Social Science & Medicine 92 (2013) 124e131

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Social Science & Medicine

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Accounting for fetal death: Vital statistics and the medicalization

of pregnancy in the United States
Lauren Fordyce*
Department of Sociology & Anthropology, Bucknell University, One Dent Drive, Lewisburg, PA 17837, USA

a r t i c l e i n f o a b s t r a c t

Article history: Recent reports by the Centers for Disease Control and Prevention have decried the high rate of fetal mortality
Available online 4 June 2013 in the contemporary United States. Much of the data about fetal and infant deaths, as well as other poor
pregnancy outcomes, are tabulated and tracked through vital statistics. In this article, I demonstrate how
Keywords: notions of fetal death became increasingly tied to the surveillance of maternal bodies through the tabulating
United States and tracking of vital statistics in the middle part of the twentieth century. Using a historical analysis of the
Fetal death
revisions to the United States Standard Certificate of Live Birth, and the United States Standard Report of Fetal
Vital statistics
Death, I examine how the categories of analysis utilized in these documents becomes integrally linked to
Medicalization of pregnancy
contemporary ideas about fetal and perinatal death, gestational age, and prematurity. While it is evident that
there are relationships between maternal behavior and birth outcomes, in this article I interrogate the ways
in which the surveillance of maternal bodies through vital statistics has naturalized these relationships.
Ó 2013 Elsevier Ltd. All rights reserved.

Introduction
Recent reports by the Centers for Disease Control and Prevention
have decried the high rate of fetal mortality in the contemporary
United States. Maternal and child health advocates estimate that
over 26,000 fetuses over 20 weeks gestation die each year, nearly as
many as the rate of infant deaths (MacDorman & Kirmeyer, 2009).
Much of the data about fetal and infant deaths, as well as other poor
pregnancy outcomes, are tabulated and tracked through vital sta-
tistics. While many people are familiar with the public forms of
birth certificates which document identity and bureaucratic
personhood, less are aware of the separate “medical and health
section” that is not a part of the public form. This section, added in
1949, is used by various biostatisticians to tabulate, track, and sur-
vey public health outcomes, as well as provides data for researchers,
policy makers, and state officials about the state of maternal and
child health both locally and nationally (Brumberg, Dozro, &
Golombek, 2012; Shapiro, 1950).
In this article, I demonstrate how notions of fetal death became
increasingly tied to the surveillance of maternal bodies through the
tabulating and tracking of vital statistics. Using a historical analysis of
the revisions to the United States Standard Certificate of Live Birth, and
the United States Standard Report of Fetal Death, I examine how the
categories of analysis utilized in these objective documents becomes
* Tel.: þ1 570 577 3371; fax: þ1 570 577 3543.
E-mail address: fordycel@gmail.com.
integrally tied to contemporary ideas about fetal and perinatal death,
gestational age, and prematurity. I do not wish to argue that there are
not objective links between maternal behavior and health and poor
fetal outcomes, but instead I interrogate the ways in which the sur-
veillance of maternal bodies through vital statistics has naturalized
these links. Part of this narrative is the intertwining histories of vital
statistics and the medicalization of pregnancy; as increasing amounts
of data were tracked and tabulated through vital statistics, the rela-
tionship between pregnancy behavior and fetal outcomes was natu-
ralized. As a means to broaden this discussion, I examine biomedical
advice regarding pregnancy within Williams Obstetrics, the leading
textbook for the study of obstetrics in the United States for the past
century (Hahn, 1995). Utilizing this analysis I denaturalize particular
contemporary notions of maternal and fetal bodies, demonstrating
these historical genealogies of these assumed objective categories.
A critical analysis of vital statistics
Analyzing the categories created and collected through vital
statistics, specifically how “fetal death” came to be distinguished
from live births and infant deaths, allows us to understand
changing notions of maternal, fetal, and infant subjects. By criti-
cally examining the drive by statisticians and epidemiologists to
discover the facts about maternal and child (and later fetal) health
which both reflect and project ideas about maternal and fetal
subjects, this article is situated within larger Foucauldian argu-
ments about the historical development and social function of
statistics (Foucault, 1980; Hacking, 1999).

0277-9536/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.socscimed.2013.05.024
 L. Fordyce / Social Science & Medicine 92 (2013) 124e131
Innovations in England during the middle and late nineteenth
century intimately linked the growing discipline of vital statistics
with the administration of public health. The growth of this disci-
pline was grounded in a notion of “population” as something that
could be enumerated, measured, and controlled through in-
terventions in public health. As the state became concerned with a
productive labor force, it began to focus on how to raise the level of
the social body as a whole. Demographic estimates, marriage and
fertility statistics, life expectancy tables, and mortality tables were
transformed into important technologies of population control.
Individual bodies and populations (or social bodies) came to be
associated with recognizable and measurable variables (Foucault,
1980; Lupton, 1995).
Hacking (1999) argues that the act of classifying people in turn
constructs them as particular objects of scientific knowledge. In
some cases, scientists created categories of people that did not
exist before. Cultural epidemiologists argue that systems of “vital”
statistics are the result of patterns and categories devised by
bureaucracies. That is, categories of analysis reflect not necessarily
realties but cultural ideas related to persons. As argued by Trostle
(2005:51), “The categories of state surveillance create vital sta-
tistics. This facilitates the conclusion that what one newly sees in
vital statistics is somehow self-evident and natural rather than
something created out of categories.” For instance, Armstrong
(1986) makes a compelling case for the “invention” of infant
mortality as it related to changing ideas about the social value of
infants as a particular class of children in late 19th century Britain.
He argues that the creation of measures for calculating rates of
infant death not only signals the social awareness of deaths of
infants, but also the recognition of the infant as a particular social
category of person. This recognition in turn reflects shifting ideas
around causes of infant death from biological to social, instigating
large scale state interventions related to poverty, hygiene, hous-
ing, and nutrition (Armstrong, 1986).
A number of anthropologists, sociologists, and historians have
discussed the ways in which biomedicine has infiltrated and
“medicalized” our daily life, by relegating moral or social world to
the jurisdiction of experts (Clarke, Mamo, Fosket, Fishman, & Shim,
2010; Starr, 1982; Zola, 1972). Scholars have criticized the medi-
calization of pregnancy and women’s health in the United States
and the United Kingdom, demonstrating how women’s bodies have
long been of interest to medical professionals, both through their
regulation and surveillance (Barker, 1998; Leavitt, 1986; Oakley,
1984; Wertz & Wertz, 1977). For instance, one argument in favor
of the medicalization of pregnancy in the early part of the twentieth
century was that increased prenatal care would result in decreased
rates of maternal and infant mortality. Yet recent research has
argued that better sanitation and water quality had greater effects
on infant survival rather than increased access to biomedical pre-
natal care (Barker, 1998; Wegman, 2001).
Although medicalization has been credited with the shift from
“badness to sickness” as individuals are no longer blamed for their
disease, critics argue that this move also permitted experts to make
conclusions about the labeling and management of patients (Lock &
Nguyen, 2010; Zola, 1972). With increased medicalization, as
evident in the monitoring of pregnancy outcomes, we begin to see a
displacement of ideas around responsibility. As researchers and
state public health organizations began tracking data about fetal
death, we see a shift in prescriptions for pregnancy care and ideas
about maternal responsibility as related to poor pregnancy out-
comes. Building on Armstrong’s (1986) analysis of the invention of
infant death, I am primarily interested in examining a number of key
variables related to fetal death as they became defined and tracked
using live birth and death certificates. By examining the develop-
ment of these variables, we see the ways in which the surveillance of
125
maternal bodies through vital statistics has naturalized the con-
nections between maternal health and behavior and fetal outcomes.
Although the official recording of live births, deaths, and fetal
deaths is the responsibility of the individual states and indepen-
dent registration areas (District of Columbia, New York City, and
U.S. territories), local certificates are modeled on the U.S. Standard
Certificates. The U.S. Certificate of Live Birth and U.S. Certificate of
Death were originally released in 1900, and are typically revised
every ten years, with the most recent revisions occurring in 2003.
Beginning in 1955, the U.S Standard Report of Fetal Death was
created and required for cases of stillbirth whereas prior to that
(1930e1955) stillbirths required the filing of a birth certificate and
a death certificate (Brumberg et al., 2012; Hetzel, 1997). Revisions
are made to the certificates with the advice and co-operation of the
state registrars, as well as the groups and organizations working in
the fields which access this data (Shapiro, 1950). Questionnaires
containing possible additions, deletions, or changes are developed
and sent to agencies and organizations with specific interest in and
experience with vital statistics collection and data. The survey data
is subsequently analyzed and presented to a variety of study
groups, and ultimately studied by the National Center for Health
Statistics in the creation of the draft certificates. Draft certificates
are then circulated among various interest groups, including state
offices with instructions for implementing the changes. Finally, the
Association for Vital Records and Health Statistics reviews the final
certificates at their annual meeting and formally endorse the new
changes. Copies of the new certificates are sent to state vital
registration offices and statistics executives with recommended
timelines for implementation at the local level (Tolson, Barnes, Gay,
& Kowaleski, 1991).
It is through these revisions to the birth and death certificates
that we see shifting ideas around fetal subjects and the increasing
medicalization of pregnancy. For instance, the quantitative evolution
of the birth certificate is clear in comparing the 33 variables collected
in 1900 versus the more than 60 items tracked since 2003 (Brumberg
et al., 2012). In this article, I focus on the revisions of 1930, 1939, 1949,
and 1955/56 as these years provide the most insight into the process
of establishing and tracking fetal death in the United States, partic-
ularly with the advent of a separate certificate for fetal death in 1955.
Although I use the term “fetus” as a monolithic category throughout
this article, this is not meant to assume that differences among fe-
tuses such as race or social class were not important. Means of
tracking social difference has existed throughout the history of
classifying live births and fetal deaths e through location (rural
versus urban), social class (occupation, education, “legitimacy”), and
race. But within the context of this article, my argument focuses
more broadly on the ways that tracking fetal outcomes became to the
surveillance of all maternal bodies.
In order to connect this “classificatory frame underpinning the
statistics” (c.f. Armstrong, 1986:230) to the “perceptual grid” of
medical reality, I utilize three editions of Williams Obstetrics, one of
the leading obstetrical textbooks used by a majority of American
and Canadian medical schools for over a hundred years (Hahn,
1995). Hahn (1995) analyzes various editions of this text in order
to examine the worldview underlying the practice of obstetrics
throughout the twentieth century, specifically focusing on labor
and childbirth. Informed by his work, I utilize the Eighth Edition
(Stander, 1941), the Tenth Edition (Eastman, 1951), and the Twelfth
Edition (Eastman & Hellman, 1961) of Williams Obstetrics as a
means of tracing the operationalizing of the variables and cate-
gories created and collected through vital statistics. To understand
some of the ways in which vital statistics and notions of maternal
and fetal health are intimately intertwined, it is useful to examine
the early history of the collection of vital statistics in the United
States, particularly as it relates to early interest in pregnancy care.
126 L. Fordyce / Social Science & Medicine 92 (2013) 124e131
Vital statistics and the governance of pregnancy
Vital statistics truly came of age in the nineteenth century, as the
growth of mathematical methods for measuring probability was
coupled with increasing interest by the state in enumerating and
measuring a “population.” Although the registration of vital events
dates back to the colonial period of the United States, during much of
the nineteenth century most of the country remained too rural to
effectively collect and maintain vital statistics. As more states recog-
nized the value of vital statistics, particularly the relationship between
death statistics and public health issues, new impetus was given to
standardize and establish strong registration systems (Shapiro, 1950).
Concurrent with the standardization of vital statistics, the cre-
ation of the U.S. Children’s Bureau in 1912 had important implica-
tions for the collection of vital statistics. The creation of a federal
agency for children was spearheaded by a group of progressive
maternalists, unified in their concern for child welfaredparticularly
advocating for infant health and against child labor as a means to
build support for the Children’s Bureau in a non-controversial way.
These women promoted the idea that motherhood should have the
“status of a profession” and governed by the insights of science and
experts (Ladd-Taylor, 1994). To this end, Julia Lathrop, the chief of
the newly formed Children’s Bureau, quickly set about promoting
birth registration as a means of understanding infant mortality. As
noted above, the Census Bureau had been authorized since 1902 to
issue national statistics on birth and death, but the accuracy of this
data depe1nded on compliance at the local level and many states
still did not have birth-registration laws at this time. The birth
registration drive relied on progressive maternalist strategies of
coalition building and scientific research. In order to encourage
registration of births and deaths, Lathrop enlisted experts from the
American Medical Association, the American Public Health Asso-
ciation and the Bureau of Census to draft a model birth registration
statute, using the General Federation of Women’s Clubs to launch a
nationwide campaign. The 1915 campaign, which evolved into a
“National Baby Week,” involved the participation of over 3000
women who conducted house-to-house surveys of infants in a
given neighborhood and then compared the count to official
records of registered births. In areas where the public records were
particularly deficient, activists successfully lobbied state legisla-
tures for better laws. By 1919, twenty-three states had passed
model registration laws, and in 1929, there were forty-six states
included in the national “birth-registration area” (Ladd-Taylor,
1994; Shapiro, 1950; Wertz & Wertz, 1977).
Using maternal and infant mortality statistics, the Children’s
Bureau, assisted by a large component of maternalist-oriented
women’s groups, lobbied the Federal Government to create a
public health service for women and children. This was achieved
with the ratification of the SheppardeTowner Act in 1921, also
known as the Act for the Promotion of Hygiene of Maternity and
Infancy. The Children’s Bureau argued that the new federal funds
would serve two purposes: (1) improve women’s understandings of
what constitutes “good” prenatal and obstetrical care; and (2) make
available adequate community resources for such care. Funding
lapsed in 1929, after successful lobbying against the legislation by
the American Medical Association (Wertz & Wertz 1977).
Federal support of maternal and child health was discontinued
until 1935, with the passing of Title V of the Social Security Act. Yet
unlike the SheppardeTowner Act, Title V was needs-based, not a
form of universal coverage for all women and children. In addition,
much of the work of the Children’s Bureau relating to maternal and
child health was transferred to the Social Security Board (Barker,
1998). Although the Children’s Bureau still distributed the money,
much of its use was determined by state and local authorities. In
addition, the American Medical Association (AMA) rejected the
Children’s Bureau’s assertion that the Shepard-Towner Act had
decreased infant mortality (supported by infant mortality vital sta-
tistics), arguing instead that maternity care would only improve with
increased cooperation between women and their physicians (Wertz
& Wertz 1977). Much of this history, which I do not have the space to
address, is a narrative of professionalization: the professionalization
of women as social workers and maternal health advocates; the
professionalization of physicians and the ascendance of the AMA;
and finally, the professionalization of statisticians, and their advo-
cacy for the science and importance of vital statistics.
In 1935, the Division of Vital Statistics, within the Bureau of
Census, was drastically reorganized and charged with a number of
important tasks, including the development of data from the birth
and death certificate and the means by which these data could be
made available for special public health and scientific needs, as well
as the stimulation of research into the analysis and solution of
important vital statistics problems. In 1946, the National Office of
Vital Statistics was created within the Public Health Service in order
to formalize the relationship between public health administration
and epidemiological research. A measure of progress was made in
1950, with the second nation-wide test of birth registration
completeness that indicated that 97.9% of infants born in that year
had birth certificates on file (Hetzel, 1997).
From stillbirth to fetal death
Anthropologists have long argued that the “margins of life” such
as birth and death are relevant markers cross-culturally, sites
where communities define and create narratives about personhood
and what “counts” as human (Lock, 2001; Morgan, 2009; Weir,
2006). To this end, the shift from the classification of “stillbirth”
to “fetal death” has important implications for understanding the
ways in which fetuses came to be marked as a social category in the
middle part of the twentieth century in the United States. Prior to
this, there was much slippage among the categories of stillbirths,
miscarriages, and abortions. And although this slippage has not
necessarily been erased in contemporary discourse, particularly as
technological advances and legal moves around fetal rights have
intensified this connections to include the spectrum from “embryo”
to “baby,” it is indeed relevant to interrogate the ways in which
attention to fetal death promoted the analysis into these categories.
As Armstrong (1986:214e5) compellingly argues, growing analysis
of infant mortality during the early part of the 20th century led to
an increased subdivision of early life into smaller components:
[W]hile there was no fundamental biological difference in the
birth of a dead foetus at any gestational age, there was certainly
a problem in distinguishing between a foetus and an infant once
the latter was seen to have a separate social identity. At this
point the view that stillbirths and miscarriages were inseparable
undermined the discrete autonomy of the infant.
These shifts relied on moves by physicians and public health
practitioners to create specific definitions and categories, and then
the subsequent surveillance of these classifications through vital
statistics. Throughout the early part of the twentieth century we see
a growing argument for specificity as well as increasing attention to
a number of variables, including gestational age and birth weight,
that are key for distinguishing what is later called “fetal death.”
In the United States, the Bureau of Census did not begin col-
lecting annual statistics about stillbirths until 1922. Prior to this,
there were wide inconsistencies in the data collected, with a few
states using specifically designed forms and most states
abstracting the data from birth and death records (Bureau of the
Census, 1934). Although a growing number of physicians were
arguing for the importance of tracking stillbirth data, there was a
 L. Fordyce / Social Science & Medicine 92 (2013) 124e131
lack of uniformity even in the definition of what qualified as a
stillbirth during this time. In 1908, the Vital Statistics Section of
the American Public Health Association adopted the following
rule, “No child that shows any evidence of life after birth should be
registered as a stillbirth” and by 1913 had amended “any evidence
of life” to include “action of heart, breathing, movement of
voluntary muscle” (Hemenway, Davis, & Chapin, 1928:25).
Throughout the first few decades of the twentieth century,
there was a wide range in period of “uterogestation” as a frame
for state definitions in stillbirth, ranging from “any product of
conception” in Maryland to “7 months and over” in Washington
and Indiana (Bureau of Census, 1934:19). In 1928, the American
Public Health Association decided to consider a threshold for
uterogestation after the Health Section of the League of Nations
proposed an official definition that designated a death after 28
weeks as a “stillbirth.” Ultimately, the American Public Health
Association recommended that every stillbirth after the fifth
month should be recorded, although also noted that states
should consider modeling their laws after Maryland and asking
for reports for even earlier periods (Hemenway et al., 1928).
Concurrently, we see at this time increasing awareness of and
interest in the causes of stillbirth. At the turn of the century, a
number of maternal and child health advocates deplored the
“apathy” among physicians and the public that assumed that
although infant loss was regrettable, it was inevitable and mostly
the result of natural selection (Meckel, 1990; Yerushalmy &
Bierman, 1950/52). Yet by the 1920s, a growing number of the-
ories argued that the causes of stillbirths were increasingly linked
to maternal health. Of particular interest was syphilis, other
infectious diseases such as tuberculosis and small pox, maternal
heart disease, as well as “morbid states of the fetus the result of
poisoning of the mother with lead, mercury, alcohol, nicotine,
etc.” (Ballantyne, 1922: 585). More importantly, stillbirths
become conceived of as preventable: “The general principles of the
prevention of stillbirths can be clearly stated. .Watchful, adequate
supervision and treatment (when needed) must therefore be given
to all expectant mothers” (Ballantyne, 1922: 587).
Notions of stillbirth and disease as something that could be
managed through prevention also reflect an important shift in
public health at this time. As medicine moved from treating acute
conditions to earlier interventions and surveillance in the name of
public health, national and local campaigns against tuberculosis
and venereal disease promoted health examinations by physicians
as an important component in taking personal responsibility for
health (Starr, 1982). For example, the representation of the pre-
vention of stillbirth as necessitating the medical management of
pregnancy was supported by public health campaigns by the
United States Children’s Bureau and their publication of the
pamphlet “Prenatal Care.” A number of scholars have argued that
this maternal education campaign during the 1920s and 1930s
was one of the key moments in the shift toward the medicaliza-
tion of pregnancy in the United States (Barker, 1998; Ladd-Taylor,
1994; Wertz & Wertz, 1977). Various editions of the text repre-
sented pregnancy as a disease-like state that requires timely and
on-going medical supervision. For example, from the 1935 edi-
tion: “More important than anything else in planning the best
possible care for mother and child is that the mother should go to
a doctor for examination and advice just as soon as she thinks she
is pregnant and should remain under his constant care until the
baby is born” (quoted in Barker, 1998: 1070). While I am not
arguing that the prevention of stillbirth is in itself a problematic
issue, I think it is relevant to examine the ways in which this
becomes tied to the medical management of pregnant bodies. In
addition, we see at this historical moment the early assumptions
that physicians are expected to intervene in and prescribe
127
particular maternal behaviors as a means to prevent poor fetal
outcomes.
Another key moment in the shift from stillbirth to fetal death
was related to the move to subdivide infant deaths into smaller
categories. A growing amount of attention was focused on the
fact that while numbers of infant deaths after the first year were
drastically dropping, there was no reduction in the rates of death
attributed to the first few hours and weeks after birth
(Armstrong, 1986; Meckel, 1990; Weir, 2006). Prior to 1910, the
US Census Bureau grouped all infant deaths in one category, and
the 1913 report was the first to confirm what maternal and child
health experts were beginning to suspect, that “neonatal” deaths
in fact comprised the largest proportion of infant mortality
(Meckel, 1990). In addition, neonatal deaths and stillbirths
became intricately linked in the research and literature related to
maternal and child health at this time. As Armstrong (1986: 215)
explains: “whereas in the 19th century stillbirths were joined to
miscarriage and abortions as manifestation of fetal loss, in the
inter-war years they become the natural partner of neonatal
mortality, separated only by a single breath.”
As noted above, although information on neonatal deaths had
been collected starting in 1910, the US Bureau of Census did not
begin collecting data on “stillbirths” (as they were referred to at that
time) until 1922. In most states, information about stillbirths was
abstracted from the regular birth certificates, or from the special
stillbirth certificates that were used in a few states (US Bureau of
Census, 1934). Most birth certificates used by states from 1910 to
1930 contained a question “whether born alive or stillborn” (Tolson
et al., 1991). The process of collecting data about stillbirths was
simplified in 1939 with the creation of the “Standard Certificate of
Stillbirth” which required states to file only one certificate
depending on birth outcome. Previously many states required the
filing of separate live birth and death certificates in the case of a
stillborn infant (Hetzel, 1997; Shapiro, 1950).
Concurrently, federal legislation was increasingly promoting the
biomedical management of pregnancy as an important component of
maternal and child health. The Social Security Act of 1935 contained
the first attempts at a federal infrastructure for maternal and child
health care. This policy was designed to address many of the extensive
cutbacks in public health occurring during the Great Depression. Title
V of Medicaid continues to provide the bulk of funding for maternal
and child health services in the United States today (Speert, 1980).
By the 1950s maternal and child health advocates were arguing for
separating stillbirth rates from neonatal rates. Yerushalmy and
Bierman (1950/52:1) argued that there was “striking parallelism be-
tween the present status of the problem of fetal mortality in the
United States and that of infant mortality around the turn of the
century.” For many advocates, the key to both elucidating the high
rates of death as well as preventing stillbirths was related to creating
clear definitions and improving the registration and collection of vital
statistics for these underreported deaths. As noted above, throughout
the early part of the twentieth century there remained much slippage
between the terms “stillbirth,” “miscarriage,” and “abortion.” In an
attempt to standardize definitions and facilitate the collection and
comparison of statistics globally, the World Health Organization
adopted the term “fetal death” at the third World Health Assembly in
May 1950 along with this specific definition:
Feoetal death is death prior to the complete expulsion or
extraction from its mother of a product of conception, irre-
spective of the duration of pregnancy; the death is indicated by
the fact that after a separation the foetus does not breathe or
show any other evidence of life, such as beating of the heart,
pulsation of the umbilical cord, or definite movement of volun-
tary muscles (quoted in Yerushalmy & Bierman, 1950/52:3).
128 L. Fordyce / Social Science & Medicine 92 (2013) 124e131
The American Public Health Association and the Public Health
Service subsequently approved this term and definition for use in
the United States where it is utilized even today. In addition, the
WHO recommended that the “tabulation of all fetal deaths is a
desirable goal and should be attained as soon as possible”
(Yerushalmy & Bierman, 1950/52:3).
In 1951, the shift in terminology from “stillbirth” to “fetal death”
was clear when the National Committee on Vital and Health Sta-
tistics established a “Subcommittee on Causes of Fetal Death.” This
Subcommittee was charged with recommending methods for the
recording and processing the statistics on fetal death and one of the
strongest recommendations to result from their discussions was
the proposal to improve the data collected on the Standard Cer-
tificate of Stillbirth, ultimately resulting in the nationwide adoption
of the “Certificate of Fetal Death” in 1955 (Hetzel, 1997). In addition,
maternal and child health advocates continued to argue for the
registration of “all products of conception.” They argued that by
increasing registration of all fetal deaths, researchers and policy
makers could begin to clarify and better define a number of other
relevant variables in pregnancy loss, particularly those such as
“viability,” and “premature birth” (Yerushalmy & Bierman, 1950/
52:8). As definitions of fetal death became more secure, maternal
and child health advocates were increasingly concerned with
examining the assumed connections between increased death rates
and gestational age and birth weight.
Death before birth as premature
In addition to promoting the reporting of all fetal deaths, the
WHO further recommended that all live births and fetal deaths be
categorized based on the following groups: Group I e Less than 20
weeks of gestation (early fetal deaths); Group II e 20 completed
weeks of gestation but less than 28 (intermediate fetal deaths);
Group III e 28 completed weeks of gestation and over (late fetal
deaths); Group IV e Gestation period not classifiable in Groups I, II,
III (quoted in Yerushalmy & Bierman, 1950/52:3). This act of clas-
sifying deaths based on gestational age becomes feasible since 1930
when both the Certificate of Live Birth and Standard Certificate of
Stillbirth added a category of “period of gestation.” Earliest mea-
sures to track gestational age began in 1930 with the category
“premature or full term.” The next revision of the certificates in
1939 shifted this category to “months of pregnancy,” which became
“length of pregnancy (completed weeks)” in 1949. By 1956, the
revision of the Certificate of Live Birth and the Certificate of Fetal
Death included the variable “date last normal menses began,”
which has continued to be the means to calculate gestational age
through today (Brumberg et al., 2012).
Fetal length was often used as an early proxy for gestational age
and fetal development in the age when last menstrual period and
intrauterine age could be easily confused. Early attempts to calculate
gestational age included calculating the “probable date of confine-
ment” by adding 280 days to the date of coitus, or by adding twenty
or twenty-one weeks to the date when the woman first felt fetal
movement (Stander, 1941). Both of these methods were viewed by
physicians as relatively prone to miscalculation given that they were
dependent on women’s embodied experience rather than an
objective measure (Karn, 1947). The use of length as a means to
measure fetal development was borrowed from the Prussian
registration system, whereby a crown-to-heel length of 320 mm was
believed to be similar to about 28 weeks gestational age. A fundal
length could easily be measured by midwives and physicians using
simple technology such as a tape measure (Woods, 2009).
Multiple editions of Williams Obstetrics (Eastman, 1951; Eastman
& Hellman, 1961; Stander, 1941) from the midpoint of the twentieth
century argue that “generally speaking the length affords a more
accurate criterion of the age of a fetus that its weight” (1941:155).
Yet birth weight becomes significant in its relationship to gesta-
tional age, particularly as maternal and child health advocates pay
closer attention to the continuum of poor birth outcomes, joining
both fetal death and neonatal mortality into this new category of
“perinatal mortality” (Weir, 2006). Taken together, the interrela-
tionship between gestational age and birth weight encompass the
“premature” or “preterm” birth (Karn, 1947; National Center for
Health Statistics, 1965; Parkhurst & Schlesinger, 1951; Taback,
1951). These links between poor birth outcomes, prematurity, low
birth weight, and length of gestation were first articulated by a
Finnish pediatrician Arvo YIppö in 1919. He shifted the contem-
porary philosophy around “congenital weaklings” to that of “pre-
maturity,” arguing that infants who were born small and early were
at most risk for perinatal death or long-term growth delays. His
study followed a cohort of over 2000 live births in a German hos-
pital for nine years, and this research concluded that prematurity
resulted not only in growth retardation, but also cerebral palsy,
blindness, deafness, and developmental delays (Dunn, 2007).
In YIppö’s work with fetal growth curves, he integrated both
gestational age and birth weight to create the definition of “low
birth weight.” This is defined as a weight at delivery of less than
2500 g, a threshold that has remained in use in contemporary
obstetrics and pediatrics (Dunn, 2007). In 1935, the American
Academy of Pediatrics was citing “prematurity” as one of the most
frequent causes of perinatal mortality: “The causes of premature
birth were studied, and the incidence of complications of the
mother’s pregnancy were found to be high. The type of complica-
tion appeared to be not so important as the time which the
complication occurred; in other words, the weight of the infant was
the determining factor in survival” (1936:110). The American
Academy of Pediatrics ultimately passed a resolution of the diag-
nosis of prematurity as a fetus that weighs 2500 g or less at birth
regardless of period of gestation (1936:117).
In the 1949 revision of the Standard Certificate of Live Birth the
category of “birthweight” was added and the category “weight of
fetus” was added to the Standard Certificate of Stillbirth (Tolson
et al., 1991). By the early 1950s, biostatisticians and maternal and
child health advocates were calling for careful attention to rates of
premature births, particularly important for planning and evalua-
tion of programs to prevent perinatal mortality as well as for care of
premature infants (National Center for Health Statistics, 1965;
Parkhurst & Schlesinger, 1951). The eighth edition of Williams
Obstetrics (Stander, 1941:800) includes a general definition of
“premature” infants as those who are born within the range of
1500e2500 g, and later editions reflect the global move to stan-
dardize prematurity into categories of “maturity”: Fetal deaths with
a weight of under 400 g are called “abortuses; ” fetuses with a birth
weight of 400e999 g are called “immature infants; ” fetuses with a
birth weight of 1000e2499 g are called “premature infants; ” and
fetuses of 2500 g or more are called “mature infants” (Eastman,
1951:1000; Eastman & Hellman, 1961:1066).
Discussions about premature labor ultimately result from the
tracking of premature births, which is relevant in analyzing the
connections between these categories and the medicalization of
pregnancy care in the mid-twentieth century United States.
Prematurity was understood to be a common cause of fetal
deaths, and these “accidents” were associated with multiple
maternal causes including various toxemias, premature separa-
tion of the placenta and placenta praevia, syphilis and “contin-
uous overwork during the later months of pregnancy” (Stander,
1941:825). By linking the predominant causes of premature
labor to a failure in pregnancy, prematurity and subsequently
fetal death was imagined as pathology of women’s bodies1
versus something originating in fetal bodies (c.f. Armstrong,
 L. Fordyce / Social Science & Medicine 92 (2013) 124e131
1986). Therefore, for maternal and child health advocates
interested in poor birth outcomes, increased surveillance of
women’s bodies throughout their pregnancy becomes the best
prescription for preventing fetal death.
The prevention of fetal death: a medicalization of pregnancy
Even in the current public health literature fetal death remains
a medical conundrum, with maternal and child health specialists
advocating for increased attention to fetal death as an important
opportunity in improving perinatal health (MacDorman &
Kirmeyer, 2009). The contemporary causes of perinatal mortal-
ity, including fetal death, remain cloaked in much of the mystery
that surrounded these poor birth outcomes at the mid part of the
twentieth century. While prescriptions for preventing fetal death
in the 1950s included increased registration of all poor birth
outcomes as well as increased surveillance of pregnant women, it
is useful to examine the change in discourses about prenatal care
at this time.
Barker (1998) aptly illustrates this shift toward the medicaliza-
tion of pregnancy in the early part of the twentieth century by
comparing two versions of the United States Children’s Bureau’s
publication Prenatal Care, published in 1924 and subsequently
revised and published in 1935. In these documents there was an
explicit shift from rules of pregnancy focusing on self-care in 1924
to the importance of a woman “placing herself under the care of a
competent physician” in 1935 (quoted in Barker, 1998:1074). These
prescriptions were echoed in Williams Obstetrics, which reminded
obstetricians in 1941 that it is “the duty of the physician to gain the
confidence of his patient and encourage her to come to him
whenever anything occurs to worry her, instead of taking advice
from her woman friends” (291). The move to ensure the expertise
of the physician over the advice of friends, or “back fence gossip”
was strengthened by the supervision of prenatal nurses, who could
be called in cases of “lack of intelligence or indolence” which may
have led some patients to fail to follow a physician’s advice (292).
By 1961, comments about the “pre-marital” doctorepatient rela-
tionship illustrated the ways in which the medicalization of
women’s bodies throughout the life course had become universal:
“[R]outine pre-marital physical examinations have aided in
strengthening the doctorepatient relationship and in removing
much of the fear of pregnancy engendered by ignorance and ‘back
fence gossip’” (Eastman & Hellman, 1961:337). Scholars such as
Casper and Moore (2009) have argued that recent public health
promotion of “preconception care” situates women’s bodies as
always potentially pregnant and therefore subject to the same
surveillance and behaviors as pregnant women, the promotion of
“pre-marital” examinations in the 1960s demonstrates a much
longer history for these ideas.
For Yerushalmy and Bierman (1950/52), two immediate tasks
remained in understanding the mystery of premature birth. The
first task was “statistical” and involved the standardization and
accuracy of prenatal, labor, and delivery records. The second task
was “clinical” and required the “need for closer clinical obser-
vation of women throughout the course of pregnancy and more
through study of deviations from normal in order to obtain clues
concerning factors which have deleterious effect on the fetus”
(15). As noted above, the routinization of prenatal care during
pregnancy began in the early part of the twentieth century and
by 1941 Williams Obstetrics was recommending that patients be
“taught” to register early in pregnancy, return to the doctor
monthly until the seventh month, and then every two weeks
until delivery.
According to the 1941 and 1951 editions of Williams Obstetrics,
one of the “credible achievements” of American obstetrics
129
consisted of the development of “so-called ‘Prenatal Care’”
(Eastman, 1951:311; Stander, 1941:291). For obstetricians as this
time, prenatal care consisted of
such supervision and care of the pregnant, parturient and pu-
erperal woman as will enable her to pass through the dangers of
pregnancy and labor with the least possible risk, to give birth to
a living child, and to be discharged in such a condition that she
may be able to suckle it and thus afford it the greatest prospect
of attaining maturity, as well as to fulfill her duties as a mother
and housewife with minimal amount of invalidism (Eastman,
1951:311; Stander, 1941:291).
In these editions we see reference to “attaining maturity” as the
ultimate goal for the living child but with little reference to dis-
tinctions between fetuses or infants, and fetal, perinatal, or infant
mortality.
These articulations disappear from the twelfth edition of
Williams Obstetrics, to be replaced by a more specific clinical defi-
nition of “antepartum care.” The shift to the term “antepartum” was
deliberate in itself; signaling a move away from prenatal as defined
as “before birth” and toward the use of antepartum or “before la-
bor” as well as part of the spectrum of such terms as “intrapartum”
and “postpartum” (Eastman & Hellman, 1961:337). Much as the
move to conjoin fetal death and neonatal death into perinatal
mortality, this subtle shift in terminology signaled a larger interest
in care of women across the spectrum of pregnancy experiences. In
addition, there was no longer just one patient involved; care of the
fetus was regarded as just as relevant as the mother. In defining
antepartum care the text explains:
The aims of antepartum care in respect to the mother are: (1) to
maintain the health and peace of mind of the pregnant woman;
(2) to reduce the complications of the antepartum course; (3) to
increase the safety of delivery; (4) to produce better health
postpartum; and (5) to insure the ability to care for all the
requirements of the fetus. The aims with regard to the fetus are:
(1) reduction of prematurity, stillbirth, and neonatal mortality
rates; and (2) optimal health for the newborn (1961:338).
Implicit within this definition of “antepartum care” was the idea
that in order to achieve the “ability to care for all the requirements
of the fetus” routine visits with an obstetrician were necessary, who
would counsel her on the appropriate behavior regarding such
things as exercise, diet, bathing, clothing, and sexual intercourse.
The shift toward detailing regular clinical examinations including
abdominal palpitations, vaginal examinations, blood pressure
measurements, routine chest x-rays, and laboratory tests, illus-
trates the increased biomedical risk surveillance that was inform-
ing obstetrical care at this time. In addition, this move toward
separation of the woman and the fetus was also reflected in other
important developments in obstetrical medicine at this time.2 In
the early 1960s, Albert Liley revolutionized the treatment of
hydrops fetalis, associated with maternal Rh sensitivity by exper-
imenting with fetal transfusions in utero and Ian Donald’s work
with ultrasound in Glasgow was drastically shifting notions of fetal
personhood (Casper, 1998; Harrison, Golbus, & Filly., 1984; Oakley,
1984).
While pregnant women’s “peace of mind” remained an
important part of antepartum care, the development of objective
definitions and measures of fetal death and perinatal mortality
during the 1950s had clearly shifted the focus on care during
pregnancy by the early 1960s. This valuation of prenatal care as
integral to the prevention of poor birth outcomes was oper-
ationalized in 1968, when the Certificate of Live Birth and Cer-
tificate of Fetal Death was revised to include the variables:
“month prenatal care began” and “total number of prenatal
130 L. Fordyce / Social Science & Medicine 92 (2013) 124e131
visits.” Researchers saw these variables as contributing useful
information about the quantity of prenatal care visits and its
relationship to infant and fetal mortality (National Center for
Health Statistics, 1968).
Conclusion
Contemporary interest in fetal deaths only has increased in the
early part of the twenty-first century, with maternal and child
health advocates echoing the concern of the 1950s with their
statements that fetal mortality remains a major but overlooked
public health problem (MacDorman & Kilmeyer, 2009). While
pregnancy “wastage” has always existed, contemporary “pro-life”
arguments have drawn increasing attention to the experiences of
fetal death. Recent scholarship has broadened this discussion to
include the women and families challenged by the emotional
trauma of miscarriage and fetal death (Layne, 2003; Sanger, 2012).
Legislation has been introduced in multiple states to memorialize
a fetal death with a ceremonial certificate of “birth” as a means to
honor the existence of the fetus in the hearts and minds of their
families (Sanger, 2012). These conversations are inevitably
complicated by debates around fetal “rights” whereby numerous
state legislatures are creating and enacting laws on behalf of the
fetus. The culmination of these recent episodes demonstrates the
perpetually shifting notions of fetal life in the contemporary
United States (Morgan & Michaels, 1999).
While much of the literature documenting the shift in notions
of fetal subjects has focused on visualization and ultrasound im-
aging (Mitchell, 2001; Taylor, 2008) and the advent of the fetal
patient (Casper, 1998), this article joins others in arguing that this
transition to an independent fetal subject has a much longer
history (Dubow, 2011; Duden, 1993; Morgan, 2009). Our
contemporary fetal imaginings would not be relevant without
earlier work to designate a specific fetus that could be accounted
for and subject to surveillance through vital statistics. Yet this
contemporary fetal subject does not remain untethered from its
maternal body. Although we see increasing recognition for fetal
patients, such that perinatology now exists as its own obstetrical
specialty, there is acknowledgment for the interdependence of
maternal and fetal bodies.
In this article I demonstrate how ideas about fetal death
became increasingly tied to the surveillance of maternal bodies
through the tabulating and tracking of vital statistics. Maternal
behavior becomes paramount to understanding fetal and infant
health outcomes (Armstrong, 2008; Oaks, 2001; Weir, 2006).
Implicit within biomedical frameworks remain theories about
responsibility for individual health, such that poor fetal and infant
outcomes are tied to maternal blame (Denham, 2012; Fordyce,
2013; Oaks, 2001; Tsing, 1992). While it is evident that there are
relationships between maternal behavior and birth outcomes, in
this article I interrogate the ways in which the surveillance of
maternal bodies through vital statistics has naturalized these re-
lationships. As more and more fetal “rights” legislation is intro-
duced at the both the state and federal level, these links between
the naturalization of maternal behavior and fetal and infant health
outcomes becomes increasingly tied to the criminalization of
pregnancy (Casper & Morgan, 2004; Oaks, 2001; Roberts, 1998;
Roth, 2003). As maternal and child health advocates look to pre-
vent poor birth outcomes in the United States, it is relevant to
critically engage these narratives of maternal blame and re-
sponsibility inherent in discussions about fetal and infant deaths.
By taking a closer look at the specific histories of fetal subjects in
the public health literature, we can begin to disentangle bio-
political narratives about women and fetal subjects, ultimately
destabilizing these monolithic “origin” stories.
End notes
1. As correctly noted by a reviewer, this is an important issue
that reflects this larger shift toward fetal death as imagined as not
only preventable, but something that pregnant women must take
responsibility for (see Fordyce, 2013). In addition, ideas about
pregnancy loss and responsibility are highly racialized as well (see
also Bridges, 2011; Roberts, 1998).
2. A growing literature of feminist research has examined these
critical developments in perinatal medicine as linked to relevant
shifts in the construction of fetal personhood (Casper, 1998;
Mitchell, 2001; Morgan & Michaels, 1999; Taylor, 2008). These
shifts are less visible through vital statistics until the extensive
revisions to the certificates in 1989.
Acknowledgments
I would like to thank Lynn Morgan for her insightful comments
on a draft of this article, as well as Florence Babb for her revisions of
this work in its earliest form. In addition, this article has been
enriched by the thoughtful and thorough feedback of a number of
reviewers.
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