A recent US News & World Report column by Dr. Bernadine Healy claims:
Just last week, the Commonwealth Fund issued a score card that flunked U.S. health system performance with newborns. The reason? Our current infant mortality rate of 6.4 per 1,000 live births is high compared with the 3.2 to 3.6 per 1,000 estimated for the three top-scoring countries in the world-Iceland, Finland, and Japan. It’s also higher than the 6 deaths per 1,000 for the European community as a whole. Before putting on the hair shirt, let’s take a look behind these numbers as these comparisons have serious flaws. They also convey little about why we lose nearly 28,000 babies a year, a starting point if we want to bring universal health to our nation’s cradles.
First, it’s shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don’t reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates.
Here’s a graph I made back in May:
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 an atrocity, and one that shouldn’t be swept under the rug.
Dr. Healy does claim that the US’s high infant mortality rate is linked to our greater “ethnic and cultural diversity.” I have to wonder about that – is there any evidence that minorities in other first world countries do far worse in infant mortality (and maternal mortality) than majority groups? Or that they do as badly as some minority groups here in the US do?
But it’s true that when it comes to infant and maternal mortality, the US is effectively two nations. As I wrote in 2003, how likely you are to die in birth – or childbirth – in the U.S. depends on race. According to the CDC, the U.S. infant mortality rate for whites is 5.7 per 1000, a rate comparable to Switzerland or Australia. The U.S. infant mortality rate for blacks is 14 per 1000, a rate comparable to Uruguay and Bulgaria. The differences in maternal mortality rates are even more stark – 5.5 per 100,000 for whites, compared to 23.3 per 100,000 for blacks. This means that as far as maternal mortality is concerned, American whites have nearly the best health care in the world – better than Sweden’s – while American blacks might as well be living in Bulgaria or Saudi Arabia. (I’m using 1995 World Health Organization data, available in word format here, to make this comparison).
Bottom line: If we judge by infant and maternal deaths, blacks in the US effectively live in the third world, rather than in the first world. (See this post for some information about infant mortality among other demographic groups in the US.)
Curtsy to Mick at Newsbadger (who seems to have entirely bought the US News & World Report spin, alas).
It’s not just blacks. Mexicans, especially first generation immigrants, have statistics that are just about as bad IIRC. Which is, of course, a natural consequence of having had two servant classes for all but the last forty years that Europeans have been in North America.
Amp,
What are you trying to show?
If your main point is that U.S. blacks have worse prenatal and maternal death outcomes than U.S. whites, you have pretty much demonstrated that. Although to cement your point, you should ideally show a graph which is limited to the U.S. and shows the total still births and neonatal deaths combined for blacks and whites. This might reduce or increase the variance between races, but either way it would be a nice comparison to see.
OTOH if your main point is that U.S. blacks are getting worse medical care than blacks in other first world countries, or that the U.S. medical system is of generally lower quality than other first world countries, you haven’t given enough data for that conclusion.
That doesn’t mean you are wrong. It merely means that you have to cite more supporting data to show that you are correct. In particular, given that you know different races in the U.S. have much lower mortality rates, you need to see whether the other countries “improved” rates are due to different proportions of races.
Also, you have to at least consider that the difference in neonatal mortality is, in fact, genetically linked. This doesn’t say anything about superiority/inferiority; it just (maybe) implies that some of the variation is not related to race or class. Think about, for example, sickle cell anemia: beneficial sometimes, harmful other times, and generally a race-linked trait.
If you haven’t done so, you may want to examine some of the CDC detailed charts. Here are some for 2001, for example:
http://www.cdc.gov/nchs/datawh/statab/unpubd/natality/natab2001.htm
Those charts provide extraordinary data for testing some underlying assumptions.
So how to figure out whether the black/white disparity results from a class issue, or from an education issue, or from a prenatal care issue, or…?
Well, one might look at this chart, which tracks”very low” birthweight (an indicator of fetal health) in relation to race and education.
http://www.cdc.gov/nchs/data/statab/natfinal2001.annvol1_27.pdf
Charts like this allow you to compare black women who have graduated from college(or grad school) with whites who have not. Then we see that, for example, 25-29yo post-collegiate black mothers have higher rates of “very low birth weight” than do 25-29yo white mothers pretty much across the board, including those who have not even completed high school.
And so on.
Having looked at the data myself in some detail in the past, it seems IMO that some sort of genetic effect is at least somewhat of a contribution, though I cannot say to what degree.
Sailorman, The problem with that argument is that foreign born Blacks who live in the US have a lower incidence of very low birth weight than American born blacks (who have a relatively high percentage of European ancestry). This provides evidence for some sort of environmental explanation.
On the issue of “ethnic diversity” causing the problem. It’s would be diversity it would be RACISM. What kind of crack are they smoking? Diversity doesn’t cause the problem, but unequal treatment does.
from the Sept. 26, 2006 Milwaukee Journal Sentinel:
Also,
http://tinyurl.com/f4q5d
Freudian slip?
To put it bluntly, we might indeed analyze what kind of crack are the groups with higher infant mortality rates smoking.
Not to say this is all-or-nothing proposition, but anyway.
Here are some quotes from a few recent abatracts of articles on this subject matter.
1. Jaffee, K.D. and Janet Perloff. 2003. “Racial Differences in Neighborhood Disadvantage among Childbearing Women in New York City: 1991-1992.”
Journal of Human Behavior in the Social Environment, 2003, 7, 3-4, 59-77.
These authors argue that ecological factors, in particular segregation into low income medically underserved areas affects Black women, at all income levels.
Quoting the abstract: “High & persistent residential segregation of Blacks & Whites in NYC has put Black women at a clear & significant ecological disadvantage compared to White women regardless of the borough where they lived when they gave birth to their infant. This study found that, when compared to White women, Black women in NYC are at a vast disadvantage regardless of income.”
2. Frisbie, Parker; Seung Song; Daniel Powers; and Julie Street. 2004. “The Increasing Racial Disparity in Infant Mortality: Respiratory Distress Syndrome and Other Causes” Demography 41, 4, Nov, 773-800.
These authors seem to be arguing that the new technologies that are saving infants at younger and younger ages are exacerbating the racial gap.
Quoting the entire abstract:
“Although substantial declines in infant mortality rates have occurred across racial/ethnic groups, there has been a marked increase in relative black-white disparity in the risk of infant death over the past 2 decades. The objective of our analysis was to gain insight into the reasons for this growing inequality on the basis of data from linked cohort files for 1989/90 & 1995-1998. We found a nationwide reversal from a survival advantage to a survival disadvantage for blacks with respect to respiratory distress syndrome over this period. The results are consistent with the view that the potential for a widening of the relative racial gap in infant mortality is high when innovations in health care occur in a continuing context of social inequality. As expected, the results for other causes of infant mortality, although similar, are less striking. Models of absolute change demonstrate that among low-weight births, absolute declines in mortality were greater for white infants than for black infants.”
I should also add this study. It was conducted by some former professors (and a grad student colleague) of mine.
Stockwell, Edward, Franklin Goza, and Kelly Balistreri. 2005. “Infant Mortality and Socioeconomic Status: New Bottle, Same Old Wine.” Population Research and Policy Review vol. 24, no. 4, pp. 387-399, Aug 2005.
Here’s a quote from this abstract:
“This paper presents the results of an ecological analysis of the relationship between infant mortality & economic status in metropolitan Ohio for the period 1960-2000. The data examined are centered on the five censuses undertaken during this 40-year period. The basic unit of analysis is the census tract of mother’s usual residence, with economic status being determined by the percentage of low income families living in each tract. For each of the five periods covered, census tracts were aggregated into broad income areas & three-year average infant mortality rates were computed for each area, by age, sex, race & exogenous-endogenous causes of death. The most important conclusion to be drawn from the data is that in spite of some very remarkable declines in infant mortality at all class levels since 1960, there continues to be a very clear & pronounced inverse association between income status & infant mortality. Indeed, the evidence indicates that the relationship has become stronger over the years. These observations are applicable for both sexes, for whites & nonwhites, for neonatal & postneonatal deaths, & for both major cause of death groups. It is concluded that while public health programs are important, any progress in narrowing this long-standing differential is unlikely unless ways can be found to enhance the economic well-being of the lower socioeconomic groups.”
I also had a personal conversation with Goza about this research and he told me that the the racial gap was more pronounced than the class gap.
I have to wonder about that – is there any evidence that minorities in other first world countries do far worse in infant mortality (and maternal mortality) than majority groups? Or that they do as badly as some minority groups here in the US do?
The short answer, as far as I can tell, is that minorities in other first world countries do worse than the majority ethnic group, but the divide isn’t as large.
For example,
A study from the Netherlands, which has a fairly large minority population Minority and immigrants in the Netherlands have a higher infant mortality rate than native Dutch do, but the risk ratio is no where near as extreme as in the US.
Similar result for Britain: Pakastani babies do worse, but not as much worse as minority babies in the US.
Also, you have to at least consider that the difference in neonatal mortality is, in fact, genetically linked.
It is not impossible that there may be genetic grounds for some of the differences between black and white neonatal mortality rates. Unfortunately, that doesn’t rule out racism as a cause.
Most studies, certainly most studies done before the 1990s, were done primarily or exculsively on whites. There are a number of reasons for this, ranging from the fact that most researchers were and are white so that they thought of white as the default “normal” and didn’t seek minorities to be part of the studies to the relative reluctance of many African-Americans to be part of medical studies which is, of course, a well justified paranoia–no one wants to be part of the next Tuskeegee syphillis experiment–but nonetheless leaves this population misses out on many experimental trials.
Whatever the reason, the result of having clinical trials be done mainly or exclusively on whites is that the data and treatments that evolve from these trials are tailored towards whites. And minority infants may not respond to these treatments in the same way. This puts them at a disadvantage when they need medical treatment and might account for some of the differences between the neonatal mortality rates of blacks and whites in the US.
I’m going to now speculate wildly about other possible reasons:
1. Dealing with racism is stressful and minorities , even wealthy, well educated minorities (maybe especially wealthy, well-educated minorities) face racism daily throughout their lives. Stress and depression are known to be bad for pregnancy and be associated with worse outcomes.
2. Too few doctors are of minority races. This means that a minority patient likely faces some cultural difficulties when dealing with their doctors and other medical personnel. Anything from overt prejudice to misunderstanding the signficance of a hesitation in speech. This can lead to trouble if not noticed.
3. As Rachel mentioned, there is still a lot of segregation in the US. Whites and blacks of similar income levels don’t necessarily live in the same neighborhoods. Black neighborhoods may have worse EMS coverage, be further from hospitals, etc.
I have to wonder about that – is there any evidence that minorities in other first world countries do far worse in infant mortality (and maternal mortality) than majority groups? Or that they do as badly as some minority groups here in the US do?
Natives in Canada have very high infant mortality rates compared to white Canadians. According to Statistics Canada, the infant mortality rate is 3 times greater for Native babies than for non-Native babies.
This may in part be because Canada has a policy of forcing pregnant Native women in northern remote communities to fly to southern (white) hospitals to give birth. Many women resist this practice by hiding when the planes come or lying about their due dates. If there is no aboriginal midwife in their community (and many communities are midwife-free, thanks to the colonial destruction of Aboriginal midwifery knowledge and practitioners), Native women may have to give birth without a skilled practitioner.
All this to say that infant mortality is definitely racialized, but it has nothing to do with whether certain ethnocultural groups are more prone to higher infant mortality rates, but rather to do with racism.
Tuomas, You live to drive me crazy don’t you. LOL!! I’m talking about the people who make these claims about diversity. You have such a consistently negative view of African Americans don’t you.
But Rachel, you provoked me! (Kidding)
I meant to point out that there are socioeconomical factors at play here: I am under the impression that altough most African-Americans are decent people, factors such as drug use, worse nutrition, and such invidual factors are at play here too, in addition to racism.
It seems plausible that infant mortality is higher among persons whose lifestyles are less healthy and who have less access to healtcare etc.
But, like I said, racism may very well be a factor here too, and it can partly explain the invidual factors too.
Like I pointed out in CD,
In other words, I agree in a way with you, but I wouldn’t attribute it all to racism, either.
Tuomas,
I see what you are saying, but I think there is an important point to be made. In the studies such as the one’s cited, they usually control for all of the individual factors and social factors you mentioned. This reduces the racial disparity, but it doesn’t make it go away. There are some who would argue that race only matters because of it’s connection to social class or subcultural variation in health behaviors, and my point is that this is not true, racism has an independent effect. Unfortunately, the demographic data collected has no measurements for racism (which is understandable given the nature of demography), so we a left with this gap, that seems to only be explainable by something that is not being measured. I hypothesize that this is racism.
Most of these studies use advance multivariate statistical methods, which allows the authors to control for these other factors. I probably should have mentioned in the some of my other comments.
Just as an interesting side note, my MA thesis was on this subject, focusing Black/White biracial children. I was never able to explain why, but I found that birth weights and early child development for this group was much better than whites or blacks. If I wanted to publish the study, I would need to go back and try to figure out why this was, but it is another anomalous finding.
That is interesting, and might be in the province of geneticists and other research medicine.
What is the evidence that this independent effect, that can not be explained by social or cultural variables, is racism?
It seems to me that often in social science the unexplained gap is explained as racism, sexism etc. because a genetic explanation is not preferable. I’m not saying that it is necessarily genetic, but it seems that the explanation of “racism” is more of a political value judgement.
Tuomas said, “It seems to me that often in social science the unexplained gap is explained as racism, sexism etc. because a genetic explanation is not preferable. I’m not saying that it is necessarily genetic, but it seems that the explanation of “racism” is more of a political value judgement.”
Both the choice of racism or genetics are politcally motivated values. The genetic variation argument doesn’t work well because the genetic variation between Whites and Black American is very limited, and if it was all about some sort of “defective African gene” then foreign born blacks would be expected to have high infant mortality rates than whites or American born blacks. This is not the case. I get what you are saying, but I think the unmeasured and unexplained variation is much more likely to be something social.
I agree that both can be political values.
Possibly. But the social value in question isn’t necessarily systemic racism.
Or likely, in the light of the lack of disparity between non-American blacks and American blacks.
Is this an annual debate? I thought we just covered this recently, and after going blind looking at pretty interesting CDC stats, it was pretty clear to me that Amp was right.
Tuomas, re lifestyle: African American women are significantly less likely to smoke than Caucasians — you should not assume that infant mortality is the result of riskier behaviors. You really need to look at the CDC data.
Barbara,
LOL!! We sure did, but there was a bog report released this week, and much of the press coverage did a piss poor job on covering the racial aspect. It’s probably worth it for us to keep hitting the nail on the head, until the mainstream media wakes up.
Statistics on indigenous infant mortality in Australia are abysmal, more than double that of the population as a whole (and significantly higher than US indigenous infant mortality). Maternal mortality is about triple in the indigenous population.
Of course, this should be a national shame, not an excuse.
One interesting fact to throw in here is that two studies have linked non-emergency c/sections with higher mortality for mothers (in one study) and infants (in another). And in urban, overcrowded hospitals with less-than-enlightened OBs on a tight schedule, c/secs get pushed pretty hard on any woman who doesn’t push out her baby in a strict timely way. Peaceful waterbirths and planned homebirths are seldom an option for women who can’t afford to pay for doulas and midwives out of pocket, or who have no insurance at all.
I do not have the data easily available, but I am almost certain that when I studied in France (1999-2000 school year) a study came out on infant mortality in France, showing that the North African Muslim population (France’s major minority) had much higher infant mortality than the population as a whole.
I am somewhat in agreement with Tuomas, as well. Culture matters–even if it was formed by racism, or by history, sometimes culture continues after the causes leave. My sister (white, from a working-class, but in a working-class black community and with a black boyfriend) had a baby a few years ago. Many of her black friends were surprised at some of the obvious (to her) prenatal preparation–nutrition, pre-natal vitamins, etc. And almost everyone was sure that nursing wouldn’t be enough food for the baby; the fact the he is healthy and grew fine convinced several of her friends to try nursing their own babies later.
Now, that’s probably the legacy of racism and poor access to health care. But this is a working-class community; almost all these people have health insurance. But cultures and histories matter–that’s why poor Southerners in rural areas (maybe elsewhere, but rural areas are what I know) often think Coke is a good thing to feed infants; before refrigeration and deep wells, it often was the safest thing available.
emjaybee, are you sure about women being pushed into c-sections in public hospitals? Because it was my understanding that women in public hospitals, particularly those without private insurance, are significantly less rather than more likely to have c-sections. My working assumption is that much (not all) of the divergence is explained by the incidence of prematurity — which could be the result of many different factors, including poorer pre-pregnancy health, poorer medical scrutiny and lower rates of aggressive intervention to stop pre-term labor, and almost certainly, higher rates of maternal hypertension and pre-eclampsia. I am pretty sure that the stats themselves adjusted for age by excluding births to women under the age of 18. But it’s pretty clearly an overall pattern of medical neglect that leads to poorer outcomes in pregnancy. Just as you can’t expect someone who went to abysmal schools between the ages of 6 and 18 to shine in University level work, when a woman becomes pregnant, you can’t expect to make up for poorer health that is the result of years of substandard nutrition, medical care and stress.