Tamara Etienne’s second pregnancy was fraught with risk and worry 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 grueling days on her feet. Financial worries weighed heavily, despite health insurance and some paid time off from her job.
And as a Black woman, her lifelong racism had warned her about unpredictable reactions in daily life and drained her of 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 labor.
“I experience it every day, not alone but with someone I have to protect,” she said. “So the cortisol levels in my body when I’m pregnant? Immeasurable.”
Two months into the pregnancy, the unrelenting nausea suddenly stopped. “I felt like my pregnancy symptoms went away,” she said. Then strange back pains 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, home monitoring of the fetus and bed rest while she was off work for months – saved the child, who was born at 37 weeks.
Women in the US are more likely to give birth prematurely than women in most developed countries. It’s a distinction that coincides with high rates of maternal and infant mortality, billions of dollars in critical care costs, and often lifelong disabilities for the surviving children.
About 1 in 10 live births in 2021 will occur before 37 weeks gestation, according to a March of Dimes report published last year. By comparison, research in recent years has put preterm birth rates at 7.4% in England and Wales, 6% in France and 5.8% in Sweden.
In its 2022 report card, the March of Dimes noted that preterm birth rates increased in nearly every U.S. state from 2020-2021. Vermont received the highest grade in the country, an “A-,” with a rate of 8%. The bleakest results were concentrated in the southern states, which were mostly rated “F” with preterm birth rates of 11.5% or higher. Mississippi (15%), Louisiana (13.5%) and Alabama (13.1%) performed worst. The March of Dimes report found that 10.9% of Florida’s live births were premature in 2021, earning the state a “D” rating.
The US Supreme Court overturned it Roe v. calf, many maternal-fetal specialists fear that the incidence of preterm birth will increase sharply. Abortion is now banned in at least 13 states and severely restricted in 12 others — states that restrict abortion have fewer maternal care providers than states with access to abortion, according to a recent analysis by the Commonwealth Fund.
This includes Florida, where Etienne lives and where the Republican legislature has enacted a number 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 is uninsured, making it difficult to start a healthy pregnancy. Women in Florida are twice as likely to die from causes of pregnancy and childbirth than in California.
“I’m losing sleep over this,” said Dr. Elvire Jacques, maternal-fetal medicine specialist at Memorial Hospital in Miramar, Florida. “Hard to say, I suppose [better birth outcomes] if I don’t invest anything in the first place.”
The causes of premature birth are varied. About 25% are medically induced, Jacques said, when the woman or fetus is distressed from conditions like preeclampsia, a pregnancy-related hypertensive condition. However, research suggests that far more preterm births are due to a mysterious constellation of physiological conditions.
“It’s very difficult to see that a patient automatically has a preterm birth,” Jacques said. “But you can definitely identify stressors for her pregnancy.”
Doctors say that about half of all preterm births are preventable, caused by social, economic and environmental factors and insufficient access to prenatal health care. Risk factors include medical conditions like diabetes and obesity, as well as more hidden issues like stress or even dehydration.
At Memorial Hospital in Miramar, part of a large public health system, Jacques takes on high-risk pregnancies referred by other OB/GYNs 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 your patient works in a factory [standing] on the assembly line,” she said, “then how are you going to tell her to wear compression stockings because they can help prevent blood clots?”
Jacques asked a business manager to leave her pregnant patient at work. She persuaded an imam to grant a stay of religious fasting to an expectant mother with diabetes.
Since diabetes is a major risk factor, she often talks to patients about healthy eating. For those who eat fast food, she urges them to try cooking at home. Instead of “Can you pay for food?” She asks, “Of the foods we’re talking about, which do you think you can afford?”
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 US from other countries, health policy experts say.
In countries with socialized health care, “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. “Many places have paid holidays, [and pregnant patients] You don’t have to worry about not being at work.”
However, as preterm births increase in the US, wealth does not guarantee better pregnancy outcomes.
Stunning new research shows that black women and their children at all income levels in the US suffer far worse birth outcomes than their white counterparts. In other words, all the resources that come with wealth do not protect black women or their babies from premature complications, according to the study published by the National Bureau of Economic Research.
Jamarah Amani saw this firsthand as executive director of the Southern Birth Justice Network and as an advocate for midwifery and doula care in South Florida. When evaluating new clients, she looks to family history, lab testing, and ultrasound for evidence of birth risk. She quickly recognizes stress related to work, relationships, food, family and racism.
“I find that black women who work in high-stress environments, even if they aren’t financially challenged, can face 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 discovered her electric bill was overdue and the utility was threatening to stop service. Amani found an organization to pay off the debt.
Of Tamara Etienne’s six pregnancies, two ended in miscarriage and four ended in premature labor. Fed up with the onslaught of medical procedures, she found a local doula and midwife to help guide her through 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 profound impact on Etienne. She is now a fertility doula herself.