First, a bit of a deep dive into global numbers is necessary to properly contextualize US infant mortality rates; not high per se but certainly higher than expected compared to several countries with similar or even much lower GDP per capita.
Specifically, the 2018 US neonatal* mortality rate of 3.5 deaths per 1000 live births is higher compared to not just Japan but also several less wealthy countries. These numbers become even more interesting when examined in light of rates back in 1990 when the US rate was 6 (table below using data from 1). *Neonatal mortality rate: probability of dying between birth and 28 days of age, expressed per 1,000 live births.
Similar trends apply to infant mortality rates which typically include mortality of neonates, under-5 and children (5 to 14 year olds). The upshot is less wealthy countries such as Poland and Slovakia that spend far less per capita on healthcare than the US and which had much higher infant mortality rates in 1990 could nevertheless reduce their rates by 2019 to such an extent that the US ranked below them at an embarrassingly low 33 out of 36 OECD countries (below from 2).
In light of such data, the question needs to be modified to ‘Given how wealthy it is, why does the Unites States continue to have such unexpectedly high infant mortality rates?‘.
Obviously only one factor couldn’t possibly explain such a complex issue. Instead, many stubborn structural and cultural idiosyncrasies set the US healthcare system apart from practically all others, especially in ways that adversely impact the outcome of birth even as it is by now well known that US healthcare spending per capita far outstrips all other countries by an increasingly wide margin. Here are some factors that contribute to less than optimal maternity and birth-related outcomes in the US.
Perverse incentives make US workplaces hostile to maternity needs
Current incentives make US workplaces singularly hostile to pregnancy and childcare. Being lackluster to say the least, current US regulations are unable to effect beneficial social and cultural changes in this regard.
- The US is the only developed country without mandatory paid maternity leave.
- ~25% of new US mothers return to work within 2 weeks of giving birth (3).
- It’s telling that the few big US and multinational corporations that do offer maternity leave to US workers do so in the form of short-term disability (4). Surely, giving birth isn’t a disability! Such a mindset only serves to emphasize that the US is a long way away from considering birth in a more humane and natural fashion.
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- For example, France has a maternity care system where nurses make house calls after a baby is born (3).
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- Consider the UK where new mothers can avail themselves of at least 6 months time off (4).
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- As things stand today, only the very affluent could realistically consider such options in the US.
Stark and steep racial, geographic and inter-state disparities in socioeconomic status and access to good quality healthcare further conspire to help ensure that both maternal and infant mortality rates stay relatively high in vulnerable US communities.
- A 2017 comparison of black versus the rest showed a shockingly high average of >11 neonatal deaths per 1000 live births for black women, >2X higher than for babies born to white women (5). No wonder then that black mothers and their babies are in crisis mode in various American communities (6, 7). Not just black women, infant mortality rates are also higher among American Indians, Alaska Natives and Pacific Islanders (8).
- Deepening rural versus urban divide in accessing adequate healthcare. With profit making the dominant idea in US healthcare, no surprise that hospitals and healthcare clinics continue to close down across the rural US as its population empties out. Since medicalized births dominate US maternity, this means women living in rural areas often have to travel further, sometimes even 100s of miles, to even access pre, peri and antenatal care (9, 10).
- In 2019, Mississippi had the highest infant mortality rate of 8.6 deaths per 1000 live births, >2X the rate compared to Massachusetts at 3.8, which had the lowest (2).
Giving birth is more expensive in the US than anywhere else in the world
Already back in 2013, a New York Times article reported that US hospital birth costs an average of ~$3400 out of pocket (11). News reports suggest that many American women and families are even now forced to declare bankruptcy after giving birth (12, 13).
- Contrast this state of affairs to Finland’s average of just ~$60 (14). And yes, Finland has universal healthcare coverage.
- Thailand and Rwanda’s examples show that universal healthcare coverage can help bring about a steep drop in neonatal mortality (from 21 and 41 per 1000 live births, respectively, in 1990, to 5 and 15.9 in 2018), with an unprecedented abolition of historic disparities between poorer and richer regions in Thailand, according to Amartya Sen (15).
- In his book Pathologies of Power, Paul Farmer contrasts Cuba’s healthcare, a country with universal healthcare coverage, to the US, a country famously lacking such coverage (16),
- That Cubans say, “We live like poor people, but we die like rich people”.
- And that Cuba’s infant mortality rate is lower than even that in the Boston neighborhood of the prestigious Brigham and Women’s hospital!
Good quality US childcare is increasingly out of reach for many new parents
At an average of ~$10000 per year, cost of full-time childcare for 0 to 4 year olds is so expensive in the US (17), it’s becoming increasingly out of reach for many new mothers.
Trustworthy data on US maternal mortality is also increasingly out of reach
US maternal mortality rates are perhaps the highest among OECD countries and in some states such as Texas, they appeared to be actually increasing and not the other way around; appeared because according to a 2017 ProPublica investigation (18), “Data collection on maternal deaths is so flawed and under-funded that the federal government no longer even publishes an official death rate”. Mind-boggling, that conclusion.
The Texas example underscores the extent of this data collection crisis. After numbers showed that Texas maternal mortality rates doubled over just a two year period from 2010 to 2012 (19), a task force established to figure out what was going on found such “sloppy and erroneous data collection”… “that more than half of the deaths that were recorded as pregnancy-related that year were recorded that way in error” (20).
Coda
For far too long, emphasizing the importance of American families has become an empty rhetorical tool cynically deployed to whip up primeval passions during US political campaigns even as in recent decades, actual US government policies and regulations have become increasingly hostile towards them.
As long as the politically dominant thought in US society continues to pretend against all evidence to the contrary that childbearing, birth and child rearing are optional luxuries among a smorgasbord of consumer choices instead of common social goods necessary for human society to truly flourish, the US will continue to outspend other countries and yet get worse outcomes from healthcare spending on the natural processes of pregnancy and birth.
Bibliography
3. The Guardian, December 5, 2017. The Mother Load: America is failing mothers. Help us change that
4. The Guardian, December 14, 2017. Your stories about motherhood in America: ‘There are no social safety nets’
6. The Los Angeles Times, Ann M. Simmons, October 26, 2017. The quiet crisis among African Americans: Pregnancy and childbirth are killing women at inexplicable rates
7. The Guardian, Leslie Casimir, June 26, 2018. Why are so many of San Francisco’s black mothers and babies dying?
9. The Politico, Lisa Rab, October 3, 2017. Rural Hospitals Are Dying and Pregnant Women Are Paying the Price
10. The New York Times, Jack Healy, July 17, 2018. It’s 4 A.M. The Baby’s Coming. But the Hospital Is 100 Miles Away.
11. The New York Times, Elisabeth Rosenthal, June 30, 2013. American Way of Birth, Costliest in the World
12. The Guardian, Jessica Glenza, January 16, 2018. Why does it cost $32,093 just to give birth in America?
13. The Guardian, January 16, 2018. Bankrupted by giving birth: having premature twins cost me everything | Jen Sinconis
14. The Cut, Gabriella Paiella, March 21, 2019. What It’s Like to Live in the Country Where Giving Birth Costs $60
15. The Guardian, Amartya Sen, January 6, 2015. Universal healthcare: the affordable dream
16. The Atlantic, James Hamblin, November 29, 2016. How Cubans Live as Long as Americans at a Tenth of the Cost
17. The Guardian, Emma, December 16, 2017. How new moms are supported – or not – in France v the US: a feminist cartoon
18. ProPublica, Robin Fields and Joe Sexton, October 23, 2017. How Many American Women Die From Causes Related to Pregnancy or Childbirth? No One Knows. — ProPublica
19. The Guardian, Molly Redden, August 20, 2016. Texas has highest maternal mortality rate in developed world, study finds
20. The Washington Post, Meagan Flynn, April 11, 2018. https://www.washingtonpost.com/news/morning-mix/wp/2018/04/11/texas-maternal-mortality-rate-was-unbelievably-high-now-we-know-why/
Other references consulted for this answer:
- Papanicolas, Irene, Liana R. Woskie, and Ashish K. Jha. “Health care spending in the United States and other high-income countries.” Jama 319.10 (2018): 1024-1039. https://www.oregonlegislature.gov/committees/hhc/WorkgroupDocuments/staff%20-%20(report%2005-23-2018%20meeting).pdf
- https://www.unicef.org/reports/levels-and-trends-child-mortality-report-2019
- Hug, Lucia, et al. “National, regional, and global levels and trends in neonatal mortality between 1990 and 2017, with scenario-based projections to 2030: a systematic analysis.” The Lancet Global Health 7.6 (2019): e710-e720. https://www.sciencedirect.com/science/article/pii/S2214109X19301639