Why Is Infant Mortality Higher in the United States than in Europe?

26/365 - Hah!

(By Kenny Louie from Vancouver, Canada – Hah!, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=24336411)

This is the question three economists recently asked in a recently published paper from the American Economic Journal: Economic Policy.  The answers they found disturbed me, and should bother anyone who pays attention to how badly well-being is distributed in the United States.

Alice Chen, Emily Oster, and Heidi Williams collected “a complete census of births from years 2000–2005, linked to infant deaths occurring within one year of birth” for three countries: Austria, Finland, and the US.  Let’s put their work in context by looking at how these countries compare for the entire group of OECD countries in 2010:

OECD IMRs

http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf

Finland leads the group with the lowest infant mortality rate, i.e. the number of deaths of children less than one-year old per 1000 live births, 2.3.  Austria is in the middle of the pack at 3.9 deaths per 1000 live births, and the US is last at 6.1 deaths per 1000 live births.

The numbers look even worse when you examine the US data over time by race:

US IMRs

http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf

No racial/ethnic group has an infant mortality rate as low as any other OECD country. African-Americans have a rate of nearly 12 deaths per 1000 births; that puts their rate at roughly the same level as the national rates for China and Mexico.

Now, as troubling are these figures, they leave open a big question: exactly when between birth and one year do these children die? Is it within a month?  Later?  This picture from Chen, Oster, and Williams’s paper provides a first pass at the answer:

infant mortality- Fig 1

Children die at a higher rate in the US right from birth, and the rate gets worse at every age until one year. The jump is especially pronounced from one month onward; that is, after mothers and children leave the hospital it’s more likely that the child will die.

Chen, Oster, and Williams then break down the data by educational attainment of mothers.  Specifically, they look at mothers who have some college education and beyond (the “advantaged group”) versus those who have a high school diploma or less the “disadvantaged group”).  Here is what they found:

infant mortality- Fig 7

Infant mortality rates for the advantaged group are identical across countries and at every age between birth and one year, and are uniformly lower at each age than those for the disadvantaged group.  Differences across countries are driven entirely by the disproportionately high infant mortality rates for the disadvantaged group in the US.

Chen, Oster, and Williams are blunt about what they find to be the causes of this: “Our results on neonatal mortality strongly suggest that differential access to technology-intensive medical care provided shortly after birth is unlikely to explain the US IMR disadvantage (p. 118).”  That is, it’s not the case that care in the hospital is worse for some groups than for others.  Instead, it’s what happens after mother and child leave the hospital

To combat this problem, Chen, Oster and Williams argue that “one policy worth mentioning is home nurse visits. Both Finland and Austria, along with much of the rest of Europe, have policies that bring nurses or other health professionals to visit parents and infants at home. These visits combine well-baby checkups with caregiver advice and support (p. 119).”  This takes the burden off of families to schedule trips to the doctor, find transportation, etc.

They also put the matter in dollars-and-cents terms: “Our estimates suggest that decreasing postneonatal mortality in the United States to the level in Austria would lower US death rates by around 1 death per 1,000. Applying a standard value of a statistical life of US$7 million, this suggests it would be worth spending up to $7,000 per infant to achieve this gain. If policies were able to focus on individuals of lower socioeconomic status—given our estimates that advantaged groups do as well in the United States as elsewhere—even higher levels of spending per mother targeted would be justified (p. 118).”

If we are serious about being our brothers’ and sisters’ keepers, we should face these facts and work on ways to deal with this national shame right away.