Infant Mortality
As requested, I’ll start leaving these posts open. At least for now.
Infant mortality data can be found in several places, but I’ll reference the CIA World Fact book . Another good source is the 2009 World Almanac, and for you medical types Up To Date has a good entry. If anyone’s interested I can provide references to back up what I present here today. No matter what source you find, it mostly adds up to the same thing however. The U.S. appears to have a significantly higher infant mortality rate than many other poorer and less medically sophisticated nations, including Cuba. Even compared to other industrialized nations like Canada and Western Europe, the rates are higher. So what’s going on here?
First off we have to know what we’re talking about. Infant mortality is defined as the number of deaths occurring in the first twelve months of life per 1000 live births. The world rate is somewhere in the mid 40s (depending on whom you ask) while the average rate for industrialized countries is around 8. I’ll talk about the definitions of a live birth in a bit, because it’s up for debate, but first let’s talk about the most common causes of death in the first year.
Traditionally, infection is the biggest enemy of children. Kids are for all intents and purposes immunocompromised because their immune systems are still learning how to operate. That said nutrition and availability of care also play a huge role. Worldwide however, pneumonia and dehydration are the biggest killers of children and account for the majority of infant deaths.
In the U.S. the odds and resources are vastly different. Birth defects and prematurity take the top two spots, followed by SIDS (it amazes me that people still put infants down prone and not supine), accidents and infection. One of the reasons that pediatricians as a whole are so paranoid about neonatal infections is that despite readily available antibiotics and hospital care, infection remains a huge killer of babies.
Birth defects as a whole are easy to talk about. Many defects are out of our control. In fact many pregnancies would spontaneously abort without proper prenatal care. Our technology, as well as America’s general attitude about voluntary abortions, allows many of these children to come to term. While some are not fatal, there are plenty of defects that put the infant at high risk for death in the first year. One example is Trisomy 18 or Edward’s syndrome. These children are extremely deformed and will likely die in the first month. Despite knowing the prognosis, parents often ‘want everything done.’
(As an aside, it makes me sick when Sarah Palin talks about how she ‘knows how it feels to have a child with a birth defect’ and ‘knows the temptation of abortion’. She doesn’t. Down syndrome kids have an excellent prognosis, especially when you’re rich and powerful. Talk to a single mother whose child has trisomy 13 or 18 and carries the fetus to term knowing that the child may live only a few hours or a few weeks.)
Back on track. Children with these types of defects will not live, and in other countries are more likely to be aborted earlier, either spontaneously or electively. They would never be counted towards the death rate. Because we have good care and a culture that mostly wants heroic measures for everyone, these infants count towards our infant mortality.
We must also discuss what constitutes a ‘live birth,’ because that definition makes the whole rankings difficult to compare. In most states, a live birth is counted as any fetus, regardless of gestational age, that exits the maternal body and shows ANY signs of life. That means even a heart beat for less than a minute counts. Let’s take previable premies as an example. If a woman comes in 18 weeks pregnant and is in active labor, there’s nothing I can do for that child if it’s born. Nothing. No resuscitate efforts will be made because it’s too small and immature to survive. However it often comes out with a heart rate. That’s a live birth. Some countries won’t count that because the infant was nonviable (though official WHO recommendations would have them do so). In fact some countries don’t count the birth if the child dies in the first 24 hours, or even the first week.
Further, we resuscitate a lot of premies. 23 weeks is about the limit of what we can do anywhere, and every effort is made to resuscitate them in the U.S. This creates a high degree of infant mortality and morbidity because often those kids are too sick to last very long. Motality for under 25 weeks gestation is 50%. Neonatologists do amazing things and save people’s babies, but some degree of mortality comes along with it. Cuba, which is technically ‘better’ than the U.S. in terms of infant mortality, does not resuscitate infants less than 30 weeks. During residency a delivery at 30 weeks didn’t even prompt a visit by the attending, and those kids have an excellent prognosis. They’ll likely have normal lives.
Virginia, along with some other states, actually has a policy where any premie infant 1000 grams or less (about a pound) is covered by Medicaid as part of a catastrophic coverage program. I think it’s an excellent idea since NICU care can cost hundreds of thousands of dollars.
One paradox of living where we do is the availability of reproductive assistance technology and resulting multiple births. While these technologies can be wonderful, multiple births (twins, triplets quadruplets) are always premie on some level. Twins aren't that big a deal, but the more babies you add, the earlier they'll be born and the more complications there are likely to be and the higher the mortality rate.
There is another paradoxical result from having a high hospital to patient ratio. In rural China, a child could be born and die and no one would ever know. But bring a hospital to the area, and every death gets counted. The mortality rate may appear to go up, when the only thing changed is your ability to count.
Now, if you take the infant mortalities from that list, you see a group of countries ranked late teens through the twenties that all have very similar rates. Among them are Canada, the U.K, and Australia, New Zealand and the U.S. They likely resuscitate just as many premies as we do, and do just as good a job. Their rates are still lower, but only slightly. Some argue that it’s access to prenatal care. That may be so. However I see a lot of people who could get access to care and refuse it. The attitude of “I can do it myself” is more prevalent in America than elsewhere whereas the idea of ignoring prenatal care is unthinkable elsewhere.
But there’s something else hidden in our numbers that people don’t like to discuss. If you look at U.S. infant mortality for African Americans, the number is almost three times that of White Americans. In fact, White infant mortality is better than the industrial world average, ranking at the top of the list. This implies that our care is excellent, but poorly distributed, at least racially. On some degree it’s likely more representative of the socio-economic discrepancy than anything else, but for whatever reason African Americans also have a much higher rate of prematurity with ensuing morbidity/mortality.
While such a statistical difference is unacceptable, I suspect that more will have to change than the healthcare system. It may justify the suspicion I see against the medical establishment I see from African Americans, or it may stem from it. Remember that in the Tuskegee Study African American males went knowingly untreated in order to ‘learn’ about the natural course of syphilis from 1932 to 1972. In my own experience most of the women without prenatal care are African American women, and lack of prenatal care is a risk factor for prematurity. Many of these women are eligible for Medicaid but never signed up, however.
So that about sums up where the U.S. is in terms of infant mortality. Some countries, like Japan and the Netherands (at 3.8 per 1000) do beat us, and probably legitimately, but ultimately the differences are small and these things are very difficult to compare. We certainly have room for improvement, and getting everyone insurance, or at least catastrophic insurance would be a start down the right path.
Thoughts? Questions?
Infant mortality data can be found in several places, but I’ll reference the CIA World Fact book . Another good source is the 2009 World Almanac, and for you medical types Up To Date has a good entry. If anyone’s interested I can provide references to back up what I present here today. No matter what source you find, it mostly adds up to the same thing however. The U.S. appears to have a significantly higher infant mortality rate than many other poorer and less medically sophisticated nations, including Cuba. Even compared to other industrialized nations like Canada and Western Europe, the rates are higher. So what’s going on here?
First off we have to know what we’re talking about. Infant mortality is defined as the number of deaths occurring in the first twelve months of life per 1000 live births. The world rate is somewhere in the mid 40s (depending on whom you ask) while the average rate for industrialized countries is around 8. I’ll talk about the definitions of a live birth in a bit, because it’s up for debate, but first let’s talk about the most common causes of death in the first year.
Traditionally, infection is the biggest enemy of children. Kids are for all intents and purposes immunocompromised because their immune systems are still learning how to operate. That said nutrition and availability of care also play a huge role. Worldwide however, pneumonia and dehydration are the biggest killers of children and account for the majority of infant deaths.
In the U.S. the odds and resources are vastly different. Birth defects and prematurity take the top two spots, followed by SIDS (it amazes me that people still put infants down prone and not supine), accidents and infection. One of the reasons that pediatricians as a whole are so paranoid about neonatal infections is that despite readily available antibiotics and hospital care, infection remains a huge killer of babies.
Birth defects as a whole are easy to talk about. Many defects are out of our control. In fact many pregnancies would spontaneously abort without proper prenatal care. Our technology, as well as America’s general attitude about voluntary abortions, allows many of these children to come to term. While some are not fatal, there are plenty of defects that put the infant at high risk for death in the first year. One example is Trisomy 18 or Edward’s syndrome. These children are extremely deformed and will likely die in the first month. Despite knowing the prognosis, parents often ‘want everything done.’
(As an aside, it makes me sick when Sarah Palin talks about how she ‘knows how it feels to have a child with a birth defect’ and ‘knows the temptation of abortion’. She doesn’t. Down syndrome kids have an excellent prognosis, especially when you’re rich and powerful. Talk to a single mother whose child has trisomy 13 or 18 and carries the fetus to term knowing that the child may live only a few hours or a few weeks.)
Back on track. Children with these types of defects will not live, and in other countries are more likely to be aborted earlier, either spontaneously or electively. They would never be counted towards the death rate. Because we have good care and a culture that mostly wants heroic measures for everyone, these infants count towards our infant mortality.
We must also discuss what constitutes a ‘live birth,’ because that definition makes the whole rankings difficult to compare. In most states, a live birth is counted as any fetus, regardless of gestational age, that exits the maternal body and shows ANY signs of life. That means even a heart beat for less than a minute counts. Let’s take previable premies as an example. If a woman comes in 18 weeks pregnant and is in active labor, there’s nothing I can do for that child if it’s born. Nothing. No resuscitate efforts will be made because it’s too small and immature to survive. However it often comes out with a heart rate. That’s a live birth. Some countries won’t count that because the infant was nonviable (though official WHO recommendations would have them do so). In fact some countries don’t count the birth if the child dies in the first 24 hours, or even the first week.
Further, we resuscitate a lot of premies. 23 weeks is about the limit of what we can do anywhere, and every effort is made to resuscitate them in the U.S. This creates a high degree of infant mortality and morbidity because often those kids are too sick to last very long. Motality for under 25 weeks gestation is 50%. Neonatologists do amazing things and save people’s babies, but some degree of mortality comes along with it. Cuba, which is technically ‘better’ than the U.S. in terms of infant mortality, does not resuscitate infants less than 30 weeks. During residency a delivery at 30 weeks didn’t even prompt a visit by the attending, and those kids have an excellent prognosis. They’ll likely have normal lives.
Virginia, along with some other states, actually has a policy where any premie infant 1000 grams or less (about a pound) is covered by Medicaid as part of a catastrophic coverage program. I think it’s an excellent idea since NICU care can cost hundreds of thousands of dollars.
One paradox of living where we do is the availability of reproductive assistance technology and resulting multiple births. While these technologies can be wonderful, multiple births (twins, triplets quadruplets) are always premie on some level. Twins aren't that big a deal, but the more babies you add, the earlier they'll be born and the more complications there are likely to be and the higher the mortality rate.
There is another paradoxical result from having a high hospital to patient ratio. In rural China, a child could be born and die and no one would ever know. But bring a hospital to the area, and every death gets counted. The mortality rate may appear to go up, when the only thing changed is your ability to count.
Now, if you take the infant mortalities from that list, you see a group of countries ranked late teens through the twenties that all have very similar rates. Among them are Canada, the U.K, and Australia, New Zealand and the U.S. They likely resuscitate just as many premies as we do, and do just as good a job. Their rates are still lower, but only slightly. Some argue that it’s access to prenatal care. That may be so. However I see a lot of people who could get access to care and refuse it. The attitude of “I can do it myself” is more prevalent in America than elsewhere whereas the idea of ignoring prenatal care is unthinkable elsewhere.
But there’s something else hidden in our numbers that people don’t like to discuss. If you look at U.S. infant mortality for African Americans, the number is almost three times that of White Americans. In fact, White infant mortality is better than the industrial world average, ranking at the top of the list. This implies that our care is excellent, but poorly distributed, at least racially. On some degree it’s likely more representative of the socio-economic discrepancy than anything else, but for whatever reason African Americans also have a much higher rate of prematurity with ensuing morbidity/mortality.
While such a statistical difference is unacceptable, I suspect that more will have to change than the healthcare system. It may justify the suspicion I see against the medical establishment I see from African Americans, or it may stem from it. Remember that in the Tuskegee Study African American males went knowingly untreated in order to ‘learn’ about the natural course of syphilis from 1932 to 1972. In my own experience most of the women without prenatal care are African American women, and lack of prenatal care is a risk factor for prematurity. Many of these women are eligible for Medicaid but never signed up, however.
So that about sums up where the U.S. is in terms of infant mortality. Some countries, like Japan and the Netherands (at 3.8 per 1000) do beat us, and probably legitimately, but ultimately the differences are small and these things are very difficult to compare. We certainly have room for improvement, and getting everyone insurance, or at least catastrophic insurance would be a start down the right path.
Thoughts? Questions?