Creative Destruction

May 22, 2006

Regarding the US’s High Infant Mortality Rate

Shortly before Mother’s Day, Save the Children released its annual report on the state of motherhood and infant mortality worldwide. As usual, the US does worse than almost every other industrialized nation when it comes to infant mortality (pdf file – see page 38).

The philosopher John Rawls suggested, as a thought experiment, imagining a “veil of ignorance.” The idea is, we sit around planning how to organize society from behind the veil; and none of us planners know what position in society we will hold, what race, what gender, how wealthy our parents will be, etc.. If the people planning society knew they might be born any race, any class, what society would they plan?

I don’t think they’d plan one in which infant mortality by race looked like this (source – pdf file):

US Infant Mortality, among whites, blacks, Asians, Latinos, and American Indians

As you can see, if you’re a newborn American infant, it kinda sucks to be an American Indian, Hawaiian, Puerto Rican, and the suckitude is simply enormous if you’re Black.

* * *

Unfortunately, the racial aspect of infant mortality in the US is usually ignored in the mainstream media. Instead, the focus is on how bad the US does, compared to other countries. The QuandO blog, like many right-wingers, responds that it’s not that the US does any worse at caring for newborns. Instead, it’s that other countries give up on low-weight and otherwise unhealthy newborns more easily, counting them as “stillborns.” In contrast, doctors in the US work hard to save those infants – but since not all of them live, the result of the superior care here in the US is that our infant mortality rate appears higher.

In an op-ed piece, critics of the Save The Children statistics suggest that we should forestall trying to correct the US’s poor results:

If we want to lower our infant mortality rate so it compares better with that of other countries, maybe we should align our rules with theirs to better determine the actual extent of the alleged “problem.”

(Does calling the problem “alleged” and putting the word “problem” in scare quotes create a sort of double negative problem?)

My first question is, how does this critique account for the enormous racial gap in infant mortality within the USA? (It seems unlikely that in the US, doctors try harder to save babies of color while categorizing similar white babies as stillborn.)

My second question is, how much truth is there to QuandO’s critique? Some truth, but not enough to justify calling the US’s infant mortality rate, compared to other wealthy countries, an “alleged problem.” The OECD Factbook explains:

Some of the international variation in infant and neonatal mortality rates may be due to variations among countries in registering practices of premature infants (whether they are reported as live births or fetal deaths). In several countries, such as in the United States, Canada and the Nordic countries, very premature babies with relatively low odds of survival are registered as live births, which increases mortality rates compared with other countries that do not register them as live births.

Yet Canada and the Nordic countries all have better infant mortality rates than the US. So the difference in reporting practices doesn’t account for all of the US’s dismal performance in this area.

If it’s true that the U.S. does just about as well as other wealthy countries in infant mortality, and we only do worse because other countries move count as stillborn cases that we count as an infant death, then that should show up in higher stillbirth rates for those countries than for the U.S.. This is something we can check; a World Health Organization report issued earlier this year (pdf link) gathered statistics for stillbirths. So lets look at the WHO stillbirth numbers next to the infant and newborn mortality statistics from the Save The Children report:

Infant mortality, newborn mortality, and stillbirth rate per 1,000 live births in seven wealthy countries

The graph includes the five countries Save The Children credited with the lowest newborn mortality rates, plus Canada and the USA. Including stillbirths does make the US look better, and is consistent with the claim that other countries may be count some infant deaths (by US standards) as stillbirths.

However, most of these countries are doing as well or better than the US in all categories, including stillbirths. That’s incompatible with the claim that the US’s infant mortality problem is a statistical illusion caused by different standards for categorizing stillbirths.

To make this clearer, look at a graph combining infant mortality and stillbirth rates. (Newborn mortality is not included because the newborn and infant mortality categories overlap).

Combined Infant Mortality & Stillborn Rates Per 1,000 Live Births In Seven Wealthy Countries

Even when stillbirth deaths are included, the US is still doing significantly worse than countries credited with low infant morality rates. It is therefore impossible that the US’s poor standing is caused entirely by the exclusion of stillborn children from infant mortality statistics (although this exclusion may be a contributing factor). The US’s terrible track record, compared to other wealthy countries, is not an “alleged problem”; it is an atrocity, and one that shouldn’t be swept under the rug rather than addressed.

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18 Comments »

  1. My first question is, how does this critique account for the enormous racial gap in infant mortality within the USA? (It seems unlikely that in the US, doctors try harder to save babies of color while categorizing similar white babies as stillborn.)

    I suspect it is due to socioeconomic factors: POC generally can not afford as good health care (general and prenatal) and may have unhealthier eating habits due to being poor (not getting all the nutrients etc.) Also, decidedly unhealthy behaviours such as drug use tend to be more common with certain ethnicities.

    To prove that this is not just a rote dismissal based on generalization, I point that among the group Hispanics, Cubans (correct me if I’m wrong) who tend to be richer the infant mortality is very slightlyless than with whites, and significantly less than with Puerto Ricans and other Hispanics.

    Ditto for similar socioeconomic analysis for Asian subgroups.

    The US’s terrible track record, compared to other wealthy countries, is not an “alleged problem”; it is an atrocity, and one that shouldn’t be swept under the rug rather than addressed.

    I agree, FWIW.

    Comment by Tuomas — May 22, 2006 @ 3:07 pm | Reply

  2. I would like to know how much it costs in the United States for a pregnant woman to give birth in a hospital if she has no health care? I have no clue but it seems to me that if 1/1000 woman in a minority, without health care decides to give birth at home, to nurse at home?

    I would also like to know if the fact that Americans are very religious and if some sects/religions refuse proper access to mothers to health care and modern medecine.

    Anyone know?

    Comment by Vilon — May 22, 2006 @ 6:27 pm | Reply

    • The price to give birth in america without any insurance costs just about 3,000 dollars and that is in Kansas I’m not entirely sure about other states.

      Comment by Izzy — July 22, 2009 @ 1:08 pm | Reply

  3. Vilon –

    It depends. If she’s poor enough to be on Medicaid, she doesn’t pay anything. There are probably some people who birth at home to avoid the stigma of Medicaid, but I doubt it’s very many.

    If you’re too rich for Medicaid but too poor to pay cash, you can show up at an emergency room and they’ll take care of you. (They have to.) They’ll bill you but not expect to be paid; so you have a hit to your credit rating but not your wallet.

    The cash price for an ordinary delivery and short hospital stay is around $10,000. (Guess who’s paying for the ER delivery.)

    The number of people whose religious convictions forbid them from having medical assistance for a delivery is very small.

    Comment by Robert — May 22, 2006 @ 7:19 pm | Reply

  4. There is a mundane, politically neutral possibility for explaining at least part of the black-white infant mortality disparity (in fact, it may explain much of why blacks have poorer health in the U.S. than whites as a whole).

    Blacks – in fact anyone with dark skin – is at much higher risk of vitamin D deficiency, particularly in northern climates where there is less sunlight. (Dark skin is designed to keep the sunlight from penetrating into the deep layers, making it useful in sunny climates where it prevents skin damage but a liability in unsunny climes where it prevents the sun from converting chemicals under the skin into vitamin D). Although associatedby most people with bone formation and calcium metabolism, it may also play arole in immune function and lack of vitamin D may be a factor in asthma. I remember reading about a study that said that a large number of black women were vitamin D deficient. (I believe that blacks are more likely to be lactose intolerant than whites, so it is also likely that not as many black people drink vitamin D fortified milk).

    Perhaps part of what is needed is a campaign to get people, particularly dark-skinned people, to eat more vitamin D, either through supplementing more things or through education, or through distributing vitamin D pills.

    Comment by Glaivester — May 22, 2006 @ 7:33 pm | Reply

  5. What are the infant mortality rates of Canadian and Norwegian ‘African Americans?’

    “And boom goes the logic”

    Blacks have a genetically higher infant mortality rate, don’t gimmie any crap about racism is a curse on the womb when pregnant whites are forcedfed government degeneracy, government bullshit, and we have a grim outlook where our lives will be spent for wars for Israel, I ain’t having any of it! (Bush, is not one of us, he’s not one of us! how many times do I have to say it, He is an honorary jew and works for international judeocorporate interests only, watch “loose change”)

    Countries like Norway and Canada are not full of blacks or white-liberal fans of black-sports and minstreltainment.

    Comment by Justice for Palestine — May 22, 2006 @ 8:07 pm | Reply

  6. Infant morality is a good proxy for extreme poverty. Very few other OECD countries have significant extreme poverty rates. Everybody gets passable shelter, decent food, and the same medical care as everyone else, whether you deserve it or not, in almost all of those other countries. The U.S. is, by comparison, deeply stingy. Pregnant women in the U.S. are disproportionately poor and that extreme poverty is concentrated in ethnic groups with the highest infant mortality rates.

    The U.S. system does guarantees everyone who walks into a hospital door a very expensive hospital delivery, while denying pregnant women inexpensive routine prenatal care that can prevent stillbirths and infant mortality (most of which has its roots in pregnancy itself) like prenatal vitamins and ultrasounds to identify high risk pregnancies as early as possible. This simply doesn’t make economic sense.

    Indeed, if we had guaranteed pregnancy care, as most of the rest of the world does, many poor women who now turn to emergency rooms to deliver babies in low risk pregnancies, might instead prefer assistance from midwives who would transfer laboring women to hospitals only when actually necessary, at a much lower cost. This cost savings alone would more than pay for universal prenatal care. Likewise, scheduling C sections in advance in high risk cases screened in prenatal care before they got out of hand, would save many lives of mothers and infants alike, as well as immense cost, currently spent handling high risk births in emergency rooms.

    Reducing infant mortality isn’t rocket science. Cuba manages to do it. The U.S. ought to be able to manage it.

    Comment by ohwilleke — May 22, 2006 @ 8:37 pm | Reply

  7. So what’s with those QuandO guys? Are they liars, or bullshitters, or what?

    Comment by Intellectual Pariah — May 22, 2006 @ 11:03 pm | Reply

  8. Infant mortality correlates with low birth weight babies, low birth weight correlates with multiple gestation pregnancies. Blacks have higher natural rates of multiple births. Multiple birth rates in general have increased in the US because of more use of assisted reproductive therapies, like in-vitro fertilization.

    The key methodological difference with foreign countries is how they register very low birthweight babies (weight at delivery of less than 1,500 grams per 100 live births), not stillborns. VLBW babies have high mortality rates and often die shortly after being born. In Cuba and many European countries births of less than 1000 grams are not counted toward mortality statistics, nor are the equivalent medical interventions as in the US attempted to save VLBW babies.

    For more:

    http://ije.oxfordjournals.org/cgi/content/abstract/24/3/583

    http://www.cdc.gov/nchs/products/pubs/pubd/hestats/infantmort/infantmort.htm

    Comment by Carter — May 23, 2006 @ 1:45 am | Reply

  9. Good post, Amp.
    Yet I wonder how on earth would anyone think that relatively high infant mortality rate in US could be explained by some “statistical scam”, as the excuse does not explain why the countries that perform better do that also in every other national health indicator such as life expectancy etc.
    Instead would it not be odd if US would be somehow as good as Canada in preventing infant mortality while lagging behind in every other respect.

    Unfortunately in this case the excuse given has some limited merit, and therefore I expect that the “statistical illusion” meme will not be defeated simply by painstakingly explaining why it is not true like this post does.
    Reality is simply much too complex for typical political discourse in this case, namely:

    1. Some countries do have lower infant mortality rates but use different registering practices than USA.
    2. Some countries do not use diffenrent registering practices but still have vastly lower infant mortality rates than US.

    Frankly, you can explain that slowly and repeatedly for “USA has the best healthcare in the world”-folk like those on QuandO blog, and it will not make an ounce of difference.

    Most likely there is a short pause when they wonder what the hell you are talking about, and pretty soon somebody will helpfully point out:
    “Dude, have you heard that those other countries have different registering practices for infant mortality”

    Case in point, this discussion.

    Policy: Access to healthcare is a privilege, not a right.
    Result: High infant mortality.

    How is this result not completely logical and expected?

    There are big, basically tax-funded efforts in other industrial countries to reduce infant mortality, and as a result for example pregnancies are much more closely monitored by professionals.

    Nobody is claiming that every American woman has the same kind access to healthcare even during pregnancy, yet somehow the suggestion that this obvious difference might lead to different outcomes is ridiculously controversial.

    Comment by Marcus — May 25, 2006 @ 4:43 am | Reply

  10. I just wrote a post about infant mortality rates in the US if anyone is interested.

    Comment by Jamila Akil — March 20, 2007 @ 5:07 am | Reply

  11. The pregnant mother’s behavior has a lot to do with it, and that is not related to the US Health Care system is it.

    Comment by Beck — July 18, 2007 @ 5:32 pm | Reply

  12. Sure socio-economic disparity accounts to a certain extent for some of these figures, but health education is probably the main deficiency at the root of these statistics.

    Basic trends such as encouragement of breastfeeding and other proper infant nutrition practices, which are promoted both in third world countries (both culturally and via international health organisations) and among the upper-middle class in developed countries, are yet to penetrate the economically depressed segments of US society.

    If simple measures such as breastfeeding were pushed the way abortion is in this country, poor/uneducated women would know how to give their babies the best chance of survival when they do have them rather than just where to go when they don’t want to have them!

    Comment by Laura — November 10, 2007 @ 8:27 pm | Reply

    • If simple measures such as breastfeeding were pushed the way abortion is in this country, poor/uneducated women would know how to give their babies the best chance of survival when they do have them rather than just where to go when they don’t want to have them!

      Breastfeeding is NOT “always best” and hippie-mothers don’t comprehend that. Breastmilk is only best if the mother is the pinnacle of good health. Every single thing the mother stresses about, feels, drinks, eats, smokes, and even the vitamins, anti-depressants (half of America), and herbal supplements ALL affect the quality of the breastmilk.

      Not to mention that women still get glared at and shunned for feeding babies (on the breast in public) and it’s also not an option for any mother who’s baby has health issues (even minor ones).

      My son was jaundiced after birth (as many babies are) and required a set bottle/eating schedule that I did not provide enough breastmilk naturally to keep on.

      Many, many women should NOT be breastfeeding and should NOT be “trying” when their children’s health is compromised or even if the child has problems nursing that way.

      I used formula and I don’t know about other countries, but formula is like a super-baby formula here that makes breastmilk seem just silly.

      Women breastfeeding because dumb people tell them to are half the reasons mortality rates are so high. These women aren’t educated in knowing that their breastmilk can be harming, hurting, or even killing their baby if they are not taking good care of themselves.

      That’s adding to the problem, not correcting it. And there are plenty of mothers such as myself who think breastfeeding is disgusting, inconvenient, and pretty much any woman who has a job or works doesn’t have the time to be dropping everything and whipping a boob out.

      This is the modern world….breastfeeding is the least of anyone’s concerns.

      Comment by Lady Raine — March 25, 2010 @ 11:52 am | Reply

  13. I would like to find data for infant mortality rates for babies born to mothers in hospital in the United States as compared to the world when the mother was given drugs as compared to mothers not given drugs.

    Also, I would like data for maternal deaths of mothers giving birth in hospitals in the United States compared to the world when the mothers were given drugs.

    Thank you so much for any information you can give me.

    Kathryn Mora
    Waltham, Massachusetts

    Comment by Kathryn Mora — February 27, 2008 @ 12:40 pm | Reply

  14. This article is very enligthening as far as how the country wiht some of the best outsomes inthe world, and determined in 2007 by Save the Childrne to be “The best country in the world to be a Mother”

    http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1448444

    Here is the link. Bottom line, midwifery care reduced maternal mortality as much as aspectic technique did. This is a stunning fact. Knowledge of normal birth is essential to good outcomes.

    Am J Public Health. 2004 August; 94(8): 1312–1320. PMCID: PMC1448444

    Copyright © American Journal of Public Health 2004

    The Decline in Maternal Mortality in Sweden
    The Role of Community Midwifery

    Ulf Högberg, MD, PhD

    The author is with Obstetrics & Gynecology, Department of Clinical Science, and Epidemiology, Department of Public Health and Clinical Medicine, University of Umeå, Umeå, Sweden.

    Requests for reprints should be sent to Ulf Högberg, MD, PhD, Obstetrics & Gynecology, Department of Clinical Science, University of Umeå, S-901 87 Umeå, Sweden (e-mail: ulf.hogberg@obgyn.umu.se).
    Accepted October 22, 2003.

    Comment by Heidi — July 1, 2008 @ 12:23 am | Reply

  15. In usa the economy is very horrible. Most pregnant women can’t afford the high quality name brand vitamins and healthcare. Even if they had medicaid, they wouldn’t receive great quality doctor visits. Im currently pregnant. I observed that women who are pregnant that don’t have the correct info to have a healthy pregnancy, most likely end up having a still birth. In my area a lot of women in the ghetto use illegal drugs and are involved in violent gangs. That’s a high risk in having a still birth. Eating healthy, staying sober, excercising would give chances of not having a still birth. Usa has a lot of poor homless pregnant women. Yea usa has great medical technology but other countries have natural remedies that are helpful to prevent stillborns. If yall notice that a hospital doesn’t use herbal remedies or old fashioned safe medicinal practices. If I had a chance to have my baby in sweden, id feel a lot safer there than the usa. Healthcare isn’t always a privilage if ur paying out of ur own pocket. The doctors have privilages in working and getting paid! Its us who pay that let doctors have jobs!

    Comment by Sommer — July 1, 2009 @ 6:43 am | Reply

  16. Infant mortality could be prevented by increasing the number of midwives of color, especially in the African American community. Also the US needs to adopt and support breastfeeding from a cultural base,as breastfeeding babies have better health and as well as the mother.

    Infant mortality causes and solutions, along with nutrition before conception needs to be taught in middle school.

    Comment by shafia m monroe — July 4, 2009 @ 10:02 pm | Reply


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