Preterm Birth in the United States is an intricate and comprehensive exploration of the persistently high infant mortality rate in the United States, to which preterm birth is a major contributor. For various stakeholders, high infant mortality in the United States is at once an “enigma,” an “issue of concern,” an “indicator of the need […] for reform,” the “trigger for ethical dilemmas,” and a “human tragedy” (p. v). In Bronstein’s skilled treatment, it is this multiplicity of perspectives—all emotionally charged—that makes preterm birth a fascinating topic for anthropological analysis.
As Bronstein demonstrates throughout the text, preterm birth is a multidimensional problem and one that we must understand through the prism of culture, even if medical and scientific discourse naturalize and obscure this fact. Indeed, it is this anthropological lens that allows Bronstein to untangle the different facets of preterm birth and the cultural assumptions, narratives, and myopias that make it such a difficult problem to understand and solve.
Preterm Birth in the United States makes three significant contributions. First, it contributes to medical anthropology by providing a unique and compelling analysis of the interplay between clinical medicine and population health. Second, the book joins Sandra Dianne Lane’s ethnography, Why Are Our Babies Dying, in casting a much-needed analytical eye on the rapidly growing industry of infant mortality research, treatment, and prevention, which, though well-meaning, barrels along with little reflection or critique. Third, the book adds nuance and clarity to our understanding of racial disparities in health by laying bare how preterm birth is part of a larger story of racialization and racism.
The book is organized into six sections, framed by a brief preface and epilog. Bronstein keeps the preface theoretically light and free from anthropological jargon, explaining just enough of what culture is and what the concept does for her analysis to orient her readers. Indeed, the virtues of a cultural lens shine throughout the book and make the monograph—and that thorny concept, culture—accessible to a wide readership. Bronstein describes three moments that led her to this project. These brief but effective accounts position her as a keen observer and sharp critic of the cultural narratives embedded in the authoritative knowledge and institutions of biomedicine. By her admission, Bronstein is not a traditional ethnographer in a “small-scale setting producing detailed descriptions of people’s modes of thinking and behaving” (p. xiii). Rather, as a social science and public health researcher she engaged in participant observation alongside other researchers and clinicians. Thus, the culture under study is the U.S. health care system, and she applies her critical lens exclusively to secondary data (e.g., peer reviewed research both quantitative and qualitative, policy briefs, congressional hearings, medical text books, etc.).
The six sections that make up the bulk of the book each tackle a dimension of preterm birth: clinical, population, cultural, political, health care, and ethical. Bronstein deftly navigates the ways that the dimensions overlap in a way that makes each chapter useful on its own, but reading all six chapters together presents a gratifying and comprehensive view.
Chapter 1 lays out the physiological mechanisms of preterm birth and the current clinical approaches to prevention and treatment. Bronstein demonstrates that evidence of efficacy is meager for nearly all available preventions and treatments, arguing that although preterm birth is approached primarily as a clinical problem, it is, in fact, our cultural assumptions about the role of medicine in managing and fixing pregnancy and childbirth that puts preterm birth in the clinical domain.
Chapter 2 is a critical examination of the research on the four major causes of preterm birth from the standpoint of population health. Bronstein effectively demonstrates that the population health research that often guides interventions for preterm birth is not as neutral or objective as scientific discourse leads us to believe. Rather, this research is “conditioned by sets of social expectations and cultural beliefs” (p. 43) in a way that reinforces and legitimizes prejudice against certain types of mothers and mothering behaviors. This chapter is an important contribution to discussions of race and racialization in medicine and science with regard to infant mortality and can be used a primer on its own.
Chapter 3 situates discourses about preterm birth within a larger cultural framework: the medicalization of childbirth. Bronstein illustrates how popular and clinical understandings of preterm birth validate the medicalization of pregnancy and childbirth. Along the way, she shows how this medicalization can increase the likelihood of preterm birth. This mutually reinforcing phenomenon occurs within a broader discourse in which three popular beliefs and assumptions about preterm birth—that medicine has the ability to “save” all babies, that fetuses are viable at nearly all gestational ages, and that mothers are responsible for poor pregnancy outcomes—make the medicalization of reproduction seem rational and necessary.
Chapter 4 illustrates how preterm birth is strategically used in contentious political fights over the distribution of government resources for family planning, poverty, and racial disparities. Interestingly, Bronstein describes how the relatively uncontroversial social desire to save babies has been used to gain popular and political support for policies that in some ways counter or challenge certain cultural narratives. For example, using preterm birth as a call to action to garner political will for anti-poverty measures exploits a moral loophole in the cultural narrative of poverty as a “negative individual trait” because children are not considered “morally culpable for their poverty” (p. 162).
Chapter 5 demonstrates how the health care system (the web of institutions, protocols, providers, and financial stakeholders) supports, necessitates, and naturalizes certain treatment protocols for pregnant women and their preterm infants. For example, because U.S. health care is largely privatized and commercial interests such as pharmaceutical and biotechnology companies hold substantial power, there is an unchecked and aggressive use of technology to intervene to treat preterm infants, even when the use of those technologies is unlikely to have good outcomes. This chapter vividly illustrates from a systems-level view how biomedicine is ill equipped to deal with the novel medico–moral landscape of preterm birth.
Chapter 6 explores ethical dilemmas that crystalize one or more of the cultural models discussed in the earlier chapters, for example that of the “good mother” or the “good clinician.” Bronstein effectively demonstrates how the ethics of preterm birth are not dilemmas in and of themselves, but are made problematic and meaningful by the cultural and structural contexts explored in the previous five chapters. This and other chapters are especially enhanced by comparisons with Canada, Great Britain, and Western Europe.
Preterm Birth in the United States should be required reading for students of medicine, nursing, and public health. It would work well as a core text in medical anthropology and comparative health systems courses, especially as a counterpoint to more ethnographic texts. Bronstein’s coupling of insider understanding with an outsider’s critique will be illuminating and likely epiphanic to those working in infant mortality reduction and research.
To great effect, Bronstein demonstrates that preterm birth is more than a poor clinical outcome, a personal tragedy, an ethical quagmire, or a policy touchstone. Rather, preterm birth is a powerful trope that justifies and complicates some of our deepest cultural assumptions and values about biomedicine, childbirth, motherhood, poverty, and race.
Lane, S. D. 2008. Why Are Our Babies Dying?: Pregnancy, Birth, and Death in America. London: Routledge.