Tamara Etienne’s second pregnancy was fraught with risks and concerns from the start – compounded by a first pregnancy that ended in miscarriage.
As a third-grade teacher at a crowded public school in Miami-Dade County, she spent hurried days. Financial concerns weighed heavily, even with health insurance and some paid time off through her job.
And as a black woman, a life of racism had left her wary of unpredictable reactions in everyday life and exhausted by derogatory and unequal treatment at work. It’s the kind of stress that can release cortisol, which studies have shown increases the risk of preterm birth.
“I experience it every day, not walking alone, 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 the pregnancy, the unrelenting 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 an emergency room, where a doctor confirmed she was at high risk of miscarriage. A cascade of medical interventions — progesterone injections, fetal monitoring at home and bed rest while she took months off from work — saved the child, who was born at 37 weeks.
Women in the US are more likely to deliver their babies prematurely than women in most developed countries. It’s a distinction that coincides with high maternal and infant mortality rates, billions of dollars in intensive care costs, and often lifelong disabilities for the children who survive.
According to a March of Dimes report released last year, about 1 in 10 live births in 2021 will occur before 37 weeks gestation. In comparison, research in recent years has reported preterm birth rates of 7.4% in England and Wales, 6% in France and 5.8% in Sweden.
In its 2022 report, the March of Dimes found that preterm birth rates increased in nearly every U.S. state between 2020 and 2021. Vermont, at 8%, earned the highest grade in the country: an “A-.” The starkest results were concentrated in the Southern states, which largely earned “F” ratings, with preterm birth rates of 11.5% or higher. Mississippi (15%), Louisiana (13.5%) and Alabama (13.1%) performed the worst. The March of Dimes report found that 10.9% of live births in Florida in 2021 were born prematurely, giving the state a “D” rating.
Since the US Supreme Court overturned Roe against Wade, many maternal-fetal specialists worry that the incidence of preterm birth will rise. Abortion is now banned in at least 13 states and heavily restricted in 12 others. States that restrict abortion have fewer maternal health care providers than states with access to abortion, according to a recent Commonwealth Fund analysis.
So is Florida, where Etienne lives, and where Republican lawmakers have enacted a raft of anti-abortion laws, including a ban on abortion after 15 weeks of pregnancy. 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, making it more difficult to start a healthy pregnancy. Women are twice as likely to die from pregnancy-related causes in Florida than in California.
“This is keeping me awake,” says Dr. Elvire Jacques, a maternal-fetal medicine specialist at Memorial Hospital in Miramar, Florida. “It’s hard to say, I expect [better birth outcomes] when I invest nothing from the start.”
The causes of preterm birth are varied. About 25% are medically induced, Jacques said, when the woman or fetus is in distress because of conditions such as preeclampsia, a pregnancy-related hypertensive condition. But research shows that many more early births are thought to be rooted in a mysterious constellation of physiological conditions.
“It’s very difficult to determine that a patient will automatically go into preterm labor,” Jacques said. “But you can certainly identify stressors for their pregnancies.”
Doctors say about half of all preterm births are preventable, caused by social, economic and environmental factors, as well as inadequate access to prenatal health care. Risk factors include conditions such as diabetes and obesity, as well as more hidden problems such as stress or even dehydration.
At Memorial Hospital in Miramar, part of a large public health care system, Jacques takes on high-risk pregnancies that have been referred by other midwives in South Florida.
When meeting a patient for the first time, she asks, Who else is in your household? Where do you sleep? Do you have substance abuse problems? Where do you work? “If you don’t know that your patient works in a factory [standing] on a conveyor belt,” she said, “how are you going to tell her to wear compression stockings because that can help her prevent blood clots?”
Jacques has urged a store manager to sit her pregnant patient while working. 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 to patients about healthy eating. For those who eat fast food, she asks them to cook at home. Instead of, “Can you afford food?” she asks, “Of the foods we’re discussing, which ones do you think you can afford?”
Access to affordable health care separates Florida from states like California and Massachusetts — which have paid family leave and few uninsured residents — and separates the U.S. from other countries, health policy experts say.
In countries with socialized healthcare, “women don’t have to worry about the financial costs of care,” said Dr. Delisa Skeete-Henry, chair of the obstetrics and gynecology department at Broward Health in Fort Lauderdale. “A lot of places have paid time off, [and pregnant patients] don’t worry about not being at work.”
But as preterm births are on the rise in the US, wealth does not improve pregnancy outcomes.
Surprising new research shows that black women and their babies at every income level in the US experience far worse birth outcomes than their white counterparts. In other words, all the resources that come with wealth don’t protect black women or their babies from premature complications, according to the study, published 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. As she evaluates new clients, she looks for clues about birth risks in a patient’s family history, lab work, and ultrasounds. She responds quickly to stress related to work, relationships, food, family and racism.
“I find that black women who work in stressful environments, even if they’re not struggling financially, can experience preterm birth,” she said. She develops “wellness plans” that include breathing, meditation, stretching, and walking.
When a patient recently showed signs of preterm labor, Amani learned that her electric bill was overdue and the utility company was threatening to cut service. Amani found an organization to pay off the debt.
Of Tamara Etienne’s six pregnancies, two ended in miscarriage and four were threatened with premature birth. Fed up with the many medical procedures, she found a local doula and midwife to assist her with the birth of her two youngest children.
“They were able to guide me through healthy, natural ways to reduce all those complications,” she said.
Her own pregnancy experiences left a deep impression on Etienne. She has since become a fertility doula herself.