Behind the Baby Count
We're a nation of beautiful babies. In a remarkable achievement, the loss of babies during their first year of life has plummeted by almost 70 percent since 1970. Yet the nation's infant mortality rate is used time and again as evidence of America's failed health system. 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. For this very reason, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country.
Infant mortality in developed countries is not about healthy babies dying of treatable conditions as in the past. Most of the infants we lose today are born critically ill, and 40 percent die within the first day of life. The major causes are low birth weight and prematurity, and congenital malformations. As Nicholas Eberstadt, a scholar at the American Enterprise Institute, points out, Norway, which has one of the lowest infant mortality rates, shows no better infant survival than the United States when you factor in weight at birth.
Mystery. Look at Iceland. It uses the same standards as we do. But it also has a population under 300,000 that is 94 percent homogenous, a mixture of Norse and Celts. Similarly, Finland and Japan do not have the ethnic and cultural diversity of our 300 million citizens. Even factoring in education and income, Chinese-American mothers have lower rates, and African-Americans higher, than the U.S. average. Environment matters as well. Lower infant mortality tracks with fewer teen pregnancies, married as opposed to single mothers, less obesity and smoking, more education, and moms pregnant with babies that they are utterly intent on having. Yet, there are still biological factors that we don't understand that lead to spontaneous premature delivery. It's a mysterious happening when a seemingly healthy pregnant woman suddenly goes into labor and delivers at six or seven months or has to face the shock and sadness of being confined to bed, hoping to hold on for another week, another month.
One sure biological factor is volume overload from multiple-birth pregnancies, something that's been on the rise with the increased use of fertility treatments. In fact, our steadily declining infant mortality rate stalled and took a slight blip upward in 2003 possibly because of that. But there are other triggers of early labor like placental deterioration, inflammation or infection, or mixed-up hormonal signals. There is also evidence that specific genes may make some families (or maybe ethnic groups) prone to spontaneous preterm births.
Recall the young son of a president, Patrick Bouvier Kennedy, who was born six weeks premature and died at Harvard Medical School's Children's Hospital Boston in 1963. He was unable to breathe because his immature lungs could not yet produce the substance surfactant, which keeps the lung's air sacs open. As a student there a few years later, I remember how doctors spoke of Patrick as a classic case of hyaline membrane disease, which was killing preterm infants of the day. Until some 20 years later when a drug form of surfactant appeared-and survival of infants like Patrick increased to over 80 percent. Now that's a score card to remember.
This story appears in the October 2, 2006 print edition of U.S. News & World Report.