Why Do Babies in America Die More Often Than Babies in Other Rich Countries?

A report (PDF) from the Centers for Disease Control published last week shows how the U.S. compares to select wealthy countries on a central measure of national health: not well. American babies die within their first year of life about twice as often as infants do in Norway, South Korea, or the Czech Republic.

Infant mortality measures how many children die before their first birthdays. A tragedy for any family, infant deaths also reflect the overall health of a country—infant mortality rates are influenced by the levels of prenatal care, the quality of medical facilities where deliveries take place, and care for infants in the first year of life. Of the 34 developed nations in the Organisation for Economic Co-operation and Development, the U.S. ranks toward the bottom. The U.S. rate is 6.1 deaths for every 1,000 live births.

Globally, the rate is about 34. In the European Union, it’s 3.8. America isn’t just behind the Nordic countries that sit at the top of many measures of well-being. Italy, Portugal, and Estonia all have far better infant mortality rates than the U.S. That’s despite how much America spends on health care—which is a lot more than everywhere else.

Infant deaths can be divided into two categories: babies born prematurely, who have tougher odds of survival, and those born after full-term pregnancies. We’ve long known that the U.S. has too many babies born “too small and too soon,” says Marian MacDorman of the CDC’s National Center for Health Statistics, the lead author of the report. The analysis shows the disparity persists even for full-term pregnancies: “If you look at these big babies born at 37 weeks of gestation or more, the U.S. infant mortality rates are about twice what it is in several European countries,” MacDorman says.

The reasons for the differences aren’t clear. Researchers suggest social circumstances affect both the rate of premature births and infant deaths after the first month of life. Earlier CDC research shows wide disparities (PDF) in infant mortality by race in the U.S.: Black babies are more than twice as likely to die before their first birthdays as white babies. Whites in the U.S. still have higher infant mortality rates than European countries do. Other research points to gaps in wealth that may explain much of the difference.

Marie McCormick, a professor at the Harvard School of Public Health who was not involved in the CDC report, says social stresses have been linked to pre-term births and higher infant mortality. “We actually don’t know, to be perfectly honest, why poverty or racism increases the risk of prematurity, but it certainly does,” McCormick says. “In some instances the populations at the greatest risk may not receive the highest quality of care.”

Many other countries “mitigate the affects of poverty through a whole variety of tax and transfer programs,” she says. “These countries do buffer socioeconomic stress much better than we do.”

In many U.S. states, poor women without health insurance aren’t eligible for coverage under Medicaid before they’re pregnant. “Our policy has basically been set up to care about the health of women only to the extent that it affects the health of the newborn,” says Paul Wise, a professor of pediatrics at Stanford School of Medicine. That doesn’t give doctors much time to try to intervene to prevent premature birth, Wise says, especially the highest-risk early births.

That’s changing in states expanding Medicaid under the Affordable Care Act to include low-income adults with no children or pregnancies. Improving the health of women before pregnancy may help reduce pre-term births and infant deaths. “In part, our problem with infant mortality in the United States is a legacy of the poor general health of women of reproductive age,” Wise says.

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