When bad mothers lose good babies: understanding fetal and infant mortality case reviews.

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When Bad Mothers Lose Good Babies: Understanding Fetal and Infant Mortality Case Reviews a

Lauren Fordyce a

Department of Anthropology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Accepted author version posted online: 30 Sep 2013.Published online: 24 Jul 2014.

Click for updates To cite this article: Lauren Fordyce (2014) When Bad Mothers Lose Good Babies: Understanding Fetal and Infant Mortality Case Reviews, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 33:5, 379-394, DOI: 10.1080/01459740.2013.844696 To link to this article: http://dx.doi.org/10.1080/01459740.2013.844696

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Medical Anthropology, 33: 379–394, 2014 Copyright © 2014 Taylor & Francis Group, LLC ISSN: 0145-9740 print/1545-5882 online DOI: 10.1080/01459740.2013.844696

When Bad Mothers Lose Good Babies: Understanding Fetal and Infant Mortality Case Reviews Lauren Fordyce


Department of Anthropology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

This article examines how the practices of the Fetal and Infant Mortality Review–Case Review Team (FIMR CRT) in “Florida City” constructs particular types of maternal and fetal subjects and how these narratives about fetal and infant death reflect particular discourses about “bad mothers” and “good babies.” I argue that the very methods of the Florida City FIMR committee structure the types of conversations and, in effect, judgments that can be made about women who experience a fetal or neonatal death. In addition, I examine how many of these ideas resonate with the discourses around fetal rights that pervade contemporary abortion politics in the United States. Keywords fetal death, fetal rights, infant death, responsibility, United States

A large body of maternal and child health literature addresses the issue of infant mortality and its devastation worldwide. Less understood and widely addressed is the etiology and experience of fetal loss, which is defined as any death after 20-weeks’ gestation, the majority occurring between 20 and 27 weeks. Because of the difficulty in understanding the incidence, etiology, and opportunities for prevention of fetal death, much of the public concern continues to focus on infant mortality (MacDorman and Kirmeyer 2009). However, an increasing number of researchers have begun to investigate the experience of fetal death, and the growth of support groups and popular literature on this attests to the move by many women and their families to ‘break the silence’ around these experiences (Cecil 1996; Layne 2003). This work is situated within its own feminist politics, bringing to light the grief and devastation that some women and their families experience over the loss of their unborn child. My own work seeks to expand feminist politics and explore the conversations about fetal death that occur at the policy level. In this article, I am interested in how these conversations enact certain notions of ‘bad mothers’ and ‘innocent babies.’ In this article, I look closely at the means through which maternal and child health policies construct particular kinds of citizen–subjects. To this end, I spent two years participating in Fetal

LAUREN FORDYCE is a lecturer at University of North Carolina at Chapel Hill. Her research examines technologies of risk in pregnancy among Haitian migrants living in South Florida. Address correspondence to Lauren Fordyce, Department of Anthropology, CB#3115, 301 Alumni Building, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA. E-mail: [email protected]

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and Infant Mortality Review (FIMR) Case Review Team (CRT) meetings in ‘Florida City.’ As I illustrate, the very methods of the Florida City FIMR committee structure the types of conversations and, in effect, judgments that can be made about women who experience a fetal or infant death. In addition, I examine how many of these ideas resonate with the discourse around fetal rights that pervades contemporary abortion politics in the United States.


OBSERVING FIMR IN FLORIDA CITY Throughout the twentieth century, infant mortality rates decreased until hitting a plateau in the early 1980s, leading maternal and child health advocates to renew calls to investigate the underlying causes of infant mortality. Although specialized care through neonatal intensive care units (NICU) and the establishment of regionalized systems of perinatal care had contributed to decreased rates of neonatal mortality in the late 1970s, thereafter rates of infant death began to climb in some US cities. Federal interest in these issues culminated in the creation of the Interagency Low Birth Weight Prevention Work Group (LBW Work Group) by the US Department of Health and Human Services in early 1984. Given the success of maternal mortality reviews in addressing medically maternal death cases in the 1950s, and the purported influence of this approach on standards of medical care and education and a decline in maternal death (Koontz, Buckley, and Ruderman 2004; Marmol, Scriggins, and Vollman 1969), the LBW Work Group reestablished ‘case reviews’ to investigate perinatal deaths. The LBW Work Group proceeded to design the National Fetal and Infant Mortality Review (NFIMR) Program. The vision was that the work of the review team would “1) lead to a better understanding of the challenges localities faced in reducing infant mortality rates; 2) provide information about local maternal and infant health care systems; 3) facilitate development of strategies to address local problems; and 4) help communities take corrective action” (Koontz et al. 2004:196). This was devised as a community-based, two-tiered process, whereby a Case Review Team (CRT) reviewed cases and drafted preliminary recommendations, and a Community Action Team (CAT) then met to discuss and disseminate findings based on these recommendations (Koontz et al. 2004). Currently, there are more than 200 local FIMR projects nationwide, including 12 projects funded within the state of Florida. In this article, I focus on the Florida City FIMR, a CRT group based in southern Florida. Cities in southern Florida are some of the more diverse in the state, home to large communities of Latin American and Caribbean immigrants. There is considerable income disparity, and the area includes many of the richest and poorest residents of Florida (US Census Bureau 2010). The Florida City CRT met monthly and members included nursemidwives, physicians, neonatal and NICU nurses, Healthy Start advocates, and social workers. I was invited to participate on the CRT during my dissertation research examining Haitian women’s experiences in pregnancy (Fordyce 2009); I was identified as ‘PhD Student’ on the committee and all CRT documents. During my research in 2005 to 2006, I attended 17 CRT meetings and two CAT events. Confidentiality remains an important aspect of the function of community CRTs; therefore case notes were returned at the end of each meeting and my own analysis relies on my extensive field notes from the meetings.1 Although members of the broader CRT committee reflected the racial/ethnic diversity of Florida City, those who attended regularly were predominantly white women who were midwives or neonatal nurses.


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At each meeting, CRT members discussed three cases—typically two fetal deaths and one neonatal or infant death. Because the FIMR is interested in making policy recommendations, the CRT only reviews cases that involve a fetal death more than 20-weeks’ gestation and greater than 500 grams.2 FIMR case files are abstracted from various available sources, including fetal and infant death records, birth certificates (in the cases of infant deaths), prenatal records, emergency room/hospital records, NICU records, autopsies, and caregiver interviews. Each case is summarized in a report by the nurse abstractor, removing any identifying data such as physician names, hospitals, or any personal information.3 These case summaries are distributed to members during the meeting and are collected again at the end of each session. CRT members spend about an hour and a half discussing the strengths and weakness of each case, guided by a checklist generated through a computer database. During this research in 2005 to 2006, Florida FIMR projects were piloting a data-tracking system to coordinate data from the statewide FIMR project. This program, ‘BASINET’ (Baby Abstract System and Information NETwork), was implemented by various Florida FIMR projects in late 2006. By using this software at the state level, local FIMR data could be collected and aggregated for state-wide recommendations to prevent fetal and infant deaths. Although the software was not implemented until the end of my participation in the Florida City FIMR, our discussion of cases was structured by the way this program would function in the future. Ultimately, case data would be entered into BASINET by the nurse abstractor, and the case ‘strengths’ or ‘weaknesses’ would be automatically generated by the program. As the CRT, we would discuss whether we agreed with the conclusions generated by the program and add or delete as we saw necessary. Before the implementation of the automatic BASINET summary, CRT members were given a summary of the case with all non-identifying details abstracted from as many records as available for each case. Members would then use the datasheet composed of numerical statements grouped into four sections: ‘Case Strengths,’ ‘Service and Information Source Issues,’ ‘Contributing Factors,’ and ‘Case Suggestions.’ After the CRT Chair read aloud the case summary, members would proceed through the BASINET checklist, calling out each item if it pertained to the analysis and recommendations related to the case under discussion. ‘Case Strengths’ listed issues related to maternal behavior and psychosocial support and ‘Service and Information Sources Issues’ focused mainly on the quality and quantity of the data abstracted for the case. ‘Contributing Factors’ evaluated maternal and infant health, provider issues, and social issues. ‘Case Suggestions’ focused on committee recommendations to institute community- and state-wide changes to prevent fetal and infant deaths. During meetings, members briefly discussed ‘case strengths,’ routinely asking, ‘What can we give her for . . . ’ and debating whether to give her ‘credit’ for her ‘early prenatal care’ or a ‘planned pregnancy.’ Yet much of the meetings focused on discussing ‘contributing factors,’ with particular emphasis on maternal health and behaviors assumed to contribute to poor birth outcomes. Although members spent a brief amount of time pointing out the strengths of a particular case, the mission of the CRT to create recommendations for community intervention structured the discussion around these contributing factors. I am not arguing that this process ignores larger systemic issues or leaves the medical establishment blameless, and many of these ‘strengths’ and ‘contributing factors’ are based on variables associated with perinatal deaths. But what I wish to draw attention to here, particularly in combination with the ethnographic component of this article, is how the conversations in conjunction with these case analyses highlight the increasing moves by public health advocates to prescribe certain types of maternal behavior in order to protect ‘innocent’ fetal health.

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MEASURING WOMEN’S COMPLIANCE During discussions of ‘Case Strengths,’ conversation often centered on women’s ‘compliance,’ which according to BASINET translated into compliance with prescribed biomedical care. Many of the choices in this section assumed a level of detail almost impossible to abstract from the records available for most cases that we reviewed, and therefore, our discussions largely centered on utilization of prenatal care that was more easily quantifiable from the data available. For instance, some of the choices in this section included ‘compliance with prenatal care/kept appointments,’ ‘early prenatal care (first trimester),’ and ‘medication compliance.’ In one case of a late-term fetal death, a pregnant woman arrived at the hospital because she had not sensed fetal movement for over two days. The fetal demise was the result of the umbilical cord wrapping around the neck and was diagnosed by ultrasound by both the attending physician and a referral to a perinatologist on staff. Much of the discussion in this case focused on her access to and utilization of prenatal care. Although she had initiated prenatal care in the thirteenth week of pregnancy and had five visits after this initial visit, FIMR members questioned her delay in initiating care. It was ascertained from the hospital records that the woman was actually an employee at the hospital where the fetal death was diagnosed, which led one member to comment, “Because she is a health professional, there is an expectation that she would be compliant with prenatal visits.” Compliance with biomedical recommendations for prenatal care was constructed as a responsible and moral act—especially inexcusable for women deemed familiar with the medical system (Maraesa 2012; Ruhl 1999). Women’s utilization of prenatal care, and therefore their perceived irresponsibility, became an important theme throughout FIMR discussions of fetal and neonatal death cases. In another case of late-term demise due to congenital anomalies, a woman’s attendance at prenatal care was questioned because she had ‘missed’ appointments according to her prenatal record. Although strengths for this case included “quality prenatal care with appropriate referrals” because of the diagnosis of abnormal cranial anatomy early in the pregnancy, this woman was also cited for “inconsistent prenatal care (missed visits)” as a contributing factor in the FIMR discussion of this fetal death. On multiple occasions, FIMR members brought up notions of ‘responsibility’ in relation to attendance at prenatal care: “Initiating prenatal care late in a pregnancy means that someone is being irresponsible!” exclaimed one member in response to a heated discussion regarding the utilization of prenatal care. Implicit within these discussions about utilizing biomedical prenatal care are notions of responsible, rational citizens. The contemporary risk model of pregnancy assumes that pregnant women will assume the individual responsibility to provide their unborn child with the ideal gestational environment, and to best provide this environment she must comply with biomedical risk management and care (Ruhl 1999; Weir 2006). As argued by Ruhl (1999:102), “the social aspects of pregnancy—economic factors that influence prenatal care, social variables such as urban decay or spousal assault that jeopardize the health and welfare of the pregnant woman and the foetus— are overshadowed in the risk model of pregnancy.” In this sense, behaving responsibly is a moral act; to refuse prenatal care is understood as neglectful or bad mothering. So although FIMR committee members may briefly discuss the socioeconomic or social factors that could contribute to a fetal or neonatal death, ultimately a pregnant woman’s compliance with the biomedical management of her pregnancy was valued over other confounding factors.



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Given our location in Florida City, discussions about the use of prenatal care often included discussions of access, particularly around immigration and use of Medicaid. In one noteworthy case, a West Indian woman reported to the emergency room after experiencing heavy bleeding where she was diagnosed with a placenta abruption, wherein the placenta separates from the uterine wall and can result in preterm labor. In this case, the dead fetus was delivered at 29 weeks and exhibited maceration, a common sign that the fetus had already been dead a day or so in utero. According to the emergency room record, the woman noted that she had not received any prenatal care in the United States but had received some care in the West Indies. This case precipitated a spirited debate among members about access to care by immigrants. Discussion quickly turned to her immigration status and how it might affect her utilization of prenatal care. One CRT member commented: “Do you think she knew about Presumptive Medicaid,4 and assumed the labor would be paid for?” Another member noted that perhaps she was going back and forth from the West Indies, because “many of them do that,” while another commented that perhaps she was “someone who knows the system well enough and knew that she wouldn’t qualify for Medicaid so therefore did not even try to get prenatal care.” These comments reflect the supposed savvy often attributed to undocumented immigrants in that they are always trying to “work the system.” The larger story being told here, one that I heard often in meetings among health care providers throughout Florida City, is that women ultimately plan on giving birth in the United States to ensure American citizenship. The idea is that they travel back and forth, often timing the latter part of their pregnancy with an extended stay in the United States. Comments such as these need to be contextualized within larger national discussions about immigration that were common during this period, particularly neoconservative concerns about women ‘illegally’ migrating to the United States to have children in order to ‘anchor’ themselves and their families here (see also Bridges 2011; Gálvez 2011). Of course women and their families can also discuss the realities of these anchor baby fantasies, particularly in cities across the United States where having children who are US citizens does not deter Immigration and Customs Enforcement authorities from deporting undocumented parents.5 In another case, an undocumented Central American woman experienced a post-term pregnancy loss at 42 weeks, and the fetus was delivered exhibiting maceration and meconium in the fluids. The medical record noted that she had not felt any fetal movements for more than four days, leading to the conclusion that the fetus had been dead for a number of days before delivery. According to the abstracted records, this woman had received no prenatal care during her pregnancy. As commented by one FIMR member, “If she is an immigrant then she won’t qualify for services. Is this why illegals don’t get prenatal care? Are they afraid that they will be deported?” Another member countered, This woman is from Central America, there is a good network of Central American immigrants here, a community that has been established a long time. There is no excuse for her not to get prenatal care. Most likely she was in denial about her pregnancy, and she chose not to receive care. This is a form of neglect. How could her family let her ignore prenatal care? Why isn’t the Department of Children and Families called in to intervene?

Cases such as these speak to narratives of citizenship and expectations for economic selfsufficiency. Legal studies scholars have demonstrated that the fear of being labeled a ‘public charge’ has led both documented and undocumented immigrants to avoid using public services, such as Medicaid, to prove in future citizenship procedures that they have never used any public


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assistance and nor will they need to in the future (Bridges 2011). But as clear in the FIMR committee discussions of this case, fear of deportation and complications to future citizenship should not trump maternal responsibility. For an undocumented woman to avoid prenatal care was equated with maternal neglect, a moral failing on the part of this woman and her family but not necessarily envisioned as a result of structural violence resulting from fear of deportation or the difficulties in accessing medical care as an undocumented migrant. In discussing ‘Contributing Factors’ for cases, ‘social issues’ often prompted much discussion, particularly in determining how to ascertain ‘poverty’ from the few details in a case. Many CRT members designated ‘Medicaid’ as an indicator of poverty: “Medicaid means poverty in Florida City, you don’t get Medicaid unless you are poor.” Other CRT members disagreed: “But women will lie to get Medicaid, many people do!” For these members, cunning women, including ‘illegal immigrants’ who abuse the system to have children in the United States, as well as low-income women lying about their income status, to access free health care through Medicaid, craftily and sneakily exploit public resources. These discussions reflect discourses of “welfare queens” (Collins 1990) and “wily patients” (Bridges 2011), in which community members must work to protect the system from pilfering by greedy and lazy women. Implicit within these discussions of Medicaid and poverty are narratives of race and class, in that immigrants and women of color are more likely to fulfill these caricatures of wily patients taking advantage of the system. Fundamentally, these discussions evaluated ‘maternal character’ as designated within ‘case strengths’ on the BASINET form. And nowhere was this discussion more fraught than when FIMR members repeatedly assumed fetal deaths were the result of maternal drug use.

SHE SMELLS OF A CRACK HEAD TO ME One of the most devastating parts of experiencing fetal loss is the complete lack of closure at understanding ‘why’ this death occurred. The most common ‘cause of death’ noted on the certificate of death in many fetal death cases is the open-ended term ‘fetal demise’—designating how little is known about fetal death. For FIMR committee members working to ascertain what local and systemic changes should be instituted to decrease rates of fetal death in Florida City, a natural place for deeper readings beyond the biomedical cause of death required a closer look at maternal ‘character’ and its links to poor birth outcomes. In a number of cases that the CRT reviewed, placenta abruption was designated as ‘cause of death.’ As discussed, this results when the placenta becomes separated from the uterine lining, and depending on the gestational age of the fetus, can often result in a fetal death. A number of risk factors for placenta abruption, including preeclampsia (or pregnancy-induced hypertension), maternal trauma such as motor vehicle accidents or gendered violence, multiple pregnancies, previous cesarean sections, tobacco or cocaine use, and various other risk factors (Cunningham et al. 2009). For many CRT members, cases of fetal death resulting from placenta abruption triggered discussions about mandatory drug testing of pregnant women. Although placenta abruption is associated with any number of causes, FIMR members became fixated on the idea that this poor birth outcome was linked to drug use. A number of midwives on the committee argued that random drug testing should be done on all pregnant women in Florida City, not only at delivery but also throughout the pregnancy.



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Two cases exemplify how ideas about fetal death are immediately tied not only to possible drug use but also to particular assumptions about maternal character. As noted, one of the sections in the ‘Case Strengths’ section of the BASINET form designated a series of attributes linked to ‘maternal character,’ which included such entries as “Teen mom stayed in school during pregnancy”; “Pt w/strong family hx of abuse, yet she has not abused her children”; “Mother demonstrated self-advocacy”; and “Mom’s positive attitude despite multiple hardships and challenges in her life.” Given the paucity of records the FIMR committee reviewed, much of these data were difficult to abstract from vital statistics. In some cases, personal information could be ascertained from prenatal or hospital records in which providers made notes about psychosocial issues of the pregnant woman. Yet because of the way that the BASINET data entry sheet structured the strengths and weaknesses of each case, much discussion often focused on evaluating maternal behavior. Evaluations of ‘maternal character’ became very clear when evaluating a case of a placenta abruption. A 24-year-old woman lost her 38-week pregnancy after a car accident. The accident resulted in multiple surgeries. She was flown from the site of the accident to the hospital when she reported not feeling any fetal activity after the accident; an emergency cesarean section delivered her deceased fetus. Both the prenatal record and hospital records contained a variety of data, and also included was the Healthy Start Prenatal Risk Screen. Healthy Start is a state-mandated program requiring all prenatal providers to administer the short questionnaire to pregnant women at her first prenatal visit. The screening instrument is sent to the local Healthy Start coalition to be ‘scored.’ Women who are scored ‘at risk’ are referred for services such as parenting classes, smoking cessation, consultations with a social worker, and mental health or other services that could benefit women designated as high-risk for psychosocial issues. In this case, the woman’s Healthy Start screen was scored ‘high risk’ based on a number of factors, including that she was single, weighed less than 110 pounds before her pregnancy, had used tobacco in the last two months, had used drugs/alcohol in the last two months, had a previous poor pregnancy outcome, and had current or previous problems with depression. Her medical record noted that she had herpes that led her to have a cesarean section for her first pregnancy, and her current pregnancy was scheduled for a planned cesarean as well. Finally, her prenatal record noted that she was a poker dealer. This case prompted a lot of discussion from CRT members: “So this woman is a poker dealer, and therefore she is out late and she probably got drunk and into a motor vehicle accident.” Another member disagreed, “According to the hospital report the accident was at 8 p.m., so I don’t think she was out late. I am more concerned with the fact that she is so underweight, is she a crack head you think?” One of the midwives countered, “She smells of a crack head to me! And how does her having herpes figure into her character? Not to mention how her fetus was exposed to all that second-hand smoke!” Finally, one of the CRT members defended her, “Well I guess we have to give her early entry into prenatal care. At least she was going to a doctor.” What is important to recognize is that although the woman’s Healthy Start Screen noted drug/alcohol and tobacco use in the previous two months, this screen is filled out at the initial prenatal care visit. This woman may have used alcohol or tobacco before she became pregnant, and there was absolutely no definitive evidence stating that she was using these substances during her pregnancy. Yet CRT members insisted on adding ‘Substance Abuse’ as a contributing factor to this fetal demise, although none of the hospital records, accident reports, or prenatal records cited alcohol or drug use as a factor in the accident.


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Where women had documented issues with drug use and addiction, FIMR members cited child neglect and recommended legal intervention. In one case of a 31-year-old woman who experienced a 35-week fetal demise, we were able to ascertain from her records only that she was HIV-positive and that her urine drug screen test was positive for cocaine at the delivery. As one member noted upon reading her record, “She gets all this prenatal care, attending all her visits and takes her HIV medication, and yet she decided to use cocaine towards the end of her pregnancy. What is wrong with this woman?” Another CRT member exclaimed, “If this woman was shot by someone, like her boyfriend or something, and the fetus was killed, well that guy would be prosecuted. But then this mother uses cocaine and her fetus dies and she just walks free!” In another case of a late-term fetal death, a woman with a history of intervention by the Florida Department of Children and Families (DCF) tested positive for cocaine and marijuana in her urine drug screen at delivery. The fetus was estimated to be between 32- and 36-weeks’ gestation at death, but the mother had no recollection of her last menstrual period and had received no prenatal care. FIMR members questioned why she had not used Medicaid to access prenatal care: “She was probably too busy being all cracked out to figure it out. It is not difficult to get Medicaid, there is no issue with ‘access to care’; with this case she is just not taking advantage of resources. She uses drugs and she is not going to get help.” A neonatologist from a local hospital added, “With her history with DCF she was probably afraid! All of her previous children have been taken into state custody. She is an addict, and often pregnant addicts use drugs in labor to cope with the pain. She is not a criminal, she has dependency issues.” This discussion reflects larger discourses around pregnancy and addiction, with narratives splitting between legal intervention and the realities of dependency. As noted by Hamilton (2012:65) in her work on meth addiction in pregnancy, “as has been described for decades, substance dependency, at its peak (which can last for years), subsumes all else; the drug of choice becomes the only focus, and life happens around the drug.” For the women she interviewed, although losing children to state custody was not unexpected, it was not experienced lightly, and it most often resulted in their continued drug use to cope with the stress and in some cases, to intensified and more risky drug behavior. While race/ethnicity and social class was never explicitly discussed in these cases, assumptions about race and class are woven into discussions of ‘crack heads.’ Like the ideas about wily patients and welfare queens that informed narratives about access to and utilization of prenatal care, FIMR committee fears about ‘crack babies’ evoked racialized assumptions about responsible, good (white, middle-class) mothers. Although heavy exposure6 to tobacco and alcohol during pregnancy is demonstrably more harmful than crack or cocaine, legal prosecution of drug use in pregnancy overwhelming focuses on women who test positive for crack-cocaine (Balsamo 1996; Daniels 1996; Paltrow and Flavin 2013; Roberts 1998). As Roberts (178) notes, “targeting crack use during pregnancy unfairly singles out Black women for punishment. Drug use can be found among pregnant women of all socioeconomic, racial, and ethnic backgrounds, but inner-city Black communities have the highest concentration of crack users.” The focus by FIMR committee members on the prosecution of drug-addicted women in cases of fetal death reflects larger legal and social ideas about drug use as neglect and bad mothering. As noted, although one physician argued that drug addiction in pregnancy needed treatment and not prosecution, most FIMR committee members favored punishing pregnant addicts. This position is dominant within public discourse, although research shows that drug testing pregnant women in prenatal care and at delivery creates barriers to positive birth outcomes rather than



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preventing fetal or neonatal death (Daniels 1996; Roberts 1998). If pregnant addicts fear prosecution, they will avoid prenatal care and other interactions with the biomedical system because of fear of state intervention in their pregnancy and family life. States incarcerate pregnant women for testing positive for drug use during pregnancy, despite that many prisons and jails are not equipped to deal with the health needs of pregnant women. Finally, many people support the prosecution of pregnant addicts under the assumption that this will force them to seek treatment for their drug use. But in reality, few treatment centers exist to support the needs of pregnant addicts. And because many of these women are already single parents, they may be fearful of being separated from their children (Balsamo 1996; Daniels 1996; Roberts 1998; Whiteford and Vitucci 1997). Ultimately, state focus on and prosecution for drug and alcohol use in pregnancy shifts attention away from issues such as pervasive poverty, racism, and a deficient health care system, with true implications for poor birth outcomes. Public discourse around ‘crack babies’ erases societal culpability in fetal and neonatal deaths, instead framing perinatal loss as the result of the depraved behavior of neglectful mothers (Roberts 1998). In FIMR committee narratives attempting to criminalize pregnant women for supposed poor mothering, we see implicit assumptions about maternal responsibility inherent with the contemporary biomedical risk model of pregnancy. Conditions of structural violence that contribute to women’s continuing substance abuse during pregnancy become erased in this process, leaving women’s behavior as the sole marker for parenting. To return briefly to the woman who used drugs in pregnancy and failed to present for prenatal care, it is worth mentioning one small note on her chart: “Baby examined, 32 weeks gestation. Photo taken, memory box given, both parents held the baby. A grief packet including the baby photo and footprints was given to the family.” Throughout the extensive discussions about this case, the father was never referenced, yet this detail makes it clear that he attended the birth, and case notes remark on the fact that both parents had held the dead fetus. This remarkability of holding the dead fetus is also reflected in the BASINET Case Strength: “Family requested to see baby after delivery to bond.” In highlighting the importance of bonding and ‘appropriate’ bereavement, FIMR committee members imbued pregnancy loss with expectations for women’s behaviors and embodiment of grief.

DOCUMENTING APPROPRIATE GRIEF An important area for discussion among FIMR members was that of ‘grief support.’ The BASINET checklist prompted this discussion in ‘Case Strengths’ with the selections: “Ref. to community grief support services after discharge”; “Chaplain, pastor, nurse, HS, or SW grief support”; “Follow up per hospital bereavement team”; and “Family requested to see baby after delivery to bond.” Discussions about these issues centered on nurses’ notes in hospital records, which could include statements such as “parents were appropriately distraught” or “parents visited NICU once a day, and were very involved.” In one infant death reviewed by the FIMR committee, we discussed the case of a 3-monthold infant who died of sudden infant death syndrome (SIDS). The hospital case notes indicated that the baby boy was born at 34-weeks’ gestation and spent two weeks in the NICU following his birth. Although he was a healthy weight for his gestational age, the records remarked

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that his mother had gestational diabetes and her own health concerns. What prompted most discussion among committee members, however, was that the infant had died at the babysitter’s house. According to the data recorded from the 911 call and contained in the case materials, the babysitter’s daughter found the baby unresponsive, prompting the babysitter to call 911; by the time emergency services arrived it was already too late. Committee members were overly concerned with the qualifications of the babysitter, although no information about the babysitter was included in the case notes:


This babysitter was probably not qualified to care for an infant. They were probably not properly educated or even licensed! And it was the daughter who found the infant, who was really watching this baby? This case screams minimal parenting to me, how does this mother know this is a safe place to leave her baby?

Another committee member was concerned that even though the infant was kept in the NICU, the mother was sent home after two days: “This is a set-up for neglect, how is she going to bond with her baby?” There was no information in the chart about the mother’s visits to the NICU, and as one physician pointed out, “Well, every baby in the NICU is in the same situation. We have no idea whether or not she was visiting because we cannot assume that from information that is not available in this case.” When discussing the ‘Case Suggestions,’ committee members recommended “Follow-up with a nutritionist” because of the mother’s experience with gestational diabetes, prompting one midwife to comment, “Not that she would actually follow through on that recommendation. I still think this case has neglect all over it!” This case is an important place to begin to think about ideas of ‘appropriate’ grief in cases of perinatal loss. The landscape of experience around pregnancy loss has radically changed in the past 25 years (Layne 2003; Reagan 2003). While much of this discourse is inspired by ‘breaking the silence’ around miscarriage, and creating more public awareness of the grief experienced by many women (and men) in the aftermath of a pregnancy loss, I join Reagan (359) in questioning the uncritical expectation of these ‘appropriate’ ways of grieving by hospitals, health professionals, and social workers. In reviewing a neonatal death resulting from severe congenital conditions, one FIMR committee member asked if the mother had held the infant during its 22-hour life: “If this was my baby, incompatible with life, I would want to be offered the chance to hold it, just once, and be told the baby’s situation.” As we looked through the nurses’ notes in the NICU chart, the only reference to the parents is a brief note that the father was at the bedside when the baby died. ‘Holding the baby’ is seen as an important behavior in perinatal loss, as expressed in the ‘Case Strength’ noted, “Family requested to see baby after delivery to bond” (see also Mitchell 2005). Nurses often encouraged women to hold the dead fetus or ‘visit’ the baby. Yet through designating ‘bonding’ with the dead fetus or infant as a strength in processing grief, the FIMR committee and hospital reframes what becomes expected as ‘appropriate’ bereavement. This emphasis on the public aspects of grief over perinatal loss is partly due to a North American social movement that emerged in the past 25 years, as women and families encouraged hospitals and the medical community to shift the treatment of perinatal loss. For many women, even when a pregnancy does not result in a live infant, the process of birth is an important transition to be marked and validated (Layne 2003; Reagan 2003). For other women, hospitals’ and



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physicians’ emphasis on counseling and bereavement rituals can be oppressive. In a 1998 letter to the editor of the New York Times, Sarah Klagsbrun wrote that when she and her husband decided against the hospital bereavement protocol and instead opted for a private religious ceremony, “the staff was reluctant to accept our wishes, and we were made to feel that we were not mourning properly” (quoted in Reagan 2003:369). Grief can also be interpreted as embodied for the FIMR committee. In one case of a neonatal death at seven days, the result of congenital problems, the FIMR nurse abstractor described how the woman refused to be interviewed for the case notes. “I was standing right in front of her, and she just said no.” This prompted one of the midwives to discuss the woman’s ‘body guilt’: “She should be concerned about the fact that she had three previous elective abortions and now lost her child to congenital problems. She probably feels guilty about losing this baby after having those abortions.” There are implicit links between pro-life narratives around abortion and the language used to describe fetal personhood weaved throughout the discourses around perinatal loss (Layne 2003; Reagan 2003). Hospital literature on the expected grief associated with perinatal loss mirrors much of the anti-abortion emphasis on ‘post-abortion trauma syndrome,’ reflecting larger Euro-American shifts in recognizing fetal subjectivity. The ‘grief packet’ given to all parents who suffer a perinatal loss at hospitals throughout Florida City demonstrates these larger moves to construct independent fetal persons through this process. Women and families are given a packet that details local perinatal loss support groups and resources, and a ‘memory box’ containing a ‘baby photo’ and footprints. These baby photos reflect earlier, nineteenth century Euro-American practices immortalizing dead children through photo albums. Although images of the dead are no longer seen as appropriate in contemporary culture, for many parents who have suffered a pregnancy loss these images may be the only ones to mark the ‘existence’ of their child (Layne 2003). But for some feminist scholars more sensitive to the undertones of fetal personhood imbued within memory boxes and grief packets, these images can be politically laden. As noted by Reagan (2003:358) on her own experience with miscarriage: “Those footprints for an eleven-week pregnancy still make my stomach turn. This material was not helpful medical material; it was sympathy with a vested political interest. Baby footprints are one of the symbols—along with roses and fetuses in jars—of the anti-abortion movement.” Although the intention of the FIMR committee and local hospitals in Florida City is to recognize the realities of grief for women and families experiencing a perinatal loss, it also becomes relevant to understand how what becomes valued as ‘appropriate’ grief is structured within very specific historical and cultural configurations of maternal and fetal subjects.

CONCLUSION According to the FIMR guides and literature, the CRT process is explicitly not about fault finding in cases of fetal and infant deaths: “The FIMR process is not about assigning blame for the death. Blame cannot be determined with the subsets of information that FIMR abstracts, nor should it be attempted” (Buckley, Koontz, and Casey 1998:3). Even so, Florida City FIMR discussions about cases of perinatal death often centered on discourses of blame tied to maternal actions and behaviors, underpinned by assumptions that bad mothers lose good babies. This increasing focus on maternal behavior as the sole agent in fetal health and birth outcomes should be situated in both

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the biomedical risk model of pregnancy and increasing legal interests in fetal rights. As argued by Ruhl (1999:97), the biomedical risk model of pregnancy assumes narratives of responsibility:


What is interesting about the responsibilization of prenatal care is the way in which it simultaneously casts the pregnant woman as an authority and agent in the care of herself and her foetus even while it supports the subtext which invokes the very opposite: the irresponsible pregnant woman who endangers the health and well-being of her foetus.

Women’s behavior throughout their pregnancy, labor and delivery, and post-partum period are now subject to both biomedical and public surveillance (Balsamo 1996). In cases of poor birth outcomes, narratives of maternal responsibility become paramount, erasing the social aspects of pregnancy, such as economic factors that influence the utilization of prenatal care and social risk factors for gendered violence and drug abuse, and instead highlight individual responsibility for fetal health (Ruhl 1999). Building on the success of anti-abortion movements in the early 1980s, fetal ‘rights’ became an important strategy at state and federal levels to circumscribe women’s bodily integrity. Incorporating ideas of a maternal-fetal ‘conflict,’ anti-abortion activists have worked to construct the fetus as a separate individual, whose interests conflict with those of the pregnant body that contains them (Markens, Browner, and Press 1997). This North American move toward establishing fetal ‘citizens’ (Casper and Morgan 2004) have gained ground through the collection of embryo and fetal specimens (Morgan 2009), fetal medicine and ultrasound (Casper 1998; Mitchell 2001; Taylor 2008), the prosecution of women for fetal ‘abuse’ (Paltrow and Flavin 2013; Roberts 1998), and workplace restrictions on women of childbearing age (Daniels 1996; Dubow 2011). As Anna Tsing (1992:282) observes: “Pregnancy, childbirth, and child rearing are no longer seen as easy and ‘natural’ routes to motherhood, but as fraught with sacrifices, perils, and challenges that women must surmount.” In many cases, this maternal responsibility for fetal health entails remaining vigilant during pregnancy: eating well, having regular prenatal visits, monitoring fetal movement, and self-educating about strategies for optimizing birth outcomes. Dominant social narratives, or ‘monster stories,’ about mothers who dump their infants in trash bags or otherwise endanger their fetuses and newborns, shape these experiences, and inform women of a new public agenda in which fetuses, and children, must be protected from their own mothers (Tsing 1992). This discourse of fetal rights predominantly shaped the discussions about perinatal death among the members of the Florida City FIMR committee. Conversations about the utilization of prenatal care focused on the responsibility of pregnant women to not only initiate care early in their pregnancy but also moderate their actions based on biomedical prescriptions for behavior and care. Women who did not conform were described as neglectful and bad mothers, and these assumptions erased any factors of structural violence that could influence women’s access to and utilizations of prenatal care. Narratives of race and class were rarely articulated yet implicit within assumptions about women’s behavior and care during pregnancy. This became particularly evident in discussions about the suspected drug use of pregnant women. Although there are numerous risk factors for placental abruption, FIMR committee members overwhelmingly assumed that ‘crack head’ women suffered this pregnancy complication. These assumptions speak to ideas of ‘stratified reproduction’: some women are empowered to nurture and reproduce, others are disempowered (Colen 1995). Finally, moves to create independent fetal subjects have informed ideas about appropriate grieving in cases of perinatal loss. Echoing other work on



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appropriate ‘mother love’ in cases of infant illness and death (Mayblin 2012; Scheper-Hughes 1992), I argue that hospitals’ and social workers’ expectations for ‘bonding’ with fetal remains reflect larger North American ideas about fetuses as autonomous persons. Although the FIMR documents explicitly state that this process is not about blame, the BASINET data sheet and guiding variables clearly structure a discussion about perinatal loss that is rooted in notions of bad mothers and innocent babies. Although I have taken a critical perspective of the discussions of the CRT committee, one of the strengths in the FIMR methodology is the effort to include narratives of women’s experiences, whereby the nurse abstractor attempted to interview caregivers about their experience with perinatal loss. When I began observing the FIMR in early 2005, case summaries rarely included interviews, follow-up was considered difficult due to lack of contact information for parents, and many were uncomfortable with being interviewed by someone from a county-affiliated agency. Yet by the end of my participant observation of these meetings in late 2006, staff of the Florida City Healthy Start noted that people were calling their office and asking to be interviewed for the FIMR CRT. This interest in sharing experiences of perinatal loss led the agency to affiliate with the national organization Share Pregnancy and Infant Loss Support, Inc. and to facilitate monthly local support group meetings at a regional health facility. For families who have experienced the devastating loss of a fetus or infant, the work of the FIMR committee can help ascertain various issues that contribute to rates of perinatal death. Yet discussions within this committee were informed by larger narratives about risk, responsibility, and maternal and fetal subjects, and demonstrate how narratives of perinatal loss are indelibly implicated within abortion politics in the contemporary United States. As an increasing number of states introduce fetal personhood legislation aimed at restricting access to abortion, it is important to recognize the effects of these laws on all pregnant women. Such legislation is utilized by state and health authorities to detain, threaten arrest, and forcibly intervene in the name of preventing ‘fetal endangerment’ (Paltrow and Flavin 2013). Inherent within this legislation are neoliberal constructions of pregnant women as responsible, moral subject, which ignores the structural realties that inform women’s everyday experiences in reproduction. Therefore, moving beyond chimeras of bad mothers and innocent babies, I join other feminist scholars of reproduction to advocate for a reframing of the ‘culture of life’ to include a continuum of reproductive experiences.

ACKNOWLEDGMENTS This article has benefited greatly from the suggestions by four anonymous reviewers as well as the work of the editor and editorial assistant at Medical Anthropology. As part of a conference panel on ‘reproductive misfortune,’ this paper was much improved based on the feedback and suggestions of my co-organizer Aminata Maraesa and our discussant Rayna Rapp.

FUNDING The research was funded by a National Science Foundation—Science, Technology, and Society Dissertation Improvement Grant.

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NOTES 1. Because of the sensitive nature of CRT cases and the confidentiality involved in reviewing fetal and infant deaths, both the identity of the area of the CRT and many of the details of the cases have been obscured. Details important to understanding the particulars of the case are included, but in some cases details from multiple reviews were combined into one case to mask any identifying features and protect the integrity of the process. 2. It is assumed that little intervention can be done in cases of fetal deaths before 20-weeks’ gestation, also considered ‘pre-viable.’ 3. Case privacy was integral to this process, and I have been very careful to disguise any identifying features of this CRT. There was much discussion about encouraging local hospitals and doctors to participate in the process, and privacy was central to this. FIMR reviews are not linked to legal issues in any way, and cases that were implicated in any malpractice lawsuits were not reviewed by this particular CRT. 4. All women who show up in a local emergency room for delivery qualify for ‘presumptive Medicaid,’ a means for the State of Florida to cover the hospital costs for women who do not qualify for insurance or Medicaid because of immigration status. 5. In an interesting twist, a ‘potential’ American citizen can prevent an undocumented pregnant woman from being deported, at least while she continues her pregnancy in the United States (see Casper and Morgan 2004). 6. Feminist scholars such as Armstrong (2008) and Oaks (2001) have argued that narratives linking fetal harm to women’s use of alcohol and tobacco in pregnancy are fraught with moral imperatives around biomedical prescriptions for maternal behavior. With attention to this point, I specifically designate ‘heavy’ exposure to tobacco and alcohol as linked to poor birth outcomes.

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