Regarding the US's High Infant Mortality Rate

Shortly before Mother’s Day, Save the Children released its annual report on the state of motherhood and infant mortality worldwide. As usual, the US does worse than almost every other industrialized nation when it comes to infant mortality (pdf file – see page 38).

The philosopher John Rawls suggested, as a thought experiment, imagining a “veil of ignorance.” The idea is, we sit around planning how to organize society from behind the veil; and none of us planners know what position in society we will hold, what race, what gender, how wealthy our parents will be, etc.. If the people planning society knew they might be born any race, any class, what society would they plan?

I don’t think they’d plan one in which infant mortality by race looked like this (source – pdf file):

US Infant Mortality, among whites, blacks, Asians, Latinos, and American Indians

As you can see, if you’re a newborn American infant, it kinda sucks to be an American Indian, Hawaiian, Puerto Rican, and the suckitude is simply enormous if you’re Black.

* * *

Unfortunately, the racial aspect of infant mortality in the US is usually ignored in the mainstream media. Instead, the focus is on how bad the US does, compared to other countries. The QuandO blog, like many right-wingers, responds that it’s not that the US does any worse at caring for newborns. Instead, it’s that other countries give up on low-weight and otherwise unhealthy newborns more easily, counting them as “stillborns.” In contrast, doctors in the US work hard to save those infants – but since not all of them live, the result of the superior care here in the US is that our infant mortality rate appears higher.

In an op-ed piece, critics of the Save The Children statistics suggest that we should forestall trying to correct the US’s poor results:

If we want to lower our infant mortality rate so it compares better with that of other countries, maybe we should align our rules with theirs to better determine the actual extent of the alleged “problem.”

(Does calling the problem “alleged” and putting the word “problem” in scare quotes create a sort of double negative problem?)

My first question is, how does this critique account for the enormous racial gap in infant mortality within the USA? (It seems unlikely that in the US, doctors try harder to save babies of color while categorizing similar white babies as stillborn.)

My second question is, how much truth is there to QuandO’s critique? Some truth, but not enough to justify calling the US’s infant mortality rate, compared to other wealthy countries, an “alleged problem.” The OECD Factbook explains:

Some of the international variation in infant and neonatal mortality rates may be due to variations among countries in registering practices of premature infants (whether they are reported as live births or fetal deaths). In several countries, such as in the United States, Canada and the Nordic countries, very premature babies with relatively low odds of survival are registered as live births, which increases mortality rates compared with other countries that do not register them as live births.

Yet Canada and the Nordic countries all have better infant mortality rates than the US. So the difference in reporting practices doesn’t account for all of the US’s dismal performance in this area.

If it’s true that the U.S. does as well as other wealthy countries in infant mortality, and we appear to do worse only because we classify cases as infant deaths that in other countries would be classified stillborn, then that should show up in higher stillbirth rates for those countries than for the U.S.. This is something we can check; a World Health Organization report issued earlier this year (pdf link) gathered statistics for stillbirths. So lets look at the WHO stillbirth numbers next to the infant and newborn mortality statistics from the Save The Children report:

Graph: Infant mortality, newborn mortality, and stillbirth rate per 1,000 live births in seven wealthy countries

The graph includes the five countries Save The Children credited with the lowest newborn mortality rates, plus Canada and the USA. Including stillbirths does make the US look better, and is consistent with the claim that other countries may be count some infant deaths (by US standards) as stillbirths.

However, most of these countries are doing as well or better than the US in all categories, including stillbirths. That’s incompatible with the claim that the US’s infant mortality problem is a statistical illusion caused by different standards for categorizing stillbirths.

To make this clearer, look at a graph combining infant mortality and stillbirth rates. (Newborn mortality is not included because the newborn and infant mortality categories overlap).

Graph: Combined Infant Mortality & Stillborn Rates Per 1,000 Live Births In Seven Wealthy Countries

Even when stillbirth deaths are included, the US is still doing significantly worse than countries credited with low infant morality rates. It is therefore impossible that the US’s poor standing is caused entirely by the exclusion of stillborn children from infant mortality statistics (although this exclusion may be a contributing factor). The US’s terrible track record, compared to other wealthy countries, is not an “alleged problem”; it is an atrocity, and one that shouldn’t be swept under the rug.

***PLEASE NOTE***
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74 Responses to Regarding the US's High Infant Mortality Rate

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  8. 8
    Brandon Berg says:

    Any idea how this compares across races within socioeconomic groups? Poverty doesn’t seem to be the sole factor, since Hispanics have much higher rates of poverty than non-Hispanic whites but similar infant mortality rates.

    And if it’s not poverty, then what is it?

  9. 9
    Ann Bartow says:

    Terrific post, Amp – thanks!

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  11. 10
    Barbara says:

    I think this is one of those times when the difference is attributable to death by a thousand cuts. Here are some reasons that could account for some of the difference:

    1. Higher rate of multiple births (multiples increase related to age of mother — late 30′s is kind of a peak — and use of fertility treatments, which European countries regulate more closely).

    2. Younger age at delivery. This might account, in particular, for the higher rate among African Americans — although teen pregnancy rates have gone down, they are still higher for African Americans, and this is definitely a risk factor for prematurity and other adverse outcomes.

    3. Higher rates of high blood pressure and gestational diabetes and other indicators of poor health at time of conception and during pregnancy.

    4. Higher age at delivery. Also a risk factor — women in their 40s have more problems during pregnancy, some of which are captured by number 3.

    So if you have more women at either end of the age spectrum giving birth for the first time, if more women have underlying health problems, and if there is a higher rate of multiple births — all of these could account for higher infant mortality and/or stillbirths, quite apart from the level of medical care provided.

  12. 11
    Robert says:

    According to the Save the Children site, the disparity in outcomes persists even when prenatal care is equal. And as Brandon notes, the figures for Hispanics, who as a group are poor relative to whites, are pretty much the same as the figures for whites. So income can’t be the whole story either.

    If level of wealth isn’t the causal factor and level of medical access isn’t the causal factor, that pretty much leaves culture and individual behavior. As noted in the Save the Children document, the lower the educational level of the mother, the higher the infant mortality rate; it’s well-known that the lower the mother’s educational level, the more likely she is to drink, smoke and take drugs during pregnancy.

  13. 12
    Q Grrl says:

    It could be that white women and middle-class women have greater access to abortion, therefore lower infant mortality rates.

  14. 13
    Barbara says:

    QGrrl, the last time I looked at any statistics, it appears that women of color are more likely to have an abortion than white women — although their pregnancy rate might be higher too, so access could still skew statistics.

  15. 14
    Dianne says:

    Robert: Prenatal care is not the only care that affects pregnancy outcomes. A woman who is less healthy going into a pregnancy is more likely to have problems, as is her child, than a woman who is healthy going into the pregnancy. So even if prenatal care is equalized, preexisting inequalities in health care may contribute to the higher infant mortality in black women in the US. And higher maternal mortality. IIRC, the maternal mortality for black women is somewhat over twice that for white women in the US.

    Another possible problem is that, unfortunately, people in medicine still tend to see “white” as the “normal” or “default” value for a person. So most research is done on whites and therefore medical care is optimized for whites rather than for blacks and other minorities. So, for example, a drug that works well in stopping premature labor or treating pregnancy related hypertension in white women may not work as well in black women. This may lead to situations in which, even with the best of intentions, black women get sub-standard medical care simply because no one knows what the best option for them is likely to be.

  16. 15
    NancyP says:

    Another reason QuandO is wrong: The medical definition of stillbirth is UNIVERSAL. A stillbirth is an infant that has never taken a breath. If it takes one breath, and then dies, that is a post-natal death.

    Dianne is right, medical care is normed against whites. The basis for the increased rate of mild prematurity in black mothers vs white mothers EVEN WITHIN PRIVATELY INSURED MODERATE TO HIGH S.E.S. subset is unknown.

    The popular press is usually unwilling to look at race and class issues behind perinatal infant mortality rates. Occasionally it does get into the popular press that there are some zip codes where the mortality ranks #100 or lower among countries, ie in the middle of the pack of developing countries.

  17. 16
    Ampersand says:

    If level of wealth isn’t the causal factor and level of medical access isn’t the causal factor, that pretty much leaves culture and individual behavior.

    As has already been pointed out, prenatal care isn’t a stand-in for total equality in medical access.

    Saying that there are only four possible causes of disparity in racial infant mortality, and since one and two are eliminated three and four must be the cause, is illogical in a number of ways.

    First of all, you haven’t shown that those four causes are the only possible causes.

    Second, thinking in terms of “the causal factor,” as if there can be only one, is mistaken. Nothing on the STC report indicates that wealth and prenatal care aren’t factors; all that can logically be said is that they have been shown to not be the sole causal factors.

    And the leap from “individual and culture” to “they drink, smoke and do drugs more” is stunning in the lack of any supporting evidence. Even if you’re right – and who knows if you are or not? – I’d be surprised if this factor provided more than a partial explanation for the racial disparity.

    As noted in the Save the Children document, the lower the educational level of the mother, the higher the infant mortality rate; it’s well-known that the lower the mother’s educational level, the more likely she is to drink, smoke and take drugs during pregnancy.

    Here’s the passage in the Save the Children report you refer to :

    Mothers on lower socioeconomic levels, with less education, have been found to be at significantly higher risk of pre-term delivery, even when controlling for other known risk factors such as weight prior to pregnancy, weight gain, alcohol and tobacco consumption, race, parity and source of prenatal care.

    In general, lower educational attainment is associated with higher levels of newborn mortality (see chart below).

    Note that they point out that differences in smoking and drinking do not account for all of the difference.

  18. 17
    Ampersand says:

    Poverty doesn’t seem to be the sole factor, since Hispanics have much higher rates of poverty than non-Hispanic whites but similar infant mortality rates.

    I agree that poverty isn’t the sole factor. However, the chart makes me suspect that poverty is a factor. After all, Cuban-Americans have (on average) much higher incomes than Puerto Ricans, and Chinese-Americans are a much more affluent group than Hawaiians (again, on average).

  19. 18
    Robert says:

    And the leap from “individual and culture” to “they drink, smoke and do drugs more” is stunning in the lack of any supporting evidence.

    I’m not a liberal; I don’t have to get a peer-reviewed study to draw on personal empirical knowledge.

    :P

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  21. 19
    Sebastian Holsclaw says:

    “Another reason QuandO is wrong: The medical definition of stillbirth is UNIVERSAL. A stillbirth is an infant that has never taken a breath. If it takes one breath, and then dies, that is a post-natal death.”

    This is flatly wrong so far as reported statistics in various countries. Like many things with specialized definitions the political definitions are different.

    “And the leap from “individual and culture” to “they drink, smoke and do drugs more” is stunning in the lack of any supporting evidence. Even if you’re right – and who knows if you are or not? – I’d be surprised if this factor provided more than a partial explanation for the racial disparity.”

    With respect to this, it is strange that we have to leap anywhere in conclusions with respect to drinking and smoking during pregnancy. A failure to address such well-known pregnancy dangers in the statistics is simply bad science if we want to talk about differences in birth outcomes. If you are going to compare risks in birth outcomes on an imprecise scientific specification like ‘race’ it makes no sense not to control for well understood risks like ‘smoking’ and ‘drinking’.

  22. 20
    La Lubu says:

    personal empirical knowledge.; known as “pulling it out of my ass” by the rest of us.

    For those of us left-leaning folks who like to consult studies, the U.S. Department of Health and Human Services has scads of tables that show pretty clearly that whites are significantly more likely to drink, smoke, and do drugs than either blacks or latinos, Robert’s “personal empirical knowledge”, i.e., driving by a pregnant black woman smoking a cigarette, or whatever.

    Breastfeeding could help explain part of the difference.

  23. 21
    hp says:

    I’m not a liberal; I don’t have to get a peer-reviewed study to draw on personal empirical knowledge.

    Personal empirical knowledge tells me that those I’ve run into who are the most likely to drink to excess, chain-smoke, and use illegal drugs (or prescription drugs to excess) are the stay-at-home wives of men making 100,000+/year.

    Aka, the neighborhoods I’ve lived in; the mothers of those I grew up with.

  24. 22
    Shannon says:

    No, Lubu! He probably heard his friend’s mother’s sister’s dogsitter talking about how he once drove by a black woman smoking. Stress levels may be important, but discuss among yourselves.

  25. 23
    Dianne says:

    I’m pretty sure Robert was kidding, but this person may not have been.

  26. 24
    Robert says:

    I would be interested in seeing those cites, La Lubu. At a guess, I’d wager the social science research may be compromised by the difficulties in assessing some populations.

    It is well-known that low socioeconomic status correlates with drug abuse (and tobacco and booze, too). Blacks are disproportionately of low SES. That’s the empirical knowledge of which I was speaking.

  27. 25
    beth says:

    oh! oh! but if we women just all treated ourselves and were treated by our healthcare establishment as “pre-pregnant” that would all go away!

    because we’re nothing but baby incubators in the first place, and this statistic shows we’re disobedient, sloppy baby incubators at that! BAD women! BAD! BAD!

    in case you couldn’t tell, i am very, very, VERY angry about this.

  28. 26
    Rachel S. says:

    I actually did my MA thesis on race and “child outcomes”–one of those outcomes was infant mortality.

    I wanted to address a few points
    @Brandon, “Poverty doesn’t seem to be the sole factor, since Hispanics have much higher rates of poverty than non-Hispanic whites but similar infant mortality rates.”
    Exactly, Latinos in particular Mexican Americans and other central Americans groups have lower mortality when education and income are control. It’s not poverty; it’s racism. What is also interesting about mortality stats for Asians and Latinos is that they tend to go up for the second and third generations. What’s even more striking is that middle and upper income Black women have significantly higher rates of infant mortality, when factors like health care access are held constant. Anthropologists have argued that this is likely related to racism related stress (which is not measured in infant mortality studies).

    @Barbara and anybody else who is interested LOL!!, Your point about age is important, but it varies by race. There is a theory called the “weathering hypothesis,” which was proposed by Arlene Geronimus. What researchers have found is that younger Black women (even Black women in their teens) have significantly lower infant mortality than Black women in their late twenties and early thirties. What the proponents of this theory believe is that the cumulative effects of racism increase Black women’s pregnancy risks from a young age. White women’s babies tend to follow the U shaped pattern you described, but infant mortality for Black babies tend to follow this shape / (not that steep, but it increases steadily with age. We do have more teen births in this country, but I’m not so sure that we have more births to old women.

    The last time I checked, which was a few years ago, the weathering hypothesis/cumulative stress hypothesis is the best explanation that we have for racial variation. I personally don’t think this explains all of the “unexplained variance” in racial differences, but for now it is the best theory we have.

  29. 27
    Barbara says:

    Rachel S., that’s very interesting. What do you think the connection between cumulative racism and adverse outcomes is — I mean, separate and apart from prenatal care, is it stress, other health factors (as in, unequal access for treatment of conditions like hypertension, etc.), or something else altogether?

    Hypertension, and PIH, are the cause of a significant number of adverse outcomes, including early birth and it wouldn’t surprise me if these conditions (or their precursor) are present in a higher proportion of African American women at an earlier age. They are significant risk factors for women giving birth over the age of 40. I’ve also read recent research that suggests that how women react physiologically to pregnancy (i.e., PIH and diabetes) is correlated with whether they contract hypertension and diabetes later on and it would make sense that those at higher risk of these conditions in general would develop greater complications during pregnancy. It would also help explain the worsening experience of Hispanics after they have lived here for several generations: Hispanics are at much higher risk for diabetes the longer they live in the U.S. Recent immigrants may actually be healthier having avoided unhealthy effects of an American diet and lifestyle while growing up. At any rate, poorer health at the time of conception must have some correlation to pregnancy outcome.

    Also, I would be interested in knowing the figures on age distribution of adverse outcomes, because when I last looked, even for African Americans, teenage birth was considered a risk factor for prematurity. Maybe someone has looked at the data more closely.

    Robert, that was very poorly done. Unless you know a large sample of African American, Hawaiian and Puerto Rican women you have no idea what proportion are abusing drugs and smoking and your empirical evidence slides into outright prejudice. When last I looked, white women are significantly more likely to smoke than either Latinas or African Americans. I don’t know about native Hawaiians.

  30. 28
    B says:

    From all information I’ve ever heard the optimal age, health-wise, to give birth is in your late teens 17-19 years old. From there on the risk for complications will increase slowly until you’re about 35 and thereafter the risk for complications, or children born with handicaps, will rapidly increase.

    I don’t know how the other nordic countries are doing but in Sweden the age of women giving birth for the first time is now up to 30. So, in terms of complications, countries where women have their first child early should actuallty have fewer stillborns and newborn deaths.

  31. 29
    Barbara says:

    B, it depends on how early. The U.S. has a much higher proportion of girls giving birth earlier than 17 — it’s not a lot of births, overall, but it’s a much higher rate than in Sweden, for instance, which probably has statistically nil births in women of that age range, and it contributes to adverse outcomes.

    The point is that there are a lot of factors that accumulate the risk for Americans in general, and for African Americans in particular. That’s why bringing the rate down is so difficult.

  32. 30
    D says:

    Smoking and general substance abuse statistics. Basically, black men are more likely to smoke, but whites are more likely to drink, and everyone abuses drugs. So Robert is only partially correct.

  33. 31
    Barbara says:

    Smoking cannot explain the higher infant mortality rate for African American women, though it might for other subgroups. FYI, according to the CDC:

    Among teenage mothers 15″“19 years, non-Hispanic white mothers had the highest smoking rates every year in the 1990s (table 1 and figure 3). In 1999, 29.6 percent reported smoking, a rate only 8 percent lower than the 1990 rate. Smoking rates are also high for American Indian teenagers, 22.6 percent in 1999. Rates for Hispanic, non-Hispanic black, and API teenagers are much lower, ranging from 5 to 9 percent.

    More interesting facts:

    Overall smoking during pregnancy rates for Hispanic mothers are low; however, rates differ considerably among Hispanic subgroups. Puerto Ricans had the highest rates of smoking during pregnancy in 1999 (10.5 percent), over 7 times higher than the rate of 1.4 percent for Central and South American women (table 2). Puerto Rican women 20″“24 years of age had the highest rate at 11.9 percent of all Hispanic origin groups of any age. The age pattern for smoking during pregnancy is similar for Mexican, Puerto Rican, and Cuban women, with those 25″“34 years of age reporting the lowest rates.

    * * *

    Throughout the 1990s, smoking rates by maternal education were highest for women with 9″“11 years of education (29.0 percent in 1999) (table 3) (1). Nearly one-half of non-Hispanic white women with 9″“11 years of education smoked during pregnancy in 1999. Women with four years or more of college continue to have the lowest rates of smoking during pregnancy (2 percent, overall, in 1999).

    * * *

    Women were more likely to have smoked during their pregnancy in 1999 if they had higher order births, were unmarried, were born in the 50 States and the District of Columbia, had a single birth, and had late or no prenatal care.

    http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_07.pdf

  34. 32
    Rob says:

    What are the factors that lead to higher infant morality for white mothers? If those factors are more common for black mothers, we’d expect to see higher infant morality. If there’s still a difference, it could be caused by environmental effects or a small biological difference. Note that I’m not a Nazi, I don’t want people dying, even if it means medicalizing race.

    i seem to recall that unmarried women have higher miscarriage rates, but I might be totally off.

  35. 33
    Barbara says:

    Also, it does seem that the CDC stats (or the ones I was looking at, anyway) exclude teen births so that doesn’t appear to be a confounding factor one way or another.

  36. 34
    Barbara says:

    More stats can be found here:

    http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_02.pdf

    Looking at some of these tables, it appears that birthweight is the factor that correlates most closely with risk (duh), but obviously, it’s what causes low birthweight that really matters.

    These stats also show maternal health issues by age (for instance, anemia is more common in those under 20, but chronic hypertension is more common for those who are older. However, the rate of chronic hypertension among Black women is nearly 2x or 3x that of white women depending on the age — and is higher in any given age group, and the difference increases even more dramatically as the age goes up. This is where I think a lot of the difference in mortality rate might lie. Maternal hypertension is dangerous because it can interfere with blood supply to the fetus.

  37. 35
    Dianne says:

    It’s been known for some time that African-Americans tend to have hypertension more often and more severely than people of other races living in the US. AA’s hypertension also responds to different medications than (particularly) European-American’s hypertension, ie AAs respond well to diuretics more often and ACE inhibitors less often. I’ve heard it speculated that the reason for this is that the middle passage selected for people who could retain sodium and water…which is, of course, good if your stuck in the hold of a ship with little food and water, but just the wrong thing for a modern American lifestyle. I’ve never seen conformation of this theory though. I would expect that the chronic stress of racism must contribute to the hypertension as well, though, again, I’m speculating. The bottom line is that AAs have higher levels of hypertension and PIH and we probably aren’t treating it as well as we are EA’s HTN and PIH because we know less about it.

    Incidently, my impression is that fewer AAs than any other group are willing to participate in clinical trials. This is entirely understandable (Tuskegee syphillis project, anyone?), but is a major barrier towards improving treatment for problems in the AA population. Thoughts anyone?

  38. 36
    Barbara says:

    The PIH stats I looked at actually did not show big variation between Blacks and Whites, but then, when the chronic hypertension is already so much higher, perhaps that is to be expected. It’s possible that African Americans don’t participate in trials also because trial participation is highest among those with the best access to care. I imagine that Hispanic participation is also low.

    I’ve never heard anything about the correlation between surviving the Middle Passage and the prevalence of intractable hypertension among Blacks. My hesitation is that Blacks are probably the canary in the coal mine when it comes to hypertension — the risk of hypertension among other non-European groups is rising fast. The next generation might hold some nasty developments on that score, including in the area of infant mortality.

  39. 37
    Rachel S. says:

    Stress could lead to more hypertension, but we also should forget diabetes. Both are very high, and can be related to the conditions that many African Americans live in.

    However, these infant mortality studies are sophisticated, and they control for those factors and the racial gap remains. So the point is that they only partially explain the racial gap. Whatever is cauing this discrepancy? It is not something that is measured in these studies. Differential treatment by doctors could be a factor, but I think a few studies have tried to examine this, and found that is did not explain all of the racial gap. At this point that exact mechanism that causes Black women at all income levels to have higher infant mortality is unclear. The weathering hypothesis is hard to test, but perhaps somebody has tried in the last few years.

  40. 38
    Dianne says:

    One question I don’t know the answer to: Does the higher infant mortality in blacks exist in other countries with minority black populations as well? For example, is the same discrepancy seen in France or Canada?

  41. 39
    Robert says:

    Dianne -

    Probably.

    France bars the collection of ethnicity information (as part of anti-discrimination law) by the government, and researchers have followed suit, so we don’t have information for them. There are racial disparities in Canada; indigenous infant mortality rates show the same pattern as in the states and Canadian researchers seem to think that it holds true for blacks as well, but there aren’t any studies around (at least from my casual Googling).

    Not the most satisfying answer, but heck, it’s free.

  42. 40
    Rachel S. says:

    Does the higher infant mortality in blacks exist in other countries with minority black populations as well? For example, is the same discrepancy seen in France or Canada?

    I am relatively certain that recent African immigrants have lower infant mortality and low birth weight than African Americans. Obviously, in African the infant mortality is very high, the highest in the world, so the closest comparision we have is to look at recent African immigrants.

    I know this does not answer your question about other countries, but it does say something about the long term effects of racism.

    A recent study also found that Latinos who are in the US for longer start to suffer more health problems, so there seems to be a connection between living in the US and declining health for people of color. (I have also seen the that life expectancy for Asians goes down in the second generation.)

  43. 41
    Rachel S. says:

    Sorry for the typos…

  44. 42
    Brandon Berg says:

    Dianne:
    I was wondering the same. I can’t find a primary source for Canadian infant mortality broken down by race, but I found several pages that claim that the infant mortality rate for First Nations (I believe that’s what they call the aborigines) is 1.5-2 times the rate for the general Canadian population, which is about what it is here.

  45. 43
    Robert says:

    I know this does not answer your question about other countries, but it does say something about the long term effects of racism…

    The long term effects of high fat diets, more likely.

    A recent study also found that Latinos who are in the US for longer start to suffer more health problems, so there seems to be a connection between living in the US and declining health for people of color.

    There’s a connection between living in the US and having a longer life span. People with longer life spans have more health problems. There’s also probably a dietary factor.

    On the other hand, perhaps I should take what I can get. Clearly, living in the US is bad for Latinos. Let’s close the border and stop them from hurting themselves so much.

  46. 44
    Dianne says:

    There’s a connection between living in the US and having a longer life span.

    To a limited extent. A number of countries have longer life expectancies.

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  48. 45
    wookie says:

    Does anyone know what classifies one birth as a stillbirth, and the other as an infant death? Because I was under the impression it was birth weight (a certain number of grams) at time of birth/death, and I don’t see how that could be mis-reported… a birth would still have a weight associated with the baby, wether it was dead prior to delivery, died within moments/hours of delivery, etc. Or is that what defines a miscarriage from a stillbirth?

    Regarding infant mortality rate for First Nations people here in Canada, keep in mind that a large percentage of those numbers are going to be coming from extremely underserviced, rural areas, like Nunavut, where even though our health care system is socialized, it isn’t as logistically available as it would be closer to the 49th parallel. If I am having a baby in Northern Saskatchewan, my only chance at a hospital is likely many, MANY hours away by vehicle… will I make it in time in an emergency?

    I’m under the impression that this logisitical issue is NOT what is causing the issue in the States.

  49. 46
    Robert says:

    To a limited extent. A number of countries have longer life expectancies.

    And none of them are Latin countries sending us immigrants.

  50. 47
    Barbara says:

    I believe that a stillbirth occurs when an infant never takes a first breath. If an infant breathes before dying, the death would be classified as an infant mortality. I am pretty sure that this is regardless of gestational age, at least after a certain point, but I believe it’s also possible that pre-viable losses could be classified as late miscarriage or fetal demise and not as births.

  51. 48
    Rachel S. says:

    Infant mortality is any death within the first year of life. I believe Barbara is correct about stillbirth. They also use the term “fetal death” for death prior to birth.

    Here is an interesting chart from the CDC….notice the difference between Black and Puerto Ricans and every other group The rankings of the causes of death are different.

    Just as an interesting side note–on most major demogrpahic indicators Puerto Rican tend to be closer to African Americans than they are to other Latino groups.

  52. 49
    Mandolin says:

    I know this does not answer your question about other countries, but it does say something about the long term effects of racism…

    The long term effects of high fat diets, more likely.

    Could be both. Seems like the best foods aren’t always available to the poor (as has been discussed here), and diet/low fat versions of high fat products can be prohibitively expensive.

    But stress — really big factor in high blood pressure. I don’t see why its impact should be minimized, unless it’s part of a greater attempt to suggest that the stresses of racism don’t really exist.

  53. 50
    Brandon Berg says:

    Rachel:
    Has there been any attempt to test the hypothesis that high infant mortality rates among black women are caused by racism? Or any explanation for the fact that Mexican women don’t have the same problem?

  54. 51
    hans says:

    Hello…Does anyone see the elephant standing in the corner? Do you think that this may talk to the quality of our health care system at all??? Time and time again, study after study show that outcomes in the U.S. fall way short of those in most ind. countries. We spend more and get way less. That is because of the inefficient “Private sector”. Yes the private sector is spending our money on admin costs and CEO retirements, not healthcare. Do you think this may have something to do with infant mortality?

  55. 52
    Dave says:

    This subject is well worn. A cogent explanation for persistence of these statistical gaps is not known. As with so many statistic driven polemics they serve as handy, if over familiar, talking points for those wishing to be critical.
    Certain things deserve to be mentioned. In the US there is a lot of public spending and personal effort that goes into prenatal and neonatal healthcare. This is financed by the 250 billion dollar a year Medicaid Program and is also funded through various state agencies. This massive industry funds innumerable local clinics, hospitals, and doctor’s offices, and this system blends in with the private health care system. There have been considerable advances over the years in maternal and neonatal care. The maternal death rate in America is low and has declined massively in the past 100 years. I don’t see anything in the way of concrete proposals coming from the critics, just the usual angst and outrage.

  56. 53
    Niels Jackson says:

    That chart was very interesting. The greatest gap between blacks and whites (re: causes of infant mortality) was “disorders related to short gestation and low birth weight.” Those, in turn, are conditions that can be causedby smoking, drinking, drugs, lack of rest, giving birth as a teenager, as well as stress, abuse, poverty, and poor nutrition.

    The black rate of Sudden Infant Death Syndrome is nearly 2.5 times the white rate, oddly enough. Why would that be? Poor sleeping habits?

    Black babies also had higher rates of congenital malformations or chromosomal deformities. Any ideas here?

  57. 54
    Marcus says:

    This subject is well worn. A cogent explanation for persistence of these statistical gaps is not known.

    Indeed. We don’t really know anything “cogently”. Some philosophers even claim that the phrase cogito ergo sum is a syllogistic inference , as it appears to require extra premise.

    However, theres no need to make this that hard.

    Here’s what we know:
    1. Other industrial countries, for example Iceland, has 2,5 times smaller infant mortality rate than US.
    2. Iceland has fundamentally different system for providing healthcare to (pregnant) women and newborns.

    Now it is entirely possible to come up with a logical hypothesis why this is so.
    Most remarkably, the same hypothesis also provides us with a theoretically if not practically simple solution.

    So when it is claimed that:

    I don’t see anything in the way of concrete proposals coming from the critics, just the usual angst and outrage.

    I wonder if there is really a need to spell it out, as certainly most critics of the critics do understand what the obviously implied solution would be.
    Hint: the hypothesis previously mentioned does contain the words “better” and “system”, because that is all we really need to know.

  58. 55
    Dave says:

    Hint: the hypothesis previously mentioned does contain the words “better” and “system”, because that is all we really need to know.

    I am tempted to say something smart-alecky like; Well after all we are a little different from Iceland, since we aren’t living on a glacier floating around in the Atlantic Ocean. However, you may be on to something when you say “better — system” I think there are a lot of studies going on concerning health care disparities. http://www.ahrq.gov/qual/nhdr03/nhdrsum03.htm#Findings If they can reveal some evidence as to the causes of these disparities, maybe something can be done about it.
    So far they show plenty of disparities, but the causes seem difficult to pin down. Is it class or race based, due to lack of good doctoring, lack of proper medical facilities, lack of cultural competency on the part of care givers, problems due to life style or culture of patients, genetics of patients, or what? Maybe it is a combination.
    Then what can be done?
    It looks like we are at the mercy of healthcare academics and professionals who are trying to devise a better systems based approach, so I lend them my skeptical support. No use getting a coronary yourself worrying about it though.

  59. 56
    Brandon Berg says:

    Marcus:
    As you can see in the charts above, the combined stillbirth and infant mortality rate is only 60% higher in the US than in Iceland. And Singapore, according to the WHO report linked above, does better than Iceland by about the same margin. It also has a longer life expectancy than any Western European nation except Andorra and San Marino.

    Of course, you could say that it’s due to genetic and/or cultural differences, and not to its mostly privatized medical system. But then you’d have to make the same allowances for the US.

  60. 57
    Marcus says:

    Marcus:
    As you can see in the charts above, the combined stillbirth and infant mortality rate is only 60% higher in the US than in Iceland.

    Yes, but I was talking about the infant mortality rate, the exact reason for using Iceland (a Nordic country) as example is the fact that according to OECD factbook the reporting practices are similar in Nordic countries, and so there’s no need to assume that the “combined” rate does tell us more about the real differences.
    Perhaps I should have used “Nordic countries” instead of Iceland as it might look like I’m cherrypicking a small country in order to make differences look more dramatic.

    However, we might very well include stillbirths and the rest of west Europe in order to accurately compare facts and it will essentially make no difference as Amp pointed out.

    And Brandon: Singapore? Apparently they have good, largely privatized healthcare system in many respects. Good for them.
    When I implied that Nordic countries might have better healthcare systems the major point was not meant to be that they are “socialized”. Obviously the actual quality and amount of healthcare for infants and pregnant women are the things that matter as far as these statistics are concerned, not how the system is funded.

    Furthermore about Singapore, it does not apply identical kind of healthcare than USA despite being largely privatized, and so it is absolutely no need to make any allowances for anyone, nor it does even remotely prove or even imply anything about the quality of US system.

    It not also not true that Singapore does better than Nordic countries (or Iceland) “by the same margin” than they do better than USA.
    Percentages might be misleading because of the nature of the phenomenon of infant mortality: there are x number of deaths that are simply not preventable by current technology. All we know about x is that it is probably smaller than the lowest infant mortality rate in the world (in Singapore) of 2,29 deaths /1000 births.
    Therefore I would say that while Singaporean achievements are extremely impressive, the difference between the infant mortality rate of 2,29/1000 (Singapore) versus 3,29/1000 (Iceland) and 6,43/1000 (USA) versus 3,29/1000 is not similar.
    You were of course combining the stillbirths to these rates, and then Singapore does vastly better than Iceland with 5,29 versus 8,29, but on the other hand if we compare the best Nordic country with the best country with partially private healthcare system, Sweden would score 5,76/1000, virtually the same as Singapore.
    Fortunately for my “Nordic patriotism”, Sweden also actually outperforms Singapore in some respects, for example, Singapore somehow has fifteen times the maternal mortality rate of Sweden. Source, pages 32-33.
    Even the US had lower maternal mortality in 2000.

    I would not hesitate to say that the healthcare system of Singapore is certainly superior in every way if the differences between the national health indicators between it and West Europe would be as big as differences between Europe an USA are. They are not.
    While claiming that European countries have better systems than US is indeed quite a strong statement that does perhaps not adequately take real cultural and genetic differences in account, I feel that it is justified by the consistently better outcomes.
    Known cultural differences like education, incomes (significantly higher in USA), smoking, drug use etc. do not explain these.

    As for what could be done, it is my understanding that despite big efforts via medicare the access for professional healthcare during pregnancy is still inferior in USA, either because of costs or the fact that private insurance does not cover simple monitoring adequatedly.

    It would be ethically very sound if fetuses and infants would be completely exempt for “healthcare is a privilege, not a right” -policy as it hard to take personal responsibility for getting the best care possible at that point of life.
    -Universal care of the same kind than countries with best outcomes for this age group, funded with combination of mandatory expenses for middle and high income patients (parents) and taxes.

  61. 58
    Rachel S says:

    Bandon, “Has there been any attempt to test the hypothesis that high infant mortality rates among black women are caused by racism? Or any explanation for the fact that Mexican women don’t have the same problem?”

    I have yet to see someone who is able to explain why Mexican Americans have such a low infant mortality rate, and I have yet to see a study that is able to thoroughly measure how racism effects infant mortality in Black women. I think the reason that we don’t know why Chicanas do so well, and African Americans do so poorly is methodological. Demographers tend to use large scale surveys, that ask broad questions. They need to do more poarticipant oberservation, and more in-depth interviews with women of color to see how these things operate.

  62. 59
    Robert says:

    It may also not be a demographic factor. Maybe the Mexican-American gene pool is just better at producing healthy babies than the African-American gene pool. Or it could be a micronutritional difference, or some other adaptation to conditions on this continent; Hispanics are living in a place where (broadly speaking) many of their ancestors lived, while blacks and whites aren’t.

  63. 60
    Curious says:

    Why would you need an explaination on why Mexican Americans have such a low infant mortality rate? The babies live and we are happy about it.

    I dont think it has to do with adaptation, maybe you can link it to religion and the respect and care catholicism emphasizes on life (pro-life theology) causes on the pregnant mothers, their families and in effect the baby. Has age of the mothers considered in this survey? It maybe naturally tilted by the fact that many educated african american families decide on fewer kids as compared to the not-so-educated (or not-so-well to do) African American families (or non-families for that matter).

    Does anyone think that the single mother stress might be a reason for overall high infant mortality?

  64. 61
    Robert says:

    Why would you need an explaination on why Mexican Americans have such a low infant mortality rate?

    Intellectual curiosity? Hope that the good result could be replicated in populations with worse outcomes?

  65. 62
    Curious says:

    If things could be replicated across populations, dont you think they would have done so in atleast one sector anywhere, anytime, anyplace? As far as I know all such attempts have failed miserably due to ignorance of the difference or differential aspects. Hence, I believe you have to work on the problem you are trying to solve, not one that is already solved or simply does not exist. I can understand curiousity though.

  66. 63
    Bill says:

    There is no credibility in the claim that IMRs are fudged in non-US countries by falsely attributing some deaths as stillborns. This is denial.

    The US may have the most expensive and decadent medical system, but has some of the worst birthing practices in the western world.

    If C-section rates thru the roof, plus every kind of dangerous intervention are not enough, you’ve got premature weaning and the carving off of pieces from a baby boy’s genitals.

  67. 64
    Patricia says:

    Is it any coincidence that the obstetrical practice in countries with significantly lower infant mortality rates completely differs from ours… and maternal and infant care is done primarily by midwives?

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  71. 65
    Dave says:

    Your 2nd WHO graph is incorrect. The US has an infant mortality rate of 7.2. The first month number is within the 7.2, not additional to the 7.2.

    This completely changes the argument.

  72. 66
    Ampersand says:

    Dave, as I said in the post, “Newborn mortality is not included because the newborn and infant mortality categories overlap.” The second WHO graph doesn’t combine infant and first month mortality rates; it combines infant and stillbirth rates.

  73. 67
    Dolon says:

    “If it’s true that the U.S. does just about as well as other wealthy countries in infant mortality, and we only do worse because other countries move count as stillborn cases that we count as an infant death, then that should show up in higher stillbirth rates for those countries than for the U.S”
    Then why does this ( http://www.cdc.gov/nchs/data/misc/itop97.pdf ) state that the US classifies stillbirths (check fetal deaths), differently among US states, and other countries also report it differently to the US. Your chart isn’t the whole story.

    Also this paper ( http://www.ajph.org/cgi/reprint/96/9/1629.pdf ) gives a nice overview of substance use during pregnancy and race.

  74. 68
    sonya says:

    I know little of much of what has been discussed but, being hispanic. I wondered if the difference between recent mexican immigrants and 1st and 2nd generation Mexicans could be a breast feeding to bottle feeding problem. I have noticed that among those I know, a recent immigrant is more likely to breast feed than is a person who has been born here.