Writing to Mark Steyn, Mark Adomanis points out that the “infant mortality rate is significantly higher in the US than it is in the UK. In fact, if you want to be precise, it’s 34% higher.”
Steyn replies:
As to infant mortality rates in general, as with “life expectancy at birth”, that’s a very interesting topic that I will be writing about at length in the weeks ahead. But, even without taking into account the significant variations in the definition of “live birth”, one thing you notice is that, by comparison with the United States, the countries with the lowest “infant mortality rate” have some of the lowest fertility rates on the planet. That’s to say, it’s not just that they have fewer infant deaths, they have fewer infants, period. They have so few, indeed, that over the medium-term (in Italy, Germany and elsewhere) it will render their government health systems unsustainable. But, as a general proposition, I would say that, when fertility rates get as low as they are in Germany, Italy, Spain and elsewhere, to the point that you now have upside-down family trees of four grandparents, two children, one grandchild, it’s hardly surprising that “infant mortality” is lower.
I’m a little confused as to what Steyn is saying. It’s possible that Steyn is arguing that a lower infant population, in and of itself, explains a lower infant mortality rate. As PG points out, if that’s Steyn’s thought, then Steyn misunderstands basic statistics.
Another possibility is that Steyn is saying that if there are more parents and grandparents per infant, that infant will get more attention and thus be less likely to die. That would make more sense, but I can’t find any evidence to support this proposition. (For instance, all else held equal, are only children significantly more likely to survive infancy than second children?)
That said, even if Steyn is mistaken about the cause of the link, he’s right that low infant mortality rates and low fertility rates are strongly correlated. As this World Bank paper points out, the trends mutually feed into each other: “Lower infant mortality can lead to lower fertility by reducing the need for replacement births. Conversely, birth spacing improves the chances of child survival.” ((For a more detailed discussion, see this paper (pdf link). )) (And, of course, both lower infant mortality and lower fertility are made more likely by wealth.)
However, Steyn is wrong to imply that the U.S. can’t lower our appalling infant mortality rate without dropping our fertility rate. Contrary to what Steyn seems to believe, there are many countries with low infant mortality rates where the fertility rate is similar to the U.S.’s. For instance, the UN rates the US and Iceland as having virtually identical fertility rates (the US is ranked 127, Iceland is ranked 128). But Iceland has the lowest infant mortality rate in the world.
There are countries which probably won’t be able to significantly lower infant mortality without lowering fertility rates — Niger, for example, which has about 7 births per woman, a number that’s way too high for health either of women or of children. But the US, with a fertility rate barely above 2 births per woman, is not in that situation. Because our high infant mortality rate isn’t being caused by a high fertility rate, we can lower infant mortality without lowering fertility.
Finally, no one should discuss US infant mortality without pointing out the elephant in the room, which is race.
In effect, whites, Asians and Latinas in the US are living in a reasonably good wealthy nation, when it comes to infant mortality — not as good as Sweden or the Netherlands, but the equivalent of New Zealand, say. But for Blacks and American Indians, it’s like living in an exceptionally poor nation — Tongo, say, or the Palestinian Territories.
Research indicates that the difference isn’t genetic; it’s discrimination. From Science Daily:
They compared birth weights of three groups of women: African American, whites and Africans who had moved to Illinois. Most African-American women are of 70 to 75 percent African descent.
“If there were such a thing as a (pre-term birth) gene, you would expect the African women to have the lowest birth weights,” David said. “But the African and white women were virtually identical,” with significantly higher birth weights than the African-American women, he said.
The researchers did a similar analysis of births to black Caribbean women immigrants to the United States and found they gave birth to infants hundreds of grams heavier than the babies of U.S.-born black women.For black women, “something about growing up in America seems to be bad for your baby’s birth weight,” David said. […]
David and Collins spoke with black women who had babies with normal weights at birth, comparing them with black women whose babies’ birth weight was very low — under three pounds.
They asked the mothers if they had ever been treated unfairly because of their race when looking for a job, in an educational setting or in other situations.
Those who felt discriminated against had a twofold increase in low birth weights. And for those who experienced discrimination in three “domains,” the increase was nearly threefold.
As depressing as this is, this also shows us that the US’s high infant mortality rate is — or should be — a solvable problem.
Hm.
The phrase “felt discriminated against” is subjective. Let’s say a black person failed to get a job because someone else applied who was more qualified. But when you apply for a job you generally have no idea who else applied and have no idea of the qualifications of the person who actually got the job. Given the history of race in the U.S. it’s quite understandable that the person who didn’t get the job “felt discriminated against” but that doesn’t mean that they were. “Felt discriminated against” != “was discriminated against”.
What I’d like to see is a correlation of both single motherhood and income with mortality and low birth weights. How do single motherhood and income correlate with race? It would be my guess that women who are going it alone in pregnancy without the support of a husband are going to have more stress, lower household income and less adequate pre-natal health care. That in turn seems more likely to lead to (not just correlate with) higher infant mortality. If higher rates of single motherhood in turn correlates with being black then you have a quantitative reason why there’s a racial differential for infant mortality. It can be checked by comparing cohorts of single women of given income levels and seeing if they have comparable rates of infant mortality independent of race.
Ron, while you’re right to point out that feelings of discrimination are not absolutely the same as being intentionally discriminated against, I think there are two valuable things you’re missing: First, feelings of discrimination are stressful, and can exponentially compound when other stressors develop; to that end, it’s irrelevant whether intentional discrimination occurs because the stress of discrimination occurs regardless.
Second, that perception of discrimination might alter willingness to seek prenatal care, especially if the only options available to you are public or pro-bono clinics that are staffed predominantly by White medical professionals. Considering the long history of maltreatment of pregnant women of color by medical personnel, it would be interesting to have asked these women whether their feelings of discrimination inhibited them from seeking care, asking certain questions, requesting certain tests or procedures, and so on.
Ron, there’s no reason to believe a husband is supportive, or even present – and there’s equally no reason to believe an unmarried father isn’t.
The income issue makes sense, and I’m sure whether or not a mom is insured is a factor as well – a friend of mine who is uninsured is having to go through ridiculous hoops (including going to court to testify who the father of her child is) to get her state’s “free” prenatal and birth care…and of course since she has a job that doesn’t offer benefits, she doesn’t get paid sick time or maternity leave, either.
Here’s a video clip that may shed some more light on this conversation. The differing mortality rates are not linked to SES or educational level.
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Thanks for a great post.
Ron, you know, researchers who get published in major publications actually have to analyze their data for obvious confounders. (That’s a fancy statistics term for other variables that may be responsible for the outcome, like poverty instead of race being associated with low birth weight). I am sorry if I sound sarcastic, but this is a pet peeve of mine.
In fact, these same researchers wrote another entire study about poverty, race and low birth weight. You said you’d really like to see research on that topic. Do you actually believe you are the first person to consider this connection, and that you wouldn’t be able to find it? Or do you mean you’d like someone else to look it up for you, and in the meantime you’d just like to muse about the harms of racism being faked in published research by whiny black mothers who are mistakenly perceiving nonexistent racism and researchers with guilt and poor analysis skills?
It’s really frustrating when someone hasn’t bothered to read any of the abundant research that shows that race is an independent risk factor (independent from income and social economic status) for all sorts of health care outcomes, including low birth weight, but feels qualified to say the outcomes are incorrect and they have a much better theory, based on seeing no data and no research.
A simple search on the authors if you were trying to read the study before criticizing it, or on the topic of race, poverty and low birth weight before hypothesizing about it would find this:
Women’s Lifelong Exposure to Neighborhood Poverty and Low Birth Weight: A Population-Based Study
Here is the abstract:
Objective To determine whether women’s lifelong residential environment is associated with infant low birth weight. Methods We performed race-specific stratified and multivariate binomial regression analyses on an Illinois vital record dataset of non-Latino White and African-American infants (1989–1991) and their mothers (1956–1975) with appended United States census income information. Results Non-Latino White women (N = 267) with a lifelong residence in low-income neighborhoods had a low birth weight (<2,500 g) incidence of 10.1% vs. 5.1% for White women (N = 10,647) with a lifelong residence in high-income neighborhoods; RR = 2.0 (1.4–2.9). African-American women (N = 18,297) with a lifelong residence in low-income neighborhoods had a low birth weight incidence of 17% vs. 11.7% for African-American women (N = 546) with a lifelong residence in high-income areas; RR = 1.5 (1.2–1.8). The adjusted population attributable risk (PAR) percent of LBW for lifelong residence in low-income neighborhoods was 1.6% for non-Latino White and 23.6% for African-American women. Conclusions Non-Latino White and African-American women’s lifelong residence in low-income neighborhoods is a risk factor for LBW; however, African-Americans experience a greater public health burden from this phenomenon.
Translation: African-American women who have lived in high-income neighborhoods had worse birth weight outcomes than white women who lived in low income neighborhoods.
There has been plenty of research that simply being a minority in this country is enough to affect you in many significant ways. It doesn’t matter if someone on a website hypothetically believes minorities have ever experienced “real” racism, just perceived racism, to make the measurable effects of racism true.
UK fertility law is changing on 1st October!!!
http://fertility-blog.blog.co.uk/2009/09/22/uk-fertility-law-is-changing-on-1st-october-7015194/
Rosa, in a given individual case I’d agree with you, but in the aggregate I’d wager that married mothers get more support from the father of their child both pre- and post-natal than single mothers. Do you think that there is no significant difference between the two?
MomTFH, that abstract is interesting, but there’s a couple of things about it that I would question. One is that there’s a rather large disparity in the N’s. The other is that I called into question the marital status of the people involved and that abstract doesn’t seem to say that marital status was controlled for.
Jill, I agree that experiencing either actual discrimination, perceiving that one has when one actually hasn’t or even experiencing the fear of such when one hasn’t either experienced or perceived the experience causes stress, and that in turn stress can cause negative effects on fetal health. It makes sense to me that racism is a factor in having a greater incidence of LBW, miscarriages, etc. among black women. What I do question is how much of a factor it is and what other factors there may be. The importance of that is that you have to understand what the factors involved are in order to figure out what to do to solve the problem. “Eliminate racism” is certainly a laudable goal and is something that people should work on both within themselves and in society as a whole. The question I ask is “What else must be done?”
RonF, you need to read more than an abstract to know what was controlled for. Also, in a multivariate analysis in which the researchers look for many risk factors, as this was, researchers may not even choose to publish risk factors that did not have clinical significance.
And, a disparity in the N numbers is not a problem with research, especially if one of the groups is a minority and is naturally present in lower numbers. In fact, the N numbers are NOT that disparate in this study, and just guessing that is true does not make it true. In fact, they clearly prove a higher prevalence of LBW in African Americans.
It’s amusing in a sick way, because the N is one of the strongest parts of this study. I am having a hard time having this discussion with you and not totally calling you out as a rabble rouser grasping at straws to apologize for and diminish racism.
If you want to discuss the fine points of statistical analysis, um, read a whole study first, and then take a biostats class.
What is important is the power of your N number. And, the power of this study is impressive. If you knew anything about research, or even read the full text of any of these studies, you would know that.
What else must be done? Well, first of all, we have to get ignorant white men to stop denying facts about the extent of the problem on websites so we can have a productive conversation about this.
In Ron’s defense (and I really have no reason to defend him), the Science Daily article does quote the researchers as saying “minority women are subject to stress caused by perceived racial discrimination” (emphasis mine). And for this particular study, it looks like they based their racism hypothesis on interviews with African-American mothers rather than rigorous statistical analyses (i.e., it doesn’t appear they control for confounders at momTFH suggests).
In general, I’m a fan of MomTFH, but this particular article is relatively weak on statistical rigor, IMO.
The statistical rigor I was referring to was of the quantitative research done by the same authors, which I link to in my very first post and from which I pasted the abstract. There is only one “N” in the qualitative interview, since there is only one group of subjects, so I assume RonF was also referring to the quantitative study when he claimed that there was a “disparity” between numbers in multiple groups.
You don’t control for confounders or variables in a qualitative study with interviews. It is not appropriate, for obvious reasons, other than in your subject selection. The qualitative research was done with a typical number of subjects for qualitative research, a small group, and is not set to the same “rigor” standards as quantitative research.
In other words, there is absolutely no statistic analysis in a qualitative study, so criticizing a qualitative study for its statistical analysis when there isn’t any, is, well, a sign you have no idea what you’re talking about. In fact, a qualitative study that tries to assign quantitative values to open ended interview answers is seriously flawed and should be criticized for even attempting statistical analysis, since the study method is not suited for statistical analysis.
Qualitative research is usually open ended interviews with a small group of subjects to get more nuanced information about complicated, multi factorial topics. Like racism, which is obviously sadly lacking in nuance in much of the discussions of the topic. It is a common technique in health issues that also involve power balance questions, such as pregnancy and birth.
As for “racial discrimination”, I am really missing the finer point here. If you show me flaws in so called statistical analysis of all of their background literature review, including the excellent quantitative study with the huge N, that point to simply being African American as being a risk factor, one that is greater than genetics or poverty or whatever other risk factors are examined, then we can talk.
It seems to me, yet again, as you are linking to the layperson’s news article that discusses the scientific article, that you, like RonF, have not bothered to read any of the original research. I would really think twice about discussing “rigor” when that is your method of looking into a study’s quality.
I know I am coming across as really pissy, and I apologize, but I would never go on a website and pretend to criticize something as technical as statistical analysis of medical research if I didn’t have a pretty good idea that I had an accurate criticism. It would be like me going on a website on engineering and start telling people their blueprints are messed up because I read some other person’s paragraph about their blueprints. It’s more complicated than all of that, and this armchair amateur hypothetical musing is one of my pet peeves.
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I sort of like Steyn’s equation of “require higher taxes on the working youth to maintain the same level of care in their government health system” with “render their government health systems unsustainable.”
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Just noticed this one.
Mom TFH, you appear to be claiming through implication that the publicized research is, through publication, properly vetted for statistical rigor, confounding factors, etc.
That simply isn’t the case. I use to do a fair bit of blogging on birth related analysis, study design, and statistics, and had a multitude of posts showing many (often well known) studies where the statistics were plain old shitty.
I won’t take a position on the worth of this particular study, since I don’t have time to read it in full (I agree: never, ever, trust an abstract.) But if you want to talk about pet peeves, the concept that “publication proves rigor” happens to be one of mine.
No, that it not what I was saying. I was saying that people who haven’t even read a study shouldn’t make wild guesses as to what was controlled for or what confounders were considered. Besides, the study in the original post is a QUALITATIVE study, which would not involve any of that. Its literature review of quantitative research would be where these analyses would be located, not the article. Which is where I began to look, and found good research. Which I read. And posted. So, I obviously did not assume it was a good article merely by being published in a peer reviewed journal, nor did I say that.
If I said you can’t judge and article by its abstract, how can you leap to think I said you can judge it simply by the title and reputation of the journal it is published in?
No, being published in a peer reviewed journal does not guarantee that an article has been completely vetted. But, it probably has been more carefully vetted than a website comment musing about the study’s hypothetical flaws based on an summary of a lay article describing the original research.
And, RonF mused if there was ANY research on the connection between poverty and racism and the effects on maternal and child health on top of whether the original study was sound. There is a large body of evidence on the connection of race and poor health outcomes published in many major journals. I did not say every study in every journal is well vetted. I said researcherS published in these journals have to analyze their data as a rule; that is why their published papers are considered to be scientific sources. Why you write about them, I am assuming, instead of writing about what Reader’s Digest has to say about health.
I was obviously talking in plural in the quote you quoted. Are you agreeing with RonF that there is not a large body of evidence supporting the health effects of being a minority race in America, including maternal and child morbidity and mortality? Or do you think that body of evidence is somehow flawed or unduly influenced?
Of all of the comments made on this thread to nitpick (and be wrong about), why would you choose mine instead of RonF’s about racism?
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