), by Edward Bishop,” The Embryo Proj­ect Encyclopedia, February 16, 2017, http://­embryo​.­asu​.­edu​/­handle​ /­10776​/­11420; Carolina Abboud, “ ‘Pelvic Scoring for Elective Induction’ (1964), by Edward Bishop,” The Embryo Proj­ect Encyclopedia, February  23, 2017, http://­ embryo​.­asu​.­edu​/h ­ andle​/­10776​/­11426. 36.  C. M. Lilienthal and J. P. Ward, “Medical Induction of L ­ abour,” BJOG 78, no. 4 (April 1, 1971): 317–321, https://­doi​.­org​/­10​.­1111​/­j​.­1471​-­0528​.­1971​.­tb00279​.­x.

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37.  “The Induction of ­Labour,” British Medical Journal 2, no. 4892 (October 9, 1954): 855; Martin Clyman et al., “Intravenous Use of Oxytocin (Pitocin) for Induc­ tion of ­Labor,” Journal of the American Medical Association 169, no. 11 (March 14, 1959): 1173–1181, https://­doi​.­org​/­10​.­1001​/­jama​.­1959​.­03000280025007. 38.  Leslie Reagan, When Abortion Was a Crime: W ­ omen, Medicine, and Law in the United States, 1867–1973 (Berkeley: University of California Press, 1997); Ben­ rubi, “­Labor Induction.” 39.  E. Condon, “Induction of L ­ abour: [1],” British Medical Journal 2, no. 4895 (October 30, 1954): 1048, http://­d x​.­doi​.­org​.­u ne​.­idm​.­oclc​.­org​/­10​.­1136​/ ­bmj​.­2​.­4895​ .­1048. 40.  Condon, “Induction of ­Labour,” 1048; Faris and Kahlenberg, “Intravenous Pitocin.” 41.  Faris and Kahlenberg, “Intravenous Pitocin,” 97. ­ abour,” October 9, 1954, 855. 42.  “Induction of L 43.  Norman Fritz Miller, H ­ uman Parturition; Normal and Abnormal L ­ abor (Baltimore: Williams & Wilkins, 1958), 185, http://­hdl​.­handle​.­net​/­2027​/­mdp​ .­39015072253829. 44.  Clyman et al., “Intravenous Use of Oxytocin,” 125. 45.  Theobald, Kelsey, and Muirhead, “Pitocin Drip,” 642. 46.  Tina Cassidy, Birth: The Surprising History of How We Are Born (New York: Atlantic Monthly Press, 2006), 177–178; Hilda Bastian, “Long Overdue: Is the Question of Induction of ­Labor and Cesarean Section Settled?” Scientific American Blog Network, September  8, 2014, https://­blogs​.­scientificamerican​.­com​ /­absolutely​-­maybe​/­induced​-­labor​-­decreases​-­rate​-­of​-­cesareans​-­study​-­finds​/­. 47.  Bastian, “Long Overdue.” 48.  Emily Oster and Nicole Cliffe, “Your Doctor Offers to Induce ­Labor. Should You Say Yes?” Slate, August 21, 2013, http://­w ww​.­slate​.­com​/­blogs​/­expecting​_­better​ /­2 013​/­08​/­21​/­l abor​_­i nductions​_­you​_­w ant​_­to​_­get​_­t he​_­baby​_­out​_­but​_­should​ _­you​_­induce​_­before​.­html; Jane E. Brody, “As Cases of Induced L ­ abor Rise, So Do Experts’ Concerns,” New York Times, January 14, 2003, https://­w ww​.­nytimes​.­com​ /­2 003​/­01​/­1 4​/­health​/­a s​-­cases​-­of​-­induced​-­labor​-­rise​-­so​-­do​-­experts​-­concerns​ .­html. 49.  Thomas F. Baskett and Fritz Nagele, “Naegele’s Rule: A Reappraisal,” BJOG 107, no. 11 (November 2000): 1433–1435, https://­doi​.­org​/­10​.­1111​/­j​.­1 471​-­0528​.­2000​ .­tb11661​.­x; Linda Geddes, Bumpology (New York: Bantam, 2013), 72; Viv Groskop, “The 40-­Week Pregnancy Myth Has Popped,” The Guardian, August 8, 2013, https://­w ww​.­t heguardian​.­com​/­commentisfree​/­2013​/­aug​/­08​/­40​-­week​-­pregnancy​ -­myth.

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50.  Roscoe Dean and Paul Hohm, “A ­Simple and Safe Method for Induction of ­ abor by Rupture of the Membranes,” Journal of the American Medical AssociaL tion 163, no. 7 (February 16, 1957): 543, https://­doi​.­org​/­10​.­1001​/­jama​.­1957​.­82970​ 420001008. 51.  Condon, “Induction of L ­ abour,” 1048. 52.  R. A. Tennent and M. D. Black, “Surgical Induction of L ­ abour in Modern Obstetric Practice,” British Medical Journal 2, no. 4892 (October 9, 1954): 834, 833, 837, https://­doi​.­org​/­10​.­1136​/b ­ mj​.­2​.­4892​.­833; “Induction of L ­ abour,” October 9, 1954, 855; F. J. Browne, “Foetal Post-­Maturity and Prolongation of Pregnancy: A Criti­ cal Study of the Incidence and Sequelae of Induction of ­Labour for Post-­Maturity in British Hospitals, with Remarks Thereon,” British Medical Journal 1, no. 5023 (1957): 851, https://­doi​.­org​/1­ 0​.­1136​/ b ­ mj​.­1​.­5023​.8­ 51. 53.  Bishop, “Dangers Attending Elective Induction,” 1954; Dick-­Read, “Induc­ ­ abour,” 1414. tion of ­Labour,” 1478; Lennon and Edwards, “Induction of L 54.  Browne, “Foetal Post-­Maturity,” 854. 55.  Dean and Hohm, “­Simple and Safe Method,” 543. 56.  Alan R. Fleischman, Motoko Oinuma, and Steven L. Clark, “Rethinking the Definition of ‘Term Pregnancy,’ ” Obstetrics and Gynecol­ogy 116, no. 1 (July 2010): 136–139, https://­doi​.­org​/­10​.­1097​/­AOG​.­0b013e3181e24f28. 57.  Jane E. Brody, “Rethinking ‘Term Pregnancy,’ ” Well, November 11, 2013, https://­well​.­blogs​.­nytimes​.­com​/­2013​/­11​/­11​/­importance​-­of​-­on​-­time​-­deliveries​/­; Kim Painter, “ ‘Full-­Term’ Pregnancy Gets a New, Narrower Definition,” USA ­Today, October 22, 2013, https://­w ww​.­usatoday​.­com​/­story​/­news​/­nation​/­2013​/­10​/­22​/­f ull​ -­term​-­pregnancy​-­definition​/­3145107​/­. 58.  Catherine Y. Spong, “Defining ‘Term’ Pregnancy: Recommendations from the Defining ‘Term’ Pregnancy Workgroup,” JAMA 309, no. 23 (June 19, 2013): 2445–2446, https://­doi​.­org​/­10​.­1001​/­jama​.­2013​.­6235. 59.  James M. Nicholson, Lisa C. Kellar, and Serdar Ural, “New Definition of Term Pregnancy,” JAMA 310, no. 18 (November 13, 2013): 1985–1986, https://­doi​.­org​ /­10​.­1001​/­jama​.2­ 013​.­277993. 60.  “ACOG Committee Opinion No  579, Definition of Term Pregnancy,” Obstetrics and Gynecol­ogy 122, no. 5 (November 2013): 1139–1140, https://­doi​.­org​ /­10​.­1097​/­01​.­AOG​.­0000437385​.­88715​.­4a. 61.  Chelsea Conaboy, “New Research Shifts Thinking on Pregnancy Dilemma: Induce ­Labor at 39 Weeks?” WBUR, Common Health, February 16, 2018, http://­ www​.­wbur​.­org​/­commonhealth​/­2018​/0 ­ 2​/­16​/­pregnancy​-­induce​-­labor​-­29​-­weeks. 62.  William A. Grobman et al., “­Labor Induction versus Ex­pec­tant Manage­ ment in Low-­R isk Nulliparous ­Women,” New ­England Journal of Medicine 379, no.  6 (August  9, 2018): 513–523, https://­doi​.­org ​/­10​.­1056​/­N EJMoa1800566; Wil­

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liam  A. Grobman, “Induction of ­Labor and Cesarean Delivery,” New E ­ ngland Journal of Medicine 374, no. 9 (March 3, 2016): 880–881, https://­doi​.­org​/­10​.­1056​ /­NEJMe1516461. 63.  Conaboy, “New Research Shifts Thinking”; William Grobman, “LB01: A Randomized Trial of Elective Induction of L ­ abor at 39 Weeks Compared with Ex­pec­tant Management of Low-­R isk Nulliparous ­Women,” American Journal of Obstetrics and Gynecol­ogy 218, no. 1 (January 1, 2018): S601, https://­doi​.­org​/­10​.­1016​ /­j​.a­ jog​.­2017​.­12​.­016; Grobman et al., “­Labor Induction”; Society for Maternal Fetal ­ abor ­a fter 39 Weeks in Healthy W ­ omen May Reduce the Medicine, “Induced L Need for Cesarean Birth,” press release, February 1, 2018, https://­s3​.­a mazonaws​ .­com​/­cdn​.­smfm​.­org​/­media​/­1338​/­FINAL ​_­Arrive​_­Release​.­pdf. 64.  Ekaterina Mishanina et al., “Use of ­Labour Induction and Risk of Cesar­ ean Delivery: A Systematic Review and Meta-­Analysis,” CMAJ: Canadian Medical Association Journal 186, no. 9 (June 10, 2014): 665–673, https://­doi​.­org​/­10​.­1503​ /­cmaj​.1­ 30925; Gabriele Saccone and Vincenzo Berghella, “Induction of L ­ abor at Full Term in Uncomplicated Singleton Gestations: A Systematic Review and Meta­ ­ rials,” American Journal of Obstetrics and analysis of Randomized Controlled T Gynecol­ogy 213, no. 5 (November 2015): 629–636, https://­doi​.­org​/­10​.­1016​/­j​.­ajog​.­2015​ .­04​.­004; Grobman, “Induction of L ­ abor”; Kate F. Walker et al., “Randomized Trial of L ­ abor Induction in W ­ omen 35 Years of Age or Older,” New E ­ ngland Journal of Medicine 374, no. 9 (March 3, 2016): 813–822, https://­doi​.­org​/­10​.­1056​/­NEJMoa1509117. 65.  Philippa Middleton, Emily Shepherd, and Caroline A. Crowther, “Induc­ tion of ­Labour for Improving Birth Outcomes for W ­ omen at or beyond Term,” Cochrane Database of Systematic Reviews, no. 5 (2018): CD004945, https://­doi​.­org​ /­10​.­1002​/­14651858​.­CD004945​.p ­ ub4. 66.  Rachel G. Sinkey et al., “Elective Induction of ­L abor at 39 Weeks among ­ omen: The Impact on Maternal and Neonatal Risk,” PLoS ONE 13, Nulliparous W no. 4 (April 25, 2018): e0193169, https://­doi​.­org​/­10​.­1371​/­journal​.­pone​.­0193169. 67.  Sinkey et al., “ “Elective Induction of ­Labor,” e0193169; Michele G. ­Sullivan, “Is Elective Induction at 39 Weeks a Good Idea?” MDEdge: ObGyn News, Feb­ ruary 2, 2018, https://­w ww​.­mdedge​.­com​/­obgynnews​/­a rticle​/­157700​/­obstetrics​ /­elective​-­induction​-­39​-­weeks​-­good​-­idea. 68.  Howard Herrell, “To Induce or Not to Induce: The 39 Weeks ‘Debate’ (Part 1),” Howardisms, June  9, 2016, http://­w ww​.­howardisms​.­com​/­obgyn​/­to​-­induce​-­or​ -­not​-­to​-­induce​-­the​-­39​-­weeks​-­debate​-­part​-­1​/­; Megan Margulies, “Should Pregnant ­Women Be Induced at 39 Weeks?” Washington Post, June 27, 2016, https://­w ww​ .­w ashingtonpost​.­c om​/­n ational​/­health​-­science​/­s hould​-­pregnant​-­women​-­be​ -­induced​-­at​-­39​-­weeks​/­2016​/­06​/­27​/­e1bb9d16​-­27fe​-­11e6​-­b989​-­4e5479715b54​_ ­story​ .­html; “Support for Elective IOL at 39 Weeks Growing,” ACOG Annual Meeting:

254

N o t e s t o pa g e s 1 9 6 –1 9 7

2016 Archive (blog), May 17, 2016, https://­web​.­a rchive​.­org ​/­web​/­20181110051804​ /­http://­annualmeeting​.­acog​.­org​/­support​-­for​-­elective​-­iol​-­at​-­39​-­weeks​-­growing​/­. 69.  Bastian, “Long Overdue.” 70.  Harrison, “On the Use of Pituitary Extract,” 326; Allan, “Use of Pituitary Extract,” 21. 71.  Moir, “Discussion on the Place of Oxytocic Drugs,” 861, quoted in Theobald, Kelsey, and Muirhead, “Pitocin Drip,” 641. 72.  Monica Hesse, “What We ­Don’t Know about How a Uterus Works Is ­Going ­ ashingtonpost​.c­ om​ to Hurt Us All,” Washington Post, May 13, 2019, https://­w ww​.w /­lifestyle​/­style​/­what​-­we​-­dont​-­know​-­about​-­how​-­a​-­uterus​-­works​-­is​-­going​-­to​-­hurt​ -­us​-­all​/­2019​/­05​/­10​/­d210ab16​-­7366​-­11e9​-­8be0​-­ca575670e91c​_­story​.­html. 73.  Sinkey et al., “Elective Induction of L ­ abor.”

Index

The letter n following a page number refers to a footnote. abortion, 48, 49, 110, 187 ACA (Affordable Care Act), 28 ACOG. See American College of Obstetricians and Gynecologists (ACOG) acupressure and acu­punc­ture, 34, 56, 57 ADHD (attention deficit hyperactivity disorder), 66 Adler, Daphne, 14 Affordable Care Act (ACA), 28 ALARA (As Low as Reasonably Achievable), 117, 118. See also ultrasounds alcohol, 94–95, 96, 97, 145, 151n Alexander, Greg, x alternative medicine for morning sickness, 55–58 American Association for the ­Advancement of Physical Education, 129 American College of Obstetricians and Gynecologists (ACOG): Bendectin, 40; dating pregnancies, 192–193; exercise, 123, 136–137, 140; fetal scans, 108, 111–112, 113, 117; folic acid, 15; induction, 196; iron, 23; morning sickness management, 33–35; sex bias in clinical ­trials, 37; vitamin D, 25; weight gain, 71, 73, 74 American College of Radiology, 117

American College of Sports Medicine, 134 American Heart Association, 131 American Institute of Ultrasound in Medicine, 111, 117 American Journal of Bioethics, 54 American Journal of Obstetrics and Gynecol­ogy, 25, 50, 57, 138, 152 American Medical Association, 8 amphetamines, 66 anatomy scan, 102–103. See also ultrasounds anemia, 22, 23 anencephaly. See neural tube defects (NTDs) anesthetics in childbirth, 165–168, 183n, 185–186. See also birth planning antihistamines, 33–34, 35, 39, 57, 58. See also morning sickness Apple, Rima, 9, 16 Armstrong, Elizabeth, 171 Artal, Raul, 136 As Low as Reasonably Achievable (ALARA), 117, 118. See also ultrasounds Ballantyne, J. W., 125 Barnett, Stanley, 117 Bastian, Hilda, 196 Beck, Julie, 122–123 Bell, W. Blair, 181

255

256 I n d e x Bendectin, 39–40 Benzedrine, 66 bias in medicine: class bias and exercise, 123–124; sex bias, 19–20, 35–37, 127, 148–149. See also feminin­ ity, standards of; inequalities birth defects: maternal markings theory, 92–94, 100; neural tube defects (NTDs), 10–15, 27–28, 136; thalidomide, 34–35; ultrasounds, 107, 109–111; vitamin A, 57 birth planning: alternative birth movement, 171–172; anesthetic use, 165–168; author’s experience, 162–164, 176–177; history of childbirth, 164–168; history of prenatal care systems, 168–173; professional re­sis­tance, 173–176. See also cesarean deliveries; dietary advice; exercise; ­labor and delivery; morning sickness; sleep; ultrasounds; vitamins and minerals; weight gain birth weights: exercise, 135; maternal weight gain, 70, 72–73, 75–76, 78–79, 81; multivitamin use, 22–23; routine ultrasounds, 106; sleep deprivation, 157, 158. See also stillbirths Bishop, Edward, 187 Bishop score, 187 body mass index (BMI), 73–74, 75, 77, 81 Bossi-­t ype uterine dilator, 180 Boston Birth Cohort, 28 Bradley, Robert, 171 Breckenridge, Mary, 170 British Medical Research Council, 12 Brody, Jane, 71, 189 Brumberg, Joan Jacobs, 88–89 Bruser, Michael, 127–128 caffeine, 145 cancer and DES (diethylstilbestrol), 35 Caraka, 87–88 Cassidy, Tina, 189 castor oil, 178, 180 Caughey, Aaron, 81–82 CDC. See U.S. Centers for Disease Control and Prevention (CDC) cesarean deliveries: exercise, 135–136, 138; induction, 186, 194–195; maternal weight gain, 75–76; sleep deprivation,

157, 158; weight gain between ­ omen’s push pregnancies, 77, 78–79; w for, 197–198. See also birth planning; ­labor and delivery childbirth. See birth planning; ­labor and delivery childhood markers of obesity, 77 ­Children’s Bureau. See U.S. ­Children’s Bureau Claiborne, J. Herbert, 166 Clinical Pediatrics, 80 Cochrane review: birth plans, 174; folic acid, 15; induction, 195; morning sickness, 41; prenatal vitamins, 22; ultrasounds, 111, 114; vitamin D, 24; weight gain, 76 Cocroft, Susanna, 100 Cohen, Pieter, 8–9, 27 Combined Textbook of Obstetrics and Gynecol­ogy, 152 Conaboy, Chelsea, 194 constipation, 94 ConsumerLab, 9 COVID-19 pandemic, ix–­x, xi–­x ii, xiii–­x iv dairy foods, 17, 96–97 DeLee, Joseph, 99–100, 125–126 Dement, William, 147, 149–150 De Ribes Bag, 180 DES (diethylstilbestrol), 35, 38 developing countries, nutrition studies, 21–22 Dexedrine, 66 diabetes. See gestational diabetes Dick-­Read, Grantley, 127, 171, 186 Diclectin (pyridoxine-­doxylamine), 40 Diclegis, 40 dicyclomine, 39 dietary advice: appetite, 88–90; author’s experience, 85–87, 100–101; cravings, 89–92; dairy foods, 96–97; fluid intake, 97; fruit diet, 95–96; historical directives, 94–99; myths and customs, 87–88, 90–91, 92–94; twenty-­first-­century advice, 99–101. See also birth planning; exercise; ­labor and delivery; morning sickness; sleep; ultrasounds; vitamins and minerals; weight gain

Index diethylstilbestrol (DES), 35, 38 diuretics, 66, 71 doxylamine, 33–34, 39, 57, 58 Drake, Emma, 83, 95 due date determination, 112–113, 189–193. See also l­ abor and delivery eclampsia, 67, 182, 184, 187. See also preeclampsia Eisenhower, Dwight, 130 electrolyte balance, 49n Ephron, Nora, 178 ergot, 180 estrogen, synthetic (DES), 35, 38 Eunice Kennedy Shriver National Institute of Child Health and ­Human Development, 114 Eu­ro­pean Journal of Obstetrics, 22 Eutocia, 92 exercise: author’s experience, 122, 139–141; class bias, 123–124; history, 123–128; move for health, 128–134; revolution, 134–139; sex bias, 127. See also birth planning; dietary advice; ­labor and delivery; morning sickness; sleep; ultrasounds; vitamins and minerals; weight gain famine conditions, 79–80 FDA. See U.S. Food and Drug Admin­ istration (FDA) femininity, standards of: activity and exercise, 124, 127, 132–133, 141; figure control, 130; hysteria, 155; weight gain, 77, 78, 87, 88–89. See also bias in medicine; inequalities feminist movement, 132–133 fertility, 150 Fessler, Ann, 167 fetal anomalies. See birth defects fetal asphyxia, 166 fetal images in Life magazine, 104. See also ultrasounds fetal monitoring. See ultrasounds fetal origins hypothesis, 100 fetal sleep, 150–151n Flaxman, Samuel, 60 Fleming, John, 114 folic acid (vitamin B9), 10–15, 21, 22, 23, 27–28

257 Fonda, Jane, 134 Fox, Harold, 105 Freud, Sigmund, 155 fruit diet, 95–96 Galen, 87, 128 gestational diabetes: exercise, 138; sex bias in clinical t­ rials, 37; sleep deprivation, 157, 158; vitamin D, 24; weight gain between pregnancies, 77 ginger, 56, 57–58, 96 Goodwin, T. Murphy, 40 Gottlieb, Scott, 120 “Guidelines for Prenatal Care” (Univ. of Michigan), 112 Hall, Harriet, 29 Hamblin, James, 55–56 Heaton, Claude Edwin, 63, 65 Heller, Zoe, 146–147 Helsinki Trial, 106–107 Hesse, Monica, 155–156, 197 Hippocrates, 45, 87, 128, 147, 180 Hoffman La Roche, 182–183 Holbrook, Martin Luther, 63, 65, 67–68, 83 Hollis, Bruce, 24 ­human chorionic gonadotropin (hCG), 5, 42 Hurst, Arthur, 49 hyperemesis gravidarum, 49n hypertension: in c­ hildren, 77; exercise, 138; management, 16n; maternal weight gain, 76–77; sex bias in clinical ­trials, 37; sleep deprivation, 157. See also preeclampsia hysteria, 154–156 induction: current practice, 193–198; history, 179–186; reasons for, 187–189, 190–191. See also ­labor and delivery inequalities: birth plans, 175; exercise, 140; internet access, xii; maternal mortality rates, xi, 20; multivitamin use, 27–28. See also bias in medicine; femininity, standards of insomnia remedies, 145–146. See also sleep

258 I n d e x Institute of Medicine (IOM): gesta­ tional weight gain guidelines, 72–75, 80; sex bias in medicine, 20, 37 Instructive District Nursing Associa­ tion, 169–170 International Federation of Gynecol­ogy and Obstetrics, 40 International Journal of Childbirth Education, 123 Jackson, Gabrielle, 20 JAMA, 34, 98, 105, 131, 134, 183, 188, 192 Jazzercise, 132–134 Johns Hopkins University, 26–27 Kaptchuk, Ted, 51–52, 55 Kennedy, John F., 131 Kiefer, Amy, 44, 60 Koerber, Amy, 155 Kotelchuck, Milton, x ­labor and delivery: author’s experience, 178–179, 181, 198; cesarean deliveries and maternal weight gain, 75–76; COVID-19 pandemic, xii; diet, 95–96; due date determination, 189–193; exercise, 124, 138; induction, history of, 179–186; induction, reasons for, 187–189, 190–191; induction t­ oday, 193–198. See also birth planning; cesarean deliveries; dietary advice; exercise; morning sickness; sleep; ultrasounds; vitamins and minerals; weight gain Lamaze, Fernand, 127, 171 Lancet, The, 11–12, 60, 73, 84, 104, 116, 156 Leavitt, Judith, 164–165 Lee, Kathryn, 154 left-­handedness, 116 Lemus, Cheryl, 9–10 Life magazine, 104 Lockwood, Charles, 196 Longfellow, Fanny, 165 magnesium, 31–32 malpractice suits, 109n March of Dimes, 27 Marr, Marjorie, 104 Martin, Nina, 38 maternal bonding, 114

maternal education, 169–170 maternal markings theory, 92–94, 100 Maternity Center Association, 170 maternity clothes, 92–93 Meaker, Samuel, 79 membrane rupture, 184–185. See also ­labor and delivery ­mental health, 48–50, 58–59, 154–157 Michigan Department of Health, 65 midwifery practices, 83, 123, 170, 193 miscarriages, 46–47, 59–60, 92–94, 187. See also birth defects morning sickness: acupressure and acu­punc­ture, 34, 56, 57; alternative medicine, 55–58; author’s experience, 31–32, 33, 60–61; causation theories, 42–44; dietary management, 33; exercise, 138; history, 45–50; phar­ma­ ceu­ti­cal management, 33–36, 39–42; placebo effect, 50–55, 58–59; preg­ nancy outcome, 46–47, 59–60; psychiatric approaches, 48–50, 58–59; rates of, 32–33. See also birth planning; dietary advice; exercise; ­labor and delivery; sleep; ultra­ sounds; vitamins and minerals; weight gain morphine, 183n, 185–186 mortality rates, infant, 168–169, 170 mortality rates, maternal: electrolyte imbalance, 49n; by infection, 180, 185; postpartum hemorrhage, 182; public health reforms, 168–169, 170; statistics, 164; in United States, x–xi. See also pregnancies Motherisk, 51 Naegele’s rule, 112, 113, 189–190 National Dairy Council, 96–97 National Institute for Health and Care Excellence (U.K.), 23–24 National Research Council (NRC), 70 National Sleep Foundation, 144 nausea and vomiting of pregnancy (NVP). See morning sickness neural tube defects (NTDs), 10–15, 27–28, 136. See also birth defects newborns and sleep disturbance, 153 ­ ngland Journal of Medicine, New E 12–13, 76, 131, 194

Index New York Bureau of Maternal and Child Health, 63 New York City, COVID-19 pandemic, xii New York Times, 19–20, 76 Nicolson, Malcolm, 114 Niebyl, Jennifer, 40 nipple stimulation, 178, 180 Norwitz, Errol, 196 NTDs (neural tube defects). See neural tube defects (NTDs) nutrition. See dietary advice; vitamins and minerals Nutrition Reviews, 31–32 nutrition science, 16–18, 20–23, 98. See also dietary advice; vitamins and minerals NVP (nausea and vomiting of pregnancy). See morning sickness Obamacare (Affordable Care Act; ACA), 28 obesity, 73–78, 81. See also weight gain O’Brien, Louise, 159 Obstetrics and Gynecol­ogy, 74, 80, 106 ondansetron (Zofran), 40–41 Oster, Emily, 80, 82, 88 overdiagnosis, 110–111 oxytocin, 144. See also pituitary extracts Parke Davis, 183 Pauling, Linus, 8 Petrzela, Natalia, 133, 140 phar­ma­ceu­ti­cals: amphetamines, 66; anesthetics in childbirth, 165–168, 183n, 185–186; antihistamines, 33–34, 35, 39, 57, 58; Bendectin, 39–40; Benzedrine, 66; DES (diethylstilbes­ trol), 35, 38; Dexedrine sulphate, 66; Diclectin (pyridoxine-­doxylamine), 40; Diclegis, 40; dicyclomine, 39; diuretics, 66, 71; doxylamine, 33–34, 39, 57, 58; induction, 181–189, 196–197; morning sickness management, 33–36, 39–42; morphine, 183n, 185–186; oxytocin, 144; Pitocin, 181, 183–186, 188, 189, 196–197; pituitary extracts, 181, 182–184; Pituitrin, 181, 183, 188; Pituitrin shock, 183n; pyridoxine-­doxylamine, 34, 39–40; quinine, 180; scopolamine, 166–167,

259 183n, 185–186; sex bias in clinical ­trials, 35–39; statin therapy, 120; thalidomide, 34–35, 38; weight gain management, 66, 71; Zofran (ondan­ setron), 40–41. See also alternative medicine for morning sickness Pharmacotherapy, 56 Pike, Ivy, 43–44 Pinkham, Lydia, 145 Pitocin, 181, 183–186, 188, 189, 196–197 Pittsburgh Sleep Quality Index (PSQI), 159 pituitary extracts, 181, 182–184 Pituitrin, 181, 183, 188 Pituitrin shock, 183n placebo effect, 50–55, 58–59 placenta, 35 Plato, 87 Poehler, Amy, 148 Pollan, Michael, 16 poppy, 145 postpartum depression, 156–157. See also ­mental health postpartum hemorrhage, 182 postpartum weight retention, 76–78 preeclampsia, 170, 187–188; milk diet, 97; multivitamin use, 22; pituitary extracts, 182, 184; sleep deprivation, 157; weight gain, 67, 75, 81 pregnancies: body changes, 18–19; dating, 112–113, 189–193; m ­ ental health, 154–157; sex during, 125–126n; ­ omen’s unfamiliar­ unplanned, 14; w ity with, 166–168. See also mortality rates, maternal; prenatal care pregnancy taboos, 92–94. See also dietary advice pregnancy tests, 143; author’s experi­ ence, 5–6 pregnant ­women in clinical ­trials, 35–39. See also bias in medicine prenatal care: author’s experience, 1–4; COVID-19 pandemic, ix–­x, xi–­x ii, xiii–­x iv; criticism of, x–xi, xiii; history of prenatal care systems, 168–173. See also birth planning; dietary advice; exercise; ­labor and delivery; morning sickness; pregnan­ cies; sleep; ultrasounds; vitamins and minerals; weight gain

260 I n d e x prenatal education, xii. See also prenatal care prenatal exercises, 126–127. See also exercise prenatal informed consent for sonography (PICS), 109 President’s Council on Youth Fitness, 130–131 Price, Catherine, 16, 17 Prochownik, Ludwig, 97 psychiatry and morning sickness management, 48–50, 58–59 PUQE (pregnancy-­unique quantifica­ tion of emesis and nausea), 51. See also morning sickness Putnam, William Lowell, Mrs., 170 pyridoxine (vitamin B6), 14, 33–34, 39, 56, 57 pyridoxine-­doxylamine, 34, 39–40

advice; exercise; l­ abor and delivery; morning sickness; ultrasounds; vitamins and minerals; weight gain Slemons, J. Morris, 100, 125, 126, 143–144, 145–146 Society for Maternal and Fetal Medicine, 192–193 Soranus, 45 spina bifida. See neural tube defects (NTDs) statin therapy, 120 Stearns, Peter, 71–72 Stephens, Merielle, 194 stillbirths, 23, 77, 158–159. See also birth weights ­Sullivan, Scott, 29 supplements. See vitamins and minerals Susrata, 87–88

Quigley, J. K., 183 quinine, 180

thalidomide, 34–35, 38 Title IX, 132 toxemia. See preeclampsia Twilight Sleep Association, 166 Tyler-­Smith, William, 45

RADIUS trial (Routine Antenatal Diagnostic Imaging with Ultra­ sound), 107–108 RDAs (recommended daily allow­ ances), 17, 25. See also dietary advice; vitamins and minerals Reinke, Carla, 172 Reynolds, Gretchen, 138 Royal College of Obstetricians and Gynecologists, 15 Russell, Rachael, 46 scopolamine, 166–167, 183n, 185–186 Seed, John, 118 sex bias. See bias in medicine sex during pregnancy, 125–126n sex education, 167 Simkin, Penny, 172 Slate, 26 sleep: author’s experience, 142–143, 159–161; defining “normal,” 151–152; disturbances in, 143–147; early studies, 152–154; effects of disturbed sleep, 154–159; fetal, 150–151n; history, 147–151; sex bias in studies, 148–149. See also birth planning; dietary

ultrasounds: author’s experience, 102–103, 113, 121; debate over routine scans, 105–111; due date determina­ tion, 191; history, 103–105; rapid adoption of, 119–121; safety, 115–119; twenty-­first-­century practice, 111–114. See also birth planning; dietary advice; exercise; ­labor and delivery; morning sickness; sleep; vitamins and minerals; weight gain University of Michigan, 28, 112 U.S. Centers for Disease Control and Prevention (CDC), 13, 15, 131 U.S. C ­ hildren’s Bureau, xi, 80, 100, 126, 145 U.S. Department of Agriculture, 96–97 U.S. Food and Drug Administration (FDA): antihistamines, 35; DES (diethylstilbestrol), 35; Diclegis, 40; fetal scans, 118; folic acid fortification, 13; sex bias in clinical t­ rials, 35–36; supplement regulation, 8–9. See also

Index phar­ma­ceu­ti­cals; vitamins and minerals U.S. National Institutes of Health: exercise studies, 131; sex bias in clinical ­trials, 37; ultrasounds, 105, 111; vitamin D, 24 U.S. Public Health Ser­v ice, 13 uterine dilators, 180. See also ­labor and delivery vaginal cancer and DES (diethylstilbes­ trol), 35 Van Blarcom, Carol, 94 vegetarians, iron requirements, 23 vitamins and minerals: Affordable Care Act (ACA) and costs, 28; author’s experience, 5–7; calcium, 14, 16; controversy, 15–19, 20–23, 26–30; docosahexaenoic acid (DHA), 16, 18; fish oil, 16; folic acid (vitamin B9), 10–15, 21, 22, 23, 27–28; history, 7–10, 98; iodine, 13, 16; iron, 14, 15, 17, 21, 22, 23–24; magnesium, 31–32; regulation, 8–9; supplement industry, 26–27, 29; vitamin A, 7, 57; vitamin B complex, 13; vitamin B6 (pyridoxine), 14, 33–34, 39, 56, 57; vitamin B12, 33–34; vitamin C, 7, 8, 15–16, 17, 98; vitamin D, 7, 13, 14, 15, 17–18, 24–26, 98; vitamin E, 16. See also birth planning; dietary advice; exercise; ­labor and delivery; morning sickness; sleep; ultrasounds; weight gain

261 Wall Street Journal, 120 wandering womb theory, 154–155 weight gain: author’s experience, 62–63, 68; controversy, 78–84; debate over new guidelines, 72–78; “eating for two” myth, 63–64, 82, 84; exercise, 137; history of restrictions, 64–70; phar­ma­ceu­ti­cals in management, 66, 71; postpartum retention, 76–77; restrictions lifted, 70–72. See also birth planning; dietary advice; exercise; ­labor and delivery; morning sickness; sleep; ultrasounds; vitamins and minerals weight gain in population, 71–72, 73–74 ­ ou’re Expecting, What to Expect When Y 87 White, J. William, 129 WHO (World Health Organ­ization). See World Health Organ­ization (WHO) Williams Obstetrics, 66, 71, 84 Wilson, J. Robert, 63 Wing, Deborah A., 189 Wishik, Samuel, 67 World Health Organ­ization (WHO): birth plans, 172; folic acid recommen­ dation, 15, 21; iron recommendation, 23; ultrasounds, 111; vitamin recommendations, 21 World War II, 79–80 Zofran (ondansetron), 40–41

About the Author

Brittany Clair is an in­de­pen­dent researcher and writer who lives and works in Maine. She holds a PhD in history from the University of Cin­ cinnati and is the author of Rest Uneasy: Sudden Infant Death Syndrome in Twentieth-­Century Amer­i­ca.

Available titles in the Critical Issues in Health and Medicine series: Emily K. Abel, Prelude to Hospice: Florence Wald, ­Dying ­People, and Their Families Emily K. Abel, Suffering in the Land of Sunshine: A Los Angeles Illness Narrative Emily K. Abel, Tuberculosis and the Politics of Exclusion: A History of Public Health and Migration to Los Angeles Marilyn Aguirre-­Molina, Luisa N. Borrell, and William Vega, eds. Health Issues in Latino Males: A Social and Structural Approach Anne-­Emanuelle Birn and Theodore M. Brown, eds., Comrades in Health: U.S. Health Internationalists, Abroad and at Home Karen Buhler-­Wilkerson, False Dawn: The Rise and Decline of Public Health Nursing Susan M. Chambré, Fighting for Our Lives: New York’s AIDS Community and the Politics of Disease Brittany Clair, Carrying On: Another School of Thought on Pregnancy and Health James Colgrove, Gerald Markowitz, and David Rosner, eds., The Contested Bound­aries of American Public Health Elena Conis, Sandra Eder, and Aimee Medeiros, eds., Pink and Blue: Gender, Culture, and the Health of C ­ hildren Cynthia A. Connolly, ­Children and Drug Safety: Balancing Risk and Protection in Twentieth-­Century Amer­i­ca Cynthia A. Connolly, Saving Sickly C ­ hildren: The Tuberculosis Preventorium in American Life, 1909–1970 Brittany Cowgill, Rest Uneasy: Sudden Infant Death Syndrome in Twentieth-­Century Amer­i­ca Patricia D’Antonio, Nursing with a Message: Public Health Demonstration Proj­ects in New York City Kerry Michael Dobransky, Managing Madness in the Community: The Challenge of Con­temporary ­Mental Health Care Tasha N. Dubriwny, The Vulnerable Empowered W ­ oman: Feminism, Postfeminism, and W ­ omen’s Health Edward J. Eckenfels, Doctors Serving ­People: Restoring Humanism to Medicine through Student Community Ser­vice Julie Fairman, Making Room in the Clinic: Nurse Prac­ti­tion­ers and the Evolution of Modern Health Care Jill A. Fisher, Medical Research for Hire: The Po­liti­cal Economy of Phar­ma­ceu­ti­cal Clinical ­Trials Charlene Galarneau, Communities of Health Care Justice

Alyshia Gálvez, Patient Citizens, Immigrant ­Mothers: Mexican ­Women, Public Prenatal Care, and the Birth Weight Paradox Laura E. Gómez and Nancy López, eds., Mapping “Race”: Critical Approaches to Health Disparities Research Janet Greenlees, When the Air Became Impor­tant: A Social History of the New ­England and Lancashire Textile Industries Gerald N. Grob and Howard H. Goldman, The Dilemma of Federal ­Mental Health Policy: Radical Reform or Incremental Change? Gerald N. Grob and Allan V. Horwitz, Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine Rachel Grob, Testing Baby: The Transformation of Newborn Screening, Parenting, and Policymaking Mark A. Hall and Sara Rosenbaum, eds., The Health Care “Safety Net” in a Post-­Reform World Laura L. Heinemann, Transplanting Care: Shifting Commitments in Health and Care in the United States Laura D. Hirshbein, American Melancholy: Constructions of Depression in the Twentieth ­Century Laura D. Hirshbein, Smoking Privileges: Psychiatry, the Mentally Ill, and the Tobacco Industry in Amer­i­ca Timothy Hoff, Practice u ­ nder Pressure: Primary Care Physicians and Their Medicine in the Twenty-­first C ­ entury Beatrix Hoffman, Nancy Tomes, Rachel N. Grob, and Mark Schlesinger, eds., Patients as Policy Actors Ruth Horo­w itz, Deciding the Public Interest: Medical Licensing and Discipline Powel Kazanjian, Frederick Novy and the Development of Bacteriology in American Medicine Claas Kirchhelle, Pyrrhic Pro­gress: The History of Antibiotics in Anglo-­ American Food Production Rebecca M. Kluchin, Fit to Be Tied: Sterilization and Reproductive Rights in Amer­i­ca, 1950–1980 Jennifer Lisa Koslow, Cultivating Health: Los Angeles W ­ omen and Public Health Reform Jennifer Lisa Koslow, Exhibiting Health: Public Health Displays in the Progressive Era Susan C. Lawrence, Privacy and the Past: Research, Law, Archives, Ethics Bonnie Lefkowitz, Community Health Centers: A Movement and the P ­ eople Who Made It Happen Ellen Leopold, ­Under the Radar: Cancer and the Cold War Barbara L. Ley, From Pink to Green: Disease Prevention and the Environmental Breast Cancer Movement

Sonja Mackenzie, Structural Intimacies: Sexual Stories in the Black AIDS Epidemic Stephen E. Mawdsley, Selling Science: Polio and the Promise of Gamma Globulin Frank M. McClellan, Healthcare and ­Human Dignity: Law ­Matters Michelle McClellan, Lady Lushes: Gender, Alcohol, and Medicine in Modern Amer­i­ca David Mechanic, The Truth about Health Care: Why Reform Is Not Working in Amer­i­ca Richard A. Meckel, Classrooms and Clinics: Urban Schools and the Protection and Promotion of Child Health, 1870–1930 Terry Mizrahi, From Residency to Retirement: Physicians’ C ­ areers over a Professional Lifetime Manon Parry, Broadcasting Birth Control: Mass Media and ­Family Planning Alyssa Picard, Making the American Mouth: Dentists and Public Health in the Twentieth C ­ entury Heather Munro Prescott, The Morning ­After: A History of Emergency Contraception in the United States Sarah B. Rodriguez, The Love Surgeon: A Story of Trust, Harm, and the Limits of Medical Regulation David J. Rothman and David Blumenthal, eds., Medical Professionalism in the New Information Age Andrew R. Ruis, Eating to Learn, Learning to Eat: School Lunches and Nutrition Policy in the United States James A. Schafer Jr., The Business of Private Medical Practice: Doctors, Specialization, and Urban Change in Philadelphia, 1900–1940 David G. Schuster, Neurasthenic Nation: Amer­i­ca’s Search for Health, Happiness, and Comfort, 1869–1920 Karen Seccombe and Kim A. Hoffman, Just ­Don’t Get Sick: Access to Health Care in the Aftermath of Welfare Reform Leo B. Slater, War and Disease: Biomedical Research on Malaria in the Twentieth C ­ entury ­Piper Sledge, Bodies Unbound: Gender-­Specific Cancer and Biolegitimacy Dena T. Smith, Medicine over Mind: ­Mental Health Practice in the Biomedical Era Kylie M. Smith, Talking Therapy: Knowledge and Power in American Psychiatric Nursing Matthew Smith, An Alternative History of Hyperactivity: Food Additives and the Feingold Diet Paige Hall Smith, Bernice L. Hausman, and Miriam Labbok, Beyond Health, Beyond Choice: Breastfeeding Constraints and Realities

Susan L. Smith, Toxic Exposures: Mustard Gas and the Health Consequences of World War II in the United States Rosemary A. Stevens, Charles E. Rosenberg, and Lawton R. Burns, eds., History and Health Policy in the United States: Putting the Past Back In Marianne S­ ullivan, Tainted Earth: Smelters, Public Health, and the Environment Courtney E. Thompson, An Organ of Murder: Crime, Vio­lence, and Phrenology in Nineteenth-­Century Amer­ic­ a Barbra Mann Wall, American Catholic Hospitals: A ­Century of Changing Markets and Missions Frances Ward, The Door of Last Resort: Memoirs of a Nurse Practitioner Jean C. Whelan, Nursing the Nation: Building the Nurse ­Labor Force Shannon Withycombe, Lost: Miscarriage in Nineteenth-­Century Amer­i­ca