Saturday was Valentine’s Day and as I have been doing for several years, I took myself out for a drink at a fancy place, one where bar seating is walk-in only, early in the evening. I like to people-watch the straight couples on their dates. Even just compared to last Valentine’s Day, the vibes this year were markedly more rancid. A gendered asymmetry of effort on all levels. Sartorially: the women were dressed up for a night out, bold lips and tasteful statement jewelry, while the men were wearing zero-effort street clothing – that horrible, universal navy gingham shirt that men wear would have been an upgrade for these fellows. Conversationally: the women carried all the conversational labor of their dates, to mixed responses. Some men were “listening” to their partners, by occasionally looking at them directly, and doing so with a painfully self-conscious smirk on their faces, as if it was the most exasperating and exhausting thing in the world to be on a dinner date with the mother of their children. Other couples weren’t talking at all and just sat silently next to one another, the woman pretending to scrutinize the menu, the man taking fulsome swigs from his glass of beer. (In context, I feel that ordering a big wheaty beer on a Valentine’s date is fundamentally aggressive, anti-sexual.) I love Valentine’s Day, and I love to celebrate it alone, and I usually come away from these little solo dates with a pervading warm and fuzzy feeling of good will towards all, courtesy of the $16 whiskey drinks I’ve just bought myself. This time I came away feeling icky and depressed, like a passing car had just splashed me with rainwater and exhaust runoff. 

Then last night I saw people talking online about a new research letter in the New England Journal of Medicine. This is noteworthy because it quantifies some things that maternal mortality researchers have been warning about for years – the number of pregnancy-related deaths that go basically uncounted and unquantified because our death reporting system, especially for deaths in and around pregnancy, is so fragmented and uneven. The authors of the letter examined maternal deaths 2018-2023 by cause of death, finding the leading causes to be those our data systems are the least optimized to measure: overdose, followed by homicide, followed by suicide. I have written about these measurement problems before, including in this newsletter from nearly two years ago (sorry for the mention of the podcast in it, I mercifully haven’t been associated with them for a long time). Briefly, because of federalized death-certificate reporting practices, it’s very difficult to count pregnancy-related and -associated morbidity and mortality here compared to in a place like, e.g., Sweden, with robust national vital statistics registries and universal health care. Please indulge me in quoting extensively from that previous newsletter:

While clinical professional groups have issued gold-star statements about standards of care for treating substance use disorders in pregnancy, the actual reality does not match the standard-of-care documents. Many states criminalize not only drug use during pregnancy, but also the treatments for substance use disorders recommended by the professional associations of obstetricians (like methadone or buprenorphine treatment). Rapid opioid dose tapering and abrupt discontinuation are associated with increased rates of fatal overdose, mental health episodes, self-harm, and suicide. If someone's treatment is disrupted because they are pregnant, because of the legal environment being constructed around pregnancy, fetal personhood, and criminal liability, is their resulting death merely pregnancy-associated? Or would we be right to count it as a "true" pregnancy-related perinatal death?

Similarly, what about assault and homicide? Perinatal deaths from these causes are similarly not related to the physiological changes wrought by pregnancy itself. But to argue that they aren't related to pregnancy seems wrong. I worked for a number of years at a domestic violence hotline. It is well known, including from my professional experience, that abuse tends to begin and escalate during pregnancy, even to the point of murder. The reasons for this are cultural and social rather than physiological -- but are they any less salient? I would argue, especially in an environment where abortion and even birth control or sex education are increasingly criminalized, as they are in our country right now, that these causes are equally salient even if they are not as amenable to chopping up for a rote multivariable regression analysis.

All the talk of trends obscures what is really going on here -- the authors of the AJOG study want, probably because they are epidemiologists, clinicians, and very old hats in the realm of maternal mortality research, to restrict the counting to these physiological, clinical things; this undercount feels to them more "accurate" than the more expansive overcounting of the checkbox method. Rather than an intensification or diminution of existing trends, I think what we are experiencing is a qualitative transformation in how pregnancy is culturally, socially, and medically conceptualized. Pregnancy is increasingly a category or a state of suspicion, criminalization, dehumanization, and control as the state assumes the role of an abusive partner for all people capable of gestation. What's at stake in these arguments about how to count pregnancy-related deaths is how much or how expansively we want to politicize the public health problem of perinatal deaths.

I agree with my 2024 self that a more expansive definition of pregnancy-related mortality is appropriate to public health, but I have to admit that I don’t understand why or to what end. My impulse, as I was reading the NEJM letter this morning, was to talk righteously about how homicide as a leading cause of pregnancy-related death exposes the limits of public health thinking about social problems versus technical problems. But what does this even mean? What is accomplished here, besides a smug reiteration of some shit we already know? Technical vs. social is a level one distinction, the problem it expresses is a mere category error. The harder problem for public health involves conceptualizing the relations between analytic “levels” for issues where multiple levels are involved, like the issue of pregnancy-associated homicide – technical and social, individual and group. How can we hold onto the findings of this research letter – that homicide is a leading cause of death in pregnancy – as something that public health should be concerned about, while accepting that it is pretty far outside the technical remit of public health? 

Well, to start, how can we even talk about where different sorts of phenomena fall relative to the technical remit of public health? Writing in 2024, I was talking about the “qualitative transformation” in how we understand pregnancy at the levels of, first,  the state – how the state “sees” it by counting – and, second, of the vague entity called society – how society encodes and represents it culturally. There is something false and disjunctive about this, still. On the one hand, how is public health supposed to act on social issues without representing them abstractly, as recognizable and actionable political categories? On the other, how much does the essential reality of social issues get distorted in that process of representation? More concretely, what I mean to say is that men who kill their partners are not, for the most part, operating on some idealized political representation of misogyny. As Theweleit says of his subjects in Male Fantasies, they aren’t “representing” anything at all. They are acting in accordance with their desires and how those desires can be repressed, channeled, vented, and otherwise expressed in the current conditions of our society, and, most crucially, in the direct circumstances and experiences of their lives. What I’m really talking about, or struggling to talk about, is what Guattari might call a “micropolitics of desire,” a particular instantiation of this micropolitics in relations between men and women (Guattari might call these “productive” relations; productive, that is, of reality). 

As I understand it, the concept of micropolitics of desire (recall, this is desire as in the Deleuze and Guattari sense of the productive force of the unconscious, not the plain-English word with its romantic connotations) is part of Guattari’s project to synthesize Marxism and psychoanalysis and find some way of articulating individual experience in the social field. He writes in “Everybody wants to be a fascist” that this micropolitics “refuses to let the disjunction remain between social groupings and individual problems.” This is different from ‘the personal is political’ formulations in contemporary politics, which still aim to “represent[ing] the masses and interpret[ing] their struggles” through higher-level, abstract political categories. Instead, Guattari says, “The social object is ready to speak without having to have recourse to representative instances to express itself,” as a “univocal multiplicity of desires” acting directly on and within the collective. 
All this is just to say is that I think that a particular micropolitics of desire (around gender) is involved here, and that it “expresses itself” directly as gross inequalities and grotesque problems of public health – the fact that homicide is the second-leading cause of death among pregnant women, for example. This expression or action feels unidirectional; it seems to me that public health as public health is fairly constrained in its ability to “act back.” Or, maybe this is hard to think about because public health does act micropolitically, but it doesn’t do so through the macro-political representations that are its bread and butter. Nobody is dissuaded from murdering their pregnant partner by the urgency of the United States’s maternal mortality rate. If public health acts micropolitically, I’m inclined to think it does so as part of the general architecture determining the direction and shape of people’s small-d desire – where it will be dammed, where it can be channeled, and how it can be expressed. Just think of the reservoir of dammed-up desires that the existing medical/public health establishment have created, that MAHA/MAGA are now able to take advantage of. I think with this formulation we can get to something a little bit more actionable and more satisfying than “public health works best when people don’t notice it.” People never notice it, but it affects the course of desire whether it’s working well or working poorly, and the question is always how it is working.