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7/30/2019 Baby Gap
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Baby GapThe surprising truth about America's infant-mortality rate.By Darshak SanghaviPosted Friday, March 16, 2007, at 7:10 AM ET
Last year, a widely distributedreport from the group Save the Children, funded by the Bill and Melinda Gates
Foundation, tied the United States with Malta and Slovakia for the second-worst infant-mortality rate among
developed nations (at about six per 1,000 live births). "I'm always amazed to see where the United States is," a
Rand researcher said of the list. "We are the wealthiest country in the world," a Save the Children spokesperson
agreed, yet many "are not getting the health care they need."
Comparing infant mortality rates between countries is fraught with uncertaintyafter all, it's hard to argue that
every country's figures are reliable. But it's still worth asking what more we can do to stop babies from dying.
Defined as death before one year of age, infant mortality frequently gets framed in the United States as a
problem of insufficient health-care funding. In December, for example, aNew York Times columnblamed it on
the lack of a single-payer health insurer. However, a closer look reveals the counterintuitive possibility that high
infant mortality in the United States might be the unintended side effect of increasedspending on medical care.
Infant deaths in poor nations are roughly six times more common than in developed areas and result mainly
from easily treated infections like diarrhea in the first few months. By contrast, the majority of deaths in
developed countries result from extreme prematurity or birth defects that kill a newborn in the first few days or
weeks of life. According to a 2002 analysis by the Centers for Disease Control and Prevention, at least a third of
all infant mortality in the United States arises from complications of prematurity; other studies assert the figure
is closer to half. Thusat the risk of oversimplifyinginfant mortality in the United States principally is a
problem of premature birth, which today complicates just over one in 10 pregnancies.
To reduce infant mortality, then, we need to prevent premature births, and if that fails, improve care of
premature babies once born. (Prematurity is also linked to other problems; for example, it's the leading cause of
mental retardation and cerebral palsy in children.) But modern medicine isn't good at preventing prematurity
just the opposite. Better and more affordable medical care actually has worsened the rate of prematurity, and
likely the rate of infant mortality, by making fertility treatment widespread. According to a2006 Institute of
Medicine report, the numbers of women using assistive reproductive technology doubled from 1996 to 2002. At
least half of their pregnancies culminated in multiple births (twins or more), which are at high risk of premature
delivery.
Meanwhile, no amount of money or resources seems to reduce the rate of preterm births. Take prevention: Of
numerous strategies, an inexhaustive list includes enhanced prenatal care, improved maternal nutrition,
treatment of vaginal infections, better maternal dental care, monitors to detect early labor, bed rest, better
hydration, and programs for smoking cessation. But, as well described inan erudite 1998 reviewin theNew
England Journal of Medicine by researchers at the University of Alabama, none of these strategies has had a
substantial impact on the risk of preterm birth in clinical trials. (Of course, some of them, like better prenatal
http://www.slate.com/authors.darshak_sanghavi.htmlhttp://www.slate.com/authors.darshak_sanghavi.htmlhttp://www.savethechildren.org/campaigns/state-of-the-worlds-mothers-report/2006/http://www.savethechildren.org/campaigns/state-of-the-worlds-mothers-report/2006/http://www.savethechildren.org/campaigns/state-of-the-worlds-mothers-report/2006/http://select.nytimes.com/gst/abstract.html?res=FA0F17FE3D540C728FDDAB0994DE404482http://select.nytimes.com/gst/abstract.html?res=FA0F17FE3D540C728FDDAB0994DE404482http://select.nytimes.com/gst/abstract.html?res=FA0F17FE3D540C728FDDAB0994DE404482http://select.nytimes.com/gst/abstract.html?res=FA0F17FE3D540C728FDDAB0994DE404482http://www.iom.edu/CMS/3740/25471/35813.aspxhttp://www.iom.edu/CMS/3740/25471/35813.aspxhttp://www.iom.edu/CMS/3740/25471/35813.aspxhttp://www.iom.edu/CMS/3740/25471/35813.aspxhttp://content.nejm.org/cgi/content/extract/339/5/313http://content.nejm.org/cgi/content/extract/339/5/313http://content.nejm.org/cgi/content/extract/339/5/313http://content.nejm.org/cgi/content/extract/339/5/313http://www.iom.edu/CMS/3740/25471/35813.aspxhttp://www.iom.edu/CMS/3740/25471/35813.aspxhttp://www.iom.edu/CMS/3740/25471/35813.aspxhttp://select.nytimes.com/gst/abstract.html?res=FA0F17FE3D540C728FDDAB0994DE404482http://www.savethechildren.org/campaigns/state-of-the-worlds-mothers-report/2006/http://www.slate.com/authors.darshak_sanghavi.html7/30/2019 Baby Gap
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care, may be good for other reasons.) Despite a doubling of health-care spending as a portion of the gross
domestic product since 1981, the rate of preterm birth has jumped 30 percent.
If preventing early birth is impossible, can we improve treatment of preemies? One promising way to reduce
death after premature birth is a dirt-cheap steroid shot for mothers in preterm labor.Endorsed for over a
decadeby the National Institutes of Health and the American College of Obstetrics and Gynecology, the shot is
one of the only maneuvers proven to help preemies before they are born. The injection jump-starts the fetus'slungs, so the baby is better prepared to breathe when born. Unfortunately, because of substandard practice, at
some hospitals only about half of eligible women get the shot.
That leaves lots of sick preemies for the neonatologist. Most preemies depend on advanced neonatal care for
survival. And there have been advances, particularly the discovery of surfactant to treat immature lungs.
However, just as better funding for infertility treatment worsened premature-birth rates, more money quite
possibly may harm the quality of neonatal intensive care.
How can that be? Today, neonatal intensive care is extremely lucrative, on average costing tens of thousands of
dollars per preterm child. Neonatologists are among the highest paid pediatric subspecialists, and neonatal
intensive-care units (NICUs, for short) are hospital cash cowswhich is why the units are proliferating wildly
nationwide. Yet ina startling 2002New England Journal of Medicine study, David Goodman and his
colleagues showed that the regional supply of neonatologists and NICUs bore no relation to actual need,
implying that some doctors and hospitals set up shop simply because there was money to be made. More
disturbingly, areas with more beds and doctors don't have lower infant-mortality rates. The authors ominously
suggest that "infants might be harmed by the availability of higher levels of resources." They argue that the
availability of a NICU may mean that infants with less-serious illnesses may be admitted to one and then
"subjected to more intensive diagnostic and therapeutic measures, with the attendant risks."
Too many NICUs are also bad for babies because hospitals that handle a high volume of sick preemies have
better outcomes. A1996 study in theJournal of the American Medical Associationconfirmed this, concluding
that concentrating high-risk deliveries in a smaller number of hospitals could reduce infant-death rates without
increasing costs, and other studies have since concurred. (Increasing evidence suggests that experienced, high-
volume centers may also save more full-term newborns with major birth defects, like congenital heart
problems.)
Throwing money at unproven programs for preventing prematurity, or at cash-cow NICUs, won't improve
America's infant-morality rate. Instead, it's critical to follow the datawhich suggest that we need fewer, not
more, hospitals to take care of the sickest babies. One reasonable suggestion is to cut funding for neonatal
intensive care, since the money now is too good to encourage economies of scale (i.e., a few hospitals with
high-volume NICUs). Another strategy, endorsed by patient-safety organizations like the Leapfrog Group, is for
insurers to steer patients only to high-volume centers. Less money and less patient choice sound hereticalbut,
in this case, eminently sensible.
http://consensus.nih.gov/1994/1994AntenatalSteroidPerinatal095html.htmhttp://consensus.nih.gov/1994/1994AntenatalSteroidPerinatal095html.htmhttp://consensus.nih.gov/1994/1994AntenatalSteroidPerinatal095html.htmhttp://consensus.nih.gov/1994/1994AntenatalSteroidPerinatal095html.htmhttp://content.nejm.org/cgi/content/abstract/346/20/1538http://content.nejm.org/cgi/content/abstract/346/20/1538http://content.nejm.org/cgi/content/abstract/346/20/1538http://content.nejm.org/cgi/content/abstract/346/20/1538http://content.nejm.org/cgi/content/abstract/346/20/1538http://jama.ama-assn.org/cgi/content/abstract/276/13/1054http://jama.ama-assn.org/cgi/content/abstract/276/13/1054http://jama.ama-assn.org/cgi/content/abstract/276/13/1054http://jama.ama-assn.org/cgi/content/abstract/276/13/1054http://jama.ama-assn.org/cgi/content/abstract/276/13/1054http://content.nejm.org/cgi/content/abstract/346/20/1538http://consensus.nih.gov/1994/1994AntenatalSteroidPerinatal095html.htmhttp://consensus.nih.gov/1994/1994AntenatalSteroidPerinatal095html.htmhttp://consensus.nih.gov/1994/1994AntenatalSteroidPerinatal095html.htm