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This Congressional Budget Office Staff Memorandum examines factors contributing to the international ranking of the United States on infant mortality, and discusses some of the problems in making infant mortality comparisons across countries. It was prepared in response to a request from Representative Willis D. Gradison, Jr., the ranking Republican member of the House Committee on the Budget.
The memorandum was prepared by Linda Bilheimer of CBO's Human Resources
and Community Development Division, under the supervision of Nancy Gordon
and Kathryn Langwell. Jacquelyn Vander Brug generated the numbers in the
tables. Harriet Komisar gave valuable comments. Sherwood Kohn edited the
manuscript. Ronald Moore provided administrative assistance for the project
and prepared the final layout of the manuscript.
SUMMARY
INTRODUCTION
THE INFANT MORTALITY RATE AND ITS COMPONENTS
INFANT MORTALITY TRENDS IN THE UNITED STATES AND OTHER COUNTRIES
MEASUREMENT OF PERINATAL OUTCOMES
RISK FACTORS FOR INFANT MORTALITY
FEDERAL AND STATE INITIATIVES TO REDUCE INFANT MORTALITY
REFERENCES
| TABLES | |
| TABLE 1 | BLACK AND WHITE INFANT MORTALITY RATES, UNITED STATES |
| TABLE 2 | INTERNATIONAL INFANT MORTALITY RATES BY RANKING |
| TABLE 3 | UNITED STATES RANKINGS ON INFANT MORTALITY INDICATORS AMONG THIRTY-ONE COUNTRIES |
| TABLE 4 | POSTNEONATAL MORTALITY, UNITED STATES, 1988 |
| TABLE 5 | LOW-BIRTHWEIGHT RATES IN DEVELOPED COUNTRIES, AS A PROPORTION OF LIVE BIRTHS, 1980 |
| TABLE 6 | BIRTHWEIGHT-SPECIFIC PERINATAL MORTALITY RATES, 1980-1982 |
| TABLE 7 | TEENAGE PREGNANCY AND BIRTH RATES, PER 1000 WOMEN BETWEEN 15 AND 19 YEARS OLD |
SUMMARY
In the United States--as in other industrialized countries--the infant mortality rate has declined dramatically during this century. Yet, despite the high quality and widespread availability of neonatal intensive care technology in this country, the infant mortality rate remains higher than that of many developed nations.
Problems of definition and measurement, however, hamper cross-national comparisons of health statistics. Alternative measures of infant mortality may provide better information but cannot completely compensate for differences among countries in the overall rates of reporting of adverse pregnancy outcomes. For example, very premature births are more likely to be included in birth and mortality statistics in the United States than in several other industrialized countries that have lower infant mortality rates.
Variations in infant mortality rates among the states and between different racial and ethnic groups in this country are greater than the differences between the United States and many other countries. Black infant mortality rates, in particular, are exceptionally high, and the relative gap between black and white infant mortality rates has been increasing over time.
Low birthweight is the primary risk factor for infant mortality and most of the decline in neonatal mortality (deaths of infants less than 28 days old) in the United States since 1970 can be attributed to increased rates of survival among low-birthweight newborns. Indeed, comparisons with countries for which data are available suggest that low birthweight newborns have better chances of survival in the United States than elsewhere. The U.S. infant mortality problem arises primarily because of its birthweight distribution; relatively more infants are born at low birthweight in the United States than in most other industrialized countries. Unfortunately, little progress has been made in reducing U.S. low birthweight rates, which would further improve infant mortality rates.
Federal and state initiatives to lower infant mortality rates have focused
on strategies to reduce financial barriers that limit access to prenatal
care and on strategies to expand the supply of prenatal care services available
to poor pregnant women. The relative advantages and disadvantages of these
and other policies to reduce low birthweight and infant mortality are the
focus of considerable debate. Recent expansions of the Medicaid program
are enabling more low-income children and pregnant women to obtain the
health care that they need. Being eligible for Medicaid does not necessarily
guarantee access to care, however, especially in areas where providers
are in short supply. Hence, federal programs that provide direct support
for maternal and child health services and primary care for low-income
populations are also important. Some policy researchers believe, moreover,
that the scope of strategies to reduce infant mortality should be broadened
from a relatively narrow focus on pregnancy care to the more general issue
of how to improve the health status of poor women and their families.
INTRODUCTION
Because of the high quality and widespread availability of neonatal intensive care in the United States, a low-birthweight baby born in this country probably has a better chance of surviving than anywhere else in the world. Nonetheless, during the 1986-1988 period, more than 10 of every 1,000 infants born in the United States died before they were a year old. This infant mortality rate was higher than those of many developed nations--including countries with significantly lower gross national products per capita, such as Ireland and Spain. A society's infant mortality rate is considered an important indicator of its health status, because infant mortality is associated with socioeconomic status, access to health care, and the health status of women of childbearing age. In addition, it is one of the few measures of health status for which data are widely available in most developed countries.
Other frequently used indicators of health status include:
Several of these alternative measures are not independent of the infant mortality rate, however, since infant mortality affects both life expectation at birth and years of potential life lost before age 65. Consequently, countries with high infant mortality rates tend to rank poorly on other health status indicators also.
Although the infant mortality rate is universally accepted as an indicator of health status, international comparisons are problematic. Many underdeveloped countries do not have functional vital registration systems and infant mortality rates have to be estimated indirectly or through samples. In developed countries, comparisons of infant mortality rates are complicated by differences in medical practices and reporting requirements. These problems have raised questions about the validity of ranking infant mortality rates on an international scale.
This paper explores the extent to which the poor U.S. infant mortality ranking reflects a real difference in health status or is the result of variations in the ways births and infant deaths are defined and reported. The infant mortality rate and its components are defined and infant mortality trends in the United States and other countries are described. Subsequent sections of the paper discuss the measurement of perinatal mortality (mortality that occurs around the time of birth), risk factors for infant mortality, and federal and state initiatives to reduce infant mortality rates.1
This document is available in its entirety in PDF.
1. This paper makes extensive use of data from the National Center for Health Statistics (NCHS). The primary sources of published data are Health, United States, 1990 (Hyattsville, Md.: Public Health Service, March 1991); and "Advance Report of Final Natality Statistics, 1989," Monthly Vital Statistics Report, vol. 40, no. 8 (Hyattsville, Md.: Public Health Service, December 12,1991). In addition, unpublished data from the Office of International Statistics at NCHS, collected as part of the International Collaborative Effort on Perinatal and Infant Mortality, have been used.