The U.S. has been considered a leader in many things — industry, innovation and health care technology. In fact, America leads the world in dollars spent on health care, likely reaching $3.2 trillion this year. Despite this extravagant spending on medical care, we have failed to protect the most vulnerable. Infant mortality is defined as the death of a baby in the first year of life; we rank 27th for infant mortality in the rich countries of the world and 56 th overall.
What does that ranking mean for babies born in the U.S.? It means they are twice as likely to die in the first year of life as children born in Korea or Spain and three times more likely to succumb in infancy than children in Finland or Japan. As a matter of fact, a baby born in America has about the same chance of celebrating her first birthday as one born in Lebanon and less chance of survival than the children of Cuba, Slovakia or Poland.
[See: Best Children’s Hospitals.]
There is significant variation from state to state, with some states approaching mortality levels of a second world country. The major causes of death in our babies include congenital malformations, extremely-low-birth-weight premature babies and sudden infant death syndrome, or SIDS, very different than the major threats of malnutrition and infection encountered in resource-limited countries.
While this should be startling news, it really is not, having been the case for decades. One must wonder then why our babies are dying despite spending trillions in the health care sector. The causes are multi-factorial but a significant percentage can be explained by health care disparities in both the extremes.
Certain contributing factors probably jump right to mind, like limited access to health care. Nearly 25 percent of U.S. women do not get access to prenatal care. There are also risks with access after birth. Unlike the other developed countries of the world, the U.S. actually shows an increase in infant deaths around 4 months old that continues to the first birthday. Why? Because small babies get great health care in hospitals after birth no matter how complicated their health issues. After discharge, lack of appropriate wraparound services and lack of ability to access care increase the risk.
Several other factors may go hand in hand with these access issues, including lower education, unmarried status, substance use and extremes of age, such as moms who are teens or over 40. Frequently, the economically challenged have both physical and societal comorbidities that can increase risk.
Obese women are 25 percent more likely to have a premature baby; 33 percent if they meet the definition of morbid obesity. Cigarette smoking, known to be directly proportional to lower socioeconomic status, can increase the risk of complications leading to early infant death by 8.4 percent. Without preventative counseling and care before delivery and no care-coordination services for new and potentially young parents after birth, the cracks get wider and the ease with which babies slip through them remains tragic.
[See: 8 Weird Ways Obesity Makes You Sick.]
Health care disparity is also visible at the other end of the spectrum. Higher socioeconomic classes frequently engage in other behaviors that are quite risky on their own. Early cesarean section (before 39 weeks) can result in poor outcomes for babies. While a week or two may not seem like much, the body is very smart regarding fetal development. Keeping babies in the nurturing environment of the uterus occurs naturally for a reason — to prepare them for life in the outside world. When there is fetal distress, the procedure is necessary and prudent, but a C-section should never be done out of convenience.
In addition, another phenomenon of the economically advantaged has been in vitro fertilization. A great technological advancement for those struggling with fertility issues, it has been successful in changing the lives of many families. However, the practice of implanting multiple embryos to increase the chances of viability carries its own risks of prematurity and early infant death. And, since this modality is expensive, it is a risk only to those who can afford it.
[See: In Vitro Fertilization Grows Up.]
Lastly, and most pronounced of all, racial disparity contributes significantly to infant mortality. In African-Americans, 1 out of every 5 births is reported to be premature. In addition, in most U.S. states, mortality rates for black infants are at least two times higher than for white infants. Sadly, this has been the trend for decades and remains untouched by public health efforts.
The sensitivities of our American society also contribute to our infant mortality numbers. In many countries around the world, babies younger than 26 weeks are not resuscitated and are considered a miscarriage or stillbirth. As our technology has improved, we will resuscitate babies on the cusp of viability, at 22 to 23 weeks gestation. The risk of mortality increases the younger the infant and the lower the weight. This practice could raise our infant mortality rates by as much as 30 to 40 percent. Many ethical questions are prompted by this fact: Just because we can support babies at younger ages, should we? What is the true survival? Does that correlate with quality of life? What are the societal costs of such interventions?
When we look at the infant mortality numbers in our country, we are outraged, but a deeper dive into the issues shows what a complex problem it represents: A society in which your risk is dependant on your ability to access good and preventive health care.
As we explore health care disparities, we cannot only look at those who are challenged but also those who have and expect carte blanche. Only when we understand both sides of this coin can we begin to level the field. Perhaps as we continue to define population health and debate the pros and cons of the Affordable Care Act, we can stimulate more conversation on access and wraparound services like care coordination. Perhaps we can adopt strategies already in place in certain areas in the European Union such as home visits after discharge from the birthing hospital. Maybe then our babies will not be at more risk going home than they are in our hospitals.
And how will we know we are doing well? When many more first birthday candles are being blown out. That will be a great party.
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U.S. Infant Mortality: a Case Study in Health Care Disparities originally appeared on usnews.com
