Eye care

Roe v. Wade: How our understanding of pregnancy has changed throughout history – Slate

It is tempting to think of pregnancy as an eternal, unchanging experience. Humans are humans, after all, and physically, the way we have made other humans has stayed the same since prehistoric times. As a high-risk obstetrics doctor, I’m grateful for this consistency; it means that the skills I have developed over years of training apply across the globe.

But of course, pregnancy is not just a physical event: It’s an emotional, social, and cultural experience that is shaped by our times and our resources. Pregnancy, from this perspective, has changed profoundly in the past centuries and decades, in ways that your great-grandmother would have trouble recognizing.

Today, we’re aware of pregnancy practically before it begins. If you have a uterus, you can pee on a stick, sold in a handy pack of 10, to predict when you will ovulate in order to optimally time you sexual intercourse for the best chance at conception. Two weeks after that, you can check an inexpensive pregnancy test of unimaginable reliability in the privacy of your own bathroom. The earliest these pregnancy tests can generally be used is around the time the upcoming menstrual cycle would be expected to start. In medical nomenclature, this would be four weeks of gestational age, though it is only two weeks after that egg was released from the ovary, met a spermatozoa, and formed an embryo. (This confusing nomenclature is a residual of our pre-technologic access: Millennia before there was a reliable way to assess ovulation or fertilization, we used a woman’s last bleed—the last externally identifiable point at which she was not pregnant—as the best timer we had.)

What happens next inside the body unfolds practically in front of our eyes. Two weeks after a positive pregnancy test, at six weeks gestational age, you can go to receive an ultrasound, and see a linear structure within the uterus; sometimes it is at this point that we can see pulsations within it that we call the fetal heartbeat, though it is weeks before anything resembling a heart will be formed. A few weeks later, if all is developing normally, that ultrasound will show a rounded structure with early limb buds that resemble the arms and legs a gummy bear. A month after that, there will be a visible fetus with a recognizable human head, arms, and legs. At 10 weeks gestational age, a blood sample can be sent that will tell the chances of Down syndrome and other genetic disorders, but also whether the developing fetus will likely develop into a boy or a girl.

These modern rituals have led to a level of bonding with an early pregnancy that is unprecedented in human history. They were designed for would-be parents to gather medical information about their pregnancy and make decisions with their health care providers. But with that insight and freedom has risen the desire to control it: Technology has made room for a variety of legislation that limits early termination of pregnancy with startling precision, including laws that prohibit abortion as early as six weeks gestational age (which, remember, is a pregnancy only four weeks after fertilization, and only two weeks after a missed period), or ones that criminalize abortion as soon as the fetal “heartbeat” can be sensed by advanced ultrasound.

As a high-risk pregnancy provider, I find these laws terrifying to the point of cruelty; I’ve written before how they seem to have been written with almost no understanding of the choices that pregnancy entails, or the complex risks that patients and their doctors may face, and almost uniformly present a cavalier dismissal of women’s bodily injury, so long as she is the vessel for a pregnancy.

For most of human history, early pregnancy was shrouded in layers of mystery and uncertainty. Historically, societies may have had ways to detect pregnancy of varying levels of effectiveness, including a relatively accurate one that involved urinating on barley or wheat, and watching it sprout. However, for most women for most of recorded time, the sign that pregnancy was underway was a delayed menstrual flow. As you can imagine, this would wreak havoc for anyone having irregular menstrual cycles, which affects  up to 15–25 percent of women. To add to the challenge, in the time before reliable birth control, many women were either pregnant or breastfeeding almost continuously from the moment they embarked upon sexual activity until menopause. In this setting, regular menstrual cycles would be a rarity. Knowing that you were pregnant—much less how pregnant—would be enormously difficult.

It would be even more challenging to detect a pregnancy that had begun but was not continuing to develop. Medically, these relatively common events are called “missed abortions,” a type of miscarriage where the pregnancy has implanted in the uterus, but has not continued to grow, and isn’t immediately expelled from the uterus. (This is in contrast to “spontaneous abortions,” a miscarriage where the patient presents with bleeding as the uterus empties itself of the pregnancy.) In these cases, the absence of a period will continue, even though the pregnancy has not. The only way that someone could definitively know that they were carrying a live pregnancy would be the eventual development of perceptible fetal movement, or “quickening.” Quickening is usually reliably sensed by 20 weeks, though some people (especially those who are experienced from prior pregnancies) may feel it earlier. Thus, the first consistent sign of a normally progressing pregnancy would only start when you would be about halfway through the whole gestation, or after about four to five missed periods. To this day, this is why many traditions delay public announcement of a pregnancy until 20 weeks or so. It is also why quickening was a fundamental landmark in many historical abortion laws.

Even as we enter modern times, the diagnosis of pregnancy was unwieldy and inaccessible. Before the availability of the first over-the-counter pregnancy tests in the late 1970s, a common doctor’s confirmation required animal-based laboratory testing, in which the patient’s urine would be injected into a rabbit, which would later be dissected. If the urine had pregnancy hormone present, the rabbit’s ovaries would be enlarged. (This test led to the euphemism “the rabbit died” as a synonym for pregnancy, though this was inaccurate, since the rabbit died regardless of whether the woman was pregnant.) Later advances switched to using a frog, which in contrast always lived: As a non-mammal, it would lay eggs in response to pregnant urine and would not require internal investigation.

All of this historical experience of pregnancy is so profoundly different from our current one, in which my patients can ooh and ahh over the fetus for months before they feel fetal movement. In a short time, these landmarks granted to us by technology—the first pee-stick, the heartbeat on ultrasound, the gender reveal—have become so entrenched as to become rituals. That is a lovely development: One of my favorite parts of my job is showing expectant parents the progression of a normal pregnancy on an ultrasound, showing them the normally formed fetal heart and watching it beat, and participating in their growing joy as they watch this process over time. At the same time, this technology has paved the way for draconian abortion laws that make it increasingly harder and more dangerous to be a pregnant person.

Daily in my work, I see this complicated reality: I celebrate the joy some of my patients find in early pregnancy, and I simultaneously fear when it is valued over a woman’s life or health. These are opposite emotions, and yet nonetheless both are true. From that vantage point, I want us to take a moment to appreciate that the way we feel about early pregnancy is not an eternal truth, or a necessary moral foundation, or an indispensable basis of human society. It can also be, like other human experiences, highly changeable and profoundly affected by the times we live in, and more flexible than we often allow ourselves to admit.

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