Last week in Ethiopia, I joined almost a thousand public health practitioners from all over the world to report on the state of human health, reflected in stories and supported by data that capture in detail the global battle against preventable death and disease, whether in the richest nations of Scandinavia or the poorest of the Caribbean.
In the world of public health, nothing says more about a nation's progress or failure in promoting the health of its people than its infant mortality rate -- the number of babies per thousand who die in the first year after birth. So, it's a source of embarrassment and sadness to me as an American that I had to explain to my colleagues in Addis Ababa why infant mortality is still a U.S. problem.
A recent study by the well-respected U.S. Congressional Research Service (CRS) reports that the U.S. infant mortality rate remains among the highest of the 34 Organization for Economic Co-operation and Development nations. With a rate of almost seven deaths per thousand, the U.S. is 31st, according to the latest data, behind every European country, including some of the newest members of the European Union -- Slovenia, the Czech Republic, Estonia, Hungary, Poland and Slovakia.
Thirty developed countries, all of which spend much less on health care than the United States, have lower infant mortality rates than we do. And the disparity within our nation is alarming.
Infant mortality rates vary as much from state to state as they do from countries in Europe to the poorest nations of Central America. The states of Mississippi and Alabama share a rate of 10 deaths per 1,000, compared to five deaths per 1,000 in Washington and Massachusetts. The overall rates have been slowly declining since 2000, yet a huge and shameful gap remains between whites and blacks. In the United States, African American women are more than twice as likely to lose their babies than are non-Hispanic white women. And level of education does not explain the difference.
So what are we doing wrong?
States and local communities in the United States have great freedom to decide what care they will provide to women and children. The problems may be cultural insensitivity and racism, a fractured system of health services, high rates of teen pregnancy in some communities, a lack of health insurance, failure to provide pre-natal care, no systems to assure that high-risk infants are delivered in hospitals with intensive follow-up care, and a dearth of support for women who lack a place to live, or who are struggling with substance abuse or a violent spouse. And these factors increase the chances a woman will give birth before her baby is at full-term. Research suggests that babies who are born before 39 weeks, and/or weigh less than they should, make up almost 20 percent of infant deaths in the United States.
The great disparity in health systems and the services they provide means that where a woman lives in the United States, and whether she is black or white, can determine whether her baby lives or dies.
Some of my colleagues in the global health community might well ask how they can hope to reduce the numbers of babies who die every year in the world's poorest regions, if our very wealthy nation seems unable to do so. But money alone is not the answer. A system has grown up around treatment of the problem in the United States. This means we often put resources into treating sick babies, rather than ensuring they are born healthy. Just one hospital in the state of Louisiana slashed admissions to its newborn emergency program by 20 percent, after doctors had been told to stop delivering babies before the 39-week mark.
It will take an entire village to make this happen in the United States. Infant mortality rates in each state are associated with the quality and level of services, the adoption of policies and regulations in each community, and the will to create well-designed health delivery systems.
The Congressional Research Service reports that rates remain high in the United States, and a once downward trend shows signs of leveling off. The CRS lists the main causes, most of them preventable, and points to disparities based on race and geography as the areas of greatest concern.
Sadly, knowing what works is not enough. It will take leaders at the state and local level, like those of Louisiana, to acknowledge that too many of our babies are dying, and that they need to do something about it.
I look forward to the day when U.S. academics and public health officials like me don't have to explain to our colleagues in other countries why infant mortality in the world's wealthiest nation is still a problem. We Americans are known for our competitive spirit. This is one challenge we will want to take on.
Deborah Klein Walker is a Vice President and Senior Fellow at Abt Associates, and former president of the American Public Health Association and the Association of Maternal and Child Health Programs.
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