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Tamara Etienne’s second pregnancy was fraught with risk and worry from its earliest days – exacerbated by a first pregnancy that ended in miscarriage.
A third-grade teacher at a crowded Miami-Dade County public school at the time, she spent restless days on her feet. Financial worries weighed heavily, even with health insurance and paid time off from his job.
And as a black woman, living a life of racism had left Etienne wary of the unpredictable reactions of everyday life and exhausted by derogatory and unequal treatment at work. This is the type of stress that can release cortisol, which studies have shown increases the risk of preterm labor.
“I live it every day – not walking alone, but walking with someone I have to protect,” she said. “So the level of cortisol in my body when I’m pregnant? Immeasurable.”
Two months into her pregnancy, the incessant nausea suddenly stopped. “I started to feel like my pregnancy symptoms were going away,” she said. Then strange back pain started.
Etienne and her husband rushed to the emergency room, where a doctor confirmed that she was at high risk of miscarriage. A cascade of medical interventions – progesterone injections, home fetal monitoring and bed rest during months off work – saved the child, born at 37 weeks.
About 1 in 10 live births in the United States in 2021 occurred prematurely — before 37 weeks gestation — according to a March of Dimes report released late last year. This is a higher rate of premature births than in most developed countries; research in recent years has cited rates of 7.4% in England and Wales, 6% in France and 5.8% in Sweden.
It’s a distinction that coincides with high rates of maternal and infant mortality, billions of dollars in intensive care costs, and often lifelong disabilities for children who survive.
“It’s very difficult to identify that a patient will automatically have a preterm delivery,” says Dr. Elvire Jacques, a maternal-fetal medicine specialist at Memorial Hospital in Miramar, Florida. “But you can definitely identify the stressors for their pregnancies.”
Doctors say about half of all preterm births are preventable, caused by social, economic and environmental factors, as well as poor access to prenatal health care. Risk factors include conditions like diabetes and obesity, as well as more hidden issues like stress or even dehydration.
In its 2022 report card, the March of Dimes found that preterm birth rates increased in nearly every US state from 2020 to 2021. The bleakest results were concentrated in Southern states, with birth rates premature by 11.5% or more. Mississippi (15%), Louisiana (13.5%) and Alabama (13.1%) were the worst performers.
States that Restrict Abortion Have Fewer Maternal Caregivers
Many maternal-fetal specialists fear that the incidence of preterm birth will soon skyrocket, with abortion now banned in at least 13 states and heavily restricted in 12 others – states that restrict abortion have fewer providers maternal care than states with access to abortion, according to a recent Commonwealth Fund analysis.
That includes the state of Florida, where Tamara Etienne lives, and where Republican lawmakers have passed a series of anti-abortion laws, including a ban on the procedure after 15 weeks gestation. Florida is one of the least generous states when it comes to public health insurance. About 1 in 6 women of childbearing age in Florida are uninsured, reducing their access to quality prenatal care and making it harder to start a healthy pregnancy. A comparison of maternal mortality rates suggests that women are twice as likely to die from causes related to pregnancy and childbirth in Florida than in California.
Social and biological stressors may interact to trigger preterm birth
The causes of premature births are varied. About 25% are medically induced, Jacques said, when the woman or fetus is in distress from conditions such as preeclampsia, a pregnancy-related hypertensive disorder. But research suggests many more early births are rooted in a mysterious constellation of physiological conditions.
At Memorial Hospital in Miramar, part of a larger public health system, Jacques manages high-risk pregnancies referred by other South Florida OB-GYNs.
When she meets a patient for the first time, she asks: Who else is in your household? Where do you sleep? Do you have addiction issues? Where do you work?
“If you don’t know that your patient works in a factory [standing] on an assembly line, Jacques said, so how are you going to tell him to wear compression socks because it can help prevent blood clots?
Jacques urged a store manager to let his pregnant patient sit while she worked. She persuaded an imam to grant an expectant mother with diabetes a reprieve from religious fasting.
Because diabetes is a major risk factor, she often talks with her patients about healthy eating. For those who eat fast food, she asks them to try cooking at home. Instead of “Can you pay for food?” she asks, “Of the foods we’re talking about, which one do you think you can afford?”
A lack of access to affordable care separates Florida from states like California and Massachusetts — which have paid family leave and low rates of uninsured residents — and separates the United States from other countries, experts say in health policy.
In countries where health care is socialized, “women don’t have to worry about the financial cost of care,” said Dr. Delisa Skeete-Henry, chair of the department of obstetrics and gynecology at Broward Health. in Fort Lauderdale. “A lot of places have paid holidays, [and pregnant patients] not having to worry about not being at work.”
Yet wealth doesn’t guarantee better pregnancy outcomes, the US is learning, as premature births rise across the country.
Race and Premature Birth Statistics Reveal a Tragic Trend
Startling new research shows that at every US income level, black women and their babies experience far worse birth outcomes than their white counterparts. In other words, not all the resources that come with wealth protect black women or their babies from premature complications, according to the study released by the National Bureau of Economic Research.
Jamarah Amani has seen this firsthand as the executive director of the Southern Birth Justice Network and an advocate for midwifery and doula care in South Florida. When evaluating new clients, she looks for clues about the risks of preterm birth in a patient’s family history, lab work, and ultrasounds. She quickly addresses stress related to work, relationships, food issues or racism.
To offer meaningful help, you need to ask the right questions
“I find that black women working in very stressful environments, even if they don’t have financial hardship, can deal with premature birth,” she said. She develops “wellness plans” that include breathing, meditation, stretching and walking.
Recently, when a patient showed signs of preterm labor, Amani discovered that the woman’s electricity bill was overdue and the utility was threatening to cut service. Amani found an organization to pay off the woman’s debt.
Of Tamara Etienne’s six pregnancies, two ended in miscarriage and four were threatened with premature delivery. Fed up with the onslaught of medical procedures, she found a local doula and midwife who helped her carry out the birth of her two youngest children.
“They were able to guide me through healthy, natural ways to alleviate all of these complications,” she said.
Her own pregnancy experiences left a deep impact on Etienne. She has since become a fertility doula herself.
KHN (Kaiser Health News) is a national, editorially independent, KFF (Kaiser Family Foundation).