Troubling data on infant deaths

By Eugene Declercq and Judy Norsigian  |  November 17, 2008 BOSTON GLOBE

PRESIDENT-ELECT Obama's healthcare reform proposals have focused intensely on two key questions: How much would reform cost and how many people would be covered? He also must address the critical issue of why the United States has such poor health outcomes despite all the money we spend.

A report from the Centers for Disease Control and Prevention documents a slight decline in the national infant mortality rate (the number of deaths to babies under 1 year of age) in 2006, but the rate has essentially remained flat since 2000, leaving the United States 29th among industrialized countries.

Advocates of health reform who focus exclusively on access presume that the United States provides effective but expensive healthcare, and that the only real problem is lack of access to this care. The reality is more complex when we examine those mortality figures. The low US ranking is misleading since many of the countries rated ahead (e.g., Singapore, Hong Kong, Norway) have fewer births than an average US state. So, what if we do a fair test - only comparing the United States with other wealthy countries that have at least 100,000 annual births?

There are 16 such countries. Among them, the United States ranks last in infant mortality, third to last in perinatal mortality (deaths in the first seven days and fetal deaths), and last in maternal mortality.

Digging further into the data reveals two more troubling findings. While the US infant mortality rate improved marginally - 3 percent - since 2000, the 15 comparison countries, which already had much better rates, improved by 21 percent in the same period. Put in concrete terms - if the US infant mortality rate merely equaled the current average rate of the other 15 industrialized countries, there would be more than 11,000 fewer infant deaths every year in the United States.

The data also rebut the argument that the United States can't be compared with these other countries because the United States has a more diverse population. In other words, the problem is not in our healthcare system itself, but in access, social supports, and inappropriate health behaviors.

Accepting that premise for a moment, we can examine the outcomes of births to US mothers at less risk and see how they compare. For example, if we looked at the infant mortality rate of only babies born to white, non-Hispanic mothers in the United States and compared that with the overall rates in the other 15 countries, where would the United States rank?

It would still rank 16th out of 16 countries.

What about limiting the comparison to US mothers who began their prenatal care in the first trimester, a basic measure of good access? Still 16th. What if we take out births to immigrant mothers and look only at births to white, non-Hispanic, US-born mothers? The United States still ranks 16th. What if we only looked at white non-Hispanic mothers who began their prenatal care in the first trimester? In that case we move up to 13th - but keep in mind that the US rate for this lower-risk subgroup is being compared with the entire populations of other countries.

What's been the response of the US healthcare system to these poor infant outcomes? The biggest recent shift in maternity care has been a 50 percent rise in the cesarean rate since 1996 to 31.1 percent (third highest among the 16 countries) in 2006. This is testimony to the US belief that more medical intervention, regardless of cost, is better - even when the evidence doesn't support such a claim. A blind acceptance of medical interventions is a systems problem that won't be solved by expanding health insurance coverage.

The first step in improving outcomes is recognizing that our problems go beyond access to care. Our poor showing can't be shrugged off as a function of some subgroup - the uninsured, minorities, immigrants (some generic "them") having health problems that undermine otherwise solid outcomes. This is not just about who gets care, but about how they're cared for. Expanding access to a system that doesn't work won't change these embarrassing rankings.

Eugene Declercq is professor of maternal and child health at Boston University School of Public Health. Judy Norsigian is executive director of Our Bodies Ourselves.