Inadequate prenatal care isn't necessarily the cause of the high U.S. infant mortality rate, Aaron Carroll writes for New York Times' "The Upshot."
Approximately six of every 1,000 babies born in the United States die within the first year of life, according to 2014 data. That places the U.S. infant mortality rate behind that of 25 other industrialized countries, according to CDC.
Some take issue with those statistics, arguing, for instance, that the U.S. rate is inflated artificially by very premature births of infants who, in countries with less-advanced technologies, would never have survived to be born. Those critics say the United States' "increased rate of infant death isn't due to deficiencies, but differences in classification," Carroll explains.
Others say that the statistics are mostly accurate and that the United States' poor performance on infant mortality is the result of inadequate prenatal care. But new evidence suggests both sides of the debate may be missing the mark: The United States' problems with infant mortality appear to start well after newborns leave the hospital—and have little to do with traditional health care.
Finding the cause
In the United States, the link between prenatal care and infant mortality appears to be weak. For instance, a 2006 study in Epidemiology examined how preterm delivery played out on active-duty military installations, where women receive uniform prenatal care regardless of race or socioeconomic status. Even in such an environment, black women were more than twice as likely to deliver prematurely.
And a Cochrane Systematic Review that looked at 17 studies examining more than 12,000 women found that additional prenatal care was associated with fewer C-sections and hospital admissions but not lower infant mortality. Other analyses have reached similar conclusions for high-income countries.
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A recent study in the American Economic Journal: Economic Policy adds another wrinkle to the story. It examined infant mortality in the United States, Finland, Britain, Belgium, and Austria, using patient-level data to make more granular comparisons of infant mortality.
As with previous studies, it found that the United States had a relatively high infant mortality rate. But it dug deeper and subdivided infant mortality between deaths prior to one month of age and deaths between one month and one year. As it turns out, the United States and the other countries in the study had roughly similar rates of infant mortality prior to one month of age—but the United States performed significantly worse in the latter period.
Race was not a significant factor correlated with deaths in the latter period. Rather, Carroll says the research largely blames sudden infant death syndrome (SIDS), accidents, and sudden deaths, which all seem to be more common among low-income families.
Making investments
So how does the United States combat its long tail, so to speak, of infant mortality?
More prenatal care is likely not the best answer, Carroll writes. But a focused intervention on infants later in their first year of life could make a big difference. The American Economic Journal study authors suggest several interventions, such as home nursing visits to reduce the likelihood of accidents and SIDS.
Assuming each life is worth $7 million—a fairly standard figure, Carroll writes—it may make financial sense to spend as much as $7,000 per infant to fight infant mortality. "Spending a significant amount of money on poor women to improve the health of their [one]-month to [one]-year-olds might not only save lives; it might be cost-effective, too," Carroll concludes (Carroll, "The Upshot," New York Times, 6/6).
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Perinatal care is a high-volume service, accounting for one-fifth of all hospital stays. Yet it is also highly variable, with significant differences in complication rates for both vaginal and cesarean deliveries between hospitals nationwide.
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