17.3.1 The Venice Forum (Global)

The Venice Forum was established in 2019 by a group of independent academics and healthcare professionals to explore the impact of economic and other crises (e.g. war and famine) on DOHaD outcomes globally. Based on evidence that crises such as the 2008 economic downturn have a disproportionate impact on women and children, the main goal of the Venice Forum is to advocate for an ethical imperative of supporting early childhood development, thus preventing the intergenerational passage of risk.

This agenda gained new urgency by the COVID-19 pandemic, which further exposed inequalities in health and well-being [Reference Penkler14], but also inequalities in responses to the pandemic. For example, research during the early stages of the pandemic (for example on vaccine safety) often excluded children and pregnant or breastfeeding women [Reference Vassallo, Womersley, Norton and Sheel20]. Post-pandemic, the focus of the Venice Forum shifted from the impact of economic crises and natural disasters on MNCH to understanding factors that build resilient societies, making an argument for embedding MNCH as core to research and policymaking aimed at developing healthier societies [Reference Jacob, Briana, Di Renzo, Modi, Bustreo and Conti21].

The Forum has often framed its policy messages in economic terms. It has developed key arguments from early-life interventions such as the Perry Preschool and Abecedarian programmes that show how such interventions can have long-term economic benefits, higher school completion rates, college attendance, lower rates of teenage pregnancy, dependency, and welfare [Reference Heckman22, Reference Heckman, Moon, Pinto, Savelyev and Yavitz23]. The rationale for employing an economic frame that emphasises long-term cost reductions and returns on investment has been the assumption that non-health outcomes are important issues from a policymaker’s perspective. Ongoing projects by the Forum include specific recommendations for policy, for example introducing parental leave for the first six months of life. The assumption is that the economic frame is more likely to elicit a response from finance ministers and other governmental departments outside healthcare. In this context, the Forum has strategically tried to promote a ‘technification’[Reference Shiffman and Shawar24] of the issue – in this case conveying the economic costs of a lack of investment in early years and in parenthood and portraying the issue as one that can – and should – be addressed primarily through science and economics, and not necessarily on the individual level, thus developing an ‘investment case’ for MNCH.

At the same time, the Forum has also adopted a contrary approach, emphasising the need to reframe the way ‘value’ is conceptualised in policymaking and financing. While supporting the development of an investment case described above, the Venice forum has also challenged the dominant view that economic growth measured by GDP is an adequate measure of success, when it does not include unremunerated contributions to society such as childbearing, domestic work, and care – largely conducted by women in most societies [Reference Meka, Jacob, Modi, Bustreo, Di Renzo and Malamitsi‐Puchner17]; see also Cohen in this volume. The Venice Forum has explored and promoted newer frames of a ‘caring economy’ [25] that include well-being as an indicator of economic success over GDP and employ alternative measures to include unremunerated work, such as the Human Capital Index or the Genuine Progress Indicator. The goal of these new frames is to shift the approach from mainstream economics that focuses predominantly on market relations towards feminist economics that values women’s contributions. However, framing issues of health in terms of economic benefits always carries the risk of contributing to rather than resisting approaches in which health only matters in terms of its economic impact, rather than emphasising health and access to healthcare as human rights and values in themselves.

The Forum has also strategically engaged in linking MNCH to the climate crisis, recommending inter-sectoral actions required to address climate change – such as reducing air pollution and low-environmental impact diets – that are also beneficial for health. Such focus on policy framed in terms of human and planetary well-being might benefit from the existing momentum for the climate crisis agenda. The Forum perceives that climate is of high importance to younger people, thus providing an opportunity to disseminate messages by highlighting their concurrent benefits for health and the environment.

The Venice Forum has also strategically decided to emphasise the benefits of intergenerational health to prioritise investments in MNCH. While a focus on child/newborn health might have greater political traction, such a focus potentially competes with the maternal health agenda when the health of the fetus is emphasised at the expense of women’s health for their own benefit [Reference Shiffman and Smith26]. A framing of MNCH in terms of long-term investments used by the forum can thus compete with an ethical frame that positions MNCH as a matter of women’s rights and equity – a frame that was also utilised by the Forum, which called for urgent action in this area due to slow progress.

Overall, the Venice Forum has targeted policymakers and international health organisations using a variety of different framings – a social justice framing, economic framings, frames related to intergenerational health benefits, synergies with climate change, and ethical frames for women’s rights.

17.3.2 The UK Preconception Partnership (United Kingdom)

The 2018 landmark Lancet series on preconception health [Reference Stephenson, Heslehurst, Hall, Schoenaker, Hutchinson and Cade19] made a strong case that ‘preconception’ forms a key period for health interventions that have long-term benefits for subsequent maternal and child health. The Partnership that formed after this series meets regularly and has worked extensively with local authorities in the UK and stakeholders such as the Office for Health Inequalities and Disparities (OHID) (under the Department of Health and Social Care, UK). Targeted engagement, particularly in the local/national context, has been an advantage for the Partnership, facilitated by the inclusion of knowledge brokers (stakeholders facilitating knowledge transfer from research to policy) in the network.

While the Partnership is interdisciplinary in its membership, there is a higher representation from healthcare organisations and the biomedical sciences (see Table 17.1). The Partnership’s stated goal is to ‘normalise’ the concept of preparation for pregnancy and parenthood, thus framing adolescence and early adulthood as a ‘pre-conception period’ where young people should be encouraged and empowered to engage in healthy activities both for the sake of their own health and also to prepare for (potential) pregnancies.

The Preconception Partnership has overall adopted a lifecourse approach to preconception care, focusing on adolescent health, inter-pregnancy health, and post-partum care as key periods to include in the definition of preconception health. The Partnership has positioned this approach within a reproductive justice framework that considers ‘the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities’ [Reference Song27]. In supporting women’s rights to make decisions related to fertility and contraception, the Preconception Partnership (among other global networks) has endorsed universal screening for pregnancy intention with clinical tools to discuss the desire to be pregnant or avoid pregnancy [Reference Hall, Barrett, Stephenson, Edelman and Rocca28, Reference Stephenson, Schoenaker, Hinton, Poston, Barker and Alwan29]. This also relates to the reproductive justice framework that includes equitable access to a range of health services such as contraception, sexual health, and abortion (which women of colour and marginalised groups often have barriers accessing as a core component). However, an overemphasis on reproductive health could propagate a view of women as ‘vessels of reproduction’ [Reference Verbiest, Shawe and Steegers30], in which young women are primarily viewed and addressed as future mothers [Reference Waggoner31]. Ongoing work by members also has focused on the extension of health behaviours to adolescence, for example through school-based interventions to promote scientific and health literacy [Reference Woods-Townsend, Hardy-Johnson, Bagust, Barker, Davey and Griffiths32].

A recent study by Jacob [Reference Jacob33] has shown different and partly competing ways of framing the internal discussions and external communications of the Partnership. On the one hand, the Partnership has framed preconception health as a systemic issue and promoted policies and public health campaigns aimed at addressing socio-economic inequalities in women’s health. One prominent Partnership initiative has been to improve the evidence base for health policy focused on the preconception period and to hold policymakers accountable for issues in preconception care that show links with deprivation. To this end, the Partnership has focused on using routine data from maternity care programmes to develop a report card on preconception health status in the UK [Reference Schoenaker, Stephenson, Smith, Thurland, Duncan and Godfrey34]. The analysis of national maternity services data (England) highlighted inequalities based on age (e.g. younger women were less likely to take folic acid supplements preconception), ethnicity, and deprivation and in turn provided outcomes and indicators for accountability. Members’ publications have also emphasised the impact of wider determinants of health [Reference Hall, Chawla, Watson, Jacob, Schoenaker and Connolly35] and called on governments as key actors to address preconception health at the policy level.

At the same time, framings of risk factors like obesity as being linked to systemic problems influenced by the environment and deprivation contrasted with recommendations to change lifestyles with support from clinicians. The clinical setting, where clinicians often meet women with or without their partners, was often framed as an effective and easily accessible platform for the dissemination of preconception health messages. In this view, postnatal care presents a ‘window of opportunity’ for both the next pregnancy and early childhood development [Reference Stephenson, Schoenaker, Hinton, Poston, Barker and Alwan29, Reference Jacob, Killeen, McAuliffe, Stephenson, Hod and Diaz Yamal36]. However, such recommendations were also critically discussed within the Partnership, as it was argued that they could lead to individual attributions of responsibility and a stigmatised framing of behaviours deemed unhealthy, particularly among low-income populations. It was argued that focusing on influencing behaviours through the dissemination of health messages also assigns a set of values and moral implications, falling disproportionately on women and addressing them primarily as reproductive agents [Reference Jacob33].

In order to address these issues, the Partnership has recently conducted several public engagement activities to investigate appropriate ways for developing and framing health messages that avoid unintended and harmful consequences. Unsurprisingly, using the term ‘preconception’ was not preferred by participants (women living in the UK) [37]. Additionally, participants also recommended gender-inclusive terms that could capture the interest of men, who often felt excluded from the conversation on health for their children [Reference Schoenaker, Gafari, Taylor, Hall, Barker and Jones38]. While the area of male preconception health and its impact on long-term health has been increasingly discussed within the Partnership, messages related to men’s health before pregnancy were often lacking in their outputs. Framing preconception health mainly around women’s health and bodies could further alienate men and non-binary individuals from engaging in health messages and conversations around preconception care [Reference Schoenaker, Gafari, Taylor, Hall, Barker and Jones38]. Studies from low- and middle-income settings have, however, shown that men were keen to be involved in engaging in such conversations [Reference Watson, Chatio, Barker, Boua, Compaoré and Dalaba39]. The need to represent health findings without causing alarm is key for the public’s engagement with preconception health messages, considering the probabilistic nature of the associations in DOHaD studies [Reference Müller, Hanson, Hanson, Penkler, Samaras and Chiapperino9]. Framings related to ‘unplanned pregnancies’ as a risk factor for a negative outcome were often used by the Partnership. This may also need to be revisited as studies have shown that people may not perceive unplanned pregnancies to be a negative outcome, nor is pregnancy intentionality a straightforward idea [Reference Grace, Shawe, Barrett, Usman and Stephenson40, Reference Johnson-Hanks41].

Another question that proved internally contentious within the Partnership was how to frame obesity. Though publications have acknowledged the wider determinants of obesity and the need to reduce stigma in clinical conversations, obesity is also framed as a condition in need of medical treatment or intervention [Reference Stephenson, Schoenaker, Hinton, Poston, Barker and Alwan29, Reference Jacob, Killeen, McAuliffe, Stephenson, Hod and Diaz Yamal36, Reference Barker, Dombrowski, Colbourn, Fall, Kriznik and Lawrence42], in accordance with recent World Obesity Federation campaigns (2018–19). However, internally members of both the Partnership and the Venice Forum have contested this medical framing, as over-medicalising the issue presents challenges in policy translation. One such challenge is that an increased focus on addressing obesity through healthcare and weight management services might lead to reduced investments in preventive policies that target systemic drivers of obesity, such as the marketing of foods or food composition. Framings of obesity as a medical condition also potentially conflict with a social justice framework. Feminist scholars and fat activists have argued that framing obesity in medical terms may contribute to weight stigma in which individuals are blamed for their body shape and ill health. Such frames in particular target women and minorities and lead to localising structural problems within individual bodies, thus potentially deflecting policy attention away from the systemic conditions that drive inequities in health. (See Lappé and Valdez in this handbook.) Additionally, conversations focusing only on weight can also lead to unintended consequences such as repeated cycles of weight gain and loss, eating disorders, weight stigmatisation, and mental health issues, thus calling for a person-centred approach [Reference Bacon and Aphramor43].

From a social justice perspective, health interventions and policies based on individual behaviour change appear as particularly problematic. Such interventions were also debated internally within the Partnership, with one point of debate being how health messages related to preconception health should be framed. Preconception health interventions that target individual behaviour change predominantly focus on rational aspects of decision-making (e.g. providing information on food-based dietary guidelines and Eatwell plates), and overall DOHaD health messaging tends to focus on risks and potential negative outcomes. In contrast, the Preconception Partnership has recommended appealing to emotional aspects of the benefits of healthy growth and development [Reference McKerracher, Moffat, Barker, Williams and Sloboda8]. This is especially relevant as health messages compete with framings by the private sector, which focus on selling comfort and happiness – for example with the use of infant formula. Framing preconception health messages in more positive terms has the goal of improving the public and policy uptake of these messages.

Thus the Preconception Partnership has used framings similar to the Venice Forum on intergenerational benefits and health across the lifecourse, social justice, and the reproductive justice framework. However, medicalised framings of obesity are still evident along with a focus on women’s fertility and pregnancy planning.

17.3.2.1 Competing Framings in DOHaD Health Advocacy

Research findings from DOHaD can be framed in different ways, imbuing them with different meanings to link to different types of policy recommendations. Such frames may not incorporate all aspects of the issue in question and present a risk of oversimplification of a complex field, as seen in the above examples. Figure 17.1 is a conceptual figure summarising examples of framings used by the networks in publications and other media, which we have listed by the potential impact it could have if applied in healthcare, policy, and interventions.

Figure 17.1 The framings used within groups and for communicating to an external audience are illustrated in the figure. Certain framings may have potentially negative consequences, while others have more positive effects as shown by the arrow.

DOHaD frames may emerge in multiple ways, not limited to evidence generated from research but also as a response to the evidence demand from governments/policymakers, major societal events, and public opinion. Efforts to bring DOHaD insights into policy and health interventions are often driven by a sense of urgency and an understanding that it is an ethical imperative to act now to improve MNCH and to address persistent inequalities in health. This sense of urgency often translates into efforts to influence policy and the public ‘effectively’, for example through strategically framing DOHaD messages in ways that make them more palatable to policymakers and the public, and thus more likely to influence policies and health behaviours.

Such efforts and emphasis on urgency can also lead to unintended consequences that may be at odds with the goal of promoting health equity and social justice – especially when the potential negative impacts of employed framings are not given adequate consideration. For example, alarmist language – obesity as ‘a ticking time bomb’, or the ‘war on obesity’ – might be an adequate way to garner policy and media attention, but it also has the potential to increase weight stigma when fat people are implicitly framed as a threat to society, economic prosperity, and the welfare state’s future [Reference Penkler, Felder and Felt44]. This becomes particularly problematic when public health campaigns are aimed at marginalised parts of the population.

Similarly, an economic frame of ‘returns on investment’ might be well suited to attract policymakers’ interests – but it carries the danger of propagating eugenic logics when women are targeted primarily in the name of the offspring’s health, as discussed by Cohen in her contribution to this volume. And a framing that highlights individual agency in relation to factors that influence the development of health and disease may be well suited to inform individual action – but runs the risk of also increasing blame and of reinforcing health inequalities as not everybody has the necessary resources to act.

The analysis of our two case studies has shown contestations around how to frame DOHaD for policy and society. Individualising and potentially stigmatising frames were critiqued in internal discussions. At the same time, there are strong incentives for simplistic frames to ‘effectively’ translate DOHaD. While such framings might make strategic sense, DOHaD researchers should be aware of the trade-offs and potential costs of such framings. This shows the need for constant reflection and negotiation around appropriate ways of framing DOHaD messages – with interdisciplinary advocacy networks being well suited to facilitate such negotiations by bringing together different disciplinary, societal, and policy viewpoints.