Tamara Etienne’s second pregnancy was freighted with risk and worry from its earliest days — exacerbated by a first pregnancy that had ended in miscarriage.

A third-grade teacher at an overcrowded Miami-Dade County public school, she spent harried days on her feet. Financial worries weighed heavy, even with health insurance and some paid time off through her job.

And as a Black woman, a lifetime of racism had left her wary of unpredictable reactions in daily life and drained by derogatory and unequal treatment at work. It’s the sort of stress that can release cortisol, which studies have shown heighten the risk for premature labor.

“I’m experiencing it every day, not walking alone, walking with someone I have to protect,” she said. “So the level of cortisol in my body when I’m pregnant? Immeasurable.”

Two months into the pregnancy, the unrelenting nausea suddenly stopped. “I started to feel like my pregnancy symptoms were going away,” she said. Then strange back pain started.

Etienne and her husband rushed to an emergency room, where a doctor confirmed she was at grave risk for a miscarriage. A cascade of medical interventions — progesterone injections, fetal monitoring at home, and bed rest while she took months off work — saved the child, who was born at 37 weeks.

Women in the U.S. are more likely to deliver their babies prematurely than those in most developed countries. It’s a distinction that coincides with high rates of maternal and infant death, billions of dollars in intensive care costs, and often lifelong disabilities for the children who survive.

About 1 in 10 live births in 2021 occurred before 37 weeks of gestation, according to a March of Dimes report released last year. By comparison, research in recent years has cited preterm birth rates of 7.4% in England and Wales, 6% in France, and 5.8% in Sweden.

In its 2022 report card, the March of Dimes found the preterm birth rates increased in nearly every U.S. state from 2020 to 2021. Vermont, with a rate of 8%, merited the nation’s highest grade: an “A-.” The grimmest outcomes were concentrated in the Southern states, which largely earned “F” ratings, with preterm birth rates of 11.5% or higher. Mississippi (15%), Louisiana (13.5%), and Alabama (13.1%) were the worst performers. The March of Dimes report found 10.9% of live births in Florida were delivered preterm in 2021, earning the state a “D” rating.

Since the U.S. Supreme Court overturned Roe v. Wade, many maternal-fetal specialists worry that the incidence of premature birth will soar. Abortion is now banned in at least 13 states and sharply restricted in 12 others — states that restrict abortion have fewer maternal care providers than states with abortion access, according to a recent analysis by the Commonwealth Fund.

That includes Florida, where Etienne lives, and where Republican lawmakers have enacted a series of anti-abortion laws, including a ban on abortion after 15 weeks of gestation. 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 are uninsured, making it more difficult to begin a healthy pregnancy. Women are twice as likely to die from pregnancy and childbirth-related causes in Florida than in California.

“I lose sleep over this,” said Dr. Elvire Jacques, a maternal-fetal medicine specialist at Memorial Hospital in Miramar, Florida. “It’s hard to say, I expect [better birth outcomes] when I’m not investing anything from the beginning.”

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The causes of preterm births are varied. About 25% are medically induced, Jacques said, when the woman or fetus is in distress because of conditions like preeclampsia, a pregnancy-related hypertensive disorder. But research suggests that far more early births are thought to be rooted in a mysterious constellation of physiological conditions.

“It’s very hard to identify that a patient will automatically have a preterm birth,” Jacques said. “But you can definitely identify stressors for their pregnancies.”

Physicians say that roughly half of all preterm births are preventable, caused by social, economic, and environmental factors, as well as inadequate access to prenatal health care. Risk factors include conditions such as 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 care system, Jacques takes on high-risk pregnancies referred from 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 issues? Where do you work? “If you don’t know that your patient works in a factory [standing] on an assembly line,” she said, “then how are you going to tell her to wear compression socks because that may help her prevent blood clots?”

Jacques has urged a store manager to let her pregnant patient sit while working. She persuaded an imam to grant a mom-to-be with diabetes a reprieve from religious fasting.

Because diabetes is a major risk factor, she often talks with patients about eating healthfully. For those who eat fast food, she asks them to try cooking at home. Instead of, “Can you pay for food?” she asks, “Of the foods we’re discussing, which one 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 U.S. 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 obstetrics and gynecology department at Broward Health in Fort Lauderdale. “A lot of places have paid leave, [and pregnant patients] don’t have to worry about not being at work.”

Yet, as preterm births rise in the U.S., wealth does not ensure better pregnancy outcomes.

Startling new research shows that at every U.S. income level, Black women and their infants experience 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 preterm complications, according to the study, published by the National Bureau of Economic Research.

Jamarah Amani has seen this firsthand as executive director of the Southern Birth Justice Network and an advocate for midwifery and doula care in South Florida. As she evaluates new clients, she looks for clues about birth risks in a patient’s family history, lab work, and ultrasounds. She homes in quickly on stress related to work, relationships, food, family, and racism.

“I find Black women working in high-stress environments, even if they are not financially struggling, can face preterm birth,” she said. She develops “wellness plans” that include breathing, meditation, stretching, and walking.

Recently, when a patient showed signs of preterm labor, Amani discovered that her electricity bill was overdue and the utility was threatening to cut service. Amani found an organization to pay off the debt.

Of Tamara Etienne’s six pregnancies, two ended in miscarriage and four were threatened by preterm labor. Fed up with the onslaught of medical interventions, she found a local doula and midwife who helped guide her through the birth of her two youngest children.

“They were able to walk me through healthy, natural ways to mitigate all of those complications,” she said.

Her own pregnancy experiences left a profound impact on Etienne. She has since become a fertility doula herself.