Janet M. Bronstein Preterm Birth in the United States A Sociocultural Approach Preterm Birth in the United States Janet M Bronstein Preterm Birth in the United States A Sociocultural Approach 123 Janet M Bronstein School of Public Health University of Alabama at Birmingham Birmingham, AL USA ISBN 978-3-319-32713-6 DOI 10.1007/978-3-319-32715-0 ISBN 978-3-319-32715-0 (eBook) Library of Congress Control Number: 2016944406 © Springer International Publishing Switzerland 2016 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG Switzerland Preface The United States is an advanced technological society It has the largest gross domestic product (GDP, the total dollar value of all goods and services produced) of all of the world’s nations It also has the largest portion of GDP that is devoted to health care, 16.4 %.1 Yet the U.S infant mortality rate ranks 33rd of the 36 nations included in the Organization for Cooperation and Development (OECD—European Union, EU applicants and selected other developed countries) This low ranking is not a recent phenomenon—it has been observed for decades, ever since comparative infant mortality rates have been available The reason for this low ranking is also clear, and has been stable for decades: the United States has a much higher rate of preterm births—infants delivered before their mothers’ pregnancies reach term (at least 37 weeks gestation) than other developed countries The U.S actually has a lower mortality rate per preterm birth age than other countries, but this high survival rate is not sufficient to compensate for the larger number of infants born before they reach term The persistence of high preterm birth rates in the U.S population has been labeled an enigma by biomedical researchers, an issue of concern by clinicians, an indicator of the need for political and health sector reform by social advocates, the trigger for ethical dilemmas in health care and social policy, and a human tragedy for the families involved It is a complex phenomenon that involves many participants, each of whom has a different view and set of experiences: the mothers who experience an early end to their pregnancies and the fathers of infants born early; their physicians, nurses and hospitals; those who finance the care of these mothers and infants and those who worry about maintaining resources for such expenditures; scientists responding to the challenge of explaining preterm birth; politicians who feel pressured to respond to preterm birth when it is framed as a social problem; and advocates who believe that their agendas offer solutions to the problem, to name just a few Each group is able to describe the phenomenon from Based on OECD data for 2013 The next highest portions of GDP devoted to health care are Switzerland and The Netherlands, each with 11.1 % v vi Preface its own perspective, and each often believes that its perspective represents the issue of preterm birth overall The situation is reminiscent of the ancient Indian story of the six blind men encountering the elephant: the one touching its side believes it is a wall, the one touching its tusk believes it is a spear, the one touching its trunk believes it is a snake, the one touching its leg believes it is a tree, the one touching its ear believes it is a fan, and the one touching its tail believes it is a rope The blind men argue vehemently about who has the most accurate view of the elephant, when in fact none of them has complete knowledge of what the elephant is like The many parties involved in the issue of preterm birth in the U.S are not blind, but it is easy to find one’s vision narrowed by the emotions and high stakes—life and death, deeply held values and paradigms, resource commitments, revenue flows and life adjustments—that are challenged when an infant is born before it reaches full term Also, with the demands of meeting the immediate challenges of preterm birth, it is easy to lose perspective on the historical circumstances that structure one’s current decisions, and to be unaware of the impact that a set of decisions made in one situation can have on the array of choices available in other situations For example, legal precedents for suing physicians for malpractice when infants die at birth puts pressure on hospitals to maintain neonatal intensive care units (NICUs) along with their maternity services Following the advice of their lawyers, doctors and hospitals believe that if newborns are moved immediately to NICUs, the providers will be following best practice guidelines, and thus will be less likely to lose malpractice cases The expansion in the number of NICUs, in part caused by this reasoning and in part caused by the potential to earn revenue from the care of preterm infants, reduces the average number of infants treated in each hospital’s unit This reduces the opportunities for staff to gain experience caring for high-risk newborns, and thus potentially lowers the quality of care available to the infants At the same time, knowing that there are on-site NICUs with the capacity to care for preterm newborns shifts obstetricians’ decisions about whether to intervene and deliver an infant before term if a pregnant woman experiences pregnancy complications The segment of infants born preterm because of physician intervention accounts for the overall increase in preterm births in the U.S over the last two decades; the number of preterm births occurring spontaneously has actually declined Each of these decisions or events is ostensibly distinct, but each one alters the circumstances under which the next decision is made or the next event occurs The primary objective of this book is to explore multiple overlapping dimensions of preterm birth in the U.S simultaneously, so that the view of each dimension of the issue can be illuminated both by history and by an understanding of the view from the other dimensions The secondary objective of this book is to use the various features of preterm births in the United States to shed light on some broader themes in U.S culture and social organization The fact that some features of the issue of preterm birth in the U.S differ from features in otherwise similar places, such as Canada, Great Britain, and other Western European countries, provides an opportunity to explore those aspects of U.S society that are both unique and pivotal in their impact on the health of the population Preface vii Six dimensions of preterm birth are explored in this book: the clinical, epidemiological (population-based), cultural, political, healthcare system, and ethical dimensions Chapter examines the clinical dimension of preterm birth as it reflects guiding interpretative paradigms in Western medicine, in particular the expectation that biological events can be consistently measured and altered by effective interventions This expectation leads to the belief that preterm birth is a type of medical problem than can be prevented or “cured” once the correct therapy is identified The chapter examines current clinical beliefs about the triggers for two types of early delivery, the type that occurs when pregnant women spontaneously go into labor before their pregnancy reaches 37 weeks gestation, and the type that occurs when physicians intervene to deliver a baby early, in order to avoid complications anticipated if the pregnancy is allowed to continue It also describes the therapies that have been tried to prevent preterm births, and notes that nearly all of them have failed Treatment for newborns born preterm is more successful than preventive interventions, but still a significant portion of infants born very prematurely die or suffer serious long-term consequences At the same time, another significant portion of these newborns survive with minimal long-term problems It is not possible, at the point of delivery, to determine with certainty what the outcome will be for any given preterm infant After a discussion of alternative ways to think about preterm birth besides as a single syndrome or disease-like phenomenon, this chapter concludes with a discussion of the clinical perspective on the reasons that the U.S preterm birth and preterm survival rates are higher than those in Canada, Great Britain, and Western Europe Chapter examines the second dimension, that of the distribution of preterm births across the population While the early ending of any particular pregnancy is not predictable, preterm births not occur randomly across the population Rather, they occur more frequently in certain sub-populations and under certain circumstances of fertility This chapter explores the reasons for high rates of preterm birth in sub-populations, identified by age, race, ethnicity, socioeconomic status and whether women intended to become pregnant, among other features At the same time, the chapter examines critically the ways that data are gathered and the ways that the population is divided up in order to create knowledge about these patterns For example, in the U.S it is fairly easy to characterize rates of preterm birth by race or ethnicity because these data are regularly recorded It is difficult to characterize rates by poverty or socioeconomic status, because relevant information is seldom recorded Ethnicity and race are considered meaningful characteristics to monitor in population composition, but it is less socially acceptable to think of the U.S as anything other than an egalitarian or “classless” society, so income, wealth, and social status of newborns are generally not recorded In lieu of such socioeconomic information, the differences in preterm birth rates by race and ethnicity are interpreted as meaning something about the relationship between poverty and preterm birth This confounding of race and poverty obscures the understanding of the complex relationship between birth outcomes and both of these features of women’s lives viii Preface This chapter also discusses the attention placed on the impact of stigmatized maternal behaviors and health statuses—smoking, alcohol, drug use, and obesity— on preterm birth Although these impacts are not large relative to other factors associated with birth outcomes, they receive considerable attention because they fit an ideologically preferred narrative about individual versus social responsibility for health, and about women’s personal responsibility for their pregnancy outcomes The comparison section of this chapter examines, from an epidemiological perspective, the reasons why preterm birth rates in the U.S are higher than those of Canada, Great Britain, and Western Europe Each high-risk segment of the population: non-White women living in predominantly White societies, teens, low-income women, and women with unintentional pregnancies, have higher preterm birth rates both in the U.S and in the comparison countries However, women with these characteristics comprise a larger portion of the population of childbearing women in the U.S than in other places The third dimension, explored in Chap 3, is that of the cultural view of preterm birth As the term is used here, culture refers to the sets of shared understandings that members of a society use to communicate and interact meaningfully with each other Every culture shares a set of understandings about childbirth In contemporary Western cultures, childbirth is understood to be a medical phenomenon, and all members of these societies are expected to defer to medical authorities for the interpretation of the experience and for interventions that are supposed to guarantee a successful birth This framing is usually referred to as “medicalization”, and it contrasts with a framing that considers childbirth to be a natural, familial, or spiritual experience Under the terms of a medicalized childbirth, attendants rely on pre-set algorithms such as the expected timing of labor and the definition of risk, rather than on observations, experience or the preferences of the laboring woman, to determine whether and when to initiate technological interventions such as drugs or surgery Medicalized childbirth itself is situated in the broader framework of social reproduction Social reproduction refers to the ways a given society determines how it will continue across generations Social reproduction is accomplished by laying out cultural rules for who becomes a parent, when and how, who claims responsibility for children, and how fetuses, infants and children are defined as independent and/or as intertwined with their families Western cultures in general view fetuses as having an independent existence from early in pregnancy, and view pregnant women as primarily vessels for fetal development This view is rooted in the patriarchal organization of these societies, in which a primary role for women is to continue a man’s bloodline and insure that he has heirs Mothers are thought to be responsible for the outcomes of their pregnancies and their children through adulthood There is thus a sense in U.S culture that a preterm birth is the result of a mistake—deliberate or unintentional—made by a mother The “wrong” types of mothers—those whose reproduction is not preferred in the social scheme, including young, unmarried, low income, and minority women—are most likely to make mistakes and this is why, according to this cultural logic, they are more likely to deliver before term This cultural logic also explains why preterm Preface ix births are popularly assumed to be preventable, even though, as discussed in Chap 1, no clinical intervention to prevent preterm births has been identified The worst mistake that a mother can make is to not follow the instructions of her physicians, so this set of beliefs both reinforces the authority of the medical system, and provides a rationale when the medical system fails to meet the expectation that it can guarantee a successful pregnancy outcome That is, culturally based beliefs hold that any poor outcome is considered the mother’s fault, and probably occurred because she did not follow her physicians’ instructions The comparison section of Chap notes similarities in the medicalization of childbirth, but also some differences in the model of social reproduction in Canada, Great Britain, and Western Europe, compared to the U.S The notion that some women should not have babies, and thus are probably at fault if their pregnancies have poor outcomes, is not as dominant in these other societies as it is in the U.S In part this difference derives from the fact that historically these societies have been less racially and ethnically divided than the U.S.; healthy reproduction for all women has been considered to be a benefit to the society as a whole Furthermore, these societies have long been concerned about low fertility rates in their populations, and the consequences of dwindling population size for their future viability In the U.S historically, low fertility rates in White middle- and upper-class women have been a concern, but public attention has been focused more on the supposedly high or too high fertility rates among Black, immigrant, and poor women Concerns about low fertility rates are the basis for social policies that support pregnant women and new parents, for example, with paid pregnancy leave, family leave, and income subsidies, all of which are absent in the U.S In addition, the regulation of abortion is framed differently, particularly in European countries, than it is in the U.S In Europe, providing abortion under controlled circumstances is seen as a way to support families in difficult circumstances In the U.S., abortion is framed as one manifestation of a presumed conflict between the interests of mothers and that of their future children The ways that the relationship between mothers and fetuses is understood has an impact on several of the sociocultural dimensions of preterm birth Chapter explores the political dimension of preterm birth, that is, how preterm birth plays into struggles over power and resources in U.S Preterm birth is framed as a social problem—a social phenomenon that legitimately demands attention by political decision makers—in three political arenas in the U.S The first is the arena of control over reproduction The occurrence of preterm births is used to justify an argument for broader contraception availability, on the assumption that pregnancies that are planned and desired are less likely to end prematurely At the same time, for those opposed to liberal abortion policies, the potential for preterm newborns to survive means that the distinction between fetuses and infants is arbitrary This in turn bolsters the conviction that performing an abortion is equivalent to murdering a child This chapter explores how the socially recognized problem of preterm births is used to justify proposals to limit access to abortion, and how policies promoted by opponents to abortion impact the care of preterm infants x Preface The second political arena where the social problem of preterm birth plays a role is in the efforts to ameliorate the effects of poverty Ameliorating the effects of poverty has been contentious in the U.S since the nation’s founding, because acknowledging and addressing poverty implies that there are structural flaws in the U.S economic system which could be addressed by restricting some aspects of free market capitalism In contrast to addressing poverty directly, providing care for innocent babies is a legitimate political enterprise, and “baby saving” (as it was termed at the turn of the twentieth century) has been used as a vehicle for a variety of social welfare reforms, including efforts to institute universal health insurance coverage The third political arena where preterm births have been important is in efforts to address racial inequality in the U.S Large disparities by race in preterm birth and infant mortality rates in the U.S are taken as concrete evidence that racial inequality persists and has damaging consequences Programs and resources to address preterm births in the Black population are an acceptable and politically attractive way to help defuse this political challenge, when more radical proposals for addressing racial inequity face resistance from entrenched interests The dynamics of these three political arenas are unique to the tensions and circumstances present in the U.S Therefore, the perceived social problem of preterm birth does not play the same political role in Canada, Great Britain and Western Europe as it does in the U.S In Western Europe, contraceptive policies are about sexuality rather than infant health, and abortion policies are about family welfare However, concerns about high-risk pregnancies and preterm births have played a role in political struggles over the extent and design of social welfare programs, and in the structure of labor laws in these countries In contrast, in the U.S., advocates for gender equity in the workplace have downplayed the relationship between work exposures and pregnancy risks, and the prevention of preterm births has not figured prominently in efforts to modify employment policies for women Chapter examines the medical care provided to pregnant women who are perceived to be at high risk for preterm birth, as well as the care provided to preterm newborns This is the healthcare dimension of preterm birth In the U.S., this care often involves technologically focused interventions, including some that are of questionable effectiveness There is variation around which pregnant women receive which interventions and what types of medical specialists are involved in their care Care for preterm newborns is more uniform than care for pregnant women, and tends to involve aggressive resuscitation at very early gestational ages This chapter examines the drivers of the generally maximalist approach to treatment in the U.S for high-risk pregnant women and preterm newborns: provider competition, an urge to action in response to cultural expectations for the success of medical care, and commercial interest in increasing revenue by providing more goods and services The chapter also examines the consequences of this approach, in terms of system organization (over-capacity of NICUs and a fragmented referral system), and high healthcare expenditures Women’s experiences of high-risk pregnancies are conditioned by shared cultural understandings of preterm birth and affected by the dynamics of the healthcare References 321 Verhagen, A A E., Janvier, A., Leuthner, S R., Andrews, B., Lagata, J., Bos, A F., et al (2010) Categorizing neonatal deaths: A cross-cultural study in the United States Canada and The Netherlands Pediatrics, 156(1), 33–37 Vila, B (2004) Where there is no shame, there is no honor (Ethiopian Proverb) (Letter) Pediatrics, 114(3), 897 Wade, K (2013) Refusal of emergency cesarean section in Ireland: A relational apprach Medical Law Review, 22(1), 1–25 Watts, J L., & Saigal, S (2006) Outcome of extreme prematurity: As information increases so the dilemmas Archives of Disease in Childhood-Fetal and Neonatal Edition, 91(3), F221–F225 Wicks, E (2001) The right to refuse medical treatment under the european convention on human rights Medical Law Review, 9(1), 17–40 Zupancic, J A F., Kirpalani, H., Barrett, J., Stewart, S., Gafni, A., Streiner, D … Smith, P (2002) Characterizing doctor-parent communication in counselling for impending preterm delivery Archives of Diseases in Childhood, Fetal Neonatal Edition, 87(2), F113–F117 Epilogue Preterm Birth and U.S Culture and Society The underlying premise of the sociocultural approach to preterm birth presented in this book is that features of social structure and culture shape the way the phenomenon manifests and is understood in the U.S By the same token, examining the way preterm birth manifests and is understood in the U.S offers a way to view more general themes in U.S social structure and culture In this epilogue, I will briefly suggest aspects of U.S culture and society which I think are illuminated by the preceding examination of preterm births in this society E.1 The Framework of Disease and the Authority of the Medical Domain First, it is clear that the mechanistic and problem-oriented paradigm of Western medicine is deeply rooted, because attempts to apply the paradigm to preterm births persist, although infant delivery before term is too heterogeneous and multi-factorial a situation to logically categorize as though it were a singular disease or health problem Also preterm birth involves an interaction between two people, mothers and newborns, and this reality challenges diagnostic practices, research approaches, and ethical decision-making in clinical care, which are all oriented towards health problems as events that occur to individual patients The Western medical paradigm reflects themes that thread through many other aspects of U.S culture, which is one reason it is hard to modify the framing to take account of preterm birth Anthropologist Deborah Gordon (1988) notes that the individualism reflected in Western medicine reinforces core values that emphasize the independence of individuals from social context, relationships and emotional ties Ultimately, she concludes, this type of individualism is associated with the belief that society is a means for individuals to achieve their own ends; there is no such thing as common good, and society is potentially a threat to individual liberty © Springer International Publishing Switzerland 2016 J.M Bronstein, Preterm Birth in the United States, DOI 10.1007/978-3-319-32715-0 323 324 Epilogue Belief in the individualized nature of diseases lends itself to an ideology that emphasizes the impact of behaviors that deviate from accepted social norms, along with demonstrations of poor self-control, as causes of health problems The association of poor pregnancy outcomes with the supposed negative actions of socially stigmatized groups—poor women, Black women, women who have sex without planning for childbirth, obese women, users of illegal substances—is an example of the application of this ideology to preterm birth The emphasis on the risks of individual behavior, rooted in a theological framework that views disease as punishment, but coinciding with modern formulations that emphasize the obligations of individuals to be healthy so that they can function well as consumers in the marketplace, downplays any obligations on the part of society to assure the health of its members (Ayo 2012) In the body of research on preterm birth, paradigms that seek individualized causes for the early ending of pregnancies become ways of obscuring the multi-faceted relationship between social disadvantage and poor health, and this is important for preserving an ideology that favors consumption and the importance of free markets over organized social reforms The medical framing of preterm births helps to reinforce the medicalization of all pregnancies and childbirth, since the occurrence of a preterm birth can be presented as a cautionary tale showing that pregnancies can have undesirable outcomes if pregnant women fail to follow medical advice The medicalization of pregnancy and childbirth in turn supports the authority of medical specialists in their role as mediators between humans and the natural world The fact that there is little that can be done from a medical interventional aspect to prevent preterm birth is culturally obscured in order to preserve the authoritative role of medicine Thus the popular belief, reinforced by many general pregnancy advice sources, is that preterm birth is preventable, and that when it occurs it is most likely because mothers made some kind of unintentional mistake or behaved in a selfish or inappropriate way The preservation of medical authority and the belief in the power of the medical domain to mediate between humanity and nature is very important in U.S society more generally The medical domain supplements and often substitutes for the legal domain in the control of undesirable behavior, including addictions, some forms of sexual activity and some criminal behavior thought to be related to mental illness It is difficult to identify what types of social institutions could handle these issues on behalf of U.S society, if doubt about the ability of medicine to control undesirable situations became widespread (Conrad and Barker 2010; Conrad and Schneider 1992) In addition, expansion of the natural states that can be addressed through medicine, starting with pregnancy but including aging and hyper-active behavior in children, for example, has opened up new opportunities to market technological innovations, such as pharmaceuticals, to the financial benefit of an important set of producers in the U.S economy (Clarke 2003; Conrad 2007) These would also be threatened if the cultural authority of the medical domain came under question Epilogue 325 E.2 Preterm Birth and Social Reproduction A particularly important second function of the medicalization of pregnancy and childbirth is to provide a legitimate cultural context for the preservation and enactment of the U.S system of social reproduction Social reproduction includes the beliefs, institutions and practices that shape how a society continues over generations Among the principles that are important for societal continuity in the U.S is the belief that fetuses are individuals who are distinct from their mothers, even during pregnancy (a component of the ideology of patriarchy which exists across all Western cultures); a belief that mothers are responsible for their children’s outcomes; and a belief that the domestic sphere encompassing mothers and children is one of the few arenas where it is appropriate to act out of selflessness and compassion (Phillips and Taylor 2009) In contrast with the social reproduction systems in comparable countries, including Canada, Great Britain, and those in Western Europe, the system in the U S considers successful reproduction an individual responsibility There are fewer protective laws, labor policies, social welfare benefits, or supportive contraception and abortion policies in the U.S than elsewhere In part this is because of the racial and ethnic diversity of the U.S population—not everyone feels invested in the reproduction of everyone else in the society—and in part because overall low fertility rates have not been framed as a political and social problem in the U.S as they have elsewhere Medicalizing pregnancy and childbirth puts medical expertise and the medical care delivery system in charge of enforcing norms for maternal behavior, and for signaling that fetuses and newborn children are societal members, not simply family members or members of a dyad with their mothers (Davis Floyd 2003) The use of population data on the frequency of preterm birth to identify maternal characteristics—age, marital status, sexual activity (expressed as pregnancy intendedness), race, poverty, obesity, alcohol, tobacco and drug use—as indicating high-risk status overlaps with the enforcement of norms about which types of women should be encouraged to reproduce, and how these women should behave The fact that clinicians are allowed to determine whether newborns will fare better if they are delivered prematurely through intervention, and are credited with keeping preterm newborns alive through medical technology, are also public demonstrations of medicine’s authoritative role in social reproduction The observation that fetuses who are delivered up to four months before they reach term are treated as infants, and can sometimes be kept alive through medical intervention, is seen culturally as illustrating the unacceptability of permitting women to choose whether to terminate their pregnancies through abortion 326 Epilogue E.3 Social Stratification As noted, the child-bearing population in the U.S.is more diverse than the populations in Canada, Great Britain, and Western Europe: a larger portion of the U.S population lives in poverty than is true in these other countries, and the U.S is divided into more racial and ethnic groups than the populations in these other countries Racial and ethnic groups are social categorizations related to ancestry that are meaningful in U.S culture Racial distinctions—the differentiation of Black Americans from others—is a particularly loaded social categorization that impacts many dimensions of peoples’ lives and ultimately affects the course of women’s pregnancies Social stratification in the U.S occurs at the intersection of race/ethnicity, socioeconomic status and gender Dividing the population along one dimension without taking the others into account gives only a partial sense of the underlying patterns of power distribution which structure peoples’ social opportunities (Landry 2006; Pascale 2007) This is particulary well illustrated by population data on preterm births in the U S., which show that race and poverty are not interchangeable, and both are associated with a greater likelihood that pregnancies will end before term Another ideological function of framing preterm births as health problems is that the emphasis on negative behaviors and poor individual health states helps to obscure the negative impacts of social disadvantage This in turn helps the U.S avoid acknowledging the dissonance between its egalitarian principles and beliefs and the realities of racial and socioeconomic inequality E.4 Privatization of the Societal Response to Social Issues Although generally preterm births are considered individual health problems, high rates of preterm birth in the U.S are thought to require some type of social response This is because these high rates contradict two overarching themes in U S culture: the assumption that problematic events should diminish with social progress (preterm birth rates should go down, not up over time as our society becomes more complex and technologically oriented), and the expectation of American exceptionalism, that the U.S is a model of moral correctness, and should be superior in all measurable ways to other societies (Madsden 1998) (preterm birth rates should be lower, not higher, in the U.S compared to other countries) These concerns give the problem of preterm birth the potential to galvanize political action for solutions, and this type of political traction means that preterm births can serve as “problem streams” in political agenda setting (Kingdon 1984) Because preterm births are an aspect of social reproduction and are interwoven with the ways U.S society is stratified, it is not surprising that, constructed as a social problem, preterm birth plays a role in political conflicts over control of fertility, addressing poverty, and addressing racial inequities Because preterm birth Epilogue 327 is also constructed as a medical problem, the politically acceptable solutions to fertility control, poverty, and racial inequity have also taken on a medical framing Framing fertility control, poverty and racial inequity as child and health-related issues has enabled reformers in these arenas to avoid ideological and interest group opposition that otherwise would assure the maintenance of the societal status quo This opposition to reform includes resistance to fertility control approaches that are intended to allow people to have sexual relations without the intent of procreation, resistance to social reforms that might redistribute wealth to impoverished segments of the population, and resistance to fundamentally altering the situation of Black Americans in relation to the broader society Framing the social efforts to cope with the social tensions around fertility control, poverty and racial inequity as a social commitment to solve the medicalized problem of preterm birth places medical expertise and the healthcare system in the role of problem solvers for these broad and pervasive issues As problem solvers, health care entities receive a considerable amount of societal resources On behalf of preterm birth, these resources include direct financial subsidies for hospitals and physicians, and public and private insurance coverage for pregnant women and preterm newborns There are public sources of financial support and producer-friendly regulations for technology innovations, and relatively little pressure to demonstrate the value of the medical care provided or to moderate prices There is also a social environment that favors rescue interventions for fetuses, and favors sustained life support for all but the least viable newborns Such an supporting environment maximizes the flow of patients into the system, which in turn generates revenue by support an expanded number of providers such as neonatologists and hospital NICUs The fact that all of these resources are invested in a sector that operates, not in the broad public interest, but as a set of interlocking business enterprises, is another telling feature of U.S society Rooted in the American Revolution, political rhetoric in the U.S has stressed the importance of protecting people from government over the value of using government to protect people from disadvantage Structurally, the legal traditions of limited government have created barriers to extensive public involvement in many sectors of activity In recent decades, as political scientist Wendy Brown has pointed out, the neoconservative movement, which resists large scale redistribution of public resources and the neoliberal movement, which favors private market solutions over organized public actions, have intersected in a way that further diminishes societal capacity to organize a public response to social problems Brown writes: As neoliberalism converts every political or social problem into market terms, it converts them to individual problems with market solutions Examples in the United States are legion: bottled water as a response to contamination of the water table; private schools, charter schools and voucher systems as a response to quality public education; anti-theft devices, private security guards, and gated communities (and nations) as a response to the production of a throwaway class and intensifying economic inequality; boutique medicine 328 Epilogue as a response to crumbling health care provision………This conversion of socially, economically, and politically produced problems into consumer items depoliticizes what has been historically produced, and it especially depoliticizes capitalism itself (Brown 2006, p 704) Although there are other reasons why preterm births are framed as medical problems and allocated politically to the domain of health care to resolve, the net result parallels Brown’s other examples of the depoliticization of social issues Thus, the increasingly common practice of converting public problems into opportunities for private sector gain is another feature of U.S culture and society illuminated by the way it addresses the occurrence of preterm births The Preface of this book presented the metaphor of the six blind men confronting an elephant: each man knows the part of the elephant that he experiences, but no one is aware of the elephant as a whole Likewise, obstetrics providers caring for women in preterm labor know the physiological complications of each case, but have no way to act on the diversity of cases that exist in the population; neonatologists can rescue individual infants but have no way to alter the flow of cases they see; political scientists can see the restrictions placed on broad social action that exist when the narrow but politically attractive frame of health is placed on a phenomenon that occurs in relation to deep societal conflicts in the U.S.; and the list goes on I hope that this book, by introducing readers to the dynamics of the many dimensions of pregnancies that end before they reach term, can contribute to a holistic view that supports beneficial actions around pregnancy and the health of newborns, for the sake of future generations References Ayo, N (2012) Understanding health promotion in a neoliberal climate and the making of health conscious citizens Critical Public Health, 22(1), 99–105 Brown, W (2006) American nightmare Neoliberalism, neoconservatism, and de-democratization Political Theory, 34(6), 690–714 Clarke, A E., Mamo, L., Fishman, J R., Shim, J K., & Fosket, J R (2003) Biomedicalization: Technoscientific transformation of health, illness and U.S biomedicine American Sociological Review, 68(2), 161–194 Conrad, P (2007) The medicalization of society: On the transformation of human conditions into treatable disorders Baltimore: Johns Hopkins University Press Conrad, P., & Barker, K K (2010) The social construction of illness: Key insights and policy implications Journal of Health and Social Behavior, 51(Supp), S67–S79 Conrad, P., & Schneider, J W (1992) Deviance and medicalization: From badness to sickness Philadelphia: Temple University Press Davis Floyd, R (2003) Birth as an American rite of passage (2nd ed.) Berkely: University of California Press Gordon, D R (1988) Tenacious assumptions in Western medicine In M Lock & D R Gordon (Eds.), Biomedicine examined (pp 19–56) Dordrecht: Kluwer Academic Publishers Kingdon, J W (1984) Agendas, alternatives and public policy Boston: Little, Brown Landry, B (2006) Introduction In B Landry (Ed.), Race, gender, and class: Theory and methods of analysis Upper Saddle River, NJ: Pearson, Prentice Hall Epilogue 329 Madsden, D L (1998) American exceptionalism Edinburgh: Edinburgh University Press Pascale, C.-M (2007) Making sense of race, class and gender: Commonsense, power and privilege in the United States New York: Routledge Phillips, A., & Taylor, B (2009) On kindness New York: Farrar, Strauss and Giroux Index A A Child is Born (Duden), 109 Abortion, 149–153 opposition, 149–153 history of, 147, 149 See also Abortion history illegal, 150, 308 legal, 154 liberalization of, 149, 150 linkage of, 152 politics, 135, 145, 146 See also Abortion politics Abortion history , 108, 109, 111, 112, 133, 147, 149 See also Fetal rights Abortion politics impact of fertility control policies on, 154–156 of fertility control, 145–146 opposition to abortion, 149–153 and support for contraception, 146–149 Affluent society, 159–162 Age, as risk factor, 46–47 pregnancy complications, 53 Alcohol use, 60–62 Alternative paradigms, of preterm birth, 29–32 Anthropology and ethics, 266, 298 Anti-dumping legislation See Emergency Medical Treatment and Active Labor Act (EMTALA) Assisted reproduction, 304–306 Assisted reproductive technologies (ART), 54 Avant term (preterm), B Baby Doe rules, 267 Baby-saving, 157–159 Baby’s first pictures, 111 Bed rest during pregnancy, 122–123 Birmingham (Alabama) News, 115 Birth control history, 144, 146, 147, 164, 181 Birth outcomes, 00 life course model of, 72 poverty-related policies, impact of, 165–167 Birth weight, C Canada assisted reproduction, 304–306 clinical dimension, 32–33 differences in maternity population, 33–35 differences in preterm newborn population, 35–36 cultural dimension, 132–136 health care dimension, 248 impact of maternity systems on care, 252–253 organization of maternity care, 250–252 public financing and ownership, 249–250 political dimension, 180 addressing poverty, 182–184 addressing racial or ethnic inequities, 184–185 fertility control, 181–182 population dimension health and health-related behaviors, 80 poverty, 80–81 pregnancy, features of, 77–79 race and ethnicity, 81–82 right to refuse screening, 306–307 substance use during pregnancy, 307–309 withholding and withdrawing neonatal intensive care, 310–313 Cesarean section, Children’s Health Insurance Program (CHIP), 162, 163, 164 © Springer International Publishing Switzerland 2016 J.M Bronstein, Preterm Birth in the United States, DOI 10.1007/978-3-319-32715-0 331 332 Index Cigarette smoking, 61 Civil rights, 174–178 Civil Rights Act of 1964, 184 Clinician views, 281–284 Cultural beliefs, 43 Cultural dimension, 91–93 Cult of domesticity, 112 Culture, 91 politics of, 145, 146 race, 167–170 Fetal rights, 108–112, 174, 277, 308, 313 baby’s first pictures, 111 infant, meaning of, 110 ultrasound imaging, 109 The First Nine Months of Life (Petchesky), 109 French abortion legislation, 134 D Defining futility, 292–295 Disease framing, 9–10, 30, 49, 144 G Gender roles, 113, 119 See also Motherhood demands Great Britain assisted reproduction, 304–306 clinical dimension, 32–33 differences in maternity population, 33–35 differences in preterm newborn population, 35–36 cultural dimension, 132–136 health care dimension, 248 impact of maternity systems on care, 252–253 organization of maternity care, 250–252 public financing and ownership, 249–250 political dimension, 180 addressing poverty, 182–184 addressing racial or ethnic inequities, 184–185 fertility control, 181–182 population dimension, 00 health and health-related behaviors, 80 poverty, 80–81 pregnancy, features of, 77–79 race and ethnicity, 81–82 right to refuse screening, 306–307 substance use during pregnancy, 307–309 withholding and withdrawing neonatal intensive care, 310–313 E Early term deliveries, Electronic fetal monitoring (EFM), 200–201 Emergency Medical Treatment and Active Labor Act (EMTALA), 174, 175 Ensoulment See Fetal rights, 00 Ethical decisions, 00 in delivery and treatment, 289–292 clinical approaches to defining futility, 292–294 parental involvement, 295–299 right to refuse screening and treatment, 306, 307 substance use during pregnancy, 307–309 third-party views, 300–303 in high-risk pregnancies, 267–268 clinician views, 281–284 interventions for, 281 multiple embryo transfers in in vitro fertilization, 268–271 parent views, 286–289 prenatal screening See Prenatal screening third-party views, 284, 285 Ethics, 265, 266, 274, 302, 303 clinical, 268, 276, 283 medical, 272 neonatal, 303 prenatal care, 308 Ethnicity, 67, 81, 82 populations, 75 Eugenics in U.S., 146, 171, 178 movement, 149, 168, 169 Expressions of compassion, 130–132 F Family and Medical Leave Act of 1993 (FMLA), 183 Fertility control, 181–182 impact of, 154–156 H Health and health-related behaviors maternal alcohol and illicit drug use, 60–62 maternal tobacco use, 58–60 maternal weight and nutrition, 57–58 Health care dimension, 195 Health problems newborn, 232 studying the distribution patterns of, 44–50 Heinz dilemma, 266 Hero’s journey, 124–127 High risk pregnancies, 93, 97, 98, 100, 103, 104, 133 Index ethical decisions for multiple embryo transfers in in vitro fertilization, 268–271 prenatal screening See Prenatal screening interventions for clinician views, 281–284 parent views, 286–287 third-party views, 284–286 web sites listings of indicators for, 101–102 High-risk pregnancy treatment impact of maternity systems on care, 252–253 prenatal care for, 197–198 commercial interests, 206–209 impact of provider competition, 198–201 urge of action, 202, 203–206 Hill-Burton program, 174 Hispanic heritage, 75 History of prenatal care, 16 333 K Kingdon’s model, 144 M March of Dimes, prematurity grade and state population demographics, 7–8 Marital status, 56–57 Maternal health and family outcomes, 28–29 Maternal mortality, 28, 34, 171 Maternal-fetal conflict, 283, 285, 300 Maternity care international comparisons, 248 impact of maternity systems on care, 252–253 organization of maternity care, 250–252 public financing and ownership, 249–250 Maternity care systems exemption from social obligations, 236 high-risk pregnant women’s experiences, 233–235 international comparisons, 250–252 obligations to try to get well, 236–239 organization of, 250 personal responsibility for high-risk pregnancy, 235 Medicaid program, 62, 96, 102, 148, 159 benefits, 162 and CHIP amendments, 164 eligibility for Aid to Families with Dependent Children (AFDC), 160 establishment and expansion of, 165, 179 impact of, 166 Medical model of routine pregnancy and childbirth rise of medicine as authoritative domain, 94–95 experience of pregnancy and childbirth acceptance and resistance to medical model, 104–106 categorization by level of risk, 98–104 impact of standardization, 95–98 Medical paradigm, 92 Medicalization of pregnancy, 13, 92, 96, 104, 105, 111 Mexican culture, 76 Mortality rates, 22 Motherhood demands, 112–114 Multiple births, 51 Multiple embryo transfers, 268–271 L Last menstrual period (LMP), 33 Latina epidemiologic paradox, 75–77 Les prematures, Life-course model, 72–74 Low birth weight, N Neonatal ethics international comparisons, 303–304 assisted reproduction, 304–306 right to refuse screening, 306–307 substance use during pregnancy, 307–309 I Iatrogenic preterm deliveries, 12 Ideology of reproduction, 43, 47, 48 Illicit drug use, 60–62, 66 In vitro fertilization (IVF), 101 multiple embryo transfers, 268–271 process of, 268, 304 In vitro fertilization ethics, 268, 269, 270, 271 Indicated preterm deliveries, 12 Individualistic fallacy, 44, 45 Infant health, 162–163 Infant mortality, 21–23 international comparisons, 32, 33, 35, 62, 67, 164 Infant, meaning of, 110 Institute of medicine (IOM), 27, 29, 44–46, 61 International comparisons health and health behaviors, 80t poverty rates, 81t unintended pregnancy, 79t Interventional preterm births, 12–14 334 withholding and withdrawing neonatal intensive care, 310–313 Neonatal ethics clinical approaches, 292–295 in delivery and treatment of preterm infants, 289–292 parental involvement, 295–300 third-party views, 300–303 Neonatal intensive care unit (NICU), 22, 92, 98, 124, 126, 130, 196, 212, 224–226 availability of, 206 care standards for, 247 decision-making in, 135 experience of parents, 239 after discharge from NICUs, 246–248 of infants in NICUs, 242–246 parent and child experiences in, 128 withholding and withdrawing, 310–313 Neonatal Research Network, 212 Neonatal resuscitation, 227, 228 experience of parents, 239 after discharge from NICUs, 246–248 of infants in NICUs, 242–246 parental participation to resuscitate at delivery, 239–242 Neonatology first generation of, 289 history of, 209–213 O Organization and financing of perinatal care, 216 perinatal regionalization away, 226–229 towards, 218–226 practice models in obstetrics, 216–218 P Parent views, 286–289 Parental involvement, 295–300 Parental participation, 239–242 Patriarchy, 106–108 Perinatal care, organization and financing of expenditures, preterm birth, 229–232 obstetrics, practice models in, 216–218 regionalization, 218 Perinatal regionalization away, 226–229 towards, 218–226 Philadelphia Inquirer, 125 Political dimension, 143–145 Politics of race, and preterm births race and fertility control, 167–170 Index Population dimension, 44 maternity, 35 preterm newborn, 35 Poverty, 62, 80, 81, 183, 165 addressing, 182–184 definitions and measurement, 62–64 preterm births and politics of, 156 racial disparities, explanation forSee also Poverty and preterm birth, 70 role of, 64–67 stigmatization of, 182 Poverty and preterm birth, 156 baby-saving, 157–159 definitions and measurements, 62–64 infant health and universal health insurance, 162–165 and infant mortality in affluent society, 159–162 poverty-related policies on, 165–167 and racial disparities, 170–174 social welfare systems, 157–159 understanding role of poverty in, 64–67 Power of technology, 128–129 Practice models in obstetrics, 216–218 Pregnancy advice literature and preterm birth, 199, 120, 121 features of See Pregnancy, features of high-risk, 93, 101, 233, 239, 267 commercial interests, 206–209 delivering care for, 195–197 ethical decisions in, 267–268 interventions for, 281 maternity systems on care for, 252–253 medical care, 233–235 personal responsibility for, 235 prenatal care for, 197–198, 206–209 provider competition, 196–201 treatment, 248, 251 urge to action, 201–206 impact of smoking in, 59 medicalization of, 13, 92, 180, 209, 282, 324–325 substance abuse in, 275, 308, 309 Pregnancy Discrimination Act (PDA) of 1978, 183 Pregnancy, features of assisted reproductive technologies, 54 definition, intendedness, 54–56 intrapartum interval, 53–54 marital status, 56–57 maternal age, 52–53 Index multiple births, 51 prior preterm birth, 50 Premature, Premature death, 30 Prematurity, Prenatal care, 15, 17, 51, 163, 199, 243, 278 absence of, 128, 129 effectiveness of, 199 ethics See Prenatal care ethics high-risk pregnancies, 198 history of, 16 poverty and lack of, 173 Prenatal care ethics clinical approaches, 292–295 parental involvement, 295–300 third-party views, 300–303 Prenatal screening clinician views, 272–274 parent views, 277–280 third-party views, 274–277 Preterm birth, 91, 92, 201, 185, 197, 198, 216, 325 abortion, linkage of, 152 alternative framing of, 51 alternative paradigms of, 29–31 biological pathways for, black-white disparities in, 67–69 Canada, 32 See also Canada causes, 1, 9, 10, 12, 21, 61, 268 See also Preterm birth causes costs, 229, 230 cultural understandings of, 93, 133 distribution of, 43 epidemiology of, 44, 47, 177 expenditures on, 229–232 GI complications of, 25 Great Britain, 32 See also Great Britain impact of, 26, 29 international comparisons, 77–79, 180, 181 interventional, 12–14 media presentations of, 123–124, 144, 145 medical framing of, 324 medicalized problem of, 327 moral decision-making about, 265–267 occurrence of, 92, 115, 156, 270 outcomes, 242, 250 See also Preterm birth outcomes phenomenon of, 21 political dimension of, 144 popular beliefs, 116–119 population distribution of, 47, 77 poverty in, 00 impact of, 67 role of, 64–67 335 prevailing models of, 31 prevention, 18–19, 47, 198, 301 racial disparities, 71, 167, 170, 174–177 recognizing and counting, 2–9 risk, factor, 45, 46, 64 social problem of, 146 society examination of, 344 spontaneous, 10–12, 20, 59, 310, 99 United States, 32, 114 culture, 114–116 population data on, 236 Western Europe, 32 See also Western Europe Preterm birth causes preterm, risk factors for, 45–46 therapeutic evidence on, 15 bed rest, 18–19 cerclage, 19–20 infections, treatment of, 17–18 prenatal care, 15–17 stress reduction, 19 third trimester progesterone treatment, 20–21 tocolytics, 18 Preterm birth costs, 229–232, 271, 302 NICU cost, 300, 302 screening test cost, 280 Preterm birth epidemiology, 44–50 web model of, 47 Preterm birth outcomes infant mortality, 21–23 maternal health and family outcomes, 28–29 short- and long-term morbidities, 23–28 Preterm birth prevention , 18–19, 112, 117 See also Fetal rights; Motherhood demands; High-risk pregnancy treatment impact of maternity systems on care, 252–253 prenatal care for, 197–198 commercial interests, 206–209 impact of provider competition, 198–201 urge of action, 202, 203–206 Preterm birth racial disparities, 14 Preterm births birth rate in the U.S., 5–7 biological pathways for, 9–10 spontaneous, 10–12 interventional, 12–14 and pregnancy, features of, 00 assisted reproductive technologies, 54 336 intendedness, 54–56 intrapartum interval, 53–54 marital status, 56–57 maternal age, 52–53 multiple births, 51 prior preterm birth, 50 recognizing and counting, 2–4 cultural features, risk factors for, 45, 46 Preterm births, international comparisons, 77 health and health-related behaviors, 80 poverty, 80–81 pregnancy, features of, 77–79 race and ethnicity, 81–82 Preterm births, and politics of fertility control, 145–146 and support for contraception, 146–149 impact of fertility control policies on, 154–156 race-related policies on, 178–180 opposition to abortion, 149–153 poverty, 156 baby-saving and establishment of social welfare system, 157–159 infant health and universal health insurance, 162–165 and infant mortality in affluent society, 159–162 and racial disparities, 170–174 poverty-related policies on, 165–167 racial disparities and civil rights, 174–177 and poverty, 170–174 Preterm infants delivery and treatment, ethical decisions in clinical approaches, 292–295 parental involvement, 295–300 third-party views, 300–303 experience of parents, 239–242 after discharge from NICUs, 246–248 of infants in NICUs, 242–246 impact of maternity systems, 252–253 parental participation to resuscitate at delivery, 239–242 Preterm neonatal care, history of, 209–213 Preterm newborn health problems of, 92 rescuing, 209 Public financing and ownership, 249 R Race, 67, 81, 82, 168 and ethnicity See Race and ethnicity, birth outcomes Index fertility control, 167–170 racial disparities and civil rights, 174–177 poverty, 170–174 race-related policies, impact of, 178–180 Race and ethnicity, birth outcomes black-white disparities, 67–69 latina epidemiologic paradox, 75–77 racial disparities biology as explanation for, 70–72 poverty as explanation for, 70 stress and life-course model, 72–74 Racial disparities in health care addressing, 184–185 and civil rights, 174–177 explanation for biology, 70–72 poverty, 70 in health care, 172, 175–176 impact of race-related policies on, 178–180 in infant mortality, 179 and poverty, 170–174 Racism, 72–74 Reproduction assisted, 304–306 ideology of, 49, 325, 113 stratified, 50, 92, 106 technologies, 54 Rescuing preterm newborns history of preterm neonatal care, 209–213 resuscitation decision, 213–216 Resuscitation decision, 213 Routine pregnancy, social reproduction model of See also Social reproduction model of routine pregnancy indicators for high-risk, 101, 102 medical model of, 93 acceptance and resistance to, 104–106 authoritative domain, 93–95 categorization by level of risk, 98–100 standardization, impact of, 95–98 social reproduction model of fetus as baby, 108–112 motherhood, demands of, 112–114 patriarchy, impact of, 106–108 S Scientific motherhood, Self-image, 266 Singleton births, Social expectations, 43 Social obligations, 236–239 Social reproduction model of routine pregnancy Index fetus as baby, 108–112 framework of, 92 impact of patriarchy, 106–108 motherhood demands, 112–114 paradigm of, 92 routine pregnancy, 106 system of, 93 Social reproduction paradigm, 92 1935 Social Security Act, 178 Social welfare system U.S., 145, 157–159, 195 addressing poverty, 182–184 addressing racial or ethnic inequities, 184–185 international comparisons, 180 See also Canada; Great Britain; Western Europe 2001, a Space Odyssey (movie), 109 Spontaneous preterm births, 10–12 St Louis Post-Dispatch, 126, 131–132 St Petersburg (FL) Times, 128 Stratified reproduction, 50, 93 Stress, 66, 72–74 Substance abuse in pregnancy, 307–309 Support for contraception, 146–149 T The Texas Tribune, 128 Tobacco use, 58–60 U Unintended pregnancy and birth outcomes, 55, 56, 60 international comparison of, 79 prevalence of, 147, 148 Universal health insurance, 162, 163 U.S culture, preterm birth in, 114–116 media presentations, 123–124 expressions of compassion, 130–132 hero’s journey, 124–127 power of technology, 128–130 popular beliefs, 116–119 pregnancy advice literature, 119–123 content analysis of pregnancy advice books, 120–121 Unintended pregnancy, 55, 56, 60, 79, 82 337 V Vermont-Oxford network, 212 W Washington Post, 127, 130 Weaklings, Weight and nutrition, 57–58 Western cultures, 265 Western Europe assisted reproduction, 304–306 clinical dimension, 32–33 differences in maternity population, 33–35 differences in preterm newborn population, 35–36 cultural dimension, 132–136 health care dimension, 248 impact of maternity systems on care, 252–253 organization of maternity care, 250–252 public financing and ownership, 249–250 political dimension, 180 addressing poverty, 182–184 addressing racial or ethnic inequities, 184–185 fertility control, 181–182 population dimension, 00 health and health-related behaviors, 80 poverty, 80–81 pregnancy, features of, 77–79 race and ethnicity, 81–82 right to refuse screening, 306–307 substance use during pregnancy, 307–309 withholding and withdrawing neonatal intensive care, 310–313 Western medicine, 3, What to Expect When You Are Expecting (Murkoff and Mazel), 119, 121, 122 Williams Obstetrics, 107, 110 Y Your Pregnancy Bible (Stone and Eddleman), 123 ... examining the international ranking of the U.S on infant mortality, and pointing out that the low rank—30th in the selection of nations used in the brief—was due to high preterm birth rates The. .. researchers and clinicians involved in the care of high-risk pregnant women and preterm infants in the U.S However, three events piqued my interest in looking at the issue of preterm birth in the U.S more.. .Preterm Birth in the United States Janet M Bronstein Preterm Birth in the United States A Sociocultural Approach 123 Janet M Bronstein School of Public Health University of Alabama at Birmingham