Motherhood and Mortality

I do respect those individuals who elect (at this time they still can sorta) to become Mothers. Many I think believe or feel that they can be good Mothers, whatever that means. Many Women do not certainly elect Motherhood I hope thinking it will be fine, they will fake it till they make it nonsense. I want to believe that Women are aware you cannot have it all. You cannot. You have to make a huge sacrifice the minute you decide to pursue Motherhood. That means your personal happiness, your own health, your financial security can be at risk and your own Marriage may also collapse with the weight of Parenthood. It is not for the faint of heart.

The United States has an appalling mortality rate regarding lives of both Mothers and Children. This also depends on where you live in the United States, your access to Health Care and Health Insurance. According to the March of Dimes that In the United States, about 6.9 million women have little or no access to maternal health care. And again the most single contributing factor is Race.

The CDC breaks down infant mortality and its causes to Five Factors. The NIH explains it as such here. And the current stats are not good as we enter year three of Covid.

This according to the CDC:

The number of women who died of maternal causes in the United States rose to 1,205 in 2021, according to a report from the National Center for Health Statistics, released Thursday by the US Centers for Disease Control and Prevention. That’s a sharp increase from years earlier: 658 in 2018, 754 in 2019 and 861 in 2020.

That means the US maternal death rate for 2021 – the year for which the most recent data is available – was 32.9 deaths per 100,000 live births, compared with rates of 20.1 in 2019 and 23.8 in 2020.

The new report also notes significant racial disparities in the nation’s maternal death rate. In 2021, the rate for Black women was 69.9 deaths per 100,000 live births, which is 2.6 times the rate for White women, at 26.6 per 100,000.

The number is rising and it is not good, particularly for Women of Color. But it is overall not good for any Woman.

According to the Commonwealth Fund, as well as the World Health Organization, The US has the highest maternal death rate of any developed nation. While maternal death rates have been either stable or rising across the United States, they are declining in most countries.

“A high rate of cesarean sections, inadequate prenatal care, and elevated rates of chronic illnesses like obesity, diabetes, and heart disease may be factors contributing to the high U.S. maternal mortality rate. Many maternal deaths result from missed or delayed opportunities for treatment,” researchers from the Commonwealth Fund wrote in a report last year.

The Covid-19 pandemic also may have exacerbated existing racial disparities in the maternal death rate among Black women compared with White women, said Dr. Chasity Jennings-Nuñez, a California-based site director with Ob Hospitalist Group and chair of the perinatal/gynecology department at Adventist Health-Glendale, who was not involved in the new report.

“In terms of maternal mortality, it continues to highlight those structural and systemic problems that we saw so clearly during the Covid-19 pandemic,” Jennings-Nuñez said.

“So in terms of issues of racial health inequities, of structural racism and bias, of access to health care, all of those factors that we know have played a role in terms of maternal mortality in the past continue to play a role in maternal mortality,” she said. “Until we begin to address those issues, even without a pandemic, we’re going to continue to see numbers go in the wrong direction.”

So the reality is that we have a rising tide no boats just Moby crashing his tail against the water to insure the waves drown us as we thrash along in the water. And here we are about to make it harder for Women to manage their own reproductive choices. Good idea says the White Man in the Judicial Robe.

I have been noting the deterioration of mental health particularly among children as they come of out the Pandemic. This generation born during the time it began in 2020 and those who were still in K-12 schools are the new generation and they are really fucked up. Do I think it matters if schools were open or closed? No it is larger than that. You cannot Teach and cannot learn in a world and an environment that surrounds you which is in chaos. Sorry you cannot put yourself in a bubble or Island to prevent the world that is outside waiting for you to emerge. Going to school everyday I believe did no more or less than those who remained online. You are kidding yourself if you believe otherwise.

I truly believe any Woman who CHOSE to become pregnant during Covid lockdowns was either incredibly selfish, bored or utterly oblivious. Denial perhaps but there is a type of arrogance that ignorance allows those so unaware of what was happening in hospitals and in medicine overall that I have little or no respect of. Your kids like you Lady are fucked up. Again I point to 946 as my Karen in that room. She is batshit crazy and that is contagious.

I reprint this from the New York Times to understand how serious this issue is. I know I am harsh but I have that luxury and I never wanted Children so that has to be taken into account. I knew early on it was not for me. Not one regret there. But I do support Women’s Reproductive Rights and with that the choice to have a child. I support public health care, public education and tax credits for children and families as well as better wages and work environments for those who care for children, but I do not support stupidity. And those are the Women who think that it is not a massive sacrifice for at least two decades worth of life. Get over yourself you are not special. I am talking to you Karen.

Covid Worsened a Health Crisis Among Pregnant Women

In 2021, deaths of pregnant women soared by 40 percent in the United States, according to new government figures. Here’s how one family coped after the virus threatened a pregnant mother.

By Roni Caryn Rabin The New York Times March 16, 2023

KOKOMO, Ind. — Tammy Cunningham doesn’t remember the birth of her son. She was not quite seven months pregnant when she became acutely ill with Covid-19 in May 2021. By the time she was taken by helicopter to an Indianapolis hospital, she was coughing and gasping for breath.

The baby was not due for another 11 weeks, but Ms. Cunningham’s lungs were failing. The medical team, worried that neither she nor the fetus would survive so long as she was pregnant, asked her fiancé to authorize an emergency C-section.

“I asked, ‘Are they both going to make it?’” recalled Matt Cunningham. “And they said they couldn’t answer that.”

New government data suggest that scenes like this played out with shocking frequency in 2021, the second year of the pandemic.

The National Center for Health Statistics reported on Thursday that 1,205 pregnant women died in 2021, representing a 40 percent increase in maternal deaths compared with 2020, when there were 861 deaths, and a 60 percent increase compared with 2019, when there were 754.

The count includes deaths of women who were pregnant or had been pregnant within the last 42 days, from any cause related to or aggravated by the pregnancy. A separate report by the Government Accountability Office has cited Covid as a contributing factor in at least 400 maternal deaths in 2021, accounting for much of the increase.

Even before the pandemic, the United States had the highest maternal mortality rate of any industrialized nation. The coronavirus worsened an already dire situation, pushing the rate to 32.9 per 100,000 births in 2021 from 20.1 per 100,000 live births in 2019.

The racial disparities have been particularly acute. The maternal mortality rate among Black women rose to 69.9 deaths per 100,000 live births in 2021, 2.6 times the rate among white women. From 2020 to 2021, mortality rates doubled among Native American and Alaska Native women who were pregnant or had given birth within the previous year, according to a study published on Thursday in Obstetrics & Gynecology.

The deaths tell only part of the story. For each woman who died of a pregnancy-related complication, there were many others, like Ms. Cunningham, who experienced the kind of severe illness that leads to premature birth and can compromise the long-term health of both mother and child. Lost wages, medical bills and psychological trauma add to the strain.

Pregnancy leaves women uniquely vulnerable to infectious diseases like Covid. The heart, lungs and kidneys are all working harder during pregnancy. The immune system, while not exactly depressed, is retuned to accommodate the fetus.

Abdominal pressure reduces excess lung capacity. Blood clots more easily, a tendency amplified by Covid, raising the risk of dangerous blockages. The infection also appears to damage the placenta, which delivers oxygen and nutrients to the fetus, and may increase the risk of a dangerous complication of pregnancy called pre-eclampsia.

Pregnant women with Covid face a sevenfold risk of dying compared with uninfected pregnant women, according to one large meta-analysis tracking unvaccinated people. The infection also makes it more likely that a woman will give birth prematurely and that the baby will require neonatal intensive care.

Fortunately, the current Omicron variant appears to be less virulent than the Delta variant, which surfaced in the summer of 2021, and more people have acquired immunity to the coronavirus by now. Preliminary figures suggest maternal deaths dropped to roughly prepandemic levels in 2022.

But pregnancy continues to be a factor that makes even young women uniquely vulnerable to severe illness. Ms. Cunningham, now 39, who was slightly overweight when she became pregnant, had just been diagnosed with gestational diabetes when she got sick.

“It’s something I talk to all my patients about,” said Dr. Torri Metz, a maternal fetal medicine specialist at the University of Utah. “If they have some of these underlying medical conditions and they’re pregnant, both of which are high-risk categories, they have to be especially careful about putting themselves at risk of exposure to any kind of respiratory virus, because we know that pregnant people get sicker from those viruses.”

Lagging Vaccination

In the summer of 2021, scientists were somewhat unsure of the safety of mRNA vaccines during pregnancy; pregnant women had been excluded from the clinical trials, as they often are. It was not until August 2021 that the Centers for Disease Control and Prevention came out with unambiguous guidance supporting vaccination for pregnant women.

Most of the pregnant women who died of Covid had not been vaccinated. These days, more than 70 percent of pregnant women have gotten Covid vaccines, but only about 20 percent have received the bivalent boosters.

“We know definitively that vaccination prevents severe disease and hospitalization and prevents poor maternal and infant outcomes,” said Dr. Dana Meaney-Delman, chief of the C.D.C.’s infant outcomes monitoring, research and prevention branch. “We have to keep emphasizing that point.”

Ms. Cunningham’s obstetrician had encouraged her to get the shots, but she vacillated. She was “almost there” when she suddenly started having unusually heavy nosebleeds that produced blood clots “the size of golf balls,” she said.

Ms. Cunningham was also feeling short of breath, but she ascribed that to the advancing pregnancy. (Many Covid symptoms can be missed because they resemble those normally occurring in pregnancy.)

A Covid test came back negative, and Ms. Cunningham was happy to return to her job. She had already lost wages after earlier pandemic furloughs at the auto parts plant where she worked. On May 3, 2021, shortly after clocking in, she turned to a friend at the plant and said, “I can’t breathe.”

By the time she arrived at IU Health Methodist Hospital in Indianapolis, she was in acute respiratory distress. Doctors diagnosed pneumonia and found patchy shadows in her lungs.

Her oxygen levels continued falling even after she was put on undiluted oxygen, and even after the baby was delivered.

“It was clear her lungs were extremely damaged and unable to work on their own,” said Dr. Omar Rahman, a critical care physician who treated Ms. Cunningham. Already on a ventilator, Ms. Cunningham was connected to a specialized heart-lung bypass machine.

Jennifer McGregor, a friend who visited Ms. Cunningham in the hospital, was shocked at how quickly her condition had deteriorated. “I can’t tell you how many bags were hanging there, and how many tubes were going into her body,” she said.

But over the next 10 days, Ms. Cunningham started to recover. Once she was weaned off the heart-lung machine, she discovered she had missed a major life event while under sedation: She had a son.

He was born 29 weeks and two days into the pregnancy, weighing three pounds.

Premature births declined slightly during the first year of the pandemic. But they rose sharply in 2021, the year of the Delta surge, reaching the highest rate since 2007.

Some 10.5 percent of all births were preterm that year, up from 10.1 percent in 2020, and from 10.2 percent in 2019, the year before the pandemic.

Though the Cunninghams’ baby, Calum, never tested positive for Covid, he was hospitalized in the neonatal intensive care unit at Riley Hospital for Children in Indianapolis. He was on a breathing tube, and occasionally stopped breathing for seconds at a time.

Doctors worried that he was not gaining weight quickly enough — “failure to thrive,” they wrote in his chart. They worried about possible vision and hearing loss.

But after 66 days in the NICU, the Cunninghams were able to take Calum home. They learned how to use his feeding tube by practicing on a mannequin, and they prepared for the worst.

“From everything they told us, he was going to have developmental delays and be really behind,” Mr. Cunningham said.

After her discharge from the hospital, Ms. Cunningham was under strict orders to have a caretaker with her at all times and to rest. She didn’t return to work for seven months, after she finally secured her doctors’ approval.

Ms. Cunningham has three teenage daughters, and Mr. Cunningham has another daughter from a previous relationship. Money was tight. Friends dropped off groceries, and the landlord accepted late payments. But the Cunninghams received no government aid: They were even turned down for food stamps.

“We had never asked for assistance in our lives,” Ms. Cunningham said. “We were workers. We used to work seven days a week, eight-hour days, sometimes 12. But when the whole world shut down in 2020, we used up a lot of our savings, and then I got sick. We never got caught up.”

Though she is back to work at the plant, Ms. Cunningham has lingering symptoms, including migraines and short-term memory problems. She forgets doctor’s appointments and what she went to the store for. Recently she left her card in an A.T.M.

Many patients are so traumatized by their stays in intensive care units that they develop so-called post-intensive care syndrome. Ms. Cunningham has flashbacks and nightmares about being back in the hospital.

“I wake up feeling like I’m being smothered at the hospital, or that they’re killing my whole family,” she said. Recently she was diagnosed with post-traumatic stress disorder.

Calum, however, has surprised everyone. Within months of coming home from the hospital, he was reaching developmental milestones on time. He started walking soon after his first birthday, and likes to chime in with “What’s up?” and “Uh-oh!”

He has been back to the hospital for viral infections, but his vocabulary and comprehension are superb, his father said. “If you ask if he wants a bath, he’ll take off all his clothes and meet you at the bath,” he said.

Louann Gross, who owns the day care that Calum attends, said he has a hearty appetite — often asking for “thirds” — and more than keeps up with his peers. She added, “I nicknamed him our ‘Superbaby.’”

Priorities Matter

I think I spend most of my time trying to find ways to prove how Racism and Classicism dominate the South as they are not mutually exclusive, and in turn further marginalize those in the lower economic classes,  and to use an appalling word, “enslaving” those to a life on the lower rungs of lifes ladder to climb.

The biggest tool is supposedly education. Let’s put that trope to rest shall we?  Schools are more segregated than they were 40 years ago. We have massive income inequality that further divide and in turn conquer.   The South loves to claim many things and particularly here in Nashville the “it” city but the facts matter (well not so much in the south).

The public schools here are of course divided by race and class.  The numbers run as such:

MNPS is 42% Black, 29% White, and 25% Hispanic. But if you look at second graders the percentages are 39% Black, 25% Hispanic, 31% White. When you look at 6th grade, it breaks down 43% Black, 26% Hispanic, 27% White. In 9th grade it is 43% Black, 25% Hispanic, and 27% White. In 12th grade it is 48% Black, 21% Hispanic, and 32% White. Total enrollment for 2nd grade is 6999, 6th grade is 6571, 9th is 5859, and 12th is 5122.

Taking a  look at Pre-k:  For Pre-K 4 out of 2917 students, 44% are Black, 22% are Hispanic, and 29% are White. 

This further demonstrates that as children age up in the system the bleed of White students continues with an odd uptick in 12th grade.  I suspect it has to do with the idea of being the biggest fish a little pond of academic success so in turn qualify for loans and grants and the misconception that this same student was in an integrated environment for four years and is a “good” student.  There are lies and misconceptions here that cannot be ignored.

The number of FRL (free and reduced lunch) is the Scarlet letter of a school    Nashville had in 2014 72% of their students qualify so to remove the stigma they in turn made lunches free for all; additionally they provide breakfast for Elementary and Middle school students.   Then in turn it lessens the impact of a school designated by the label FRL which in turn causes Parents to look elsewhere to educate their likely white and of course above average child.   I will point out that the food quality is appalling and led to one high school having a walkout over the food last year.  But it is free and one never says no to a free lunch.   But again does this measure mean anything and by removing that measurement tool Nashville has nothing to compare or measure.  That may be the point.   Priorities matter.

I have long commented that the concepts of accessibility and availability are on par with equality and equity. They are not the same and have clear distinctions that are usually defined by money.  Those who have it have it those who don’t can but don’t.  Priorities matter.

So when I read this article about pre-term births I shrugged.  That is my de facto response these days when I read article after article in our local news that discusses what restaurant is opening or what property sold for millions, I troll down the page and find this buried under sports.  Priorities matter.

I cannot tell you the damage the Black and Hispanic children I meet.  I meet many Middle Eastern/European children as well but ultimately the most significant behavior problems and issues that exist are with Black children.  There are fights daily on campuses across the spectrum.  As I wrote last week at being at a school where  Student head butted a Teacher.  But the fights are no longer recorded so we get no information as to schools that have a predominate amount of problems and in turn know anything about the environment we are walking into.  I also shared the story about the school that has had 60 fights this year and are working on climate change.  I am sure it will be the same as the one we have with regards to the other environment.    This is the South.    Priorities matter.

It is because of those observations and experiences that had led me to question my own values and believes about race until I asked of all people an Uber driver who was Black and from California what was happening to me.  He told me it was the South and the way the dynamics are set up it is to ensure that the myth of equality exists but the reality is just a unicorn held up as something unattainable and unreal. And in turn those largely affected by it finally give up and resign themselves to a life less lived.   And in turn Children who do not have the barometer or filter yet still demonstrate the frustration and confusion that is their lives.  I cannot make excuses anymore I just accept it and in turn want to get as far away from this as soon as possible.  Priorities matter.

I am at the prestigious high school today in Special Ed.  It is all white and all the kids are articulate and polite and the “bad” kid I met last week is the most funny smart kid I have met and hence that in this school is perhaps the worst they have so they do in fact suspend kids but for a day or two.  They no longer do with minority children and have attempted to establish a restorative justice program, the same program that led 40% of a school in Highline District in Seattle to walk out and a Teacher to write a blog in length discussing the level of fear that existed in the school and the climate that resulted from failing to have a program that worked with Students at risk. 

When you are born prematurely, fed garbage, take drugs earlier, live in an environment literally our environment that has dangerous air and water, to a family marginalized, who don’t speak English, who themselves were the victims of violence or terror be it domestic or international, the children have no future,  just existence.    Violence begets violence and it is not easy to escape despite best efforts.  Just ask those who suffered at the hands of the New York terrorist, San Bernadino, Orlando. The reality is that Religion is not the reason, anger is and anger emerges in destruction – to self or to others.

We do little to help those climb out and upward.  We like to ensure our own place on the ladder the rest be damned.  Priorities matter.

Tennessee gets ‘D’ for preterm babies, raising concerns about women’s health

Holly Fletcher, USA TODAY NETWORK – Tennessee Published Nov. 1, 2017 |

The number of babies born prematurely in Tennessee increased from 2015 to 2016 — a trend that underscores disparities in women’s health around the state, a maternal health expert said.
Overall, Tennessee earned a “D” for its preterm birth rate of 11.3 percent in 2016 from March of Dimes, a nonprofit focused on pregnancy and the health of babies.

The counties with the highest preterm birth rates in the state:

Hamilton: 13 percent
Shelby:  12.6 percent
Rutherford: 10.5 percent
Davidson: 10.4 percent (Nashville)
Knox: 9.7 percent
Montgomery: 9 percent

The data is troubling to Dr. Kimberlee Wyche-Ethridge, assistant director for public health practice at Meharry Medical College, because of what it means about the status of women’s health and factors that influence health — such as education, housing and food — across the state.

“We’re not doing enough to make sure all of our babies are being born to thrive and survive,” said Wyche-Etheridge. “Babies are the canary in the coal mine. They are a measure of how healthy a community, a state or a society is. If we see that our babies aren’t doing well, we know our communities aren’t doing well.”

Black women had highest percentage of preterm births from 2013 to 2015 with 14.3 percent. White women came in second with 10.2 percent followed by Hispanic women with 9.1 percent and Asian/Pacific Islander women with 8.4 percent.

March of Dimes has a goal of a nationwide rate of 8.1 percent by 2020. Preterm birth rates worsened in more than 40 states. Tennessee is one of 11 states and Washington, D.C., to receive a “D” on the Premature Birth Report Card.

In 2007, 11.8 percent of babies born in Tennessee were preterm, or before 37 weeks. Since then, the rate dipped to 10.8 percent in 2014, only to climb back in the succeeding years.
The organization is calling for more research and education about the social factors that impact health, ranging from neighborhood safety to income and jobs.

There are state and local initiatives aimed at reducing preterm births, which can lead to lifelong chronic problems as the person grows.

Focusing on women’s health before they become pregnant is important, Wyche-Etheridge said, because it lays better groundwork for healthy babies.

“Since prematurity hits every aspect of the community, no one is protected per se, and we have to take care of all of our women in all of our families so all of our babies have a chance at a healthy start.”

Health screenings and controlling high blood pressure, weight and diabetes are important factors in a woman’s health before she becomes pregnant, said Wyche-Etheridge, a public health pediatrician who has worked on maternal health issues for 20 years. Reducing stress is vital, she said, noting that can come from worrying about finances, housing or other facets of life.

Davidson County public health officials analyzed the preterm births by neighborhood and found a wide discrepancy. Babies born to women who live in The Nations and North Nashville were twice as likely to have a low birth weight or be preterm than those born to women who live in Sylvan Park, the neighborhood on the other side of Charlotte Pike.

Wyche-Etheridge said preterm pregnancies can have a cyclical impact on communities.
“What we find is her health prior to pregnancy is key, which means if we don’t have a community that values women’s health then women are not going into a pregnancy in tip-top shape,” said Wyche-Etheridge.

“Without healthy babies, it’s less likely we have healthy adults, and we can’t have a healthy state.”

Psst, Codeword is….

Back in the day before the NSA we were all sure that Big Brother was watching, sadly now we know they weren’t after all.  But you always spoke in some sort of obtuse code to buy or sell drugs.  Bill Maher does a hilarious bit about that as he put himself through college selling pot. One thinks  of drug dealers as these nefarious souls, a cross between Shaft and Superfly, um no they are the boy next door – literally and figuratively.

But in reality today to buy drugs one wants and actually needs it is easier to get pot. I can got down the street to the left or right and buy as much pot as I am legally “prescribed.” Which means backache, headache, fill in the blank ache.  Shame I don’t smoke pot.  But if I actually needed medications, given my lack of insurance or the kind I could afford, the prescriptions probably not covered.  Back when I used Birth Control it was around $10/month, wow again nostalgia for the good old days is starting to mean I am one step from my Medicare prescribed and partially paid for scooter chair.

With once again the whole strum and drang over the Affordable Care Act and the collapse of the online sign up we neglect to actually talk about what it does or does not do.  It will not reduce the costs of medicine nor make it for many more accessible and in turn affordable. And there is still the issue of infant mortality.  The same crowd who likes to preface every rant and rave “for the children” rarely do anything for them – such as fund pre school, education, food and nutrition, reduce college costs or well secure affordable safe homes for them to live in which to do any of that.  But hey I am picking noses, fences, fights, whatever… just don’t sweat the small stuff!

So I put below two articles that discuss both.  One about the lengths people go to to “smuggle” drugs and the thought that we do nothing to help rise our rate of infant mortality. What Eduardo also forgot to mention is age of mother and the income of the family which I believe is a major reason for this “problem”;  along with pre and post natal care, we have no to little maternity or family leave which may also be a contributing factor to why many children don’t make it to vote. Something the town criers need to think about.

As Drug Costs Rise, Bending the Law Is One Remedy

By ELISABETH ROSENTHAL
Published: October 22, 2013

Lee Higman, a 71-year-old artist from Bellevue, Idaho, who considers herself a law-abiding citizen, was shocked last month when she got a notice from the Food and Drug Administration telling her: “A mail shipment addressed to you from a foreign country is being held.”

< The 90 tablets of Vagifem, prescribed by her physician, that she had ordered from a Canadian pharmacy had been impounded as an illegal drug at Los Angeles International Airport. First marketed in 1988, Vagifem estrogen tablets are used by millions of women to relieve symptoms of menopause. There is no generic version available in the United States, and brand-name drugs are expensive here.

So about five years ago, Mrs. Higman started ordering the tablets from Canada, where a year’s supply that would cost about $1,000 in the United States sells for under $100. “The price went up. And we’d lost a lot on the stock market, and we’re living on fixed incomes,” Mrs. Higman, who is an artist, said in an interview.

She and her husband, a writer, are covered by Medicare. In an e-mail to the Food and Drug Administration, she sought the release of the package, explaining, “When it became economically imperative I ordered it from Canada, a country with strict drug requirements.”

The high price of many prescription drugs in the United States has left millions of Americans telling white lies and committing fraud and other crimes to get their medicines.

In response to a New York Times article about the costs, hundreds of readers shared their strategies, like having a physician prescribe twice the needed dose and cutting pills in half, or “borrowing” medicines from a friend or relative with better insurance coverage. But an increasingly popular — though generally illegal — route is buying the drugs from overseas.

The Canadian International Pharmacy Association, a 10-year-old group, said its members fill prescriptions for one million Americans each year. “It’s the Americans who are seeking us out,” said Tim Smith, the group’s general manager. “Clearly there’s a need.”

In surveys from 2011 by the Centers for Disease Control and Prevention, about 2 percent of adults and about 5 percent of the uninsured said they had bought prescription drugs from other countries. The figures most likely underestimated the practice because people may be reluctant to admit to doing something illegal, even though the law is rarely enforced in such cases.

The Food and Drug Administration says on its Web site that “in most circumstances it is illegal to import drugs into the U.S. for personal use” because the agency cannot guarantee they are safe and effective. The government also prohibits “reimportation” of drugs made in the United States because it cannot guarantee the medications were not tampered with or stored improperly.

The agency said it does not track the volume of such imports. However, it “typically does not object” to people buying imported medicine for personal use “under certain circumstances,” the agency said. Those include using the drug to treat a serious condition for which an effective alternative is unavailable in the United States and purchasing less than a three-month supply. But those ambiguous edicts have left patients wary.

Dr. Stephen Barrett, a retired psychiatrist and health care advocate in North Carolina, said he has saved thousands of dollars buying medicines from overseas in the past decade. “It may be technically illegal, but I don’t think anyone would ever get prosecuted,” he said, adding that such laws reflected “protectionism” for drug makers. Although the Obama administration initially proposed allowing some importation of drugs, the idea was dropped from the Affordable Care Act after intense opposition from the pharmaceutical industry.

Mr. Smith, of the Canadian pharmacy group, said members follow strict pharmacy and prescription protocols and dispense only medicines approved by Health Canada, which regulates them. Members also broker purchases from licensed pharmacies in other countries, like Britain and Australia, which may further reduce the costs. Package inserts in foreign languages must be translated into English.

He acknowledged that consumers must take care to ensure an online pharmacy is legitimate, noting that in 2011 his association sent hundreds of cease-and-desist letters to Web sites — some of which were not based in Canada and were not even pharmacies — that were fraudulently using the group’s certification seal.

Dr. Barrett said he uses Web sites like PharmacyChecker.com to screen online pharmacies and prefers products from English-speaking countries.

Some purchases from overseas pharmacies are identical to products sold in the United States. When a Food and Drug Administration compliance officer told Mrs. Higman that her order of Vagifem was held because it was an “unapproved” drug, she responded, “This drug might come from Turkey, however, it is in the same box, the same packaging, the same labels, the same manufacturer, Nordisk, as the outrageously priced Vagifem in the United States.”

Identical drugs sold in other countries may have different package inserts, slight variations in dose or different brand names. But that is frequently a function of patent law and business decisions by drug makers, rather than medical efficacy.

Diana Simonson, 42, a freelance computer programmer in Glens Falls, N.Y., said she started ordering her inhalers from Canada after she nearly died of an asthma attack in the United States, where she cannot afford her preventive treatments.

For decades, she was able to control her asthma with a steroid inhaler. But it was banned a few years ago because it contained a propellant that was deemed environmentally harmful. The replacement product cost $250 a month. “That was like another car payment — I couldn’t do it,” said Ms. Simonson, who has a high-deductible insurance policy through the Freelancers Union.

With an income of about $35,000 and a child to raise, she tried to do without. But at an air show with her 7-year-old son, she became so short of breath that she had to be rushed by ambulance to an emergency room.

The inhalers she gets from Canada every three months are the same brand, and by the same manufacturer, that she used to buy in the United States. But often they are produced in a third country, like Turkey or Malaysia.

Kristen Bailey of Colorado started ordering medicine by mail from India when she was given a diagnosis of Crohn’s disease after graduating from college in 2011 with no insurance. Her medicine retails for tens of thousands of dollars in the United States.

The process is simpler for patients who live near the border. Joshua Kalish, 70, of Silver City, N.M., said that before he was eligible for Medicare, he drove to Mexico to fill his prescriptions, calling it a “common practice.”

Mrs. Higman said she is also heading for the border. Despite her pleas, the Food and Drug Administration told her that her Vagifem tablets would be returned to Canada or destroyed.

To tide her over, she has spent $233 for two months of Vagifem at a local pharmacy. “Fortunately my children and grandchildren live in Seattle, so the next time we go over there, I’ll take a little trip up to Vancouver, British Columbia, to buy my medicine,” she said. “I’ll save enough money to get room service in a five-star hotel there and still have enough left to claim I saved a couple of bucks.”

New Front in the Fight With Infant Mortality

By EDUARDO PORTER
Published: October 22, 2013

As the health care bill that was to become known as Obamacare was making its way through Congress in 2009, Senator Jon Kyl, Republican of Arizona, sought to block the requirement that health insurers cover a minimum set of health benefits determined by the federal government.

“I don’t need maternity care,” said Senator Kyl, who retired from the Senate last year at the age of 70. “Requiring that on my insurance policy is something that I don’t need and will make the policy more expensive.”

Mr. Kyl’s proposed amendment embodied the conservative view: The Affordable Care Act that passed Congress in 2010 is an unacceptable intrusion into the private decisions of American families and businesses.

The Senate Finance Committee, by a vote of 14 to 9, rejected the amendment, opting for a different approach that could change, in subtle but profound ways, the nature of the American social contract.

Pregnant women, across the country and anywhere along the income spectrum, will for the first time have guaranteed access to health insurance offering a minimum standard of care that will help keep their babies alive.

The benefit may seem narrow. But it offers the best opportunity in a generation to tackle one of the United States’ most notorious stigmas: an intractably high infant mortality rate that hardly fits one of the richest, most technologically advanced nations on earth. If it succeeds, it could provide Americans with an alternative view of how government can serve society.

I have brought up infant mortality before as a marker of the drawbacks inherent in the United States’ model of relatively low taxes and modest government, leaving more social outcomes to the sway of market forces. < The United States was not always at the bottom of the charts. Four decades ago, Americans lost proportionately fewer babies than average among industrialized nations. The United States lost more than France but fewer than Germany, more than Sweden but fewer than Luxembourg. By 2010, however, virtually every other advanced country had surpassed the United States.

 In Portugal, 2.5 babies out of every 1,000 born alive died before they were a year old. In Finland and Japan the figure was 2.3. Though the United States has made progress recently, it still lost 6.1. Among members of the Organization for Economic Cooperation and Development, only Mexico, Chile and Turkey did worse.

It is unclear to what extent Obamacare might help prevent these earliest of deaths. Infant mortality is a complex problem. The frustration of hundreds of thousands of Americans fruitlessly trying to buy health insurance on the new federal exchange raises legitimate questions about whether such a mind-bogglingly complex reform can fulfill its main purpose of providing near-universal health coverage.

Still, the experience of other countries — not to say common sense — suggests that offering broad access to health care to women before, during and after their pregnancy could help close the gap with the nation’s peers.

“This is a sea change,” said Genevieve Kenney, co-director of the Health Policy Center at the Urban Institute, a nonpartisan research center in Washington. “The needle could move.”

Consider Finland. Mika Gissler, a research professor at the National Institute for Health and Welfare in Helsinki, told me that Finland decided to take action against infant mortality in the 1940s, when the country had a poor agrarian economy.

Today the Finnish government provides free prenatal care to every woman who wants it. Of every 1,000 pregnant women, some 997 — including illegal immigrants — visit the maternity clinics 13 to 15 times during their pregnancy, on average.

They are screened for risk factors. They learn about breast-feeding and how to care for their baby. Fathers too, learn what to expect and how to contribute once their baby is born.

Partly as a consequence, the infant mortality rate has fallen to about one-sixth of what it was in 1970. Mr. Gissler notes that only 5.7 births out of 100 are premature, about the same as a quarter of a century ago.

In the United States, such maternity care is rare. Individual health policies usually do not cover pregnancy. Fewer than two out of three pregnant women in Texas or Maryland have even one prenatal care visit in their first trimester. And almost 12 American babies out of 100 are born prematurely, more than twice the rate in Finland and 18 percent more than 25 years ago.

Prenatal care alone is not enough. The causes of the high death rate of American babies remain, to some extent, nebulous.

For a while, experts hoped measurement differences might explain it away: unlike some European countries, the United States counts the fleeting existence of very premature babies as live births. Yet while this accounts for part of the gap, the American mortality rate remains substantially higher among babies who are delivered closer to their full term, too.

The large number of premature deliveries — many more than in the rest of the developed world — is probably the most important factor. But experts don’t have a clear picture of what causes so many babies to be born before, sometimes well before, 37 weeks of gestation.

An in-depth report published in 2006 by the Institute of Medicine of the National Academies of Science identified a wide range of overlapping “behavioral and psychosocial factors, neighborhood characteristics, environmental exposures, medical conditions, infertility treatments, biological factors and genetics.”

Pregnant women who have diabetes or high blood pressure are more likely to deliver premature babies prone to die early. So are obese women, women who smoke, teenagers and women who have second babies soon after the first.

The pattern follows familiar contours of social and economic deprivation. Infant mortality is much higher among black babies than among whites. The babies of less educated women die at a higher rate than those born to women with more education. But these factors alone do not explain the entire picture. Non-Hispanic white babies also die at a higher rate than in Finland, Mr. Notzon told me.

The complex causes behind America’s high infant mortality might suggest there is little the government can do. It might do better than to stick its finger into the maw of social and economic forces it has little power to sway and does not fully understand.

Washington has tried before and failed. In an attempt to reduce infant mortality, starting in the second half of the 1980s Medicaid was expanded broadly to cover more pregnant women. According to one study, Medicaid covered almost half of births in 2010. And yet infant mortality rates improved little.

President Obama’s health care law might stand a better chance. That expansion of Medicaid picked up women only once they became pregnant. And it dropped them a few weeks after giving birth, cutting them off from advice on family planning, breast-feeding and healthy behaviors for a new mother.

The Affordable Care Act, by contrast, should offer broader, consistent access to care for all women. It puts a lot of emphasis on prevention and fostering healthy behavior. It could help reduce unwanted pregnancies, which often lead to premature births, or even relieve the financial stress of going without adequate health care.

“Women of lower income and education whose jobs don’t provide health care will have more consistent care on an ongoing basis,” Ms. Kenney said. “For women of reproductive age, this is a sea change.”

Today, the United States’ private health care industry offers the most advanced care in the world for premature babies and their survival rate is higher than elsewhere. Technology, however, has done nothing to help there.

“The problem is not the technology,” said Gaetan Lafortune, an economist at the O.E.C.D.’s health division. “The problem is having so many women delivering babies at half term.”

For this, Obamacare might do a better job. If it cut into the United States’ rate of infant deaths, it might offer a new perspective on government’s ability to address the nation’s health and, perhaps, other social dysfunctions.