America's real infant-mortality problem.

Health and medicine explained.
March 16 2007 7:10 AM

Baby Gap

The surprising truth about America's infant-mortality rate.

Babies in the NICU. Click image to expand.
A neonatal intensive care unit

Last year, a widely distributed report from the group Save the Children, funded by the Bill and Melinda Gates Foundation, tied the United States with Malta and Slovakia for the second-worst infant-mortality rate among developed nations (at about six per 1,000 live births). "I'm always amazed to see where the United States is," a Rand researcher said of the list. "We are the wealthiest country in the world," a Save the Children spokesperson agreed, yet many "are not getting the health care they need."

Comparing infant mortality rates between countries is fraught with uncertainty—after all, it's hard to argue that every country's figures are reliable. But it's still worth asking what more we can do to stop babies from dying. Defined as death before one year of age, infant mortality frequently gets framed in the United States as a problem of insufficient health-care funding. In December, for example, a New York Times column blamed it on the lack of a single-payer health insurer. However, a closer look reveals the counterintuitive possibility that high infant mortality in the United States might be the unintended side effect of increased spending on medical care.


Infant deaths in poor nations are roughly six times more common than in developed areas and result mainly from easily treated infections like diarrhea in the first few months. By contrast, the majority of deaths in developed countries result from extreme prematurity or birth defects that kill a newborn in the first few days or weeks of life. According to a 2002 analysis by the Centers for Disease Control and Prevention, at least a third of all infant mortality in the United States arises from complications of prematurity; other studies assert the figure is closer to half. Thus—at the risk of oversimplifying—infant mortality in the United States principally is a problem of premature birth, which today complicates just over one in 10 pregnancies.

To reduce infant mortality, then, we need to prevent premature births, and if that fails, improve care of premature babies once born. (Prematurity is also linked to other problems; for example, it's the leading cause of mental retardation and cerebral palsy in children.) But modern medicine isn't good at preventing prematurity—just the opposite. Better and more affordable medical care actually has worsened the rate of prematurity, and likely the rate of infant mortality, by making fertility treatment widespread. According to a 2006 Institute of Medicine report, the numbers of women using assistive reproductive technology doubled from 1996 to 2002. At least half of their pregnancies culminated in multiple births (twins or more), which are at high risk of premature delivery.

Meanwhile, no amount of money or resources seems to reduce the rate of preterm births. Take prevention: Of numerous strategies, an inexhaustive list includes enhanced prenatal care, improved maternal nutrition, treatment of vaginal infections, better maternal dental care, monitors to detect early labor, bed rest, better hydration, and programs for smoking cessation. But, as well described in an erudite 1998 review in the New England Journal of Medicine by researchers at the University of Alabama, none of these strategies has had a substantial impact on the risk of preterm birth in clinical trials. (Of course, some of them, like better prenatal care, may be good for other reasons.) Despite a doubling of health-care spending as a portion of the gross domestic product since 1981, the rate of preterm birth has jumped 30 percent.

If preventing early birth is impossible, can we improve treatment of preemies? One promising way to reduce death after premature birth is a dirt-cheap steroid shot for mothers in preterm labor. Endorsed for over a decade by the National Institutes of Health and the American College of Obstetrics and Gynecology, the shot is one of the only maneuvers proven to help preemies before they are born. The injection jump-starts the fetus's lungs, so the baby is better prepared to breathe when born. Unfortunately, because of substandard practice, at some hospitals only about half of eligible women get the shot.

That leaves lots of sick preemies for the neonatologist. Most preemies depend on advanced neonatal care for survival. And there have been advances, particularly the discovery of surfactant to treat immature lungs. However, just as better funding for infertility treatment worsened premature-birth rates, more money quite possibly may harm the quality of neonatal intensive care.

How can that be? Today, neonatal intensive care is extremely lucrative, on average costing tens of thousands of dollars per preterm child. Neonatologists are among the highest paid pediatric subspecialists, and neonatal intensive-care units (NICUs, for short) are hospital cash cows—which is why the units are proliferating wildly nationwide. Yet in a startling 2002 New England Journal of Medicine study, David Goodman and his colleagues showed that the regional supply of neonatologists and NICUs bore no relation to actual need, implying that some doctors and hospitals set up shop simply because there was money to be made. More disturbingly, areas with more beds and doctors don't have lower infant-mortality rates. The authors ominously suggest that "infants might be harmed by the availability of higher levels of resources." They argue that the availability of a NICU may mean that infants with less-serious illnesses may be admitted to one and then "subjected to more intensive diagnostic and therapeutic measures, with the attendant risks."

Too many NICUs are also bad for babies because hospitals that handle a high volume of sick preemies have better outcomes. A 1996 study in the Journal of the American Medical Associationconfirmed this, concluding that concentrating high-risk deliveries in a smaller number of hospitals could reduce infant-death rates without increasing costs, and other studies have since concurred. (Increasing evidence suggests that experienced, high-volume centers may also save more full-term newborns with major birth defects, like congenital heart problems.)

Throwing money at unproven programs for preventing prematurity, or at cash-cow NICUs, won't improve America's infant-morality rate. Instead, it's critical to follow the data—which suggest that we need fewer, not more, hospitals to take care of the sickest babies. One reasonable suggestion is to cut funding for neonatal intensive care, since the money now is too good to encourage economies of scale (i.e., a few hospitals with high-volume NICUs). Another strategy, endorsed by patient-safety organizations like the Leapfrog Group, is for insurers to steer patients only to high-volume centers. Less money and less patient choice sound heretical—but, in this case, eminently sensible.



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