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Infant Mortality in the U.S. and Canada
However, we are far from being “the best” in the world.
Forty nations surpass the United States in infant mortality, including Singapore (2.29 per 1,000), Sweden (2.77 per 1,000), and Japan (3.26 per 1,000).
Because the U.S. and Canada are neighbors and share a border, similar economies, and comparable levels of technologic sophistication, it is of interest that Canada's infant mortality is 30% lower than that of the United States, which was estimated by the CIA to be 6.5 per 1,000 in 2004.
In 2002, infant mortality worsened slightly in both countries, prompting renewed scrutiny of an ever-important issue.
The Centers for Disease Control and Prevention reported that in 2002, U.S. infant mortality edged upward to 7.0 per 1,000 live births from 6.8 per 1,000 in 2001.
This represents the first rise in 44 years. However, even if this anomaly were a one-time occurrence, it's concerning to note this 0.02% increase when we view the statistic in the context of more than 4 million births.
The same trend occurred in Canada, where infant mortality rose from 5.2 per 1,000 in 2001 to 5.4 per 1,000 in 2002, after progressively falling since the 1960s.
There are numerous factors that may help to elucidate this trend. At the very least, this upturn in infant mortality indicates that perhaps we are not progressing at a pace that many believe is one of the most important measures of a nation's health.
Infant mortality can be divided into two categories: neonatal deaths occurring within the first month of life, and postneonatal deaths occurring later in the first year.
Postneonatal deaths have not increased. In fact, tremendous advances in the etiology and prevention of sudden infant death syndrome have substantially reduced postneonatal deaths over the past decade.
The neonatal increases noted in 2002—and the disparity between the United States' and Canada's infant mortality—have occurred in the early weeks of life, when the most common causes of death include congenital anomalies, problems of transition, and complications of preterm birth. Among these factors, preterm birth stands out as a significant contributor to rising infant mortality.
In the United States, preterm births increased to 12.1%, from 11.9% the previous year.
Although the preterm birth rate also rose slightly in Canada, it was 7.6% in 2002—nearly 40% lower than in the United States.
Why is the preterm birth rate trending upward?
The evidence suggests that the trend is being driven by the use of reproductive technology, leading to multiple births; by women giving birth at later ages; by the necessity of earlier obstetrician intervention when the fetus is in jeopardy; and by complications attributed to a lack of early, consistent prenatal care.
The attempt to save an infant via early delivery has allowed many preemies to live who might have been stillborn in years past.
The recent changes in social trends have influenced the ages at which women decide to have their children. In Ottawa, where I practice, over 60% of mothers in 2003 gave birth when they were older than 30 years, and 23.2% when they were older than 35 years. Although women have a right to be informed about their chances of conceiving and delivering healthy singletons at different ages, physicians have no desire to dictate social policy or individual choice. I have a 5-year-old, and I'm not a young man.
We understand that older women have a higher risk of having a preterm baby, in part because they have a higher risk of having multiples, having pregnancy complications, and having babies with congenital anomalies, three factors that contribute to infant mortality.
Older mothers also are more likely to require assisted reproductive technology (ART).
Although ART procedures are similar in the United States and Canada, and are basically patient-funded in both countries, reproductive technology is increasingly subject to oversight in Canada. A bill that recently passed both the House of Commons and the Senate would strictly regulate clinics and procedures, for example.
A great many ART centers in Canada are university-affiliated, not-for-profit programs, rather than independent clinics. As a result, a controversial issue—such as the implantation of multiple embryos—is debated within the wide academic community of endocrinologists, ob.gyns., neonatologists, pediatricians, and ethicists.
When three sets of quadruplets were born in 1 year at the University of Ottawa, the university-affiliated fertility center demonstrated its responsibility by revising its policies to limit the number of embryos transferred during each cycle. Today, we rarely see quadruplets, although triplets are still not a rarity.
Throughout Canada, rates of multiple birth are lower than in the United States, contributing to lower rates of preterm birth. However, in looking at overall preterm birth statistics, it is worth noting that both nations have unequal rates across populations.
The U.S. National Center for Health Statistics reports that African American infants are nearly twice as likely as non-Hispanic white infants to be born prematurely.
In Canada, the disparity is most clearly defined by income, with those in the lowest income quintile having an infant mortality rate two-thirds higher than that of the highest income quintile. As infant mortality secondary to congenital anomalies and other causes has fallen significantly, the differential is largely a result of a higher rate of preterm birth in lower-income families.
Canada's First Nation and Inuit people face serious health problems, including infant mortality in many communities that is twice the national rate, as do America's Native American populations. Although Canada is an increasingly racially diverse country, other racial disparities are less obvious in measures of health care, such as prenatal care or preterm birth. Income is perhaps a more fitting measure of comparison, and deserving of a wider perspective.
One interesting study examined the gross national products and income distribution in 20 poor and 15 rich nations, determining, as one would expect, that overall infant mortality was inversely proportionate to income.
In rich countries, however, the main contributor to higher infant mortality was not income, but income disparity (Lancet 1999;354:2047).
The United Nations, in its annual Innocenti report card for 2000, explored child poverty in rich nations by using consistent indices to identify the percentage of children living in families with incomes below 50% of each nation's median income.
Child poverty levels ranged from 2.6% in Sweden to 26.6% in Mexico. Canada was 15.5%, and the United States was 22.4%.
Some governments, including those in Scandinavia, take a very active role in making sure that people don't live in poverty. Income disparity is low.
Conversely, income inequality is very high in the United States and may contribute to exceedingly elevated preterm birth rates and infant mortality among African Americans.
A related issue, of course, is access to medical care, which varies greatly among the industrialized nations of the world.
In Canada, where we have universal medical care, prenatal care is available at no cost, with no disincentives to seeking care in the system. Even pregnant women who do not have a primary care physician can walk into a clinic in any city and be seen that day.
As a result, in 2000, well over 95% of Canadian women received prenatal care beginning in the first trimester, compared with 83.7% of American women.
Once again, disparity is evident in the U.S. numbers, with only about 75% of African Americans and fewer than 70% of Native Americans receiving early prenatal care. Indeed, 3.6% of women delivered with no prenatal care, or with care initiated only in the last trimester.
Although the U.S. rate of early prenatal care has improved quite dramatically in the last 15 years, rising 10% since 1990, it still falls short of the care rates in most Western nations. Conversely, I should point out that the Swedes think that even Canada's prenatal care numbers are lousy. In Sweden, virtually 100% of women receive prenatal care throughout their pregnancy.
I would also be remiss if I left the impression that the Canadian health care system, the Swedish system, or any system, for that matter, is perfect. In Canada, one faces a long wait for a hip replacement. Far too many Canadians (about 10%) depend on walk-in clinics because they can't find a primary care physician of their own. Canadians who make more money tend to live longer, and certain groups, such as First Nation and Inuit people, have unequal health outcomes despite access to free care.
In Canada, we learn a lot from the United States, from the abundance of medical research and education to the excellent health care available to many. But in the spirit of learning from each other, U.S. physicians may be interested in studying a neighbor that spends less on health care yet produces not only lower preterm birth rates and infant mortality, but also lower mortality overall.
Sources
▸ The National Center for Health Statistics publishes regular reports on infant mortality. The final data for 2002 can be found in Natl. Vital Stat. Rep. 2003;52:1-113. The center's latest annual report on trends in health statistics is “Health, United States, 2004,” which includes a chartbook on trends in the health of Americans as well as interactive links (
▸ The Central Intelligence Agency publishes the World Factbook each year in printed and Internet versions. Data noted in this Master Class can be found online at
www.cia.gov/cia/publications/factbook/rankorder/2091rank.html
▸ Canadian infant mortality statistics can be found at
www.phac-aspc.gc.ca/publicat/cphr-rspc03
▸ The United Nations Children's Fund (UNICEF) uses data collected in annual report cards from its Innocenti Research Centre. The first report card was published in June 2000, and—along with more recent report cards—can be accessed at
www.unicef-icdc.org/publications
▸ Simon Hales, M.B., and colleagues published the results of their study of the relationship among infant mortality, gross national product, and income distribution (Lancet 1999;354:2047).
However, we are far from being “the best” in the world.
Forty nations surpass the United States in infant mortality, including Singapore (2.29 per 1,000), Sweden (2.77 per 1,000), and Japan (3.26 per 1,000).
Because the U.S. and Canada are neighbors and share a border, similar economies, and comparable levels of technologic sophistication, it is of interest that Canada's infant mortality is 30% lower than that of the United States, which was estimated by the CIA to be 6.5 per 1,000 in 2004.
In 2002, infant mortality worsened slightly in both countries, prompting renewed scrutiny of an ever-important issue.
The Centers for Disease Control and Prevention reported that in 2002, U.S. infant mortality edged upward to 7.0 per 1,000 live births from 6.8 per 1,000 in 2001.
This represents the first rise in 44 years. However, even if this anomaly were a one-time occurrence, it's concerning to note this 0.02% increase when we view the statistic in the context of more than 4 million births.
The same trend occurred in Canada, where infant mortality rose from 5.2 per 1,000 in 2001 to 5.4 per 1,000 in 2002, after progressively falling since the 1960s.
There are numerous factors that may help to elucidate this trend. At the very least, this upturn in infant mortality indicates that perhaps we are not progressing at a pace that many believe is one of the most important measures of a nation's health.
Infant mortality can be divided into two categories: neonatal deaths occurring within the first month of life, and postneonatal deaths occurring later in the first year.
Postneonatal deaths have not increased. In fact, tremendous advances in the etiology and prevention of sudden infant death syndrome have substantially reduced postneonatal deaths over the past decade.
The neonatal increases noted in 2002—and the disparity between the United States' and Canada's infant mortality—have occurred in the early weeks of life, when the most common causes of death include congenital anomalies, problems of transition, and complications of preterm birth. Among these factors, preterm birth stands out as a significant contributor to rising infant mortality.
In the United States, preterm births increased to 12.1%, from 11.9% the previous year.
Although the preterm birth rate also rose slightly in Canada, it was 7.6% in 2002—nearly 40% lower than in the United States.
Why is the preterm birth rate trending upward?
The evidence suggests that the trend is being driven by the use of reproductive technology, leading to multiple births; by women giving birth at later ages; by the necessity of earlier obstetrician intervention when the fetus is in jeopardy; and by complications attributed to a lack of early, consistent prenatal care.
The attempt to save an infant via early delivery has allowed many preemies to live who might have been stillborn in years past.
The recent changes in social trends have influenced the ages at which women decide to have their children. In Ottawa, where I practice, over 60% of mothers in 2003 gave birth when they were older than 30 years, and 23.2% when they were older than 35 years. Although women have a right to be informed about their chances of conceiving and delivering healthy singletons at different ages, physicians have no desire to dictate social policy or individual choice. I have a 5-year-old, and I'm not a young man.
We understand that older women have a higher risk of having a preterm baby, in part because they have a higher risk of having multiples, having pregnancy complications, and having babies with congenital anomalies, three factors that contribute to infant mortality.
Older mothers also are more likely to require assisted reproductive technology (ART).
Although ART procedures are similar in the United States and Canada, and are basically patient-funded in both countries, reproductive technology is increasingly subject to oversight in Canada. A bill that recently passed both the House of Commons and the Senate would strictly regulate clinics and procedures, for example.
A great many ART centers in Canada are university-affiliated, not-for-profit programs, rather than independent clinics. As a result, a controversial issue—such as the implantation of multiple embryos—is debated within the wide academic community of endocrinologists, ob.gyns., neonatologists, pediatricians, and ethicists.
When three sets of quadruplets were born in 1 year at the University of Ottawa, the university-affiliated fertility center demonstrated its responsibility by revising its policies to limit the number of embryos transferred during each cycle. Today, we rarely see quadruplets, although triplets are still not a rarity.
Throughout Canada, rates of multiple birth are lower than in the United States, contributing to lower rates of preterm birth. However, in looking at overall preterm birth statistics, it is worth noting that both nations have unequal rates across populations.
The U.S. National Center for Health Statistics reports that African American infants are nearly twice as likely as non-Hispanic white infants to be born prematurely.
In Canada, the disparity is most clearly defined by income, with those in the lowest income quintile having an infant mortality rate two-thirds higher than that of the highest income quintile. As infant mortality secondary to congenital anomalies and other causes has fallen significantly, the differential is largely a result of a higher rate of preterm birth in lower-income families.
Canada's First Nation and Inuit people face serious health problems, including infant mortality in many communities that is twice the national rate, as do America's Native American populations. Although Canada is an increasingly racially diverse country, other racial disparities are less obvious in measures of health care, such as prenatal care or preterm birth. Income is perhaps a more fitting measure of comparison, and deserving of a wider perspective.
One interesting study examined the gross national products and income distribution in 20 poor and 15 rich nations, determining, as one would expect, that overall infant mortality was inversely proportionate to income.
In rich countries, however, the main contributor to higher infant mortality was not income, but income disparity (Lancet 1999;354:2047).
The United Nations, in its annual Innocenti report card for 2000, explored child poverty in rich nations by using consistent indices to identify the percentage of children living in families with incomes below 50% of each nation's median income.
Child poverty levels ranged from 2.6% in Sweden to 26.6% in Mexico. Canada was 15.5%, and the United States was 22.4%.
Some governments, including those in Scandinavia, take a very active role in making sure that people don't live in poverty. Income disparity is low.
Conversely, income inequality is very high in the United States and may contribute to exceedingly elevated preterm birth rates and infant mortality among African Americans.
A related issue, of course, is access to medical care, which varies greatly among the industrialized nations of the world.
In Canada, where we have universal medical care, prenatal care is available at no cost, with no disincentives to seeking care in the system. Even pregnant women who do not have a primary care physician can walk into a clinic in any city and be seen that day.
As a result, in 2000, well over 95% of Canadian women received prenatal care beginning in the first trimester, compared with 83.7% of American women.
Once again, disparity is evident in the U.S. numbers, with only about 75% of African Americans and fewer than 70% of Native Americans receiving early prenatal care. Indeed, 3.6% of women delivered with no prenatal care, or with care initiated only in the last trimester.
Although the U.S. rate of early prenatal care has improved quite dramatically in the last 15 years, rising 10% since 1990, it still falls short of the care rates in most Western nations. Conversely, I should point out that the Swedes think that even Canada's prenatal care numbers are lousy. In Sweden, virtually 100% of women receive prenatal care throughout their pregnancy.
I would also be remiss if I left the impression that the Canadian health care system, the Swedish system, or any system, for that matter, is perfect. In Canada, one faces a long wait for a hip replacement. Far too many Canadians (about 10%) depend on walk-in clinics because they can't find a primary care physician of their own. Canadians who make more money tend to live longer, and certain groups, such as First Nation and Inuit people, have unequal health outcomes despite access to free care.
In Canada, we learn a lot from the United States, from the abundance of medical research and education to the excellent health care available to many. But in the spirit of learning from each other, U.S. physicians may be interested in studying a neighbor that spends less on health care yet produces not only lower preterm birth rates and infant mortality, but also lower mortality overall.
Sources
▸ The National Center for Health Statistics publishes regular reports on infant mortality. The final data for 2002 can be found in Natl. Vital Stat. Rep. 2003;52:1-113. The center's latest annual report on trends in health statistics is “Health, United States, 2004,” which includes a chartbook on trends in the health of Americans as well as interactive links (
▸ The Central Intelligence Agency publishes the World Factbook each year in printed and Internet versions. Data noted in this Master Class can be found online at
www.cia.gov/cia/publications/factbook/rankorder/2091rank.html
▸ Canadian infant mortality statistics can be found at
www.phac-aspc.gc.ca/publicat/cphr-rspc03
▸ The United Nations Children's Fund (UNICEF) uses data collected in annual report cards from its Innocenti Research Centre. The first report card was published in June 2000, and—along with more recent report cards—can be accessed at
www.unicef-icdc.org/publications
▸ Simon Hales, M.B., and colleagues published the results of their study of the relationship among infant mortality, gross national product, and income distribution (Lancet 1999;354:2047).
However, we are far from being “the best” in the world.
Forty nations surpass the United States in infant mortality, including Singapore (2.29 per 1,000), Sweden (2.77 per 1,000), and Japan (3.26 per 1,000).
Because the U.S. and Canada are neighbors and share a border, similar economies, and comparable levels of technologic sophistication, it is of interest that Canada's infant mortality is 30% lower than that of the United States, which was estimated by the CIA to be 6.5 per 1,000 in 2004.
In 2002, infant mortality worsened slightly in both countries, prompting renewed scrutiny of an ever-important issue.
The Centers for Disease Control and Prevention reported that in 2002, U.S. infant mortality edged upward to 7.0 per 1,000 live births from 6.8 per 1,000 in 2001.
This represents the first rise in 44 years. However, even if this anomaly were a one-time occurrence, it's concerning to note this 0.02% increase when we view the statistic in the context of more than 4 million births.
The same trend occurred in Canada, where infant mortality rose from 5.2 per 1,000 in 2001 to 5.4 per 1,000 in 2002, after progressively falling since the 1960s.
There are numerous factors that may help to elucidate this trend. At the very least, this upturn in infant mortality indicates that perhaps we are not progressing at a pace that many believe is one of the most important measures of a nation's health.
Infant mortality can be divided into two categories: neonatal deaths occurring within the first month of life, and postneonatal deaths occurring later in the first year.
Postneonatal deaths have not increased. In fact, tremendous advances in the etiology and prevention of sudden infant death syndrome have substantially reduced postneonatal deaths over the past decade.
The neonatal increases noted in 2002—and the disparity between the United States' and Canada's infant mortality—have occurred in the early weeks of life, when the most common causes of death include congenital anomalies, problems of transition, and complications of preterm birth. Among these factors, preterm birth stands out as a significant contributor to rising infant mortality.
In the United States, preterm births increased to 12.1%, from 11.9% the previous year.
Although the preterm birth rate also rose slightly in Canada, it was 7.6% in 2002—nearly 40% lower than in the United States.
Why is the preterm birth rate trending upward?
The evidence suggests that the trend is being driven by the use of reproductive technology, leading to multiple births; by women giving birth at later ages; by the necessity of earlier obstetrician intervention when the fetus is in jeopardy; and by complications attributed to a lack of early, consistent prenatal care.
The attempt to save an infant via early delivery has allowed many preemies to live who might have been stillborn in years past.
The recent changes in social trends have influenced the ages at which women decide to have their children. In Ottawa, where I practice, over 60% of mothers in 2003 gave birth when they were older than 30 years, and 23.2% when they were older than 35 years. Although women have a right to be informed about their chances of conceiving and delivering healthy singletons at different ages, physicians have no desire to dictate social policy or individual choice. I have a 5-year-old, and I'm not a young man.
We understand that older women have a higher risk of having a preterm baby, in part because they have a higher risk of having multiples, having pregnancy complications, and having babies with congenital anomalies, three factors that contribute to infant mortality.
Older mothers also are more likely to require assisted reproductive technology (ART).
Although ART procedures are similar in the United States and Canada, and are basically patient-funded in both countries, reproductive technology is increasingly subject to oversight in Canada. A bill that recently passed both the House of Commons and the Senate would strictly regulate clinics and procedures, for example.
A great many ART centers in Canada are university-affiliated, not-for-profit programs, rather than independent clinics. As a result, a controversial issue—such as the implantation of multiple embryos—is debated within the wide academic community of endocrinologists, ob.gyns., neonatologists, pediatricians, and ethicists.
When three sets of quadruplets were born in 1 year at the University of Ottawa, the university-affiliated fertility center demonstrated its responsibility by revising its policies to limit the number of embryos transferred during each cycle. Today, we rarely see quadruplets, although triplets are still not a rarity.
Throughout Canada, rates of multiple birth are lower than in the United States, contributing to lower rates of preterm birth. However, in looking at overall preterm birth statistics, it is worth noting that both nations have unequal rates across populations.
The U.S. National Center for Health Statistics reports that African American infants are nearly twice as likely as non-Hispanic white infants to be born prematurely.
In Canada, the disparity is most clearly defined by income, with those in the lowest income quintile having an infant mortality rate two-thirds higher than that of the highest income quintile. As infant mortality secondary to congenital anomalies and other causes has fallen significantly, the differential is largely a result of a higher rate of preterm birth in lower-income families.
Canada's First Nation and Inuit people face serious health problems, including infant mortality in many communities that is twice the national rate, as do America's Native American populations. Although Canada is an increasingly racially diverse country, other racial disparities are less obvious in measures of health care, such as prenatal care or preterm birth. Income is perhaps a more fitting measure of comparison, and deserving of a wider perspective.
One interesting study examined the gross national products and income distribution in 20 poor and 15 rich nations, determining, as one would expect, that overall infant mortality was inversely proportionate to income.
In rich countries, however, the main contributor to higher infant mortality was not income, but income disparity (Lancet 1999;354:2047).
The United Nations, in its annual Innocenti report card for 2000, explored child poverty in rich nations by using consistent indices to identify the percentage of children living in families with incomes below 50% of each nation's median income.
Child poverty levels ranged from 2.6% in Sweden to 26.6% in Mexico. Canada was 15.5%, and the United States was 22.4%.
Some governments, including those in Scandinavia, take a very active role in making sure that people don't live in poverty. Income disparity is low.
Conversely, income inequality is very high in the United States and may contribute to exceedingly elevated preterm birth rates and infant mortality among African Americans.
A related issue, of course, is access to medical care, which varies greatly among the industrialized nations of the world.
In Canada, where we have universal medical care, prenatal care is available at no cost, with no disincentives to seeking care in the system. Even pregnant women who do not have a primary care physician can walk into a clinic in any city and be seen that day.
As a result, in 2000, well over 95% of Canadian women received prenatal care beginning in the first trimester, compared with 83.7% of American women.
Once again, disparity is evident in the U.S. numbers, with only about 75% of African Americans and fewer than 70% of Native Americans receiving early prenatal care. Indeed, 3.6% of women delivered with no prenatal care, or with care initiated only in the last trimester.
Although the U.S. rate of early prenatal care has improved quite dramatically in the last 15 years, rising 10% since 1990, it still falls short of the care rates in most Western nations. Conversely, I should point out that the Swedes think that even Canada's prenatal care numbers are lousy. In Sweden, virtually 100% of women receive prenatal care throughout their pregnancy.
I would also be remiss if I left the impression that the Canadian health care system, the Swedish system, or any system, for that matter, is perfect. In Canada, one faces a long wait for a hip replacement. Far too many Canadians (about 10%) depend on walk-in clinics because they can't find a primary care physician of their own. Canadians who make more money tend to live longer, and certain groups, such as First Nation and Inuit people, have unequal health outcomes despite access to free care.
In Canada, we learn a lot from the United States, from the abundance of medical research and education to the excellent health care available to many. But in the spirit of learning from each other, U.S. physicians may be interested in studying a neighbor that spends less on health care yet produces not only lower preterm birth rates and infant mortality, but also lower mortality overall.
Sources
▸ The National Center for Health Statistics publishes regular reports on infant mortality. The final data for 2002 can be found in Natl. Vital Stat. Rep. 2003;52:1-113. The center's latest annual report on trends in health statistics is “Health, United States, 2004,” which includes a chartbook on trends in the health of Americans as well as interactive links (
▸ The Central Intelligence Agency publishes the World Factbook each year in printed and Internet versions. Data noted in this Master Class can be found online at
www.cia.gov/cia/publications/factbook/rankorder/2091rank.html
▸ Canadian infant mortality statistics can be found at
www.phac-aspc.gc.ca/publicat/cphr-rspc03
▸ The United Nations Children's Fund (UNICEF) uses data collected in annual report cards from its Innocenti Research Centre. The first report card was published in June 2000, and—along with more recent report cards—can be accessed at
www.unicef-icdc.org/publications
▸ Simon Hales, M.B., and colleagues published the results of their study of the relationship among infant mortality, gross national product, and income distribution (Lancet 1999;354:2047).