Why do so many new-born babies die unnecessarily in America, the City on a Hill?

Summary: America has wealth and power never before seen in history. Yet the 1% reap the gains of our astonishing productivity while an underclass grows in our cities and rural areas. This post looks at one aspect of this, the price paid by American babies for our national mismanagement. There is no point in getting angry about this — unless you decide to act.

For we must consider that we shall be a city upon a hill. The eyes of all people are upon us, so that if we shall deal falsely with our God in this work we have undertaken, and so cause Him to withdraw His present help from us, we shall be made a story and a byword though the world.

— John Winthrop in A Model of Christian Charity (1630).

America: City on a Hill

 

Why is Infant Mortality Higher
in the U.S. Than in Europe?

NBER Bulletin on Aging and Health, 2015 (1)

Graphics and red emphasis added.

 

The U.S. infant mortality rate (IMR) compares unfavorably to that of other developed countries, ranking 51st in the world in 2013. In the U.S., there are nearly 7 infant deaths during the first year of life per 1000 live births, roughly twice the rate in Scandinavian countries. The U.S. IMR is similar to that of Croatia, despite a three-fold difference in GDP per capita.

What explains the U.S.’s relatively high IMR? This is the subject of a new NBER working paper by researchers Alice Chen, Emily Oster, and Heidi Williams, “Why is Infant Mortality Higher in the U.S. Than in Europe?” (NBER, September 2014).

There are numerous theories as to why the IMR is higher in the U.S. than in other countries.

  • There may be reporting differences for infants born near the threshold of viability, with the U.S. more likely to count them as live births while other countries are more likely to count them as miscarriages or stillbirths.
  • Babies in the U.S. also may have lower birth weight or a lower gestational age at birth, predisposing them to worse outcomes.
  • U.S. babies may experience a higher neonatal mortality rate (deaths within the first month of life) or higher post-neonatal mortality rate (deaths in months 1 – 12) than do babies of similar birth weight and gestational age in other countries.

To quantify the importance of these potential sources of the U.S. IMR disadvantage, the authors combine natality micro-data from the U.S. with similar data from Finland and Austria. These countries provide a useful comparison because Finland has one of the lowest IMRs in the world and Austria has an IMR similar to much of continental Europe.

To address the reporting difference issue, the authors limit their sample to infants born after 22 weeks of gestation with birth weight over 500 grams, since births are required to be reported above these thresholds. They also limit the analysis to singleton births, as access to reproductive technologies has increased the frequency of multiple births, which have higher mortality rates.

Making these restrictions reduces the U.S. IMR disadvantage by about 40%, but a substantial disadvantage remains. In this sample, the U.S. IMR is 4.65 per 1000, versus 2.94 in Austria and 2.64 in Finland.  See the graph…

Infant Mortality Rate: US vs Finland

How much of the remaining U.S. IMR disadvantage can be explained by the other three factors? To explore this, the authors conduct a counterfactual exercise, as reported in the figure.

  • The first column shows the IMR difference for singleton births after 22 weeks and above 500 grams – 1.70 for the U.S. versus Austria and 2.00 for the U.S. versus Finland.
  • The next column reports what the IMR difference would be if the U.S. infants had the same birth weight and gestational age distribution as babies born in Austria or Finland but the relationship between birth conditions and mortality remained what it is in the U.S. currently. Under this scenario, the U.S.-Finland IMR difference would decline by 75%, to 0.53 deaths per 1000 live births, due to the higher birth weight and later gestational age of Finnish infants.
  • By contrast, the U.S.-Austria IMR difference would decline by 30%, to 1.14, because birth conditions in Austria are only modestly better than those in the U.S.

The remaining two columns show what the IMR difference would be if U.S. infants had the same birth conditions as they do currently but experienced the neonatal or post-neonatal mortality rate of Austrian or Finnish infants. Conditional on birth conditions, the neonatal mortality rate in the U.S. is similar to that in Austria and actually lower than that in Finland, so making this change does not reduce the IMR difference. However, the post-neonatal mortality rate is much lower in Austria than the U.S., so the U.S.-Austria IMR difference would fall by two-thirds, to 0.57, if the U.S. had Austria’s postneontal mortality rate. Applying Finland’s mortality rate, the U.S.-Finland IMR difference would fall by one-third, to 1.26. In short, worse conditions at birth and a higher post-neonatal mortality rate are both important contributors to the U.S.’s higher IMR.

Finally, the authors explore how the U.S. IMR disadvantage varies by racial and education group. They find that the U.S.’s higher post-neonatal mortality rate is driven almost entirely by excess mortality among individuals of lower socioeconomic status. As the authors note, “infants born to white, college-educated, married women in the U.S. have mortality rates that are essentially indistinguishable from a similar advantaged demographic in Austria and Finland.”

Cumulative probability of death, by country, by socioeconomic group
Click to enlarge this sad, powerful graph

Probability of infant death: by class in US and our peers.

The authors conclude, “these new facts suggest that a sole focus on improving health at birth (for example, through expanding access to prenatal care) will be incomplete, and that policies that target less advantaged groups in the post-neonatal period may be a productive avenue for reducing infant mortality in the U.S.” As an example of a potential policy lever, they point to home nurse visiting programs, which have been shown to reduce post-neonatal mortality rates in randomized trials.

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“Telemachus, now is the time to be angry.”
— Odysseus to his son, when the time came to deal with the Suitors. From the movie The Odyssey (1997).

For More Information

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Ending the Class War

30 thoughts on “Why do so many new-born babies die unnecessarily in America, the City on a Hill?

    1. Stats,

      Wow. Thanks for flagging this (although it’s a sickening comparison).

      Cuba: per capita GDP of $19 thousand, infant mortality rate of 5 per 100 thousand.

      USA: per capita GDP of $56 thousand, infant mortality rate of 6.

      Who cares more about their people? Which is better run in the interests of their people?

    1. Stats,

      That shows an important but little-known fact: the US health care system is (like its finance system) to some extent a parasite — consuming resources disproportionate to its value-added. Other nations have equally good health care systems without its health-care workers (esp doctors) being far better compensated that others with similar years of education. Cuba is the extreme demonstration of this.

  1. Editor,

    There is also another problem for health systems like the US one, healthy people are not a good business, sick people are a great business. How else could you explain this:

    Scientists develop first lung cancer ‘vaccine’“, Financial Times, 13June 2013 — “its developers in Argentina say that the drug – the brainchild of scientists at Cuba’s Centre for Molecular Immunology – offers a novel and effective way of boosting treatment of lung cancer and hope to be selling the drug in 25 countries by 2015.”

    Cuba’s medical breakthroughs have caught U.S. attention“, Tampa Tribune, 2 August 2015.

    like really, these people are working with subpar 40 year old equipment, on a budget 15 times smaller and they find a vaccine for the most lethal type of cancer worldwide. People with cancer are a great business in the US system. lets be serious.

    I must remind you as a side note that Commander Ernesto Guevara was an MD and that it was him in the begining of the revolution who designed and conceived how the doctors of Cuba were going to be
    educated in order to provide the Cuban people the best health level possible. The rest is history.

    When you do medicine as a business, you have no chance of competing
    with someone that does medicine to heal and care for people.

  2. Comments: 1) The lack of an Aids vaccine fits into the pattern. Drug sales can go on for 25 yrs or more.
    2) Big Pharma is powerful enough to influence journal articles. We are losing true science under extreme capitalism as biology was affected under communism (Lysenko).
    3) IMO medical care was in a Third Sector about 40 yrs ago being neither pure capitalist or socialist (mostly non-profit). Doctors fees and hospital costs were strongly influenced by tradition. There was nothing like the huge disparity in cost/benefit compared to other countries.

    1. Joshua,

      That graph is quite bogus, and has been known to be so since 2012. Please be more careful when playing with Google, and try to have some skepticism about what you read.

      That graph is from an article by Dan Munro at Forbes, 29 December 2012. Forbes not being an especially reliable source for information, more of a blog aggregator. Excerpt:

      “This next one was orignally assembled by Carnegie Mellon University professor Paul Fischbeck – and reported by Mark Roth of the Pittsburgh Post-Gazette (December, 2009) – and highlights our Per Capita Healthcare Costs by Age as compared to four other countries (Germany, the U.K., Sweden and Spain).”

      He got it from Dr. Fischbeck, an engineering professor who runs an Internet database called DeathRiskRankings.com — which no longer exists at that URL. Dr. Fischbeck’s health care spending figures were drawn from “WHO’S GOING BROKE? COMPARING HEALTH CARE COSTS IN TEN OECD COUNTRIES” by Christian Hagist and Laurence J. Kotlikoff, December 2005.

      Two days after the Forbes article, it was reviewed at the website of Austin Frakt, an expert in health care economics (bio here): “Chart deemed bogus.

      The original charts in the Kotlikoff study are for 10 countries, for different years from each country, and, most importantly, THE DATA IS ONLY FOR GOVERNMENT SPENDING. From the Kotlikoff study: “…for age groups under 65, the average values of government health expenditures used to form the U.S. profile are averages over the entire population at a particular age, including those not eligible for Medicaid and, therefore, receiving no benefits.”
      Accordingly, it does not include the lion’s share of healthcare spending for those under 65, skewing the chart.

      The Kotlikoff paper did not chart them together presumably because the data was from different years, currencies, etc. It also mentions that of the 10 countries studied, the US was at one extreme, Austria, Germany, Spain, and Sweden at the other, and Japan, Norway, the UK, Canada, and Australia are in between. This chart conveniently removes the in between countries to make the US appear more extreme. I don’t know how Prof. Fischbeck chose to normalize the 5 cherry-picked countries for one chart, but it doesn’t appear he had data do do so accurately.

    1. The point was to discuss the implications of the data relative to the topic being discussed, and including their veracity. In fact, following up a bit looks pretty interesting and educational to me, including comments by Munro and Fischbeck and discussions about the problems with the chart. I certainly didn’t intend for the chart to be considered definitive.

      http://www.arnoldkling.com/blog/fake-chart/
      http://theincidentaleconomist.com/wordpress/chart-of-the-day-health-care-spending-by-age-and-country/

      Sorry if you don’t agree that the discussion is interesting – must be that you knew all of the material already:

  3. Joshua,

    “In moderation”

    Your comments were going into the spam trap. Did you get an “in moderation notice”?

    This sometimes happens. I get a thousand or so spams per week (that’s just the questionable spams, not including the obvious ones), so it’s necessary to crank its sensitivity to the max. Sometimes — fortunately rarely — it just decides to trap innocent comments, for mysterious reasons. Just post a note and I’ll retrieve them.

    This class of problem will only grow worse as we rely more on arrhythmic driven machines. Soon we’ll be arguing with our toasters, and have our self-driving cars refuse to take us where they believe we shouldn’t go.

  4. According to the CDC, the infant mortality rate in the U.S. is more than twice as high for blacks as for whites. Perhaps there is a socio-economic contribution to that, but the rate for Hispanics is the same as for whites. So I suspect that the socio-economic effect in this study is mostly an effect of race.

    Is there any evidence that infant mortality has anything to do with the health care system? I am not aware of any.

    1. Mike,

      That’s an interesting perspective. To skew the data so strongly by socio-economic class, the racial effect must be large. There is almost certainly research about this!

      As for infant mortality being affected by health care system — yes, there is a proven large effect. For example (from memory), home visits by nurses have a big effect when used in Europe. Needless to say, the odds of that happening in the US inner cities range from zero to not-gonna-happen. I was a social worker in Appalachia. We wouldn’t do home visits. I was told that the police would not there alone; calls to do so got “10-7” (out of service).

  5. At least one program does exist, with randomized, control trials showing success (one study showing $5.70 return on every dollar invested), although I haven’t seen anything that shows benefits specifically w/r/t infant mortality.

    http://www.nursefamilypartnership.org/about

    Obviously, disparities in healthcare access in the U.S. affects demographic disparities in infant mortality, although that wouldn’t seem to explain the data presented on the differences between non-Hispanic Blacks and Blacks.

    ==> “Another factor to consider would be age of the mother.”

    Do you think that would explain the “Latino Health Paradox?” w/r/t infant mortality? Are Black mothers younger on average than Hispanic mothers?

    Related:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2031221/

    1. Joshua,

      That nurse family partnerships sounds like something that might well be helpful. Of course, it is a very different thing from what is usually meant by “health care” in political discussions. I find myself wondering if what it is doing, in part, is providing some of the wisdom and support traditionally provided by grandma (or other relatives) and that is so often missing these days.

      If you click on “fact sheets” there is a link for a document on “Memphis trial outcomes” that claims reduced mortality for both infant and mother. Unfortunately, no information on sample size, so there is really no way to judge the numbers.

      I never heard of the Latino Health Paradox. I am no expert on this subject.

    2. Mike,

      “Of course, it is a very different thing from what is usually meant by “health care” in political discussions”

      True, but that’s a relatively recent development. Personal relationships with the patient was seen as a critical part of medicine in 19th and most of 20th century western medicine. As incomes and profits rose throughout the health care industry, the system optimized to lower costs by substituting drugs and such for the now-expensive labor.

      It’s a reversible choice.

  6. Mike –

    There is a projection here in terms of infant mortality for the program overall…not terribly large (500 infant deaths prevented for 177,517 pregnant women):

    http://www.nursefamilypartnership.org/assets/PDF/Fact-sheets/Ted-Miller-2015-Summary.aspx

    Seems to be an impressive body of research on a larger range of benefits:

    http://www.nursefamilypartnership.org/about/news/journals-and-reports

    ==> “Of course, it is a very different thing from what is usually meant by “health care” in political discussions.

    It’s definitely a trend that’s a part of a movement towards “patient-centered” healthcare. Related: http://www.rwjf.org/en/library/articles-and-news/2014/02/improving-management-of-health-care-superutilizers.html

    The economic advantages of what would seem like expensive home visit programs (for “super-utilizers”) are pretty stunning.

    ==> “I find myself wondering if what it is doing, in part, is providing some of the wisdom and support traditionally provided by grandma (or other relatives) and that is so often missing these days.”

    Makes some sense – I wonder if a similar aspect might help explain the epidemiological paradox mentioned above.

    Interesting anecdotal story. My “daughter-in-law” had a medical emergency recently when traveling in Cambodia. When she was in the hospital there, all the nurses did was dispense medication. (They also lacked some basic nursing skills…she’s a nurse herself and she had to deal with on her own with an air bubble in her IV because the nurses didn’t know what to do about it). “Nursing,” as we might think of it, is generally done by family members of the patients in Cambodia …to the point where the family is expected to provide food – the hospital didn’t give her food.

  7. It would be interesting to see how many infant deaths occurred while in the care of a parent vs. in a child care facility, and whether that plays a role in a higher American IMR?

    1. Laughing at FB now (in a playful way of coarse). Child care facility or daycare facility, the places where millions of children are raised so mom can go back to work. Often these places are brought under fire for the poor care they provide to children under a year of age and the news occasionally reports on deaths of infants in these places. Just a question of curiosity about weather or not that factors into the situation; or how the US compares to some of the other countries mentioned in the post for percent of children in daycare vs. at home and what the IMR rates are between the two.

    2. KA,

      That is an interesting point, but I wonder how well the *usage* of child care explains the socioeconomic difference in results. Poor and rich have access to child care, but not remotely of the same quality.

      I was wondering how many of the deaths occurred in health care facilities, and how that number varied by class. That might point to access to care as a major variable.

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