Investigating Infant Mortality in the United States

From a lecture series presented by The Great Courses

One of the most interesting vital statistics in any nation is its infant mortality rate. Similar to life expectancy, you might think the infant mortality rate has improved dramatically in recent years and would be the best in wealthy nations, such as the United States, but in actuality, it is a little bit more complicated.

A Doctor measure the size of a Baby

A news article from The Washington Post started with this headline: Below the headline and byline, and above the text of the article, was a very telling bar graph, comparing the infant mortality rate in the United States to that of 26 other wealthy countries. At the top of having a low infant mortality rate was Finland; then the rate progressively declined for Japan, Spain, Greece, and Poland; at the bottom, with a very high rate of infant mortality was Slovakia; and at the very bottom was the United States.

Bottom of the Barrel?

The United States was last among the wealthy countries of the world, and with almost three times the infant mortality rate of Finland. Over six of every 1,000 live births in the United States will not survive infancy.

This is a transcript from the video seriesThe Skeptic’s Guide to Health, Medicine, and the Media. Watch it now, on The Great Courses Plus.

The text of the Post article, and many similar articles from other media sources, really hammers the point home; the purpose of the infant mortality rate comparisons was meant to be shocking. A baby born in the United States is about three times as likely to die as one born in Japan, and about twice as likely to die as one born in Korea. A baby born in the United States is less likely to reach his first birthday than a baby from Hungary, Belarus, or Cuba. Even more so, particular states within the United States have very poor infant mortality rates. If Mississippi were a country, its infant mortality rate of 9.6 would put it between Botswana and Bahrain. In the United States, we’re used to being one of the wealthier nations of the world and being a leading nation in most other ways, too. Except, now, in terms of the infant mortality rate, we’re not even close to faring well at the top. But what accounts for this difference? A closer look at how the rates are calculated is needed.

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The Post article, in the sixth paragraph, finally gets to some of the important meat of the story. After hammering on the statistics that honestly do make the United States look pretty bad, the article gets to some of the reasons for our high infant mortality rate. A big factor is just a matter of record keeping. In the United States, we use a different definition of live birth: Any baby born, at any gestational age, that has any signs of life is considered a live-born baby.

However, in many countries babies deemed too premature to survive aren’t counted at birth—these often include babies born before 22 weeks of gestation, or weighing less than 500 grams. These babies are very, very unlikely to survive, even with the best, most high-tech and sophisticated neonatal intensive care. So many countries don’t count them as alive when they’re born. We do. That single difference, the article points out, probably accounts for 40 percent of the U.S. infant mortality disadvantage as compared to the other wealthy countries on the list. Putting it another way, if we remove that 40 percent from the calculation, the U.S. infant mortality rate is probably around 3.7, which puts us in the middle of the pack, similar to Israel and France.

A Closer Look at the Numbers

Now, that’s honestly just a statistical guess; these numbers aren’t reported out consistently, so we don’t really know exactly what our infant mortality rate would be if we used the counting method as used in most of the world. But the U.S. infant mortality rate is clearly not as bad as it appears. But, even excluding extremely premature births, our infant mortality rate still isn’t very good. We spend more health care dollars than anyone else. So why are we lagging behind other wealthy nations?

That’s when the story really does get interesting, and when we might be able to learn something that can help us make some changes. We’re down to paragraph eight now in the Post article, when we learn that the United States actually has a very similar neonatal mortality rate as other wealthy countries. That is, when babies are born, they’re about as healthy as anywhere else, or at least as healthy as they’re supposed to be for their level of prematurity. The big difference in the infant mortality rate starts after birth, and it’s really a difference in post-neonatal mortality, or death rates in the first year of life. As infants grow older in the first year, a substantial gap opens up in the mortality rate as compared to other countries, and that gap increases as babies approach their first birthday.

The Post article brought the threads together well. Although it started with heavy handed and startling comparisons to other nations, it then provided good context on the numbers. Then, in paragraph 10, the article got to the most important facts learned from the statistics. The statistics showed that “the higher U.S. mortality rates are due entirely, or almost entirely, to high mortality among less advantaged groups. To put it bluntly.” The article continued with “babies born to poor moms in the U.S. are significantly more likely to die in their first year than babies born to wealthier moms.” Infant mortality rates among wealthy Americans are similar to rates in Finland and Austria, at the top of the heap. And neonatal mortality, that is, just looking at the first few weeks of a baby’s life, are also similar. How can this be?

Since almost all babies in the United States are born in hospitals, the level of care is about the same, regardless of the economic and geographic background of the mother and baby. Hospitals in the United States provide high-quality care for mothers and babies. In fact, our obstetric and neonatal care is, in many ways, the best in the world.

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The disparity in infant mortality rate begins once mothers and babies return home after their hospital stay. Poor American families have less access to quality care. The infant mortality rate—that is the rate of death over the whole first year of a baby’s life—is dramatically higher among families who are poorer, have less education, and come from homes where the mother is not married and where the mothers are African American.

The headline of the Post’s article “Our Infant Mortality Rate Is a National Embarrassment,” should alert us that everyone in our country should have access to high-quality medical care in order to give birth to and raise healthy children. The Post article closes, “Research like this drives home the notion that economic debates in this country—about inequality, poverty, healthcare—aren’t just policy abstractions. These are real lives at stake.”

A Big Challenge before Us

The LA Times covered this disparity in stark terms with their piece, “In the U.S., Infant Mortality Gaps Costs the Lives of about 4,000 Black Babies Each Year.” The reviewed research showed that nearly 60 percent of the deaths of black infants could be accounted for by, essentially, preventable or treatable conditions, including the complications of low birth weight and prematurity. Better access to health care could eliminate, or at least decrease, the death risk of babies born to black families, who currently have about 2.5 times the risk of death in their first year as compared to white babies.

CNN’s coverage in 2012 included a story, “Infant Deaths: Searching for Answers in Mississippi.” Mississippi has long had the highest infant mortality rate of any U.S. state. The article points out that there are multiple, overlapping factors contributing to the rate. One factor is obesity in mothers—Mississippi leads the country in that, too—which contributes to gestational diabetes and hypertension, which both can contribute to premature birth and other complications. There’s also a high incidence of poverty and a low educational background in Mississippi and other southern states. Those problems, though certainly difficult to tackle, at least have known strategies for trying to put into place, and hope for progress; but there are more intractable issues at play, too. African American women, all else being equal, still have a higher rate of premature and low birth weight, and the risk of SIDS is about double in black infants born in the United States. Progress in improving the high infant mortality rate can be made, but it’s not going to be easy to tackle these overlapping and additive issues.

NBC News reported what they called a “rare bit of good news” about these statistics in 2017, under their headline “Infant Mortality Rates Fall 15% in U.S.” Credit was given to falling rates of SIDS, or sudden infant death syndrome, which has been the target of safe-sleep education initiatives starting in the 1990s. There’s also been a fall in teenage pregnancy rates; teenage pregnancies can lead to premature births and babies born into poverty and social disadvantage.

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Considering life expectancy and infant mortality rates in the United States, what should we as a nation be doing to help us live healthier, longer lives? The biggest contributors to falling life expectancy and increasing infant mortality rates include: obesity; lack of exercise; poor control of chronic conditions, like high blood pressure and diabetes; and negative social determinants of health, like poverty and poor access to healthy food and quality education.

From the lecture series The Skeptic’s Guide to Health, Medicine, and the Media, taught by Professor Roy Benaroch, M.D.