Carrying On: Another School of Thought on Pregnancy and Health

By Brittany Clair

In the twenty-first century, expecting parents are inundated with information and advice from every direction, but are often strapped for perspective on how to think through it. Unlike traditional pregnancy guidebooks that offer recommendations, Carrying On helps expecting parents make sense of the overwhelming amount of counsel available to them by shedding light on where it all came from. How and why did such confusing and contradictory guidance on pregnancy come to exist?
 
Carrying On investigates the origin stories of prevailing prenatal health norms by exploring the evolution of issues at the center of pregnancy, ranging from morning sickness and weight gain to ultrasounds and induction. When did women start taking prenatal vitamins, and why? When did the notion that pregnant women should “eat for two” originate? Where did exercise guidelines come from? And when did women start formulating birth plans?
 
A learning project with one foot in the past and the other in the present, Carrying On considers what history and medicine together can teach us about how and why we treat pregnancy–and pregnant women–the way we do. In a world of information overload, Carrying On offers expecting parents the context and background they need to approach pregnancy and prenatal health from a new place of understanding.

• Language: English
• Publisher: Rutgers University Press
• Release date: Jan 14, 2022
• ISBN: 9781978801028

Book preview

Carrying On

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 contemporary 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

Another School of Thought on Pregnancy and Health

BRITTANY CLAIR

RUTGERS UNIVERSITY PRESS

NEW BRUNSWICK, 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, without written permission from the publisher. Please contact Rutgers University Press, 106 Somerset Street, New Brunswick, NJ 08901. The only exception to this prohibition 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

List of Abbreviations

Introduction: On Carrying On

1 Provide

2 Endure

3 Grow

4 Eat

5 Watch

6 Move

7 Sleep

8 Plan

9 Commence

Acknowledgments

Notes

Index

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 women who are expecting right now, who are doing their best to navigate the mystery of pregnancy and to prepare for birth in a world characterized by uncertainty above all else. 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 daughter, 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 daughter and son, as children and citizens of the world. They will never 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 today, at this moment.

And at this moment, we are all asking questions. About everything—about the way we work, the way we shop, the way we commute, the way 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 doing 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 women). By design, prenatal care was structured to identify complications or abnormalities among pregnant women, with the understanding that doing 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 equivocal. Their overall synopsis was bleak:

Unfortunately … the 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 progressive changes in prenatal care content and practice, even though it has suggested that clinical guidelines should be reassessed … the rigorous 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 professionals have called America’s prenatal care system into question, and for good reason.³ Far from being a leader in maternal health, the United States ranks dismally in terms of infant and maternal mortality. Women giving birth in the United States face greater odds of dying 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), things 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 mortality 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-all approach to delivering prenatal health care (which itself is designed to serve privileged, insured women) is failing untold women who lack access to information, resources, and care.⁷

It is startling, in fact, to confront how little 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 appointments confer the most benefit; but the current visit schedule of twelve to fourteen recommended visits for a healthy singleton pregnancy is derived from the Children’s Bureau’s 1930 edition of Prenatal Care—which borrowed its timetable from a 1929 statement issued by Britain’s Departmental 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 protocols modified more in a matter of weeks than they had in the century prior. In the initial wave of the pandemic in the spring of 2020, many nonessential office visits were cut entirely or amended, routine screenings and testing procedures were kept to a minimum, visitors were excluded from momentous junctures (like ultrasounds), and the conventional wisdom of what constitutes essential was turned on its head. In a particularly dark moment, New York City hospitals barred any visitors from labor and delivery wings, and laboring women there were asked to leave their partners, family, friends, doulas at the door.

Thankfully, that policy was reversed within a matter of days. But other pandemic changes to maternity care have held steady. In some places, pregnant women 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, these do-it-yourself changes may be empowering; for others, they may be nerve-wracking; for still others, they are simply unavailable. The pandemic has thrown systemic inequality into stark relief: thousands of pregnant women 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 will 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 things every day—in pregnancy and childbirth as in the rest of our lives—without 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 future) I have come to recognize that although I consider myself a devotee of medical evidence, there are a great many things I do despite available evidence indicating their futility. When I was pregnant, I took multivitamins, indulged in prenatal ultrasounds, drank prenatal tea. Perhaps others of my decisions were 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 woman is seven times more likely to deliver prematurely and five times more likely to lose her infant. It is precisely because 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 backyard 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 predominantly 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, really, 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 experience of pregnancy in America. In moments of crisis, priorities change shape; I imagine some of those things that kept me awake at night, wondering, will change for women who are pregnant now or become pregnant in the near future. And yet some things likely will not, because the uncertain 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 won’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 century. 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 else rebuild a better vessel entirely.

Abbreviations

Carrying On

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 buoyant, nonchalant, assured, but I couldn’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 uncertain terms—if I am still pregnant, if I have a baby in December, if we have a child.

As it turned out, everything went wonderfully. I had an utterly unremarkable pregnancy (I can’t find anything wrong with you! my doctor joked at every prenatal visit), and a grueling but equally unremarkable birth.

This time I aspire to a sense of calm. I will not succumb to my fears. I will not retreat into anxiety. I am having a baby. Probably in December, maybe in January. I will become a mother again. My husband will become a father again. My son will become a brother. My family is growing.

But—

But I cannot deny myself or my instincts. I am pregnant; I am a historian; 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, this is a luxury. I will indulge in my own pregnancy through scholarship. I will let my curiosity roam free, and I will follow it obligingly.

I am: the daughter of a surgeon, the sister 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 schedules, itineraries. I believe: in knowledge, in expertise, in research, in experience. I am also: among the more than 3.5 million pregnant women in the United States who seek a doctor’s care each year, and among the untold numbers 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 will 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 else who has harbored curiosities about pregnancy, who has wondered about the extraordinary human 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 milestone 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 education 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.

But I hope that there may be some overlap.

My research into each of my inquiries incorporates outlining basics, tracking historical origins, surveying twenty-first century evidence and customs, consulting multiple disciplines’ perspectives, and mapping the terrain for ongoing debates. I want to apprehend these topics, to unravel their interdisciplinary connections, to gain insight into society’s approaches toward 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 second month of pregnancy, I find solace in learning everything I can about morning sickness; studying my condition becomes my survival mechanism. 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 whether 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 pregnancy 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 every 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 pregnancy more fully, to sleep better and feel more rested, and to decrease my 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 pregnancy. Comprehension eludes me, but I do find some self-assurance. I gain a sense of calm and control through understanding. No amount of information 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 woman’s life to pregnancy is unpleasant, 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 disinterested 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 struggle with the awesome surrender pregnancy commands every 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

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 second line appears. I am pregnant.

In just that second, everything 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 after the office opens on Monday morning. I know I am pregnant, but I want more: more confirmation, more information, more details. I am a planner. I love mapping things out, knowing the next steps, scheduling the future, 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.

And yet I am grateful, thrilled even, that they ask me to come anyway. 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, everything is different. And yet everything 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 were 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 insurance policy in a bottle.

Tonight, I cup the tablet in my hand. I scan the ingredient list, marveling at the bean-sized innovation I swallow so devotedly every evening after dinner, and I am overcome with questions. What is this? Why am I taking it? How many expectant mothers before me have done the same thing?

THE APPEARANCE OF VITAMIN MAGIC

The word vitamin comes from the original term vitamine, coined in 1912 to designate the vital amines—the 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