Pregnancy As Window of Opportunity? A Danish RCT on Physical Activity During Pregnancy

ABSTRACT

Pregnancy is seen as a window of opportunity for health interventions, with the potential to produce long-term health changes for mother and child. The RCT FitMum investigates the effects of different regimes of physical activity during pregnancy. We suggest that rather than hitting a window of opportunity, the trial works in choreography with different timescapes through the processes of management of time. These timescapes are characterized by linear progression and futurity, alongside composite, complex time. We reconceptualize the intervention as a navigation of flows and passages in collective efforts, providing a situated and sustainable approach to interventions.

KEYWORDS:

• Clinical trials
• Denmark
• health promotion
• physical activity
• pregnancy
• timescapes

In this article we study the production of different timescapes in a clinical trial on physical activity during pregnancy. Timescapes are practiced approaches to time, enacted through everyday actualizations, resistances, and contradictions that are practical, embodied, and entangled (Puig de la Bellacasa 2017). We base our study on empirical material from the Danish RCT (Randomized Clinical Trial) FitMum, which investigated the effects of two formats of physical activity on pregnant women (Roland et al. 2021). FitMum is based on the assumption that pregnancy is a promising phase in life for the implementation of lifestyle changes: it is a window of opportunity (Stallknecht et al no date, Heslehurst et al. 2020). There is an increased focus on pregnancy as a critical period for interventions that have epigenetic effects and could improve the health of future generations Valdez (2022)). Here we investigate whether pregnancy can be conceptualized as a window of opportunity, and if so, how that might work in practice. We study how time is produced through sociotechnical practices, and what the ontological effects of such timescapes might be (Law et al. 2011). We focus on the encounter between changing bodies and the socio-material apparatus of the trial, how the ambiguity of pregnancy is handled in FitMum, and how the engagement of the RCT with pregnant subjects affects the production of timescapes, bodies, and health practices.

Anthropological studies of health interventions, the production of clinical knowledge, and concepts of time

There is a rich field of anthropological literature engaging with health interventions and the production of knowledge in clinical trials. Yates-Doerr and Carruth have emphasized the critically constructive and caring forms of engagements performed by anthropologists in the study of health interventions (2023). They highlight the dominance of western, colonizing medical regimes conducting medical interventions in reductive, universalizing, and linear fashion, to the detriment of subaltern knowledge forms and complex, relational and situated understandings of health. In practice, interventions rely on situated adaptations, local structures and practices, and anthropological methods are well suited to take relational and situated approaches to interventions and health (Yates-Doerr et al. 2023). Several anthropological studies have critically engaged with the RCT model of producing medical knowledge, such as Adams et al. (2014), who note the discrepancy between the scientific ideal of producing globally applicable evidence and facts that can be quite far from what works in local practice in all its messy specificities, or Dumit and Sanabria (2022), who criticize the colonializing and universalizing practices that dismiss and mask the contingencies and socially situated processes of producing health knowledge.

Focusing on the tensions between knowledge regimes, in relation to the handling of pregnant bodies, Simonds distinguishes between a medical/masculinist, a naturalist/feminist, and a consumerist/liberal feminist conception of time in practices of birth care. As Simonds argues, the medical/masculinist time discourse is based on a pathological view of women’s bodies focusing on time as measurable progression toward birth (Simonds 2002). Women’s bodies are perceived as medically and technologically manageable in accordance with predefined acceptable timeframes. In contrast, Simonds connects the profession and practice of midwifery with a holistic naturalist/feminist view on pregnant and birthing bodies: time is not to be managed, measured, or fought against, but something birthing women can take (Simonds 2002:569). Bledsoe describes the coexistence of different models of time; a linear and a contingent one, the former often associated with fertility, menopause, and senescence as inevitable stages of life tied to chronological age, and the latter, where these phenomena are shaped by actions and social resources and relationships (2002). Both are practiced and experienced in different contexts, and thus present an understanding of what we tend to understand as bio-chronological processes as social and situated.

Hardon and Pool (2016) discuss the tensions between clinical knowledge produced in laboratories and everyday lives, and open for exploration the tensions and contingencies of producing evidence through ethnographies from within clinical trials. Jespersen, Bønnelycke, and Hellerup Eriksen have shown the underrecognized practices of carework on which the production of evidence relies (Jespersen et al. 2014). Thompson describes how seemingly opposing ontological positions can be interdependent through the notion of ontological choreography, where women undergoing fertility treatment shift between subjectification and objectification through sociotechnical arrangements (Thompson 2005). Thompson shows the simultaneous coexistence and oscillation between ontological positions making the medical procedures possible. In this vein, rather than producing dichotomies between good/bad, natural/unnatural, or masculine/feminine, we seek to understand how seemingly contradictory regimes and practices might coexist. We study how FitMum is founded on a universalist and linear notion of health interventions, while working as a flexible apparatus, relying on practices of care. We draw on Latour and Serres’ understanding of time as multiple and folded, and Puig de la Bellacasa’s conception of socio-technical timescapes.

Within the field of medical anthropology, others have focused on pregnancy and the experience of bodily, social, and identity-related changes (Andaya and Kotni 2022; Carter 2010; Young 1984), and norms regarding body size and weight (Longhurst 2000), or the biopolitics of pregnancy (Rivkin-Fish 2023), all relevant themes that were not the focus of this study. For a more in-depth analysis of the experience as a participant in a clinical trial of learning to notice and exercise with the pregnant body, see Bønnelycke et al. (2022), and for an analysis of the relations between caring and clinical practices in the socio-material practice of the RCT, see Larsen et al. (2022).

Theory

The notion of time as progressive and linear is powerful in the FitMum intervention, which prescribes actions of assessing and predicting stages of pregnancy, capturing pregnancy inside a timescape of progression and linearity. Another version of time in the trial was time as uncontrollable, elusive, slippery, making leaps and bounds that escaped the careful mechanisms of planning and measuring. This contrasted with the sociotechnical orderings of things and processes and kept clashing with attempts to control it. The struggle of reconciling these two kinds of time characterized the way pregnancy was experienced by participants, and the ways pregnancy was performed in the trial. To grasp the multiplicities and entanglements of timescapes, we turn to authors who address time as produced, experienced, and complex.

The multiplicity and relationality of time

Jespersen and Elgaard Jensen (2012) draw on Latour and Serres (Latour 1987; Serres and Latour 1995) to suggest a relational and compositionist approach to time. Latour describes science-in-the-making as the point in time where facts are not yet stabilized, relations are unsettled and results are uncertain, in contrast to ready-made-science; the finalized results and established procedures that produce predictable outcomes (Latour 1987). Drawing on this, Jespersen and Elgaard Jensen suggest time-in-the-making as an entry to studying the socio-material processes of constructing time, where flows of events are organized to become manageable (Jespersen and Elgaard Jensen 2012). This gives a variable ontology of time which provides the possibility to study how time is produced in arrangements of relations (Jespersen and Elgaard Jensen 2012).

Serres has suggested understanding time as multiple and folded, using fluids as metaphor for the movements of time: seeping and moving in several directions simultaneously in turbulent patterns (Serres and Latour 1995:58–59). We study the entanglements of different timescapes in compositions of times, and the relations between different, coexisting temporalities with their dynamics and tensions. The tensions between these times, and the struggles that are experienced by staff and participants, are not to be understood through dichotomization or solved through a choice of a better timescape. They are to be understood as different, related, and simultaneously enacted versions of time.

The production of timescapes through socio-technical and embodied practice

We build on Puig de la Bellacasa’s (2017) work on timescapes, understood as practiced approaches to time, enacted through everyday actualizations, resistances, and contradictions that are practical, embodied, and entangled. She states that time is produced through socio-technical arrangements and everyday practices. We employ this understanding in the context of the clinical trial, looking at the timescapes produced through the socio-technical arrangement of the RCT, and through the everyday practices of the trial participants. The aim of the trial is to create better interventions in everyday life, and as such, everyday complex, socio-material practices must be engaged and changed in collective efforts (Bønnelycke et al. 2019). This includes pregnant bodies, families, technologies, jobs, and time, amongst many other actors of the everyday.

Study design and methods

The purpose of the FitMum study, performed at a hospital in the Capital Region of Denmark in 2019–2022, was to study the feasibility and effects of two exercise models; one following a group-based, structured exercise program, and one where counseling and group sessions provided the basis for individually conducted exercise (Roland et al. 2021). One of the drivers behind FitMum was the hypothesis that physical activity during pregnancy will have positive health effects for mother and child, and that establishing good exercise habits during pregnancy might support sustained activity postpartum (Roland et al. 2021). The trial was relatively flexible, enabling the adaptation of exercise forms and frequency to the condition and preferences of the participants, regardless of randomization group (Craig et al. 2008). This meant that the at-home part of the trial, where participants had to conduct their exercise, was modifiable, while clinical visits, tests and measurements were mandatory.

Participants in the trial were all healthy women exercising between 1 and 15 weeks and were pregnant with only one child when enrolled. Participants were randomly distributed into: 1) two planned, supervised training sessions a week; 2) motivational counseling supporting home training; 3) a control group. All participants had clinical measurements taken throughout the trial and were required to wear an activity tracker until one year after giving birth (Roland et al. 2021). At enrollment, all participants, both pregnant women and partners, gave informed consent, and data was collected, analyzed, and stored according to the Danish National Committee on Health Research Ethics and the Danish Data Protection Agency (see also Roland et al. 2021).

We conducted ethnographic fieldwork during 2019–2020 as part of the FitMum trial, with the aim to investigate effects (physiological, social, and ontological) of the trial. The authors (ethnologists) were an integrated part of the FitMum research team, consisting of both junior and senior researchers of physiologists, midwives, pediatrics, laboratory technicians and nurses. Scientific and clinical staff collaborated on producing knowledge and data. Methods were participant observation during all parts of the trial, semi-structured interviews, and short qualitative interviews at baseline and follow-up (Tjørnhøj-Thomsen and Whyte 2008). All 220 participants were interviewed at inclusion (average duration 15 minutes), 30 were also interviewed halfway through their participation (av. 1 hour), 14 were interviewed after they decided to drop out (av. 15 min), and 52 have been interviewed at the end of participation in the trial (at follow-up 1 year after giving birth – av. 15 min.). The interviews touched upon themes such as expectations and motivation, prior experience with physical activity, best and worst aspects of physical activity, and the experience of being part of FitMum. Interviewing the same participant before, during and after creates a longitudinal perspective on the process of going through the trial. Sixty-five sessions in which the researchers performed participant observation were conducted during the clinical visits and the training sessions, focusing on the procedures, interactions, and relations between participants, staff, technologies, and materialities. All the qualitative material was transcribed, and coded using Nvivo, and analyzed using thematical analysis (Braun and Clarke 2006). Analytical themes were developed during analytical workshops and in team meetings (see also Bønnelycke et al. 2022). Halfway through the trial, the COVID-19 pandemic necessitated the conversion of the trial to an online format, where all training sessions and meetings were conducted via Zoom, except for the clinical tests and measurements. The conversion to online sessions increased participation, as participants perceived the format as more flexible and accessible.

Pregnancy and the postpartum period in a Danish context

In Denmark, health care, pregnancy visits, and medical checkups are free. The study participants were encouraged to follow all standard pregnancy visits, and any medical advice given by their GP or midwife. Pregnancy and parental leave are paid, starting 4–8 weeks before due-date, and at the time of the study, the mother had up to 46 weeks of leave.¹ This means that the participants were part of the trial both before and after going on parental leave. Denmark has an infrastructure making it safe and possible for all to walk or bike both in cities and countryside, and access to fitness or exercise facilities is relatively easy and affordable, either via private memberships or local associations which offer pregnancy activities and mother-child activities. For participants randomized to exercise on their own, access to spaces for exercise was therefore not a challenge, and any potential issues were addressed and mitigated with help from the staff.

Analysis

We turn to time-in-the-making in the embodied practices and activities of the trial, where socio-technical arrangements are assembled to create order and standard operating procedures of chaotic events (Latour 1987). Firstly, we look at how the medical procedures and clinical arrangements produce a time that serves to construct pregnancy as a window of opportunity. Then we work to nuance and multiply the time produced in the conjunction of clinical and embodied practice, to develop a conceptualization of pregnancy as the collective navigation of flows and passages through timescapes produced by conflicting notions of temporality.

Progressive time: controlled and measurable pregnancies

In Denmark, pregnant women partake in a series of visits and consultations with doctors and midwives to monitor the health condition of mother and child. They are presented with guidelines for health and diet during pregnancy and given advice on childcare and nutrition. Measurements are taken that document fetal development based on weight increase, fundal height, and ultrasound scans. The FitMum trial uses the same standard procedures for monitoring the progression of the participants’ pregnancies. The measurements are compared to health authority recommendations and textbook standards for the stages of pregnancy. When participants are weighed and their fundal height measured, the numbers are inserted into a graph that depicts the development of the specific pregnancy compared to average development. Thus, it can be assessed whether the pregnancy progresses “as it should,” as seen in this excerpt:

[Participant] lies down and removes her dress so the belly is exposed. [Staff] sterilizes her hands (…). She palpates to find the outline of the uterus and presses down on the top of the belly. She presses down firmly and grabs the measuring tape. (…) She presses down the measuring tape and draws it from the pubic bone across the big belly, repeating the process three times.

Alright. 33.5 cm” she says. [Participant] looks at her expectantly: “Is that good?

Yes, it’s just in the middle. You must be just a bit below your gestational age, the rule goes, and you’re in week 35, so being 5 cm below that would still be within the norm.

The medical apparatus is based on a ready-made model of linear and progressive time, where pregnancy progresses through predictable stages based on the physiological development of the fetus from conception to birth. For instance, weight and fundal height measurements of the pregnant women are recorded in graphs and compared to standard development curves, and optimum weight and fundal height and fetal growth curves are calculated based on population standards. This progressive way of conceptualizing pregnancy is general and oriented toward a medical time discourse with a linear progression based on the stages of pregnancy (Simonds 2002:562). As the quote reveals the trial apparatus operated based on this time, and the pregnant women were also drawing on it, when formulating expectations, and in how they understood their own pregnancy, identifying themselves by their gestational week. This progressive time aligns with the medical time discourse based on a masculinist view on women’s bodies as pathological, justifying technological and medical management (Simonds 2002:560). However, alongside this progressive time is introduced an interventionist time, where the trial seeks to establish pregnancy as a window of opportunity.

Interventionist time: shaping the future through healthy actions

Employing the trope of a window of opportunity as part of intervention strategies is founded in the evidence-based knowledge, that during pregnancy, the health of both mother and child are affected by the lifestyle habits of the expectant mother (ACOG 2020; Meander et al. 2021; Moyer et al. 2016). The increasing focus on long-term impact of maternal health and exercise during pregnancy emphasizes potential epigenetic effects, possibly over several generations, of parental behavior (Alves-Wagner et al. 2022; McMillan et al. 2019; Nakahara et al. 2021; Stanford et al. 2017). In addition to the epigenetically inherited disposition to overweight are the “socially inherited” dispositions, i.e., the lifestyle patterns passed on from parents to child, predicting that active parents will more likely raise active children (Carson et al. 2020; Garriguet et al. 2017). In other words, good health is both biologically and socially hereditary. This is why it is considered to be important to initiate and establish good lifestyles as early as possible for the sake of both mother, child, and the generations to come. Hence the articulation of pregnancy as a window of opportunity for founding new, healthier generations through the establishment of healthy habits already before birth. The assumption that a pregnant woman is inclined to be interested in health because she is pregnant, was in part supported by the motivations explained by the women themselves in the screening interviews performed with all the women who enter the FitMum trial. When asked about their motivations for joining the trial, many of the women stated they wished to be more physically active. The drivers ranged from wanting to minimize weight gain, prevent pregnancy complications, be in shape for the birth, promote an easier healing process postpartum, and positively impact the health of the baby.

… and then there was also the perspective that maybe it affects the pregnancy in a good way, and the baby too. And [fiancée] was also like maybe it will give the baby something good from the start, if the baby feels a lot of activity while he’s in the belly. (…) I am pretty curious to see if the physical activity will influence him when he gets out, and how he will behave. If we are influencing him in the right direction as parents.

Interview excerpt, FitMum participant.

This woman expressed the potential for achieving long-term health and behavioral effects for the child from changes made during pregnancy. In this linear and future-oriented timeframe, healthy actions in the present are connected to healthy lives in the future for both mother and child. Considering the pregnancy as a window of opportunity generates a shortcut to healthy predispositions for the child, by creating an epigenetic imprint as well as a social one by giving the child an inherited disposition for physical activity. This was expressed by several participants, who were aware of the connections between parental health condition, physical activity levels, and practices of physical activity on children. They expressed their participation as an action to benefit both themselves and their child long-term. Thus the pregnancy is enacted as a potential investment in/intervention of the future. As Adams et al. note, we inhabit a time marked by anticipation; “a self-evident ‘futurism’ in which our ‘presents’ are necessarily understood as contingent upon an ever-changing astral future that may or may not be known for certain, but still must be acted on nonetheless” (Adams et al. 2009:247). This anticipatory regime, in its biopolitical manifestation, has encroached upon reproduction from conception to fetal management to birth. The window of opportunity-trope can be seen as an expression of this anticipatory regime. This interventionist time is dependent on the progressive time enacted by the standard medical procedures and the expectation, that pregnant bodies behave in a certain manner, and that certain levels of activity, mobility, and states of body can be expected at predefined stages.

Composite time: improvisatory arrangements and folds in time

The changes that occur during pregnancy vary from woman to woman, and do not always follow the standard curves or the ready-made timeframe. Some changes are indeed predictable, and others are more complex, challenging the trial, which must adapt to the changing conditions of the pregnant women. This refers both to the participants’ bodily state, and their emotional, social, and practical state: for instance, when marital issues arise, or sickness, work challenges, house moves, false contractions, or stress intervene. Such chaotic elements both affect exercise plans and clinical appointments, and the overall health and wellbeing of the mother, and thus the pregnancy and her ability to exercise. Their growing bellies affect both how they participate in the trial, as they must constantly adjust their exercise approach, and how they experience and navigate within the world. Routes and activities that before were considered easy and unproblematic can become challenging or impossible. As motherhood approaches, emotional states change, and perceptions of self, world, and others are affected (Bønnelycke et al. 2022).

The trial constantly adapted to produce samples and data, engaging with the body-at-present in relation to past-and-future-bodies. Again and again, time folds and flows in different directions simultaneously (Serres and Latour 1995). Several temporalities coexist and intermingle, as the present state of the body is always handled, assessed, and understood in the light of past experiences and future changes. In every session where the pregnant woman was measured and interviewed, plans and predictions are made based on the confluence of times and bodies, where the present state was assessed and linked to future expectations, based on past experiences and conditions.

Here an example from one of the clinic visits, where staff and participant revisited her experiences since the last visit.

P [Participant] recounts that she has been very busy with work and the kids since last visit, so the exercise results don’t look as good as she would like them to be. (…) It is completely impossible right now and quite stressful to try and do it every day. If she misses one session, she must do double the next day.

Staff says that this is no good. It doesn’t work if it is all stressful and impossible to do. They must make a new plan and see if it can work:

“Let’s go through your numbers and then plan for the period until our next meeting in November.”

(…) They continue in detail about her activities every day. Staff says that she thinks the goal of 10,000 steps still seems appropriate, and that they probably shouldn’t change it now. But maybe they should change the activity-minutes from 30 a day to 30 minutes three times a week?

“That’s probably more doable what with everything that is going on now,” she says. “Or what do you think”?

P says she isn’t sure. She only has a 30-minute lunch break, and she rarely ever takes it because she’s so busy. And after work there is school run and then dinner, night ritual and then it’s 8 PM and she’s just too tired.

(…)

“What about weekends then?” staff asks.

“I don’t know, there is so much with the house sale and everything,” P says. “I could probably do once or twice in the weekend, and then once or twice on workdays. It has been possible before, so it should be again now.”

They agree on putting in 3 times weekly, and then they go on to talk about the program and exercises she could do.

Excerpt from clinical observations.

The quote illustrates how the situation is different each time the pregnant women check in with the staff. The detailed work-through of all parts of P’s everyday life and activities in this excerpt served both to hold P accountable for her activities, to make sure she reached her goals, and for the staff to assess the feasibility of the exercise plan, and for planning the next period. By looking at how P’s days have played out, staff gauged where there was potential and tried to adjust for the next two months until the next visit. It is a careful contextualization of the exercise plan, and a situated engagement with the moment-by-moment events of the timeline of the pregnancy. It is also a way of relating to the past to make commitments for the future, as the staff’s questions made P acknowledge that since it has been possible before, it might be again. Again, time folds. It also takes the shape of a negotiation with P, who had a say in what she found feasible, and thus the trial adapts to personal experience and preference. This is time-in-the-making, through careful tinkering and adjustments to everyday practicalities (Jespersen and Elgaard Jensen 2012; Mol 2008).

J [Participant] is talking with Staff about her experience with the pregnancy in general, and the exercise program in particular. J tells that she is very bothered by false contractions; they keep her awake at night and bother her whenever she is active during the day. It is uncomfortable, but she isn’t worried as such. It was like that in her first pregnancy, and everything went just fine. She just has a hard time figuring out when to relax to make them go away, and when to press on. Especially because in the fall her husband is leaving for business again, and then she must take care of everything for herself, so she is trying to rest in advance right now, which doesn’t really make sense to her, because soon she’ll be on her own anyway. Staff emphasizes that J needs to go to her own doctor to get checked, and J promises to do so.

A little while back she woke up all locked in her pelvis and legs and could hardly get out of bed. She felt partially paralyzed, and it was painful and most of all scary, but it has gotten better. […] She asks staff if she has any ideas about the cause? Staff says there could be any number of reasons, but since it hasn’t been that long since J’s last pregnancy, it is possible that carrying the little one around can cause tensions and imbalances, and then add on ligament loosening causing pelvic instabilities.

J confirms that she did have a lot of lower back pains after the first pregnancy; she carried a lot of stuff and did a lot of no-good movements. They talk about the need to take extra good care of herself when her husband leaves again, to prevent a recurrence.

Excerpt from clinical observations.

In this example, J drew on her previous experience of pregnancy to interpret and act on the sensations she experienced in this pregnancy. Recollecting the false contractions from last time enabled her to assure herself that they were uncomfortable but harmless. At the same time, the contractions caused mental discomfort in the sense that she did not know how she could handle them in the future. With the prospect of her husband leaving for work for a longer period, she did not know if she will be able to rest as needed then. The past and projected experience of future contractions shaped her experience and management strategies of the present contractions. Trying to employ the strategy of resting in advance did not seem very meaningful to her yet is an attempt to anticipate contractions. When the discussion turned to her incident of paralysis it became evident, that P’s body was still affected by her previous pregnancy and the following period of nursing and carrying an infant. Again, her past experiences affected the strategies employed for handling the future and preventing further incidents.

For most of the second- or third time mothers, the past seemed to take more mental space than the future. Knowing that the postpartum period is highly unpredictable, they tried not to make too many plans or set goals for exercise, as seen in this excerpt:

L and J are first-timers, whereas M has a 2-year-old, and this difference quickly becomes evident. L and J have multiple questions directed at M about birth, the postpartum body, and life with an infant. They have many questions about when they can resume exercising after birth, whereas M is more cautious about making any assumptions or commitments about what she can do after giving birth. When Staff asks about their plans for exercising postpartum, M merely states that she will have to wait and see about the state of her body and her baby, knowing it will probably be hard though she does not know how hard exactly.

L asks staff how soon after birth she can start exercising, and J wants to know if she must wait 8 weeks before getting on horseback again, and staff states, that depending on the state down there, and whether they had any stitches, they can start as soon as they feel ready, and their body is up for it.

Observation excerpt.

Here, pasts were revisited or revoked by the present experiences of pregnancy, and past selves interfered as either supportive or recalcitrant to the ambition to exercise.

For many women pregnancy is experienced as a barrier to physical activity. Most of the participants recounted having previous practices of physical activity, which they had not been able to uphold. The women who had previously given birth experienced that their old habits were dismantled by their “new” life as mothers. They expressed hope that being more active during pregnancy would make them able to continue being active after birth.

These insights serve to nuance the notion of window of opportunity. The pregnant women were open to physical activity primarily not because of their pregnancy, but the pregnancy seemed to touch upon previous experiences of change and actualize old struggles and conflicts. The women recounted the offer of FitMum as a major factor influencing their decision to join, as the trial offered a supportive environment, and a structure to facilitate physical activity with knowledge and guidance. From the perspective of the participants, FitMum activated old experiences, habits, and struggles, as well as opening potential for new and different futures. The notion of window of opportunity connotes to an ultimate transformation through a suggested compression of time-and-space, which is rendered a smooth and homogenous space, conjured by scientific methods and health intervention strategies. We suggest that the trial creates folds in time, creating contact points between past, present, and future (Jespersen and Elgaard Jensen 2012; Serres and Latour 1995). Coordinating and planning intervention stages, exercise programs, and visits are constant exercises in anticipating and thus enacting futures; futures that change in an instant with the shift of the present assemblage. They build on pasts and present in combination with imagined futures (predicted, desired, or feared), relating to past experiences, present emotions and states, and techno-scientific techniques for prediction. The intervention strived to enact an interception of the future by means of the past and present, grasping onto straws of stability to serve as predictors for futurity. This practice is situated and messy, socio-technically complex, and full of swirls and flows.

Creating lifestyle changes requires more than individual efforts; it is a task undertaken by the socio-material collectives that are composed of numerous everyday practices (Bønnelycke et al. 2019). Working with a complexity-oriented approach, attentive toward the constant shifting and fluidity of socio-material assemblages, neither woman nor trial is singular and alike from the first visit to the next (Bønnelycke et al. 2019). The staff must take multiple actors and factors into consideration when assessing the past period and planning the next. They also must make many allies and mobilize many different actors in the socio-technical ensembles that perform the trial. Carefully, situated, tinkering, they consider each step taken before moving ahead (Mol 2008; Mol et al. 2010). Husbands, co-participants, school runs, work hours and house sales are part of the everyday complexities that make or break the new exercise regimen.

It is this situated, careful and collective approach that makes the trial strong and effective, as recounted by a participant:

She says that FitMum got her back on track again and gave her a push in the right direction. Both in terms of the counseling and the measurements.

I had a bad start on the pregnancy. I was in pain, felt really bad and could actually feel that I didn’t get any [exercise] done, even though I know how important it is. (…) Then I saw the brochure, and just thought I could give it a try, and it sounded like a really good project! (…) I saw it as an opportunity to get that help to get started, which is also kind of embarrassing when you are a physiotherapist, because I know what to do, I just couldn’t make myself do it. But this really gave me a push, and it has been so nice to come back to doing the things I am used to doing.

Interview excerpt, FitMum participant.

In this case, as in many others, pregnancy did not automatically open a window of opportunity; on the contrary, this participant felt that it was harder to be active. Instead of a window opening automatically, succeeding in adhering to a regimen of physical activity during pregnancy, is a matter of navigating unruly streams of complex, situated, socio-material collectives and alliances (Bønnelycke et al. 2019; Jespersen et al. 2014).

A reconceptualization of pregnancy: from window of opportunity to navigating through flows and passages

We suggest that, rather than understanding pregnancy and the related activities as linear progressions, the trial enacts a collective effort of navigating through flows and passages. The ready-made time that neatly presents itself with promises of a smoothly developing pregnancy is challenged by the situated, messy, and multidirectional flows that are better captured through time-in-the-making, where actions adapt to changing circumstances (Jespersen and Elgaard Jensen 2012). Pregnancy can be conceptualized as a folding of times, where each moment is understood and experienced in relation to multiple pasts and futures. Puig de la Bellacasa describes, how socio-technical regimes produce future-oriented nows based on risks, efficiency, and imminent needs (Puig de la Bellacasa 2017). The socio-technical regime of the trial produces pregnancies and births that are time-bound and tightly choreographed according to optimum course of time and action. With the window of opportunity-trope, the health intervention latches itself onto the dominant timescape of late modernity (Puig de la Bellacasa 2017), one that enacts the present in relation to the future, where each step and action of pregnancy and everyday life is rendered meaningful in terms of its potentiality for impact on the future. Valdez notes how pregnant women are caught in the expectation that they can manage and control their own body, and are thus made responsible for their own and their babies’ health, while being subjected to uncontrollable environments and conditions. They are caught in the moralizing blame-game of 20^th century biopolitics despite epigenetic analytical models revealing the many factors that are outside individual control. Simultaneously to blame for ill health, and unable to control the factors that might influence this, the pregnant women are subjected to the hyper-focus of medical regimes on the pregnant body (Valdez 2022). In modern practices of pregnancy and birth, the present is enacted in constant anticipation of the future. It is a present that caters primarily to socio-technical, biopolitical, and capitalist regimes conducting improvements on the terms of maximum yield and impact, rather than on sustainable transitions and ecologies of time and living. And the unidirectionality enacted by the window of opportunity is very far from the temporalities at stake in the everyday experience of pregnancy and the practical enactments of different time-flows in the RCT. Every clinical procedure is a socio-technical performance of entangled times, where past, present, and future bodies, experiences, and states are interconnected. Experiences from the trial unfold a diversity of interdependent temporalities, showing that neither pregnancy nor intervention is a one-off or chronologically linear event, but rather a complicated navigation between time-flows in heterogeneous enactments.

The orchestrated, extensive, and repeated efforts of the entire FitMum collective emphasize pregnancy not as a window of opportunity in terms of a sudden apparition of an open gap and a brief transgression of a threshold to be followed by a permanent residence in a new sphere. On the contrary, establishing and maintaining exercise during a pregnancy is more akin to the continuous effort of navigating troubled waters, steering through barely discernible passages, changing direction along the way, sometimes doubling back to stay safe. A habit, once established, perhaps through the meticulous work of aligning actors and processes, quickly needs to be adapted to a new set of circumstances, as body, abilities, and resources shift. Contrary to the window of opportunity discourse, the transition from pregnancy to motherhood is not defined by a clear-cut demarcation, but a process of expansion and of the intermingling of past, present and future experiences, and states of being. The expectant mothers are exactly that: expecting, and throughout pregnancy grasping at making connections between the here-and-now, the past body, experiences and selves, and the future ones.

Rather than conceptualizing the trial as building on a window of opportunity, we understand it as the creation of ad-hoc improvised choreographies, attuned to the states of bodies and relations. Rather than the shift from one state to another as connoted by the notion of window of opportunity, our studies point to the intermingled production of different timescapes in the trial, where the drive to create lasting behavior changes based on a linear and progressive notion of time clashes with cyclical and confluent timescapes based on the experiences of simultaneous change and continuity during pregnancy. Continuously, the goals and means must be reassessed and renegotiated, as the conditions within and outside the pregnant body change. There is no simple recipe for making that change in lifestyle, as it is not singular, but plural, and continuously evolving. Socio-technical regimes produce future-oriented nows based on risks, efficiency, and imminent needs for pregnancies and births that are time-bound and tightly choreographed according to an optimum course of time and action. In contrast, socio-material collectives navigate and coproduce flows and passages, employing patience and calm reactions by carefully assessing the current state and flowing with such currents through eddies and unexpected turns. The present that is produced in socio-material collectives, is not progressive, not being purely chronological nor based entirely on biological processes of development or aging. It is social, situated, experiential and contradictory.

Reconciling conflicting timescapes with Chronos and Kairos

Papastephanou (2014) engages critically with the dominance of managerialism in the present day’s pervasive conception of time as linear and future oriented. Our actions are governed by futurity and are shaped by the efforts to live by “measurable, invested and managed chronological time” (Papastephanou 2014:719). Our present is perceived in the light of the future. Papastephanou employs the ancient Greek terms of Chronos (measurable time) and Kairos (lived time) to question “the currently dominant and dichotomous priority of a chronological sense of time as invested and managed” (ibid). She suggests a conjunction of Chronos and Kairos to expand the opportunities for living in time encompassing openness, chance, and radical possibility. Navigation, travel, and journey as lived experiences are metaphors connected with the conjunction of Chronos and Kairos, allowing for adventurous exploration rather than unidirectionality and time-economization. Added to this, is the constant drive for improvement as fast and efficiently as possible.

As these determining factors are closely linked to measurability; (…) to reaching standards within set time spans; and to investing time in practices that visibly and quickly pay off, the underlying prioritization of the chronological conception of time becomes evident. (Papastephanou 2014:721)

This approach suggests a qualitative engagement with time, lending new perspectives to the choreographies of times and bodies in the clinical trial, challenging the notion of windows of opportunity for action. It resists the urge for constant forward movement, and replaces it with dwelling, and letting things happen all in their own good time. Cairosophy, as Papastephanou introduces, is about making time, reconsidering planned actions, leisurely walking without destination, exploring, and discovering. In the study of the experience of pregnancy, we find the struggle between Chronos and Kairos evident; the strain experienced by the pregnant women to reconcile the push to move forward, orient oneself toward the future, and anticipating through action and management, with the necessity to pause, feel, and allow for events and experiences unfold in their own time and place, as the pregnant body overrules plans and ambitions. The pregnant bodies become a battlefield for different timescapes, and we have described how these timescapes are reconciled through careful and situated practices that allow for the coexistence and balance between Chronos and Kairos; of acting and making plans, yet surrendering to the needs and demands of changing pregnant bodies and complex everyday lives.

Conclusion

The FitMum trial was a flexible trial model that sought to accommodate a clinical trial format to the complex and changing conditions of pregnant women while adhering to the parameters for conducting medical evidence. It thus bridged different practices of knowledge production and of relating to and managing pregnant bodies. Rather than produce dichotomies or antagonism between regimes, our contribution is to create a deeper understanding of the ontological effects of each, and how they can coexist.

The study showed that physical activity during pregnancy can improve quality of sleep and decrease sedentary time during pregnancy. It did not show any difference in weight increase or any of the other parameters (occurrence of gestational diabetes, frequency of C-sections, or birth weight) between the groups, but it did show differences in the perception of what it meant to be physically active between the groups, where those conducting physical activity on their own found it more attainable to be physically active and had a more broad perception of, what qualified as physical activity. In other words, those in the most flexible program gained a more flexible understanding of physical activity. This supports our notion that different sociotechnical arrangements and practices produce different realities, and they coexist side by side. This brings us back to the notion of time: In FitMum, we see several timescapes being produced, alongside the struggle to reconcile or balance opposing notions of temporality. One based on Chronos; chronological, managed, and measured time. A timescape enacting calculations, linear progression, and predictive measures: A ready-made and future-oriented time. Another based on Kairos, the timescape that is linked to experience, “to a season when something appropriately happens that cannot happen at ‘any’ time, but only at ‘that time,’ to a time that marks an opportunity which may not recur” (Smith 1969:1). They are entangled and reconciled through the collective practice of time-in-the-making. Without the quantitative measure of time, the qualitative experience of a certain event and state cannot be pinpointed or make sense. Kairos’ “right time” requires the quantitative fixture of Chronos. However, neither captures the timescapes produced in the sociotechnical practices of a clinical trial on pregnancy. It is easy to mistake pregnancy for an embodiment of Kairos, and the clinical trial as a representation of Chronos, and the struggles of the women to juggle bodies, norms, exercise regimes, and expectations to progress to certain states at certain time as the juxtaposition of Chronos and Kairos. In the socio-material, collective production of timescapes, Chronos and Kairos are not opposed, but reconciled to work dynamically, not succumbing to the dominance of untamable and “natural” time, nor time purely controlled by the techno-scientific management of modern society. Opportunities and openings are gently produced and supported through a practice of time-in-the-making. There is no “now or never” for intervention; there are possibilities produced. Through our analysis, we have redefined the notion of window of opportunity as something that is collectively enacted, crafted through relations and workings, sustained, and flowing in various directions, not a one-off event. If in health interventions there is a window of opportunity, it is less to be understood as a moment for action, and more as a long, winding passage that can be maneuvered only as a collective, complex time-consuming-and time-producing effort. The window of opportunity can be opened in many times and ways, and the circumstances that produce it are not uniform nor universal. So even though FitMum might have been able to increase possibilities for lifestyle changes, the concept of window of opportunity might not be the most apt term to describe the long-term and complex efforts required to sustain lifestyle changes.

Acknowledgments

The authors wish to thank Caroline Borup Roland, Signe De Place Knudsen, Anne Dsane Andersen, Saoud Alomairah, Jane Bendix, Tine D. Clausen, Stig Molsted, Andreas Kryger Jensen, Ellen Løkkegaard, Bente Stallknecht, and all the staff and participants in the FitMum project and at Nordsjællands Hospital for their valuable help and collaboration needed to produce the empirical material for this paper.

The study was approved by the Danish National Committee on Health Research Ethics (#H-18011067) and the Danish Data Protection Agency (#P-2019-512)

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by TrygFonden [128509].

Notes on contributors

Julie Bønnelycke

Julie Bønnelycke (PhD, MA in European Ethnology) is an Assistant Professor at University College Lillebælt, Department of Applied Business Research. Julie works within social studies of science and health and studies the production and communication of scientific knowledge within epistemic regimes. Julie has worked with clinical trials, health promotion practices, codesign workshops and science museums as apparatuses of production of scientific knowledge, scientific citizenship, and matters of concern.

Maria Larsen

Maria Larsen (MA in European Ethnology) was, at the time of the project, scientific assistant at the Copenhagen Centre for Health Research in the Humanities, University of Copenhagen. In her ethnographic studies, Maria explores health and disease, and body and self as sociocultural phenomena. Maria was involved in the FitMum intervention studying possible barriers and sociocultural factors to promote physical activity during pregnancy.

Astrid Pernille Jespersen

Astrid Jespersen (PhD, MA in European Ethnology) is a Professor at University of Copenhagen, the Saxo-Institute, Department of Ethnology. Astrid’s main scientific expertise is on cultural analysis and humanistic health research with special attention to health in everyday life, lifestyle changes, obesity, aging, physical activity, and interdisciplinary collaboration. Astrid heads the Copenhagen Centre for Health Research in the Humanities (CoRe) at the Saxo-Institute, UCPH

Notes

Since 2022, this has changed: today each parent has up to 24 weeks of leave after birth.