Explaining the Country’s Infant Mortality Rate – Part 1

The measurement of infant mortality says a lot about a country, especially its quality and accessibility of good public health. Even in some of the wealthiest countries in the world, though – such as the United States – infant mortality rates remain high. Infant mortality is defined as the death of a newborn baby before his or her first birthday, and there are three major causes for it in this country: birth defects, sudden infant death and prematurity.

Listen in to part one of two as Dr. Arthur James, Associate Professor of Obstetrics and Gynecology, The OSU College of Medicine, and co-director of the Ohio Better Birth Outcomes project at Nationwide Children’s Hospital and also co-director of the Ohio Department of Health’s Collaborative to Prevent Infant Mortality, talks about the main contributing factors of infant mortality in the United States. He’ll also bring to light some ways in which the state of Ohio and Nation Children’s are working to bring the infant mortality rate down. In part two of this podcast, he’ll continue to talk about initiatives aimed at reducing this rate, as well as the role of life experience as a contributing factor, specifically racism.



Rick McClead: Why does one of the most developed nations in the world have one of the highest infant mortality rates? What is being done about it? Why is this problem important to you?

The problem of infant mortality in the United States, next on Children’s on Quality.

Welcome to Children’s on Quality. This is your host, Dr. Rick McClead, Medical Director for Quality Improvement Services at Nationwide Children’s Hospital.

With me to discuss the problem of infant mortality in the United States is Dr. Arthur James, Associate Professor of Obstetrics and Gynecology, the Ohio State University College of Medicine, and Co-Director of the Ohio Better Birth Outcomes Project at Nationwide Children’s Hospital and also Co-Director of the Ohio Department of Health’s Collaborative to Prevent Infant Mortality.

Dr. James, welcome to Children’s on Quality.

Arthur James: Thank you, Dr. McClead. I’m happy to be here.


Rick McClead: All right, I want to begin with two quotes that appeared in the October 3rd, 2011 op-ed pages of “USA Today”.

Quote, “Twenty years ago, the United States was doing better than countries such as Cuba, Poland and Estonia in keeping newborn babies alive. Not anymore. As other nations improved this key indicator of women’s and infants’ health, the U.S. lagged, dropping to 41st worldwide in newborn death rates behind these three countries and 37 more,” unquote.

Contrast that with the opposing editorial by Dr. Scott Atlas, a Senior Fellow at the Hoover Institution and a professor at the Stanford University Medical Center. Quote, “Infant mortality rates are extremely misleading, contaminated by factors unrelated to health care quality and plagued by inconsistencies and gross inaccuracies, all of which specifically disadvantage the United States,” unquote.

Now I suspect that both of these statements are true. What should the public understand about the problem with infant mortality in the United States?


Arthur James: Well, first off, let’s define ‘infant mortality’. Infant mortality by definition is the death of a newborn baby before his or her first birthday. And we generally compare different countries or different groups by looking at what’s referred to as the infant mortality rate, which is the number of infant deaths per 1,000 live births.

So when we look at this, I actually think there’s some accuracies in both of those statements. Though infant mortality rate measures the number of babies who die in the first year of life per 1,000 babies born, the infant mortality rate is also one of the most sensitive measurements we have for the quality of life for any group.


So that when you look in the United States, first off, compared to other countries, while generally speaking our overall infant mortality rate does not compare as favorably as we would like, a lot of that is because of the contribution that some groups make to bring the United States infant mortality rate down, like African-Americans in the United States who have a significantly higher infant mortality rate than do the majority group in this country.

If you disaggregate the data and look just at the white infant mortality rate in the United States and compare that to other countries, then while the United States still isn’t at the top, we compare much, much, much more favorably. And so part of the issue for us in terms of trying to understand our infant mortality rate is to take into consideration that there’s some groups who don’t compare well.


I want to concentrate a little bit, though, on the second quote that you’ve mentioned that indicates that infant mortality rates are extremely misleading, contaminated by factors unrelated to health care quality.

Some of those factors that we normally don’t look at as being important to us in terms of health care issues are factors that influence the quality of life. And since infant mortality rates capture many of those other factors, things like poverty, under-education, unemployment, which are not generally considered quality measures in terms of health care, are things that have a significant impact on infant mortality.

Rick McClead: Well, putting the whole issue of what the real rate is and how we compare with the rest of the world, what are those factors that clearly are contributing to infant mortality in this country?


Arthur James: Well, let’s first start with the medical issues. Generally, when we measure infant mortality from a clinical perspective, we measure it by looking at clinical issues that significantly contribute to why babies die in the first year of life.

And I like to put infant mortality in the following perspective for people: If we look at all of childhood death, so all the death that occurred to children from birth through 18 years of age, those deaths that occur in the first year of life, what we refer to as infant mortality, account for two-thirds of all childhood death.

So putting it in appropriate perspective, then, in that first year of life, two-thirds of all children die from zero to 18 years of age. So that first year of life is pretty crucial for us. And within the first year of life, the period of time that’s most crucial is actually the first month of life, where about two-thirds of infant mortality occurs.


And the primary reason for that is the contribution of prematurity and of congenital anomalies. After the first month of life, post-neonatal, or that after the first month of life cause of death, the most common cause is sudden unexpected infant deaths. So from a clinical perspective or a medical perspective, those three things stand out: prematurity, congenital anomaly, sudden unexpected infant death.

Rick McClead: Before we go to the non-medical issues, what are we doing about those three things? Just summarize that.

Arthur James: Well, where prematurity is concerned and where congenital anomalies are concerned, there’s of course been a lot of work by the March of Dimes nationally to try to lead and spearhead some of our efforts.


Currently, where prematurity is concerned, the issues that the March of Dimes feels that we ought to address include decreasing the incidence with which scheduled but non-medically-indicated births occur before 39 weeks gestation.

They also suggest that we should work hard with our endocrine and fertility doctors to cut down the number of multiple gestation births that occur as a consequence of assisted reproductive technology.

They also advocate that we provide 17-hydroxyprogesterone to any woman who has experienced a previous pre-term birth because she is at risk for a repeat pre-term birth, and the data suggest to us that 17-hydroxyprogesterone helps to decrease the incidence with which those births occur.


And the other piece that the March of Dimes advocates pretty strongly is that we attempt to decrease the incidence with which women smoke during pregnancy, because in doing so, we believe we can cut down the incidence of miscarriages as well as pre-term birth.

So that from a clinical perspective, that’s what we’re doing in terms of the prematurity issue.

Where congenital anomalies are concerned, we continue to advocate pretty strongly that all women be on folic acid, preconceptually but especially during the early phases of pregnancy.

In the state of Ohio, we are also pushing real hard to try to decrease the incidence with which women are exposed to illicit drugs but also prescription drugs that can have teratogenic or harmful effects to the baby to help decrease risk of those pregnancies to babies.


And where the sudden unexpected infant deaths are concerned, we are strong advocates of the American Academy of Pediatrics’ October of 2011 revised recommendation for creating safe sleep environments for babies that emphasize the ABCs of back to sleep, that babies should sleep alone, that they should be put on their backs for every sleep, and that they should sleep in a crib or bassinet or a safety-approved sleeping surface.

I want to emphasize here that in sleeping alone that we are advocating that we don’t bed-share, that we do believe that it’s fine to room-share, but we suggest that babies not sleep on a surface that is designed for adults. So even when babies are sleeping alone, don’t lay them on an adult bed or on a sofa but a designated safe spot for the baby to sleep.


Rick McClead: Well, what about those non-medical causes that seem to be contributing to infant mortality?

Arthur James: Yeah, I think the easiest way to think about them is that for the last 15 or 20 years, there’s been an international effort going on that challenges us, for health care issues in general, to look at this concept that’s referred to as the ‘social determinants of health’.

So these are non-medical things that occur in our communities, issues that occur where people live, where they grow up, where they work that have significant impact on not only the quality of our lives but on our health, so that there are social determinants that will influence how long somebody lives as well as the health that they experience during the course of their lifetimes. And those social determinants contribute to infant mortality.


So what do I mean by some of these social determinants? Well, think for a second about an individual who lives in a community that is significantly under-resourced, a community that experiences a significant amount of poverty.

Those communities, we generally have lower graduation rates from high school, we have higher unemployment rates, we therefore have people who generally will work in situations where their jobs don’t provide them with insurance. But because of the wages that those individuals make, they are more likely to live in neighborhoods that are higher in crime, that are associated with, as I said earlier, a larger amount of poverty.


And while we generally in this country think about those things but don’t connect them with health, I think the data is starting to suggest to us that there is a pretty strong connection.

And so as we look to improve infant mortality in this country, I’m hoping that we will also look at approaches that attempt to improve the social determinants of health as a major means by which of improving not just infant mortality in general but the disparities that occur in this country in infant mortality.

Rick McClead: Well, you talk about the issue of disparity and how it contributes to prematurity rates, infant mortality. Share with our listeners what’s your understanding about this whole problem, disparity, and how it plays a role in infant mortality.


Arthur James: So if you look at the most recent year for which we have data, which is 2010, for the state of Ohio, we’ll concentrate right here where we are, the overall infant mortality rate for Ohio in 2010 was 7.7 infant deaths per 1,000 live births.

The white infant mortality rate during that period of time was 6.4, the black infant mortality rate, 15.5. So that in the state of Ohio, black babies currently die at about just under two-and-a-half times the rate that white babies die.

Keep that in mind, and also hear these other figures.


That in our three largest counties in the state of Ohio, so for Cuyahoga County in 2010, black babies accounted for 39% of all the births in Cuyahoga County, but those same babies accounted for 69% of all the infant deaths in 2010 in Cuyahoga County. In Hamilton County, black babies accounted for 31% of the births in Hamilton County and 61% of the deaths. For Franklin County, black babies accounted for 28% of the births, 42% of the deaths.

And that kind of disparity is business as usual in our state. If you look overall at the state of Ohio, in 2010, black births accounted for 17% of all births in the state of Ohio but 33% of all the infant deaths. And blacks were the only group that had a disproportionately large percentage of deaths compared to their percentage of births in our state.


So the disparity is real. It’s been going on for a long time. There are a lot of us who unfortunately have it in our mind that that disparity is fixed, that there’s nothing that we can do about it, that we can’t really improve infant mortality. And I point to several pieces of evidence that suggest to us that we can do better.

First of all, if we look at infant mortality by decade and go from 1950 to 2010, if we look during that period of time, what we see is that the infant mortality rate for whites and the infant mortality rate for blacks improve.

Because the infant mortality rates for whites improve at a faster pace than the infant mortality rate for blacks, the disparity between the two, generally speaking, goes up, and there are two exceptions during that 70-year period of time that we look at here.


The first exception occurred from the 1960s to the 1970s, when the disparity ratio between blacks and whites for infant mortality decreased.

In that decade, what changed wasn’t some miraculous difference in terms of how we take care of infants, although that was a period of time where neonatal intensive care units nationwide began to really grow. What contributed to a decrease in that disparity most was the Civil Rights Act. And what that Civil Rights Act meant especially for black women in the South was that it was the first time that they had an opportunity to go to the hospital to actually have a baby.


The second period of time where the disparity ratio actually decreased, believe it or not, was from the 2000s to 2010. During that 10-year period of time, the infant mortality rate in the United States for whites decreased by 16%, for blacks by 25%. So during that decade, the disparity ratio improved.

So what was it that changed most recently here in the United States? Well, if we go back and look at Healthy People 2010, David Satcher, and others that proposed our national goals for health-related issues during that period of time, suggested to us that at least in six health care areas, we should look to eliminate disparities overall.


And one of those health care areas that he suggested that we eliminate disparity in was in infant mortality, and he called, he challenged the nation to achieve an infant mortality rate of 4.5 per thousand by 2010. Now, we never got to 4.5 per thousand by 2010 for our overall infant mortality rate.

But throwing out the gauntlet that suggested to us that we begin to work toward the elimination of disparity in infant mortality resulted in efforts throughout this country that improved the black infant mortality rate so much that, again, the disparity between blacks and whites in infant mortality decreased.

There are programs like what has occurred in the Northern Manhattan Perinatal Project where from 1995 to 2008, for the cohort of women that they followed, the infant mortality rate has decreased by 85%, and in that cohort of women, 85% of them are African-American.


And when we compare, for example, the 2010 overall infant mortality rate for the state of Ohio, which, remember, was 7.7 per thousand, with other states like California, where the overall infant mortality rate is 4.7 per thousand or in places like New York City where the overall infant mortality rate, I believe, is about 4.9 per thousand.

And where in those places while they continue to have significant disparities between blacks and whites, the numbers for those infant mortality rates for those groups are so significantly better than ours that it just suggest to us that a change in our approach that includes not only an emphasis on addressing the medical and the clinical stuff with also attempting to address the social determinants, I believe, is the way that we want to move in our next several years for trying to not only improve the overall infant mortality rate for all groups but also to begin to address the social determinants and therefore the disparity that occurs in infant mortality.


Rick McClead: Well, that is all the time we have for this edition for Children’s on Quality. We have a link to Dr. James’ presentation to the Infant Mortality Awareness Conference on our website.

Children’s on Quality is produced by Kelly Nightingale. Our theme music was written by Ryan McClead.



Rick McClead: Please join us next time for part two of my conversation with Dr. Arthur James about infant mortality.

Arthur James: The other piece that I think is going to require a substantial paradigm shift for us is to really begin to accept that there are the significant non-clinical, non-medical things that have huge, huge impact on our health.

Rick McClead: Until then, this is your host, Dr. Rick McClead, wishing you the best of good health.


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