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Why Is Infant Mortality So High in the United States? - Mo's Journal
November 29th, 2007
03:15 pm

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Why Is Infant Mortality So High in the United States?
I know the simple, and simple-minded, answer: because we have a grossly inefficient health care delivery system that denies care to large numbers of USAmerican citizens. But I'm thinking more of just how and why we have rates of infant mortality that are higher than most of the developed world.

First of all, definitions: the infant mortality rate is the number of deaths of babies under one year divided by the number of births in a given year. That's then expressed as the number of deaths per 1000 births (because typically it's small enough that percentages don't make sense to use). The U.S. infant mortality rate was 6.8 in 2004, the latest year for which figures are available. A partial list of countries with lower (i.e. better) infant mortality rates: Czech Republic, Cuba, Greece, Portugal, Australia, Austria, Canada, Denmark, Ireland, Italy, Luxembourg, Netherlands, New Zealand, Spain, United Kingdom, Belgium, Finland, France, Germany, North Korea, South Korea, Norway, Switzerland, Iceland, Japan, Sweden. In the case of the last three, the rate is less than half that of the U.S.

So the US continues to lead the developed world in high rates of infant mortality. The rates have gone down over the years, and even in recent years. In 1950 the rate was 29.2, in 1960 26.0, in 1970 20.0, in 1980 12.6, in 1990 9.2. Rates are much higher for babies born to black mothers than to white mothers, higher for the poor than the wealthy. Race and income definitely affect infant mortality but in in all racial and socioeconomic categories the rate is going down.

So, like I said the simple - and perhaps simple-minded - answer is our health care delivery system: without universal health care and universal insurance we have a number of bad outcomes and infant mortality is one. But I'm not sure how that works, or how to factor in (if it's true) the impression one gets that in this country money and effort is spent on saving lives of infants that would not be expended in a lot of countries (the "extraordinary measures" argument). Maybe extraordinary measures just don't work very often, and that's why they're not reflected positively in infant mortality figures although they are reflected negatively in our health care costs.

The leading causes in this country of infant mortality are birth defects and complications resulting from pre-term birth. Those two groups account for more than half of infant mortality in the United States.

How would better access to health care reduce infant mortality? What would happen that would make babies less likely to be born early or born with congenital problems? If lack of prenatal care is an issue, how does it lead to premature birth or birth defects?

Could it be that in some countries greater access to prenatal testing and abortion keeps the rate low? I note that the big drop in 10-year rates in the US happened when abortion became legal. Were a lot of women forced previously to give birth to babies that could not survive? Is that still happening in the US in places where abortion is hard to get, or where women don't have prenatal testing to know of congenital abnormalities? And why does the US rate - although high compared to other countries - keep going down at a time when the numbers of uninsured are increasing?

Thoughts? Discuss amongst yourselves.

ETA: Someone anonymous pointed out that I forgot to mention that the rate is expressed in terms of deaths per 1000 births. So I changed that. S/he also pointed out that different countries may count differently.

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From:titti
Date:November 29th, 2007 08:35 pm (UTC)
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I don't think it has anything to do with insurance. Any pregnant woman, legal or not, will get full coverage in this country. In fact, I can tell you from experience that an uninsured mother gets better medical services here than in Italy where it's supposedly free and equal for everyone (but better if you have the money to pay for private). On the contrary, I think we have better medical service and that leads to higher death.

One factor I would think is that we have the most liberal laws in terms of artificial insemination. For example in Italy, only a married couple (I think younger than 40) can legally go through artificial insemination. Other European nations have similar rules.

Normally, with artificial insemination, you inject three to four fertilized eggs, and there is a great chance that most will result in premature births and possible complication. For example, I know a lawyer who had the first insemination, brought to terms all three and all three died because they were born too soon. The next time, she aborted two fetuses and brought to term only one.

Another fact that is connected to artificial insemination is the age of the mother. Medicine has allowed older women to get pregnant, but the chance of birth defects is proportional to the parents' ages, and sky rockets after age 40.

Finally, a lot of pre-term birth are the result of medical attempts to keep the fetus viable. That friend I was talking about was in bed, with over the phone constant monotoring and drugs that she injected every four hours. A few years ago, and in other country, it wouldn't happen, because she would have naturally aborted them long before they were considered viable.
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From:mofic
Date:November 29th, 2007 08:49 pm (UTC)
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. Any pregnant woman, legal or not, will get full coverage in this country.

Yet many pregnant women in this country don't get prenatal care, and fewer get early prenatal care than in many other countries. And as more *have* gotten pre-natal care, infant mortality rates have dropped. I do think there's a connection between access to care and infant mortality, just not a simple one.

Artificial insemination rates are very low - even if in this country we let lesbians and not just those in marriages have access to AI :-). As to the age issue, highest infant mortality rates are with teen mothers and the lowest are for women 30-34.
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From:thefourthvine
Date:November 29th, 2007 09:39 pm (UTC)
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Any pregnant woman, legal or not, will get full coverage in this country.

I'd like to rephrase this to: most pregnant women can get full coverage in this country. There are significant obstacles to obtaining coverage that result in many women not getting care, or not getting care early. A woman who knows she is entitled to care and knows how to get it certainly can. But many women don't know that.

Normally, with artificial insemination, you inject three to four fertilized eggs, and there is a great chance that most will result in premature births and possible complication.

I'm confused here. I've been artificially inseminated, and sperm are injected, not ova; your body ovulates as usual, and unless you use fertility drugs, your chances of having multiple ova released during one cycle are the same as those of a woman conceiving through non-artificial insemination. I think you might be thinking of IVF, where ova are removed, fertilized outside the body, and then injected back. (Even then, the number of embryos inserted is, I believe, the choice of the potential parent(s) and their health care provider. Many do not choose to try with three these days, and four is even rarer.) But IVF pregnancies make up a tiny percentage of our overall pregnancies. (Even if you threw in AI pregnancies as well, that would still be a tiny fraction of total pregnancies in this country.)

If you're thinking that the increase in multiple pregnancies (and it has increased, from 1 in 100 at the start of the 20th century to 1 in 33 now) is driving the higher infant mortality rate, the primary reason that the rate is probably rising is that women are older when they get pregnant. (Older women are more likely to have multiple ova released in one cycle. They're also more likely to need fertility drugs to conceive, and fertility drugs definitely increase the risk of multiple pregnancy.) So my question would be - is infant mortality linked to the age of the mother? If so, that would provide some support for the multiple birth hypothesis. I'd also like to know what the multiple pregnancy rate is in those countries with lower infant mortality rates.
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From:daybright
Date:November 29th, 2007 10:18 pm (UTC)
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Could it be that in some countries greater access to prenatal testing and abortion keeps the rate low?

I would think that would be one of the reasons here in Iceland, we have excellent health care so that is also a big factor too.
If I remember correctly then in the last 5 years only 1 Downs Syndrome child was born to a mother that had early prenatal testing, all other opted to abort.
All mothers over 35 are offered the test that tests for various birth defects and anyone can request it. I assume that parents choose abortion over other serious birth defects as well.


Edited at 2007-11-29 10:20 pm (UTC)
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From:mofic
Date:November 29th, 2007 11:40 pm (UTC)
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That's very interesting! Here there's not only a large anti-abortion contingent and somewhat limited access to abortion in much of the country, but there's a lot of anti-prenatal testing feeling from various segments of society. For some it's the belief that it will lead to abortion, for others it's a feeling that it's "unnatural" and so on.
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From:executrix
Date:November 29th, 2007 10:30 pm (UTC)
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I think that a lot of teenagers either don't have access to contraception or think that contraception is only for sluts, not for girls like them swept off their feet by Wonderful True Love. Then if they know they're pregnant (which, given the state of sex education, is not a given) they are likely to refuse to deal with the problem, just hoping it'll go away. They certainly won't jump through the hoops necessary to get prenatal care. And if the baby dies...well, it's sad, but the problem DID go away.
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From:mofic
Date:November 29th, 2007 11:56 pm (UTC)
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I think you may be onto something. Also, given the state of sex education, they may not know how to care for themselves when pregnant. And they certainly aren't likely to be doing things prepregnancy to reduce the likelihood of bad outcomes (like taking folic acid, giving up smoking and alcohol).
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From:kosiah
Date:November 29th, 2007 11:46 pm (UTC)
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My vote would be for the culture of intervention in hospital births. I think it probably saves a lot of infant lives, even as it can also lead to more complications. Twenty years ago, c-section rates weren't at 30% -- these days any risk factors or hints of risk factors can lead to one. I'm not saying that's a positive thing, but I do think it could probably account for lower infant mortality rates.

Our health care system is abysmal and inefficient, but from what I've read and experienced, most women, even the poor and uninsured give birth in hospitals, which are pretty good at delivering live babies. Now, the fact these same hospitals release them 24 hours later after watching a "how to care for baby" video with a pack of formula and some diapers is a whole 'nother story...
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From:kosiah
Date:November 29th, 2007 11:55 pm (UTC)
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Oh wait, okay so that's why the rate has gone down... uh, my theory.

As to why it's higher than other "first-world" countries -- even with the best insurance and best prenatal care our system has to offer most women still work up until the day they go into labor... and most women don't have the best insurance and the best prenatal care. I'm sure that the anti-abortion culture may be a contributing factor... but there are plenty of Catholic countries with lower mortality rates, yes? Our medical system is built around the "take extraordinary and expensive measures at the last second" kind of approach.
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From:mofic
Date:November 30th, 2007 12:47 am (UTC)
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As you pointed out elsewhere, these are really arguments for *low* infant mortality, but countries with routine home birth and few c-section have lower rates than ours. Also, any benefits of hospital birth would likely only show up in perinatal mortality, and much of the infant mortality we're seeing is later on in the year. It's often due to something that happened during pregnancy, or to preterm labor, but it's not death during childbirth.
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From:lilacsigil
Date:November 29th, 2007 11:57 pm (UTC)
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Don't forget the high US teen birth rate - poor sex education, poor access to contraception and abortion, poor access to healthcare in general. Your healthcare system is used as an example to scare people in other countries, and for a good reason! Additionally, the US has a much higher birthrate than most of the other countries in your list - is the poor access to contraception and abortion meaning that less healthy women (which often equates to "poor") are forced to have more children?

Extraordinary measures are certainly used here in Australia to keep premature infants and those with birth defects alive, so I'm not sure where that argument comes from - we also have a relatively high IVF rate. I suspect the infant mortality rate keeps going down because the rate of absolute poverty among young American women is not drastically increasing, and the rate of medical advances are - and from what I can tell, your healthcare policies are extremely focused on saving infants (as opposed to giving women more options about pregnancy).
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From:mofic
Date:November 30th, 2007 01:04 am (UTC)
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Yes, clearly teen births have something to do with it. The rate has dropped a lot, but it's still high relative to lots of countries.

Birth rate, though, doesn't seem to be such a pattern to me. I mean it is in the gross sense - the countries with very high infant mortality rates also have very high birth rates. But the US birth rate isn't much different from much of Eurupe...

From:(Anonymous)
Date:November 30th, 2007 04:45 am (UTC)
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>>>the infant mortality rate is the number of deaths of babies under one year divided by the number of births in a given year. The U.S. infant mortality rate was 6.8 in 2004<<<

I don't think that formula is right... dividing the number of deaths by the number of births will never give you a number greater than one, and that would only happen if every baby died. There's no way to get 6.4. I've seen infant mortality rates as deaths per 1000 births, which makes 6.4 seem like a more reasonable number.

I've also rate that different countries calculate their IMRs differently... some don't count infants who are born before 28 weeks gestation, or who die during birth, but some do.

OTOH, lack of prenatal care can definitely contribute to pre-term labor, especially for women who have an underlying medical condition or aren't maintaining a healthy lifestyle.
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From:mofic
Date:November 30th, 2007 12:08 pm (UTC)
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Yeah, it's expressed as the number per 1000 births, as opposed to a percentage. I'll make that clearer in edits.
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From:libgirl
Date:December 1st, 2007 11:06 pm (UTC)
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I don't know a lot about this issue, but I can say this much. When my mother was pregnant with me, her doctor actively encouraged her to abort because of the complications with the pregnancy. She carried me, had two miscarriages, carried my sister on full bed rest for about 6 months and then had two more miscarriages.

I don't really know that my comment adds anything to this topic so I'll go a step further. I have two friends who both had unexpected pregnancies and both were not in the position to pay for health care. Both received assistance through the federal/state/local agencies. Both waited as long as possible before seeking that care--in both cases until they were nearly through the first trimester. In both cases it was a combination of factors: not knowing (or wanting to know) that they were pregnant and not wanting to accept/need assistance being the two more prevalent. If using or needing social assistance programs comes with a stigma--and I think we can agree that it does--then one of the results of that stigma is that people will wait as long as possible before seeking that assistance. If the first few months of the pregnancy are some of the most important--in terms of prenatal needs/care/nutrition then that reluctance to rely on that assistance can have serious ramifications.

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