We combine comprehensive micro-data on births and infant deaths in the US from 2000 to 2005 with comparable data from Austria and Finland to investigate this disadvantage. Differential reporting of births near the threshold of viability can explain up to 40% of the US infant mortality disadvantage. Worse conditions at birth account for 75% of the remaining gap relative to Finland, but only 30% relative to Austria. Most striking, the US has similar neonatal mortality but a substantial disadvantage in postneonatal mortality. This postneonatal mortality disadvantage is driven almost exclusively by excess inequality in the US: infants born to white, college-educated, married US mothers have similar mortality to advantaged women in Europe.
Aaron Carroll at the Incidental Economist looks at the paper and makes the following comment:
Reporting differences (the favorite explanation of those defending the US healthcare system from the infant mortality metric attack) explained up to 40% of the disadvantage in US infant mortality. But that would only get us closer. It would still leave us way worse….
More concerning, though, is that our neonatal mortality (or the mortality in the first month of life) wasn’t so different than the other countries. What accounted for the real disadvantage was postneonatal mortality, or mortality from one month to one year of age. That difference was almost entirely due to excess inequality in the US.
In other words, most of the infant mortality difference between the US and other countries was due to really high postneonatal mortality in less advantaged groups. If differences were due to neonatal mortality, then you would want to try and reduce preterm births. That’s often what we’ve been trying to do. But this study shows us that this isn’t where the lesion is. It’s in the postneonatal period. (This point is consistent with Austin’s latest post about NICUs on the JAMA Forum.) It’s possible that the inpatient care is excellent right after birth, but once babies go home, their access to care is different along socio-economic lines. To fix that, you likely need to improve the health care system, or inequality in the US.
The first take-away that I get from this is that the US healthcare system is extremely fragmented and is technological heroism inclined. Every few years there is a wave of articles about face to face contact as the next paradigm buster in public health. And then nothing happens but massively capital intensive machines and systems are readily bought. We have a bias towards heroism and not towards maintaining good health.
My second thought was to pull the recent data on infant mortality within the United States to see if the international comparison has relevance to inter-state comparisons. The Kaiser Foundation has fifty four states or territories listed for the 2007-2009 time period. There is one state that was in the Confederacy(Texas) that had a lower Kaiser calculated infant mortality rate than the national average. Seven of the ten worst states were Confederate states.
Oh me, oh my, I must be making a spurious correlation to public health,
race and class and states rights advocacy.