Teen Mamas

My daughter Molly and I are still talking about why America's infant mortality rate is so high. Molly found that when it comes to prenatal care (the lack of which is an obvious factor in our high mortality rate), the biggest gap between Americans and Europeans occurs in the first trimester - and that half of the American mothers who got no early prenatal care didn't even know they were pregnant.*

Didn't know? What were they, children?

Could be.

I took the UN data from 2006 and compared mothers' ages in the United States, France, Sweden, and Italy. Then I made these charts. Start reading just past 12:00 (0%: though there are births to women between 45 and 49, there are too few to register on a pie of this size) and go clockwise.

In the United States in 2006, 10.7 percent of births were to mothers between the ages of 15 and 19. (The good news is that five years later, in 2011, only 8.3 percent were to mothers in that age group.)

By contrast, in Italy only 2.7% of births were to teenagers:

... in France, only 2.1%:

... and in Sweden, just 1.4%:

 

According to the March of Dimes, the highest infant mortality rate in the United States is to mothers under the age of 20 (9.7 deaths per 1,000 live births). That's nearly twice as high as the rate for American mothers in their 30s (5.6 deaths per 1,000 live births).

Sadly, it's the teen mamas who are least likely to get adequate prenatal care, most likely to have preterm babies, and most likely to lose their babies before the babies' first birthday.

What is America doing wrong? What are France, Italy, and Sweden doing right?** Can we learn from them?
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*These links are to articles written in the 1990s. We were unable to find more recent data comparing prenatal care in Europe and America; if you know where to find some, please let us know.

**In case you're wondering, the U.S. abortion rate is higher than France's or Italy's and about the same as Sweden's. So abortion isn't the explanation.

Infant mortality - why is America in 51st place?

[Picture by Brian Hall, Wikimedia Commons]

After I blogged about expensive American childcare earlier this week, my daughter Molly directed me to a March of Dimes web page showing the extremely high rate of preterm births in the United States. "Born Too Soon," a 124-page report issued in 2012, "ranks the U.S. 131st in the world in terms of its preterm birth rate of 12.0 per 100 live births, almost tied with Somalia, Thailand, and Turkey. Nearly half a million babies are born too soon in the U.S. each year."

According to a 2009 report from the Centers for Disease Control, "the main cause of the United States’ high infant mortality rate when compared with Europe is the very high percentage of preterm births in the United States" - in spite for the fact that "infant mortality rates for preterm (less than 37 weeks of gestation) infants are lower in the United States than in most European countries." In addition, "infant mortality rates for infants born at 37 weeks of gestation or more are higher in the United States than in most European countries."

It costs a lot to keep those preterm babies alive and healthy.  According to a 2012 article in The Lancet as reported by US News, infants born prematurely account for "12 percent of U.S. live births per year, but their care consumes close to 60 percent - or $6 billion - of total spending on initial neonatal care."

How effective is the spending? Quite, if you compare America to Poland: for every 10 preterm American babies who die, says a CDC report, about 15 Polish babies die. Not so much, if you compare America to Sweden: for every 10 preterm American babies who die, fewer than 8 preterm Swedish babies die.

Here's the question: why does America have so many preterm babies?

• Is it because American mothers are waiting to have babies until they're older? So are Western European mothers. In fact, the birthrate for women ages 40-49 is higher in most Western European countries than in America (you can check it out here).
• Is it because Americans are really into assisted reproductive technology, which is more likely to produce twins or triplets? According to the CDC, just over 1% of American babies born in 2011 were the result of ART. However, "in Belgium, Slovenia, Denmark, Netherlands and Sweden more than 3.0% of all babies born [in 2009?] were conceived by ART" (source: European Society of Human Reproduction and Embryology).
• Is it because "20 percent of U.S. women (18.7 million) ages 19-64 were uninsured in 2010, up from 15 percent (12.8 million) in 2000, according to a new [2012] Commonwealth Fund report on women's health care"?

That's my best guess: a lot of our babies come early because their mothers can't afford prenatal care. And because so many of us think it's somehow un-American to provide good quality healthcare for everyone, we end up spending huge amounts to save the babies who, lacking prenatal care, are born before their time.

Sadly, our efforts are too much, too late. Though we spend more than twice as much on childbirth-related expenses as any other country in the world, our newborn infants have a higher death rate than newborns in some 50 other countries.

Economically, this is a stupid approach to childbirth. Morally, it is reprehensible. For bereaved families, it is tragic.

How to make childbirth safer for mothers and infants (hint: not by spending more money)

"American Way of Birth, Costliest in the World." 

That's the headline of an article by Elisabeth Rosenthal in yesterday's New York Times. The article includes a chart comparing childbirth costs in seven countries. In the United States, the average amount paid for a conventional delivery in 2012 was $9,775; for a Caesarean section, it was $15,041. Those are the highest prices for childbirth anywhere in the world.

To get an idea of just how high, I made a chart using the figures in the NYT chart. Childbirth costs in the other six countries range from 21 to 43% of US costs, even though American women typically spend far less time in hospital.

This chart is based on prices that are actually paid, whether by individuals, insurers, or the government. [Chart by L. Neff; data from the International Federation of Health Plans 2012 Comparative Price Report]

You'd think America's higher costs would mean that American women and infants get better care. Not at all. "Despite its lavish spending," Rosenthal writes, "the United States has one of the highest rates of both infant and maternal death among industrialized nations." And among lots of other nations as well: according to the CIA's World Factbook, 50 countries have a lower infant mortality rate than the US, and 47 countries have a lower maternal mortality rate.

 Here's some comparative data in graph form. The longer the line, the more dangerous the country is for mother and child.

South Africa is so dangerous for childbirth that its graph line would not fit on this blog page. For every 1,000 births, there are 56 infant deaths. For every 100,000 births, there are 400 maternal deaths. [Chart by L. Neff; data from WHO]

Rosenthal mentions one reason that high costs often do not translate into low death rates: "The fact that poor and uninsured women and those whose insurance does not cover childbirth have trouble getting or paying for prenatal care contributes to those figures." I decided to use the Gini Index - a scale that measures "the degree of inequality in the distribution of family income in a country" - to compare the seven countries in the NYT graph. Here are the results:

South Africa's red line is missing because for every 100,000 births in that country, there are 400 maternal deaths. The chart would have had to be six times wider to accommodate the data. [Chart by L. Neff; data from CIA and WHO]

Wow. I didn't expect the results to line up so neatly, but there you have it: The more inequality in a country's  distribution of family income, the more mothers and babies die in childbirth. Of the 136 nations reported by the CIA, South Africa is #2 on the inequality list. Chile is #15, the United States is #41 (that means that 40 countries have less income equality than the US, while 95 countries have more). Britain, France, the Netherlands, and Switzerland, at numbers 60, 101, 111, and 117 respectively, all have significantly more income equality than the US.

Number 136, the nation with the least inequality of all, is Sweden. Swedish infant and maternal mortality rates are even lower than Switzerland's - in spite of the fact that Sweden spends about 1/3 less per capita on healthcare.

CALL THE MIDWIFE by Jennifer Worth

"Call the Midwife," a BBC miniseries about intrepid nuns and nurses in London's East End in the 1950s, was the UK's most popular TV show in 2012, with even more viewers than last year's wildly popular "Downton Abbey."

I had not heard of the TV show three weeks ago when, browsing in a Chicago bookstore, I noticed Jennifer Worth's memoir by the same name. Always on the lookout for cheerful stories, I jotted down its title so I'd remember to look for it at my public library.

The book did not disappoint.

In 1965, my parents and I spent a summer in Bracknell, a middle-class suburb about 35 miles west of central London. Some 10 years earlier, Jennifer Worth had been working as a midwife in the London Docklands, about 6 miles east of central London. Only 10 years and 40 miles separated my comfortable (even though it lacked central heating and had altogether too much cabbage) world from the world Jennifer served:

I often wondered how these women managed, with a family of up to thirteen or fourteen children in a small house, containing only two or three bedrooms. Some families of that size lived in the tenements, which often consisted of only two rooms and a tiny kitchen.... Washing machines were virtually unknown and tumble driers had not been invented.... Most houses had running cold water and a flushing lavatory in the yard outside.

It was an area of bombed-out ruins from World War II air raids. "Knifings were common. Street fights were common. Pub fights and brawls were an everyday event. In the small, overcrowded houses, domestic violence was expected." Certain streets were well known as centers of prostitution.

So why am I calling this book cheerful?

Because Jennifer tells so many stories about people who work hard, who love one another, who survive against incredible odds, who welcome new life, who do their best.

Because even her heart-breaking stories--the teen-aged Irish prostitute, the weird old crone who hangs around when babies are due--reveal sensitive humanity under the off-putting exteriors.

Because her nuns, from bawdy Sister Evangelina to spacey Sister Monica Joan, are a hoot.

Because she's so good at describing all her characters, most notably Camilla Fortescue-Cholmeley-Brown ("just call me Chummy"), drolly played by Miranda Hart in the TV series.

Because she included a 13-page appendix "On the difficulties of writing the Cockney dialect."

Because Jennifer's storytelling shows her living by the philosophy she says she learned from a dying nun: Accept life, the world, Spirit, God, call it what you will, and all else will follow.
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 "Call the Midwife" is being shown on PBS stations Sunday evenings from September 30 to November 4, 2012. If you've missed some episodes, you can get them online until December 3. Here's a link to Episode 1.

CREATING WITH GOD by Sarah Jobe

Last week I went to Johnsen & Taylor Inspirational Books and Gifts to listen to five women authors from the Redbud Writers Guild present "Women and Writing: The Importance of Using Your Voice for Christ's Kingdom." After the lively discussion, I wandered through the store looking at book jackets. Most of the books, all aimed at evangelical readers, were written by men. Most of the shoppers in the store were women.

I suppose some men feel less queasy about walking through displays of fluffy angels and inspirational wall plaques if they know that stacks of books by male authors await them in the back of the store, though few men were there that evening. I believe that men - and women, too -  can learn a lot from male authors. On the other hand, I also believe that men - and women, too - can learn a lot from female authors. And I know that there are things that simply can't be said unless a woman says them.

Sarah Jobe is saying some of those woman things.

Creating with God: The Holy Confusing Blessedness of Pregnancy isn't an obvious reading choice for a 63-year-old grandmother, but I picked it up anyway - and was almost immediately laughing out loud. "This book is an attempt to name how pregnant women are co-creators with God at precisely the moment in which we are pooping on the delivery table," Jobe writes in the author's note. "I will claim that pregnant women are the image of Jesus among us not in spite of varicose veins but because of them."

I remember pregnant. First baby nestling so deep within me that there was no room left for stomach, lungs, bladder, or various other organs I had formerly enjoyed using every day. Second baby perched so far beyond me that walking became perilous and friends pointed and laughed when they saw us waddling their way. And my pregnancies were a breeze compared to Jobe's, though her midwives dubbed hers "uncomplicated."

What bothered Jobe - who has an M.Div., is an ordained pastor, and works as a prison chaplain - is that she couldn't figure out "how God could be present in pregnancy in spite of back pain, financial stress, hormonal shifts, and constipation." But as she progressed through two back-to-back pregnancies, she writes, she "learned a startling truth. God is not present in pregnancy in spite of all the crap (and I mean that in the most literal sense). God is present in pregnancy at precisely the places that seem least divine."

If Jobe's wry frankness got me into the book, her theological ruminations kept me intrigued. Who knew that Eve's exclamation at the birth of Cain could just as well be translated a quite different way? That the glow of pregnancy might be related to the glow seen on Moses' or Jesus' face? That groaning in labor is not only inevitable, but also productive and even Godlike? That communion, the placenta, and breast milk have a lot in common?

Such observations are not often made by male writers. And even if they are, how many males could achieve Jobe's "been there, done that" realism? Listen to her reflect on how she was feeling days after her due date, with no sign of imminent labor:

In Matthew's Gospel, Jesus tells a story about waiting for the kingdom of God. There are ten virgins waiting to greet their bridegroom. They wait and wait, but he doesn't come.... Jesus chooses a negative example; a story about how not to wait. But he could have told a story about how to wait well by simply trading in the virgins for some pregnant women.

Pregnant women surely would have fallen asleep (probably before the virgins) but by the time the bridegroom came, they would have woken up twice to pee and once for a little snack of peanut butter toast and milk. When the bridegroom came striding in at midnight, at least three lamps would already be on. The pregnant woman struggling with insomnia would welcome him to the kitchen table for a midnight cup of herbal tea. The second-time mom would motion the bridegroom to the couch while she finished nursing her firstborn. And the third-time mom would say with a large dose of exasperation, "It's about time you got here - my six-year-old can't sleep for excitement about this wedding feast!" All of them would have their hospital bags packed and waiting by the door. Jesus could have said, "Wait like a pregnant woman."

That night at Johnsen & Taylor's bookstore, I did see books written by women, of course. Most of the novels had female authors. A few books by women were in the Christian Living section. As a retired editor for a variety of religion publishers, I'm happy to see women contributing to any and all categories. But I'm especially happy when women use uniquely female experiences as ways to see God.

The image of God is male and female. Half a God may be better than no God at all - or it may be dangerously distorted. It's way past time to let light shine on the neglected half of God's image. Thanks, Sarah Jobe - and please keep writing.