CHAPTER 1
Premature Predicaments
It was not natural. And she was the first. Come from a country of many tongues tortured by rupture, by theft, by travel like mismatched clothing packed down into the cargo hold of evil ships sailing, irreversible, into slavery.
— June Jordan, Some of Us Did Not Die (2002)
When my babe was born, they said it was premature. It weighed only four pounds; but God let it live. I heard the doctor say I could not survive till morning. I had often prayed for death; but now I did not want to die, unless my child could die too. Many weeks passed before I was able to leave my bed. I was a mere wreck of my former self. For a year, there was scarcely a day when I was free from chills and fever. My babe also was sickly. His little limbs were often racked with pain. Dr. Flint continued his visits, to look after my health; and he did not fail to remind me that my child was an addition to his stock of slaves. ... As the months passed on, my boy improved in health. When he was a year old, they called him beautiful. The little vine was taking deep root in my existence, though its clinging fondness excited a mixture of love and pain. When I was most sorely oppressed I found solace in his smiles. I loved to watch his infant slumbers; but always there was a dark cloud over my enjoyment. I could never forget that he was a slave. Sometimes I wished that he might die in infancy. God tried me. My darling became very ill. The bright eyes grew dull, and the little feet and hands were so icy cold that I thought death had already touched them. I had prayed for his death, but never so earnestly as I now prayed for his life; and my prayer was heard. Alas, what mockery it is for a slave mother to pray back her dying child to life!
— Harriet Jacobs Incidents in the Life of a Slave Girl (1861)
This epigraph is from an autobiographical narrative written by Harriet Jacobs under the pseudonym of Linda Brent, which is how I will refer to her in this chapter. Incidents chronicles the excruciatingly painful life of a girl born around 1813 in North Carolina and forced into bondage in the Flint household in 1825 around age twelve. Brent's life was cloaked in abuse enacted by her owner, Dr. Flint, a physician, who emotionally abused and threatened her, as did his wife, Mrs. Flint, who despised her. Brent informs readers that she was also in a sexual relationship with an older man: a white lawyer, Mr. Sands — who ultimately became a congressman. While that relationship appears to be one into which she entered of her own accord, it is difficult to embrace the characterization that a fifteen-year-old enslaved girl "chose" to have sex with an older white man. If nothing else, it was a survival strategy — a move to ward off Dr. Flint's advances. Mr. Sands impregnated Brent when she was fifteen, and she subsequently gave birth to her son, Benny, described in the epigraph. At twenty, Brent was pregnant again and this time had a daughter, Ellen. Both children, fathered by Sands, were Flint's property. Believing that if she ran away Flint would sell her children to their father, Mr. Sands, Brent hid for seven years in the attic crawl space of her grandmother's shack.
Brent's story haunts the more contemporary stories told in this book in its evocation of the temporal persistence of Black women's premature births. Several compelling themes emerge from this excerpt, which speak to my aims here. This book represents a vantage point of reproduction that has been overlooked in the anthropological literature, that of Black women. It serves to illustrate how archival sources, of which slave narratives are but one example, can be used to contextualize current issues. In this book, the archives consist of materials — narratives, medical and popular journals, and autobiographies, among other sources. The time period of these documents ranges from the 1700s to the fairly recent past. Notably, the archival sources and primary documents elucidate contemporary concerns. Some aspects of Brent's account of the premature birth of her son — the actual event and ensuing angst — echo those by the contemporary Black women whose stories we will hear. Black women's reproductive lives have historically been controlled by a predominantly white medical profession (J. L. Morgan 2004; Schwartz 2006). This fact directs us to consider that Linda Brent's owner was a physician. Even though medical knowledge — especially knowledge of reproductive health — was nascent at the time, that does not preclude raising questions about the medical care that Brent, as a Black woman, received. Indeed, the question is an entrée into considering the present-day prenatal and obstetric care Black women receive in light of their high rates of adverse reproductive outcomes. These are outcomes that exist despite advances in medical knowledge.
Brent's account enables consideration of three questions this chapter seeks to answer. First, the passage suggests that prematurity is defined based on weight. Brent's son, Benny, was not expected to live because he "weighed only four pounds" at birth. But what is prematurity, and has race played a role in its definition? Although one might suspect what may have led Brent to give birth prematurely, no cause is mentioned in the narrative. Thus, the second question concerns: What is the etiology of premature birth? And third, what do Black women's narratives about pregnancy and prematurity tell us about their medical care and race? These initial questions are important because reproductive disparities have beleaguered Black women for more than two centuries in the United States. During the antebellum period, infant mortality rates overall in America were excessive, but enslaved women lost nearly 50 percent of their children (Berry and Alford 2012). Linda Brent's narrative demonstrates this disparity. Her experience as described in Incidents affords us one way to think about the issue of pregnancy and premature birth — from Black women's standpoint. This is important, especially given the limited attention Black women's reproduction has received (except, see Mullings and Wali 2001; Bridges 2011; D. E. Roberts 1997).
When Linda Brent gave birth in the 1830s, prematurity and infant mortality were events in the lives of many enslaved women — indeed, of most women. Rates of premature births were inestimable because childbirth typically took place in the home, rendering it essentially a private, familial matter. However, the consequence of premature birth, infant mortality, was recorded. Beginning in the 1850s, birth and death rates, by race — including infant mortality — were calculable. We know that, just twenty years after Linda Brent gave birth prematurely in 1830, the white infant mortality rate was 216.8 per 1,000 compared with a Black infant mortality rate of 340 per 1,000 (Haines 2008). Table 1.1 illustrates the Black-white differences for a range of reproductive issues: birth rates, fertility rates, life expectancy, and infant mortality rates over the last two centuries. Infant mortality rates are germane to this discussion because the dominant cause of infant mortality was and still is premature birth. The table also shows that birth and fertility rates are calculable and that by 1850 a more detailed picture of the racial disparity in birth outcomes had emerged. According to the table, in 1850, the Black infant mortality rate was one and a half times higher than the rate for white infants. In 2000, the disparity was two and a half times higher. It is astonishing to see that even under the strictures of enslavement, Black women had significantly better birth outcomes than they do today.
Early in US history, premature births were not framed as a health crisis because in cases when births were attended by physicians, they "saw no effective means of aiding these babies in their doomed struggle to survive" (Golden 2001, 180). Child death was unremarkable. Indeed, premature births, like infant mortality, did not become an urgent public concern until the early twentieth century (Zelizer 1994). Ultimately, both prematurity and infant mortality materialized as crises during the Progressive Era, leading to the establishment of the Children's Bureau in 1912.3 At that time, the bureau sought to rectify the mercurial infant mortality rates in the United States, including by documenting rates of births and deaths. From that point on, life and death became institutionally "registerable" events, with many states collecting birth and mortality statistics, although the entire nation did not participate in vital registration until 1933 (Haines 2008).
This chapter includes four sections. It begins with a discussion of how prematurity was defined. This was a process that began in earnest in the nineteenth century, and one that continues, relative to the way that prematurity needs to be medically managed alongside shifts in knowledge and technological advancement. Yet defining prematurity not only has served the purpose of medical management but also has been used as an adjunct of racial science — by which I mean aiding scientific inquiry for the purpose of proving the existence of racial categories in support of racial hierarchies. The second section brings select documents from the Children's Bureau archive into conversation with the history of racial science through the lens of prematurity. The third section explores the causes of prematurity. The final section offers four accounts of pregnancy, labor, and birthing by Black women over three centuries. The stories of Aunt Nancy, Anne Lewis, Ashley Bey, and Melissa Harrison illuminate how Black women have had, and continue, to bear the burden of premature birth. They do so to a greater degree than any other group of women in the United States.
Defining Prematurity
Prior to the late nineteenth century, physicians did not even classify infants who were born early; such infants were simply categorized as weak and feeble (Baker 1996, 4). Members of the medical profession used the terms "feeble" and "premature" interchangeably based on the assumption that premature babies would not survive. Defining prematurity played a critical role in ensuring classificatory uniformity. That is to say, defining the term facilitated both the documentation of the event and the medical management of premature infants' health needs. To do so, it was necessary to designate a consistent set of characteristics as to what constituted prematurity. Classificatory uniformity, then, made it possible to compare data on premature births and deaths.
Prior to the adoption of a formal definition of prematurity by US-based professional associations, prematurely born infants had been a subject of medical inquiry in Europe and the United States since the mid-1800s (Baker 1996), mostly in relation to poor women, who often gave birth in lying-in hospitals. Early on, the definition of prematurity was based on characteristics such as the weight of the infant, along with indicators such as skin texture, undeveloped nails, and fluctuating body temperature (Hughes, Black, and Katz 2017).
Among the events that precipitated the standardization of prematurity's definition, one stands out: the findings of Arvo Ylppö (1919), a Finnish pediatrician who laid the foundation for defining prematurity based on anatomical and pathological analysis. From 1909 to 1918, Ylppö conducted a study of 2,168 births at Charlottenberg's Empress Auguste Victoria Center for the Prevention of Infant Mortality in Germany, with the goal of identifying the clinical course and autopsy findings among neonates born prematurely. Of the 2,168 births he studied, 114 were preterm based on a weight of 2,500 grams, or approximately 5.5 pounds. Interestingly, Ylppö never provided a justification for the 2,500-gram weight limit, but it became the standard and has influenced public health practice into the present (Salihu n.d.). By 1935, the American Academy of Pediatrics had resolved that all live-born infants weighing 2,500 grams at birth should be treated as premature regardless of the length of gestation (American Academy of Pediatrics 1936). By this measure, Linda Brent's son Benny, at four pounds, certainly fit the criteria for prematurity and provides context for its definition during the antebellum period.
However, what is indiscernible is the length of time that Linda Brent was pregnant. This was likely because gestational time did not command a great deal of attention until 1922, when Dr. Julius Hess — considered to be the father of American neonatology — published the first book on prematurity and birth defects. In that text, he stated that when the designation of prematurity "is used, it refers to those infants born three weeks or more before the usual termination of pregnancy" (Hess 1922, 9). Hess classified two types of premature infants: those who were born possibly at term but were weaklings, and those who suffered severely during their intrauterine existence through factors that interfered with their nutrition and thus their development. Classifying prematurity in this manner paved the way for the US Bureau of Census and the American Public Health Association to recommend gestation as the definition of prematurity in 1935. Ultimately, prematurity was defined as a pregnancy of less than forty weeks, with birth taking place three or more weeks before the baby is due, around the start of the thirty-seventh week. The lower limits were set at twenty-eight weeks "because it is the consensus that a fetus of less than 28 weeks' gestation has not developed sufficiently for extrauterine survival" (Dunham 1948, 1). Gestational age gained greater currency in understanding prematurity in the 1950s, partly due to its relationship to infant mortality (Hughes, Black, and Katz 2017).
Weight, length, and gestation were all presumed to be factors in a premature infant's viability. For example, Fred L. Adair, a founder and former president of the American Congress of Obstetricians and Gynecologists, argued that newborns between 400 and 1,000 grams in weight, and twenty-eight to thirty-five centimeters in length, or of twenty-two to twenty-seven weeks' gestation, were products of conception that did not require being reported as premature. Instead, he said newborns born so early were termed abortions "because even if they showed signs of life at birth, they could not survive due to insufficient development" (Adair 1940, 904–5). The expectations for survival were so low that weight and gestational age sometimes precluded an infant from even qualifying as premature. In some cases, they were classified as previable (Dunham 1948, 3). Previability, however, came with a caveat, since some infants survived who had been born at previable weights and gestational age. Those who did live, no matter how long, could be designated as premature because the definition was modified by a live-birth statement. "A live-born child is one which shows any evidence of life (breathing, heartbeat, or movement of voluntary muscle) after complete birth. Birth is considered complete when the child is altogether (head, trunk and limbs) outside the body of the mother, even if the cord is uncut and the placenta still attached" (Dunham 1948, 1–2). This history of defining prematurity illustrates the medical construction of prematurity and how its definition shifted over time relative to the development of medical specialties such as pediatrics, public health, and obstetrics and gynecology.
