Every day, as I rush to preterm deliveries on the labor floor of my safety-net hospital and work beside incubators and clear plastic hospital bassinets, one of my patients’ mothers confides to me her belief that if she had only done that one thing differently during pregnancy, her child might not be in the NICU. Women tell me about catching COVID-19, eating spicy food, working outside the home, exercising, not exercising. I hear from mothers who tripped over that last step off the bus – hidden beneath their pregnant bellies – and ascribe their ultimate pregnancy outcome to that single stumble. A mother picked up her toddler while 26 weeks pregnant because he was crying, arms raised; she started contracting two hours later. I flashed back to my second pregnancy and my older son sobbing on the sidewalk. I couldn’t debunk this association that I knew would gnaw at her forever.
The FDA’s conclusion earlier this month that injectable progesterone does not prevent preterm birth, on the heels of the March of Dimes detailing an increase in maternity-care deserts across the nation, solidified my belief that prematurity will remain inevitable for one in ten American newborns until our nation makes some dramatic changes. While each family’s experience with prematurity, which affects 370,000 American babies annually, is unique and some decisions and circumstances may make preterm birth less likely, I hear recurrent themes of inequity and oppression uniting these journeys. Lists abound with evidence-based suggestions for how to prevent preterm birth. But imploring pregnant people to be healthy by obtaining prenatal care, eating well, and not smoking – to name but a few examples – fuels a myth that they control their own pregnancy outcomes. When their outcomes are undesirable, many of my patients’ parents are awash in maternal self-blame and mistakenly think they did something to merit them.
Myriad pregnant people make choices that align with healthy pregnancies, yet hundreds of thousands deliver early, nonetheless. Many discover that prenatal care alone cannot prevent preterm birth. In part because quality prenatal care, which is unambiguously important, is inconsistently available and, as the March of Dimes so succinctly delineates, access is contracting. And in part because many elements contributing to preterm birth are not modifiable at an individual level and are at play long before pregnancy.
In medical school, I learned that diverse and differing reasons contribute to any individual preterm delivery, and this epidemic is therefore poorly understood. My education focused on maternal physiology, on how the human body acts and reacts to pregnancy. I read articles in which biomedical researchers explained the effects of inflammation and infection and hormones. Injectable progesterone as a potential therapy emerged from this line of research. Other articles emphasized that exact mechanisms detailing why some pregnant people labor early remained elusive.
Over time, listening to the journeys that brought my patients’ parents to the NICUs of North Philadelphia helped me realize what others already understood: the preterm birth epidemic is not only about what transpires inside pregnant bodies. It is also about how elements of our modern American society strain those bodies. That the deteriorating neighborhoods and redlining surrounding my hospital impact the pregnant mothers I encounter feels evident as they tell me about their crowded rowhomes and cruel landlords. Mothers who did not miss a single prenatal visit describe the toll of poverty as they recount waiting in line at church food pantries and WIC offices. When I pace through the NICU late at night, postpartum mothers visit their children wearing work uniforms after returning to their days as fast-food workers, nursing home aids, factory workers, and other service occupations. They explain their need to pay their bills before their babies come home.
When mothers describe the multiple barriers they must navigate, I sense what research supports. Given that pregnancy stress and racism’s many tentacles contribute to preterm birth, many pregnant bodies simply cannot keep the weight of society at bay for the full 37 to 40 weeks needed to gestate to term. That prematurity disproportionately affects pregnant American Black women – around 15% of whom deliver preterm – is a consequence not only of social and structural determinants but also of the obstetric racism my own hospital strives to extinguish. The collective narrative told by women of color, one of disrespect and unmet medical and social supports, enrages me as I serve beside my team to save babies and support families.
By the time I care for my patients, American society has already denied their parents reproductive justice. Impassioned debate over a pregnant person’s right to choose has reigned since the Supreme Court overturned Roe v. Wade. But the societal and environmental factors contributing to preterm birth mean that many people who do remain pregnant are not provided the chance to choose a healthy pregnancy or birth healthy children. “Being oppressed,” wrote bell hooks, “means the absence of choices.”
No pregnant person chooses to subject their fetus to the air pollution, climate change, plastics, and other toxins that increase the likelihood of preterm delivery. These environmental mediators are potent, but they are also invisible. I have never had a mother equate the air she breathes with her baby’s tenure in the NICU. Yet this association is jarring.
Infant health mirrors maternal health. The irony of fighting over fetal personhood without dismantling the environmental, economic, and racist structures that harm pregnant people – and their fetuses – has never felt more apparent than when I peer through incubator tops at newly born preemies, with their translucent skin, their life-sustaining tubes, their machine-assisted breaths.
I want to unlock the doors to my NICU where the urgency to champion maternal health is palpable. Hundreds of thousands of discrete futures incubating in NICUs like mine are more than a collection of their individual circumstances.
Correction, Nov. 3
The original version of this story mischaracterized the FDA’s findings on progesterone and preterm birth. The FDA found that injectable progesterone, not vaginal progesterone, does not prevent preterm birth.
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