Finally: a comprehensive analysis of US infant mortality

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I’ve been writing about this problem for many years: no, not the high US infant mortality rate, but the refusal to address the most important causes of high US infant mortality.

Five years ago, in November 2009, I wrote in Detailed report on infant mortality neglects the most important detail:

The new CDC report on infant mortality, Behind International Rankings of Infant Mortality: How the United States Compares with Europe [by MacDorman et al], is an object example of how to deceive with statistics. It purports to be a detailed investigation of infant mortality, but it inexplicably fails to investigate the most important detail…race. Unfortunately, African descent is a major risk factor for prematurity, and prematurity is a major cause of infant mortality. Therefore, it is hardly surprising that the US has a higher infant mortality rate than Sweden. The US has the highest proportion of women of African descent of any first world country. Sweden, of course, has virtually none.

And last year in The March of Dimes and dishonesty about prematurity, I wrote:

The March of Dimes has chosen to misrepresent prematurity as being caused by early elective delivery. While early elective delivery poses risks, it also has significant benefits (reducing the stillbirth rate) and, in any case, is only a tiny contributor to the problem of prematurity…

The MOD has been publishing a yearly “report card” on prematurity. The report card is rather farcical since while claiming to grade states on prematurity rates, it is basically grading them by the proportion of African-Americans in each state.

Finally, someone has analyzed the US infant mortality rate with the object of improving it, as opposed to using it for selfish ends. The new paper, Why is infant mortality higher in the US than in Europe?, is written by Professor Emily Oster and colleagues. Oster is the author of Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong—and What You Really Need to Know.

Oster et al. lay out the dimensions of the problem:

In 2013, the US infant mortality rate (IMR) ranked 51st internationally, comparable to Croatia, despite an almost three-fold difference in GDP per capita.1 One way to quantify the magnitude of this infant mortality disadvantage is to consider that the US IMR is about 3 deaths per 1000 greater than Scandinavia…

While the US IMR disadvantage is widely discussed and quantitatively important, the determinants of this disadvantage are not well understood, which hinders policy efforts aiming to reduce the US infant mortality rate. A key constraint on past research has been the lack of comparable micro-datasets across countries. Cross- country comparisons of aggregate infant mortality rates provide very limited insight, for two reasons. First, a well-recognized problem is that countries vary in their reporting of births near the threshold of viability. Such reporting differences may generate misleading comparisons of how infant mortality varies across countries. Second, even within a comparably reported sample, the observation that mortality rates differ one year post-birth provides little guidance on what specific factors are driving the US disadvantage.

In other words, as I’ve written countless times over the years, direct comparisons of national infant mortality rates are invalid because the US includes very premature babies born alive, while many other countries do not. Since the highest death rates are in very premature babies, failure to include them makes other countries’ infant mortality rates look far better than they really are.

How did Oster et al. address this problem?

… We combine US natality micro-data with similar data from Finland, which has one of the lowest infant mortality rates in the world, and Austria, which has similar infant mortality to much of continental Europe. We first provide a detailed accounting of the US IMR disadvantage, quantifying the importance of differential reporting, conditions at birth (that is, birth weight and gestational age), neonatal mortality (deaths in the first month), and postneonatal mortality (deaths in months 1 to 12)… Second, we provide new evidence on the demographic composition of the US IMR disadvantage.

What did they find?

… Differential reporting of births near the threshold of viability can explain up to 40% of the US infant mortality disadvantage. Worse conditions at birth account for 75% of the remaining gap relative to Finland, but only 30% relative to Austria. Most striking, the US has similar neonatal mortality but a substantial disadvantage in postneonatal mortality. This postneonatal mortality disadvantage is driven almost exclusively by excess inequality in the US: infants born to white, college-educated, married US mothers have similar mortality to advantaged women in Europe. Our results suggest that high mortality in less advantaged groups in the postneonatal period is an important contributor to the US infant mortality disadvantage.

First, nearly half the differential in infant mortality is due to failure of other countries to include extremely premature babies born alive.

Second, the disparity in infant mortality (death from birth to one year) has little if anything to do with obstetric care since US neonatal mortality (death from birth to 28 days) is similar to other industrialized countries.

Third the disparity in post neonatal mortality is attributable to race and socio-economic status.

In other words, while birth activists, including CDC statistician Marian MacDorman, who is also (surprise!) the Editor of the Lamaze journal Birth: Issues in Perinatal Care, and organizations like the March of Dimes have been wailing about American obstetric care in general, and early elective induction in particular, the relatively high US infant mortality has nothing to do with American obstetric care in general, and early elective induction in particular.

Which raises the question why the people supposedly concerned with reducing the infant mortality rate haven’t bothered to address the real causes of US infant mortality. It appears they don’t really care about infant mortality and prematurity beyond using it as a cudgel to chastise American obstetricians. The tragedies of women of color, and poor women are exploited to serve the ends of birth activists, not to improve the outcomes for those who suffer. The poor infant mortality rate is used as a slogan to increase market share and profits for midwifery among Western, white, well off women, the demographic most likely to choose midwifery services. The victims of high US infant mortality are left to fend for themselves.

90 Responses to “Finally: a comprehensive analysis of US infant mortality”

  1. Guest
    October 8, 2014 at 4:40 pm #

    It’s interesting to compare this report to the video Eugene Declerq recently posted plotting U.S. infant mortality alongside other countries. He never mention that the U.S. counts very premature babies as alive, while other countries don’t.

  2. Dr Kitty
    October 8, 2014 at 8:38 am #

    I had another thought about other things that make the USA different to Europe.
    Climate and natural disasters.
    Europe doesn’t get affected by tornados, hurricanes and the polar vortex in the same way.
    We don’t often get huge forest fires, droughts, floods or blizzards, and if we do the scale is smaller in terms of the damage done and the loss of life. Most European countries don’t get the extreme seasonal changes of temperature that the U.S. does either.

  3. just me
    October 8, 2014 at 12:28 am #

    Haven’t read the study. Agree that there are many problems in this country with disparities in care etc.

    But since we are talking about mortality btwn 28 d – 1 year, what about SIDS? I thought I read somewhere that aa parents were more likely to be debate and put babies on their tummies. Sorry if the study covered and dismissed this issue.

    Off topic, but very upset to find the every mother counts org. which I think does great work in the world has a blog pushing home birth lamenting “over medicalization” of birth etc. Just lost a potential donor.

  4. Sue
    October 7, 2014 at 10:51 pm #

    Australia shares the same disparity with our Indigenous population. And what has been the response of the ideological side of the midwifery community? Let them give birth closer to home (which is often remote from sophisticated medical care)>

    But they have it back-to-front. The prematurity and other conditions affecting neonates (fetal alcohol syndrome, high rates of smoking) area result of the chronic health problems of poverty, disadvantage and remoteness.

    The way to improve outcomes for the babies is to improve the lives of their families, including reducing the rates of smoking and alcohol consumption. When the birth risk is lower, birthing closer to home can be considered. Putting the cart before the horse will only lead to more tragedy.

    • attitude devant
      October 8, 2014 at 10:24 am #

      It’s the same thing everywhere: if you take care of mothers (make sure they have a safe clean heated place to live, have enough food, have transportation, have medical care) you improve the outcomes for babies.

  5. Sara
    October 7, 2014 at 8:28 pm #

    Does anyone know how many US states now pay HB midwives through public insurance?

    I know it’s happening and it seems like exactly the wrong thing to do to change these statistics…. but it’s cheaper, and in the eyes of some HB activists it helps to “normalize” homebirth and make it more widely accepted.

    • Bombshellrisa
      October 7, 2014 at 8:55 pm #

      Washington state is one

    • Liz Leyden
      October 8, 2014 at 5:14 pm #

      Vermont Medicaid pays for home births.

      • Sara
        October 10, 2014 at 3:25 pm #

        I actually went that route one time, years ago. It was a bad idea.
        Along with the many other issues I have with it (like lending legitimacy to midwives with questionable credentials), there is a reason that hospitals have policies for the staff to treat everyone essentially the same regardless of their payment method.

        When the one person who is both handling your medical care and doing your billing wants to hold it against you that she gets 15% less for serving you instead of another client, who is there to stop her?

        I saw this Medicaid-enrolled midwife complaining on FB a few years later about how much money she lost because of her “Medicaid moms.” The Medicaid thing was her choice, and it was a selling point for her.

        I should have gotten a screen cap and passed it on to the Board of Medicine or someone.

  6. Gozi
    October 7, 2014 at 1:07 pm #

    “The victims of high US infant mortality are left to fend for themselves.”

    Not much of a surprise when you consider how these victims are usually viewed and treated in this country. I personally am having a hard time wrapping my mind around the US chastising other countries about human rights.

  7. jhr
    October 7, 2014 at 12:45 pm #

    Many years ago, I remember a professor at the Johns Hopkins School of Hygiene and Public Health (now the Blumberg School) noting that comparing health statistics between the United States and other 1st world countries tell us nothing because the populations in first world countries are generally homogeneous where is the US is broadly diverse–particularly with regards to race. This professor, speaking in the early 1970’s, was pointing to both physical as well as social differences among groups driving the data such as disproportionate percentage of premature births among young Black teenagers. The combination of physical immaturity plus impoverished circumstances.

    • The Computer Ate My Nym
      October 7, 2014 at 1:52 pm #

      But why do minorities have poorer outcomes? Getting pregnant at a young age is not something that is genetically determined like skin tone or platelet polymorphism. Saying “oh, the US has more minorities so of course it has poorer outcomes” only begs the question.

      Incidentally, Britain has a pretty large African and Asian population and Germany and Holland both have significant Asian minority populations. Just to name a few countries that I know have major minority populations. So I’m not sure the “excuse” even holds.

      • TsuDhoNimh
        October 7, 2014 at 2:02 pm #

        “But why do minorities have poorer outcomes? ”

        It’s poor people of any color – outcomes for poor whites in MT are no better than outcomes for poor blacks in AL which are no better than outcomes for poor Apaches in AZ …

        Because we have crap for a public health care system
        Hard to get medical care for children
        Hard to get adequate diet for children
        Hard to get treatment for chronic medical issues (diabetes, blood pressure, obesity)

        “Getting pregnant at a young age”
        Our sex education is pathetic.
        Hard to get birth control information and methods.

        Closing of low-cost women’s clinics is considered a good thing by many politicians.
        Basically, we do not have the “safety net” that other industrialized countries

        • Gozi
          October 7, 2014 at 2:15 pm #

          I have noticed that women often get a lot of government and social assistance with their health while they are pregnant, but all of that (or just about all of that assistance) is cut off a couple of months postpartum. I am not saying we have to coddle people for the rest of their lives, but if a woman can’t afford decent health care while pregnant, then she usually can’t magically afford it after the baby is born. Wouldn’t improving overall health improve pregnancy outcomes?

          I can’t speak for the rest of America, but where I live there is one low cost clinic and they stink. The medical mistakes they make are embarrassing. Once the insurance I carried told me to go to a critical care clinic for a health issue. WHAT CRITICAL CARE CLINIC?!?! She might as well told me to go to the Land of Oz.

          • fiftyfifty1
            October 7, 2014 at 4:00 pm #

            “but all of that (or just about all of that assistance) is cut off a couple of months postpartum.”
            I agree. This is a huge problem. Often public insurance cuts off soon after a woman’s 6 week visit. If she doesn’t make her 6 week post-partum visit, then she is left without access to birth control that she might use for family spacing. Closely spaced pregnancies are one of the risk factors for premature birth and poorer pregnacy outcomes.

          • Sara
            October 7, 2014 at 4:28 pm #

            A lot of states have programs for birth control that are independent of pregnancy care or other medicaid services. This is true even in my state where medicaid services are horrible, and have recently been cut back to what I believe is the minimum required by the Fed. govt.

          • Certified Hamster Midwife
            October 7, 2014 at 7:02 pm #

            People still have to know about those programs, and also know how to access them.

          • fiftyfifty1
            October 7, 2014 at 7:53 pm #

            That may be true, but there are still barriers. Women living in poverty have a lot on their plates and typically poor transportation. They may not prioritize a birth-control only visit due to all the other things they face. What might bring them to the doctor instead might be their child being sick. As a family doctor, I might see a sick child and then ask the mother “Since you are here, is there anything YOU need?”. If she has insurance, I can help her, whether that need is that she herself is sick, a flu shot, help quitting smoking, or birth control. But as so often happens, her insurance has just run out. Then the best I can do is remind her that there are family planning clinics she technically could go to…if she had transportation…and she will need to make an appointment…and bring proof of income…etc.

          • Sara
            October 7, 2014 at 8:09 pm #

            Right, the system is barely adequate. It would make the most sense if women who are just losing their pregnancy benefits were automatically enrolled in in the contraceptive care program, but that doesn’t happen. I think all medicaid programs now have to include transportation services. Not sure how that actually plays out.

          • Hooligan
            October 8, 2014 at 1:25 am #

            as a once poor white woman being reasonably well educated and having graduated H.S. I was able to read and make phone calls and get help and assistance for things like finding a clinic for birth control when I had no health insurance. The embedded racism in so many areas of our country makes it extremely difficult for women of color to find, access, understand and become educated about their choices, their options and their lives. Infant mortality is just one, tragic, example of what this constant racism does to a whole race of people. Infant mortality for the “average” poor white woman compared to the “average” poor black woman is still hugely disparate. Racism is still alive and well and thriving in some areas, and babies die and are injured because of it. Women of color combat racism IN the healthcare systems as well, not just gaining access, but once in, they face many more hurdles to adequate care.

          • Cobalt
            October 8, 2014 at 5:56 am #

            And if she has a postpartum complication that takes longer to manage than the end of the calendar month after the baby is born, it doesn’t get treated. High blood pressure, prolapse, poorly healing incision/tear. Or the IUD to prevent the next pregnancy has to be ordered and doesn’t arrive quickly enough.

          • AmyH
            October 8, 2014 at 9:11 am #

            I had continued pain after the birth of my son. Not super bad – it was only a first degree tear, but I didn’t want to live with it. My insurance expired 60 or 90 days after his birth (don’t remember which). I decided to make an appt about 3 days before it expired, “just so they could tell me it was normal.” Turned out the tear had developed granulation. Due to the insurance situation, I had it cauterized right then and there while my mom was in the waiting room with my son.

            It really didn’t turn out that bad for me; I would have preferred to be squeezing my husband’s hand instead of the nurses, but OTOH if I’d had time to go home and google it I would have been scared silly. It hurt even with a local but I survived.

            However, my point is that if I’d waited another week, I’d still be dealing with it. I am low income, but I’m used to advocating for myself as necessary, if that makes sense. At my six week checkup they’d told me to call them if the pain persisted past X weeks and I was taking it seriously and keeping track of time. I know a lot of women are left with problems, not to mention the situations you mentioned where time simply runs out. I don’t necessarily feel like anyone owes me long term insurance, but I can certainly see the problems we live with without it.

          • Trixie
            October 7, 2014 at 9:04 pm #

            For that matter, automotive accidents contribute to infant mortality. Being unable to access or properly use a suitable, non-expired child restraint for your baby will have a measurable effect on infant mortality, I’d expect.

          • Mariana Baca
            October 7, 2014 at 9:26 pm #

            Or, for that matter, much greater number of miles driven, with or without a car seat. Most other developed countries have much better public transport or denser population centers.

          • Young CC Prof
            October 7, 2014 at 9:27 pm #

            And in countries with paid maternity leave, babies don’t need to get driven to child care on a daily basis in the first place.

          • Sally RNC-NIC
            October 8, 2014 at 12:12 am #

            Medicaid varies from state to state, and OH how it varies from state to state. It makes a huge difference on the quality of care. Unfortunately.

        • auntbea
          October 7, 2014 at 2:41 pm #

          “outcomes for poor whites in MT are no better than outcomes for poor
          blacks in AL which are no better than outcomes for poor Apaches in AZ”

          I really don’t think this is the case. Poverty is obviously the strongest determinant of bad outcomes, but racial disparities persist after we control for poverty. True for life expectancy, infant mortality, school test scores, whatever.

        • DiomedesV
          October 7, 2014 at 2:51 pm #

          “outcomes for poor whites in MT are no better than outcomes for poor
          blacks in AL which are no better than outcomes for poor Apaches in AZ

          Citations, please.

        • fiftyfifty1
          October 7, 2014 at 4:11 pm #

          “It’s poor people of any color – outcomes for poor whites in MT are no better than outcomes for poor blacks in AL which are no better than outcomes for poor Apaches in AZ …”
          Completely untrue. I see concrete examples of how this is not true on a regular basis. I work at a clinic in a poor urban neighborhood. There are 2 main ethnic groups, and they have very different pregnancy outcomes. The housing is the same, the poverty is the same, the clinics are the same, the Medicaid is the same, the schools are the same. But the social customs are night and day different. And while both groups face racism, the racism is different. One group has very poor reproductive health outcomes, the other actually quite good even despite a high teen pregnancy rate (that is an accepted/expected part of the culture).

      • auntbea
        October 7, 2014 at 2:38 pm #

        The UK is 92% white and 2% black. The US is 72% white and 13% black.

      • jhr
        October 7, 2014 at 2:49 pm #

        There was no attempt to proffer excuses or justification of care for poor minorities in the US in this class. Rather, the professor’s goal was to introduce a broader range of biological and social variables in understanding health data, not just absolute numbers. And one of the results,in fact, was that this understanding of the data corroborated the racism, inadequate societal services, and resulting social pathology that we, as a country were finally beginning to discuss. Remember, this was the 1970s. The public conversation was far less sophisticated than it is now.

        In comparing health statistics from Reykjavik and Atlanta, for example, he pointed to issues such as the number of young African-American teens giving birth during that period (inadequate prenatal care + poor nutrition + underdeveloped pelvic cavities resulting in much higher prematurity and infant/maternal morbidity and mortality), when speaking of live births as compared to the racial homogeneity (i.e., Nordic/Gallic) and health policies of Iceland. He also insisted on including variables such as social attitudes towards and prevalence of smoking, air and water pollution in a specific society, when discussing cancer data. So no, he was not “excusing” anything. He was debunking a naive reliance on conclusions arising from un-evaluated statistics.

        • The Computer Ate My Nym
          October 7, 2014 at 4:51 pm #

          Sorry, I didn’t mean to disparage your professor, it’s just that I’ve seen people say “oh, but you can’t compare the US to other countries because we have minorities” and end the discussion there. In that context it seems like an excuse. At the beginning of a course discussing the details of how prejudice, biology, and other issues play into the statistics, it’s entirely different. My apologies for not distinguishing between the two.

      • Sara
        October 7, 2014 at 4:18 pm #

        I suspect it’s at least partially geographic. The majority of African
        Americans live in the south. Where they do live, they are often
        geographically isolated from surrounding areas with better resources. I have worked with communities (not in healthcare) that were 90+% black where the nearest store for anything at all was 45 minutes away. In Louisiana and Mississippi, where we have some of the worst healthcare statistics (actually, THE worst, I’m pretty sure) the states are near 50% minority population and many are in rural or poorly resourced urban

        I am having trouble copying and pasting from this report, but basically the areas with the lowest HDI (Human Development Index) tend to have high minority populations, and those doing the best have lower. I am not from this area, and when I came here it was shocking how the segregation is just sooo obvious. Those communities that are carrying the biggest burden are just kind of out of sight, out of mind.

  8. lilin
    October 7, 2014 at 12:29 pm #

    This is a great post, and shows the hypocrisy of the home birthers. They keep claiming that hospitals use scare tactics, but they are clearly using scare tactics. More importantly, they’re ignoring the real cause of death for babies of minority and poor women in order to promote their profitable pet cause.

  9. staceyjw
    October 7, 2014 at 12:03 pm #

    And forget about tackling that glaring inequality. We are cuttting food assistance, even with 450k homeless.families.and.millions of homeless.overall. bringng back cash assistence, and increasing wages is unthinkable here. poverty and racism isnt so3 big mystery. we have the abilityto fix this stuff, we.simply refuse to allocate the resources.

    • Sara
      October 7, 2014 at 4:57 pm #

      Yes, sadly. And when you point it out you have so many people complaining about the “race card” or saying stuff like “well I have it hard, too, because of this, this and this and I don’t want to pay for someone else’s troubles.”

      It’s ignorance and selfishness, and yep, plain old racism.

    • auntbea
      October 7, 2014 at 6:53 pm #

      If it makes you feel better USAID is increasingly funding direct cash transfers to poor people in OTHER countries.

      • yugaya
        October 7, 2014 at 7:14 pm #

        Don’t worry, the bulk of USAID money never reaches the poor people in other countries, it gets siphoned off into staff salaries, local corruption, influencing political outcomes through humanitarian bribery and useless projects that do not make any real difference or reach the people who are supposed to benefit from it.

        • auntbea
          October 7, 2014 at 7:42 pm #

          Well except for the part where a huge amount of academia’s best research on preventing corruption, and identifying voters’ true preferences is funded by USAID…

          • Amazed
            October 7, 2014 at 8:01 pm #

            Truly wasted money. No one needs money spent to identify voters’ true preferences. I could do the job myself without much effort. Pity that no one approached me with offers to do it for money.

            Seriously, we had elections on Sunday. I kid you not, I got the results right, with only a few percent being wrong. Alas, my pessimism proved justified.

          • auntbea
            October 7, 2014 at 8:08 pm #

            Wow. Lol. I am going to assume you are NOT one of the people on this board who knows what I do for a living. Either that or you are just quite rude.

          • Amazed
            October 7, 2014 at 8:16 pm #

            No, I don’t know what you do for a living. Sorry if I offended.

            Yes, no one needs to spend money for identifying voters’ true preferences. Indeed, I should have added “where I am”. The situation is so shitty that it’s quite obvious what’s going on. Worse, the details of it offer no help. Maybe in other places it does make sense. But here, young people voting for those who promise increase of pensions because they are unemployed and rely on dear old grandma’s pension… grim enough without digging further, eh?

            And yes, I am quite rude. In this case, not intentionally. But facts are facts.

          • yugaya
            October 8, 2014 at 1:08 am #

            Auntbea I have no idea what you do fo r living either, but I’m guessing Amazed who is from the same region like I am has similar ideas on this subject like I do that stem from knowing exactly how huge the difference ’round here is between what the project documentation and reports say and what is really going on. 🙂

          • auntbea
            October 8, 2014 at 9:04 am #

            I’m a political scientist. I do things like use USAID money to identify voters’ true preferences (in African countries.) I’m not really sure where you are or what situation you are talking about (Scotland?). It is possible that you are right and the reports you are reading are badly done. Especially if by reports you mean newspaper analysis — my rule of thumb is to assume newspaper pundits are telling you the *opposite* of what is true. But, generally speaking, when you and an academic political scientist disagree about something, you should listen to the political scientist. Most Americans, for example, hold all sorts of erroneous beliefs about who votes for which party and why, even people who are very well educated and informed.

          • Amazed
            October 8, 2014 at 12:44 pm #

            Indeed. Sometimes, when I listen to the reports about various projects and their results – especially that! – I think I’d love to live in the country they are referring to. Alas, I live in real world.

  10. lawyer jane
    October 7, 2014 at 11:36 am #

    This is a very important post, and strikingly similar to work I am doing on race-based outcome disparities in a completely different policy area (having nothing to do with health). But how do you reach your conclusion that the poor outcomes for women of color have nothing to do with obstetric care? Couldn’t the quality of obstetric care be a factor in prematurity leading to postneonatal mortality? If obstetric are is not the issue, what do you think is the solution?

    • attitude devant
      October 7, 2014 at 12:43 pm #

      I think your first question mischaracterizes what she said. Your confusion may stem from your unfamiliarity with how mortality statistics are kept. Neonatal mortality is from birth to 28 days. Generally, if there is some complication of labor and delivery resulting in infant death, that death will have occurred by 28 days. Infant mortality is different; it’s birth to one year. What she says is: US neonatal mortality (first 28 days) is as good as any other industrialized country, but our infant mortality rate in the POST-natal period is high and the culprits lie in racial and economic disadvantages.

      I think she’s right and I can tell you what those disadvantages are, because I see them every day. I see homeless new mothers. People with inadequate heat. People who have insurance under Obamacare but no car to get them to the doctor, and no money for prescription co-pays. People with untreated chronic mental illness trying to raise children. Social workers whose ginormous caseloads don’t let them adequately monitor these high-risk families. It’s a disgrace really, and I will stop typing now before I get completely depressed.

      • The Computer Ate My Nym
        October 7, 2014 at 1:43 pm #

        Can I add to your depression? I see much the same thing, in the context of people with life threatening hematologic problems. It’s almost worse when people can come to an office visit but can’t afford any of the treatment recommended. “Well, we could give you drug X which works in about 70% of people with your condition, not to mention drugs Y and Z which would make you feel better, even they don’t alter the course of the disease, except that you don’t have the money to pay for X, Y, or Z. Also, extreme temperatures make your condition worse so remember to keep warm/cool in your unheated/air conditioned apartment.”

        Yes, I’ve had conversations like that. They usually end with me hysterically crying to the social worker who then turns herself inside out trying to find some way for the patient to get the medication. Sometimes it works. We have a small fund to help with copays and things and so sometimes we can help directly. The funds come from a bake sale. Yes, I work for a billion dollar hospital that literally has a bake sale to fund at least one of its programs.

        • Gozi
          October 7, 2014 at 1:58 pm #

          Wow, a bake sale…

        • T.
          October 7, 2014 at 3:24 pm #

          … I am feeling horrendously grateful for my NHS now.

          • KarenJJ
            October 7, 2014 at 10:09 pm #

            Me too. I get my expensive medication from the publicly funded hospital (not federally funded via the PBS due to it being too rare, but the doctors have “drug budgets” where they can get approval for some treatments if they get approval via the “drug committee”). There can be a fight for some patients to get access, but I’ve been “lucky” (also = more affected than most with my condition). That said, compared to those in the US, I get access with a small copay of $30 per month and it doesn’t matter who I work for/what insurance I have. I am also not facing bankruptcy due to medical bills, which several US families are facing.

      • Staceyjw
        October 7, 2014 at 2:53 pm #

        And to think, that’s in a so called liberal city that’s almost entirely white, with a high number of educated people, with good coverage for low income people, and a good mental health care system. If the problems are so serious here, where most people have quite a bit of privilege, imagine for a minute what its like elsewhere.

        I used to live in a part of Cleveland that is extremely impoverished. If you think it can be depressing in the PNW, try some of the rust belt cities. The combination of racism, segregation, redlining, white flight, with disinvestment in manufacturing/middle class wage work, has left most black people poor, and stuck in vast swaths of crumbling urban areas. Eliminating even the modest cash assistence programs has caused an upsurge in extreme poverty and homelessness, and the number of hungry people is insane, in a nation that pays its farmers not to work.

        Barely funded education, plus a militarized and aggressive police force and private prison conspire to destroy everyone in their path. Available health care is minimal and rarely respectful. It’s no big mystery why our numbers lag behind.
        This is the back drop to those those stats.

        There are some amazing people living and working in those neighborhoods, but they are obstructed at every turn.

        If we don’t fix the mass inequality, racism, and sexism, these numbers will never improve. The system is rotten to the core, as are those that prop it up. I can see why people do anything they can to lay blame elsewhere, to ignore the root causes- actually fixing things might shake up the status quo.

      • lawyer jane
        October 7, 2014 at 3:53 pm #

        No, I get that! My question is, if prenatal OB care relates to health of babies in the first year, then maybe OB care is related to racial disparities in postnatal mortality in the first 28 days – 1 year. What the results for neonatal mortality (birth – 28 days) seems to suggest is that any issues with OB care don’t have to do with L&D itself. BUT seems possible that prenatal care could have a role. Also, I wonder if the extreme early preemies that are excluded from this paper also show a race disparity that could potentially be linked to quality of prenatal care.

        • Sara
          October 7, 2014 at 5:02 pm #

          I think you are making a good point. I have seen stats from the CDC for WHY babies die in the first year and often it is due to congenital defects (presumably some preventable, even though many are not) and prematurity– but not the very early prematurity that is killing many newborns. These are still outcomes that *may* have been preventable during the prenatal time.

          • attitude devant
            October 7, 2014 at 5:15 pm #

            Ummm. No. Please see my note above. If you haven’t been exposed to this idea before it takes some getting used to, but it is true: if a baby survives that first 28 days, the issues leading to death are not related to obstetrical care.

          • Sara
            October 7, 2014 at 7:10 pm #

            I was thinking more of a lack of obstetric care causing more chronic problems that arent necessarily deadly in the first 28 days. Maybe I have misunderstood what this thread was about.

          • attitude devant
            October 7, 2014 at 7:25 pm #

            No, you’re fine. But we are talking about mortality as an indicator. So by definition we are not talking about chronic problems. Not that chronic problems aren’t important…..

          • Sara
            October 7, 2014 at 7:43 pm #

            I mean if an infant is born with a problem and survives the first 28 days in NICU with an ongoing condition, but then dies somewhere within that first year from the same condition, that would be classified as an infant mortality even though the problem began much earlier.

          • attitude devant
            October 7, 2014 at 9:15 pm #

            Sara, I get what you’re saying. I struggled with these concepts too. Mortality as a measure of care is a VERY crude metric. Yes, if poor care leaves someone chronically ill they might die later. Yup. But as I say above that situation is statistically a blip on the radar. There just aren’t enough of them to make a big shift. And once an individual has made it 28 days there’s no reason they will die in the first year instead of the second, third, or fourth, assuming they have good care during that period. That’s the nature of chronic conditions.

          • Sara
            October 7, 2014 at 9:39 pm #

            “…once an individual has made it 28 days there’s no reason they will die in the first year instead of the second, third, or fourth…”

            Thanks, this makes more sense.

        • attitude devant
          October 7, 2014 at 5:13 pm #

          No. Stop and think. Can you think of ANY mechanism in which OB care would be the cause of death after 28 days? The vast majority of babies that are going to die from prematurity or from complications of delivery or from anomalies incompatible with life are going to die in that time frame. I’m not saying a premie NEVER makes it beyond 28 days and then dies, or that a Trisomy 18 baby never makes it to 5 weeks, I’m just saying that it’s unusual, unusual enough that for population statistics it’s not relevant. So, postnatal infant death is for all intents and purposes not an obstetrical quality metric.

          • lawyer jane
            October 8, 2014 at 9:21 am #

            But what about increased risks for RSV, SIDS, etc, that all connect to prematurity and quality of prenatal care, but might cause death after 28 days? Given everything we know about disparities in health outcomes, I really don’t think we can discard quality of/accesss to prenatal OB care as having a connection to high postnatal mortality rates among people of color.

          • lawyer jane
            October 8, 2014 at 9:24 am #

            Also, there are studies demonstrating racially disparate outcomes in the neonatal period (first 28 days).

            I really think that all this study does is show that for white women, care is as good as other countries. For black women, what does it say?

          • lawyer jane
            October 8, 2014 at 9:35 am #

            This study makes me wonder if the outcomes for black babies at poorly performing hospitals is worse than white babies born in homebirths. My guess is yes. Not that the answer is homebirth, obviously, but does put this all into perspective.

          • Young CC Prof
            October 8, 2014 at 9:26 am #

            Here’s what the statistics say (CDC).

            – Preemies account for the majority of neonatal deaths.

            – Preemies are at increased risk of postneonatal death, but the majority of postneonatal deaths occur in full-term babies.

            – Week for week, the USA does an extremely good job of keeping preemies alive.

            – Even among full-term babies alone, the post-neonatal mortality rate is too high, and it’s largely driven by things unrelated to health at birth like accident or violence.

          • attitude devant
            October 8, 2014 at 10:30 am #

            YCCP is absolutely correct. lawyer jane, this all concerns the difference between acute and chronic disease. Yes chronic disease is important, but in terms of looking at mortality rates, chronic disease is just not going to show up much. What WILL matter in the post-neonatal period is all the basic stuff. Nutrition, a safe place to live, access to pediatric care, etc.

          • lawyer jane
            October 8, 2014 at 12:35 pm #

            Ok, but what about the race-based disparities in perinatal deaths?

          • attitude devant
            October 8, 2014 at 1:52 pm #

            What about them? They’re real. And we haven’t even gotten to race-based disparities in maternal outcomes, which are VERY concerning. Why, for instance, are African-American much more likely to develop peripartum cardiomyopathy, which is a devastating disease?

    • TsuDhoNimh
      October 7, 2014 at 12:50 pm #

      But how do you reach your conclusion that the poor outcomes for women of color have nothing to do with obstetric care?

      It’s in the paper … “Given that one of the most striking facts about infant mortality in the US is the disparity in mortality between black and white infants, it is important to note that the facts we document in this paper are essentially unchanged if we exclude US blacks from the sample”

      I’m still reading and looking at graphs … might have to ask the SO’s daughter, this is what her recent PhD was in.

      • auntbea
        October 7, 2014 at 2:42 pm #

        ? How can excluding blacks from the sample tell anything about the difference between blacks and whites?

        • The Bofa, Being of the Sofa
          October 7, 2014 at 3:05 pm #

          It doesn’t tell you about the difference between blacks and whites, it tells you about the difference in medical care provided in the US vs other countries. If you control for differences in populations served, you find that there is no differences in the results. Therefore, you can’t blame the poor outcomes in the US to quality of the doctors.

          So now the challenge is to identify those factors that prevent african-american patients from receiving that quality of care.

          • auntbea
            October 7, 2014 at 3:11 pm #

            The latter is the question I thought we were asking. Are the poor outcomes among blacks a result of disparities in the quality of care (caused by income or otherwise) or something else? The fact that obstetric care overall in the US is the same as elsewhere on average doesn’t mean that poor obstetric care *for blacks* isn’t the cause of bad outcomes.

          • The Bofa, Being of the Sofa
            October 7, 2014 at 3:24 pm #

            No, the question we are asking is, why is the US infant mortality so bad? That we get to the point of being able to ask what’s the racial problem is due to the fact that it’s not the quality of care that’s possible.

            Imagine the implication if they had found that the US infant mortality in the US was also for the controlled populations? That would have been HUGE. However, the fact that they didn’t is very important, because it shows us that to solve the problem for US infant mortality, we need to figure out what causes the differences for the outcomes for white and black.

          • auntbea
            October 7, 2014 at 3:31 pm #

            Yes, I get that’s the question and conclusion of the Oster study. I meant the question Lawyer Jane was asking. She wants to know how we can be sure that bad outcomes for blacks are not a result of bad obstetrical care. Average obstetrical outcomes in the US are great, but that doesn’t mean it isn’t highly variable. There could be strong racial disparities in care (perhaps directly attributable to race) that are hidden within the average.

          • lawyer jane
            October 7, 2014 at 3:46 pm #

            Yes, this is what I mean. One reasonable hypothesis is that the bad outcomes for people of color are due to overall reduced access to healthcare or worse healthcare – including OB care. (Goes without saying that the answer to this would not be to push homebirths!)

  11. no longer drinking the koolaid
    October 7, 2014 at 11:35 am #

    Hutzel Hospital in Detroit, and the PRB lead by Robert Romero are doing something about preterm birth. Dr. Hassan’s work on short cervix and progesterone use (17 OH) is making a difference. This is why Detroit has set up the free program to help women get access to care and the needed medications.
    If midwives and doulas were really interested in making a difference in infant M&M secondary to preterm birth, they would be volunteering to get these women to their prenatal appointments, provide them with adequate calories of healthy food, and tell them that US and medications have a definite place in getting their babies full term.
    Oops, sorry, have offered a medical solution supported by the evidence, rather than wishful management.

    • no longer drinking the koolaid
      October 7, 2014 at 5:00 pm #

      BTW: the population served is inner city Detroit, about 98% AA, a smattering of middle eastern, African, hispanic, and a very few caucasian. I think it is about 99% using Medicaid for insurance. One of the worst neonatal mortality rates in the country.

    • araikwao
      October 7, 2014 at 5:03 pm #

      Oh my gosh, Roberto Romero is my new hero – I’ve just finished a literature review (well, part 1) that involved a heap of papers he authored (and Vincenzo Berghella). I geekily admit I got quite a thrill seeing his name here!! (and Sonia Hassan, too – another big gun in the literature)

      • no longer drinking the koolaid
        October 7, 2014 at 8:25 pm #

        I have Berghella’s 5/12 paper from AJOG (PTL and progesterone) on my side table.
        I work for the PRB reviewing charts for the clinical samples.
        Have you seen the paper from Science a couple of months ago describing PTL as a syndrome rather than a single, distinct event?

        • araikwao
          October 8, 2014 at 2:51 am #

          No,I did reference the super-awesome Romero’s paper on the preterm parturition syndrome, though. Can’t remember which journal. Will have to look that one up, thanks!
          How exciting! I am just a lowly med student, will be doing a 10-year audit of the high-risk pregnancy clinic at one of the big womens’ hospitals in my (Australian) state, we’re hoping to get some more data looking at amniotic fluid sludge, cervical length, etc. So I will be doing a heap of chart reviewing too!

  12. Amy Tuteur, MD
    October 7, 2014 at 11:06 am #

    This is post #1500 on The Skeptical OB.

    • PrimaryCareDoc
      October 7, 2014 at 11:59 am #

      Congrats! Keep up your great work.

    • jhr
      October 7, 2014 at 12:46 pm #

      excellent and important work.

    • KeeperOfTheBooks
      October 7, 2014 at 2:37 pm #

      Congrats! Keep it up!!!!!

    • Leah
      October 7, 2014 at 9:49 pm #

      Thank you for your hard work.

    • KarenJJ
      October 7, 2014 at 10:12 pm #

      Congratulations! I’ve been following this blog for years now. I find it to be one of the most interesting and thought-provoking blogs on the internet. Thankyou for your hard work.

    • areawomanpdx
      October 8, 2014 at 2:57 am #

      The only blog I visit on a regular basis.

    • Sue
      October 9, 2014 at 12:56 am #

      and thanks for creating and sustaining such a great community!

    • amazonmom
      October 9, 2014 at 2:48 pm #

      I love this blog! I can’t tell you how many times I’ve used the information in the posts at work. Personally it helped me realize that Emperor Natural has no clothes.

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