Why is the infant mortality rate in the United States so high?

While infant mortality rates around the world have dramatically decreased over the past decades, data shows the U.S. isn’t keeping pace, particularly with other highly-developed nations around the world.

The U.S infant mortality rate in 1960 was 25.9 deaths per 1,000 live births, the 12th lowest in the world, according to the United Nations Interagency Group for Child Mortality Estimation, which compiles data for the World Health Organization and UNICEF.

By 1980, the U.S. rate had dropped to 15.9 deaths per 1,000 live births, but that was only 18th lowest in the world. And in 1990, the U.S. rate was 9.4 per 1,000 live births, still dropping, but now the 26th lowest in the world.

That means that most developed countries in the world are surpassing the U.S. in lowering the infant death rate more quickly than our own.

The infant mortality rate in most developed countries in 2017 — such as Japan, Iceland, Sweden, Austria, South Korea, Italy, France, Sweden, among several others — tended to hover at around 2 to 3.5 deaths per 1,000 live births, or approximately two to three times less than the U.S. rate.

In 2017, 54 countries had a lower infant mortality rate than the U.S., according to the Central Intelligence Agency’s World Factbook, which compiles a wide range of data on countries around the world for use by U.S. government officials. The U.S. rate in 2017 was 5.8, which was tied with Serbia, just a hair higher than Bosnia and Herzegovina, which had a rate of 5.5, and slightly lower than Qatar, which had a rate of 6.2.

Japan had the lowest rate of any country — 2 deaths per 1,000 live births. The infant mortality rate in Hong Kong, which is often listed as a separate country than mainland China, was 2.7, or roughly half the U.S. rate. Cuba, the Communist island nation just south of Florida, had a rate of 4.4.

The infant mortality rate in the U.S., however, is far from uniform. Data from the federal Centers for Disease Control show a wide disparity among all 50 states and the District of Columbia in 2017, ranging from 8.6 deaths per 1,000 live births in Mississippi to 3.7 deaths per 1,000 live births in Massachusetts.

Indiana, for its part, had an infant mortality rate in 2017 of 7.3 deaths per 1,000 live births — the seventh highest rate in the country. Only Mississippi, Arkansas, Oklahoma, South Dakota, Alabama and Tennessee had higher rates. The rate in Indiana was 9.5 in 1990 and 7.5 in 2000.

If the Hoosier state was a country, it would have had the 64th lowest infant mortality rate in the world in 2017 — sandwiched between Kuwait and Lebanon on the list.

Rates in Indiana

Additionally, state data shows a large disparity between regions of the state.

The Central Southwest Hospital Region — Clay, Greene, Owen, Parke, Putnam, Sullivan, Vermillion and Vigo Counties — saw its infant mortality rate nearly double from 5.4 to 9.5 from 2013 to 2017, according to the Indiana State Department of Health. The Midwestern Region — Cass, Fulton, Jasper, Miami, Newton, Pulaski, Starke and White counties — also saw its rate dramatically rise from 5.3 in 2013 to 8.8 in 2017.

The Southern Region, which covers Bartholomew, Clark, Crawford, Floyd, Harrison, Jackson, Jefferson, Jennings, Orange, Scott, Switzerland and Washington Counties, had a rate of 5.9 in 2017, the lowest out of all regions in the state. The rate in the Southern region also was 5.9 in 2013.

There are also racial disparities. In Indiana, African-American women are 42 percent more likely to have a preterm birth than all other women, according to the March of Dimes. African-American infants in Indiana are 2.6 times more likely to die than white infants, according to the Indiana State Department of Health.

While not all causes of infant death are preventable — the United States as a whole, and particularly Indiana, tends to fare poorly in many measures of public health and social determinants considered risk factors for infant mortality.

“A healthier mom leads to a healthier pregnancy and a healthier baby,” said Dr. Tracey Wilkinson, assistant professor at the Indiana University School of Medicine, licensed pediatrician and board member at Physicians for Reproductive Health.

Indiana ranked 41st out of 50 states in United Health Foundation’s 2018 America’s Health Rankings, including 44th in smoking, 39th in obesity, 40th in diabetes, 26th in low birth weight and 29th in child poverty.

Additionally, Indiana ranked 27th in uninsured residents and 48th in public health funding, spending approximately $51 per capita in combined state and federal funding in 2017 and 2018. Alaska spent the most of any state, $281 per capita. The U.S. average was $86. The March of Dimes estimates that preterm births cost Indiana $417 million each year in medical costs, lost wages and lost productivity.

“When you don’t invest in public health, your outcomes are not going to be good,” Wilkinson said.

In 2017, 47.3 percent of infant deaths in Indiana were attributed to perinatal risks (from 22 weeks of gestation until one year after birth), 18.1 percent to congenital malformations (birth defects), and 16.6 percent to SUIDs, or the sudden unexpected infant death, according to the Indiana State Department of Health.

Perinatal risks typically are “health conditions caused by being born too early and too sick,” said Jeena Siela, director of maternal child health and government affairs for March of Dimes in Indiana.

“If we could address preterm birth, we could significantly reduce infant mortality,” Siela said.

Risk factors

Some of the factors that directly related to prematurity and low birth weight that are preventable include smoking and appropriately spaced pregnancies, which refers to how soon the mother should wait after one pregnancy before getting pregnant again, said Wilkinson, who typically advises mothers to wait 18 to 24 months between pregnancies. Obesity is another factor that directly relates to preterm birth and low birth weight, she said.

“The strongest predictor for a healthy pregnancy is a planned pregnancy, and Indiana has one of the highest rates of unplanned pregnancies,” Wilkinson said. About half of pregnancies in the United States are unplanned, according to the Centers for Disease Control.

The smoking rate in Indiana also is relatively high among pregnant women. Around 13.5 percent of women in Indiana smoke during their pregnancy, according to the Indiana State Department of Health. The national rate is 12.6 percent. In 2018, 18 percent, or nearly one in five, of women who gave birth at Columbus Regional Hospital reported smoking during their pregnancy, according to Kylene Jones, tobacco awareness coordinator at Healthy Communities and CRH.

Approximately one in three Hoosiers, or 33.6 percent, were obese in 2017, according to the State Health Access Data Assistance Center, a multidisciplinary health policy research center affiliated with the University of Minnesota. Obesity is defined as having a body mass index greater than 30. In 1990, Indiana’s obesity rate was 13.3 percent, according to the State of Obesity, an annual report by Washington, D.C.-based non-profit Trust for America’s Health and the Robert Wood Johnson Foundation, a public health philanthropy based in New Jersey.

In 2014, the state of Indiana released a report that looked at potential ways to reduce infant mortality in the state to reach its goal of a statewide infant mortality rate of 4.5 deaths per 1,000 live births.

The report found that “infant mortality risk in the state of Indiana is not randomly distributed, but exhibits statistically significant patterns that could be used for targeted investment of resources to improve outcomes.” Not getting adequate prenatal care, young age of the mother and being enrolled in Medicaid were among the biggest predictors of “adverse birth outcomes,” according to the report.

“What stands a lot in Indiana is a lot of access-to-care issues,” Siela said. “We have about 35 counties in Indiana that we consider to be a maternal care desert. What that means is that women in those counties, particularly in rural counties, have to travel across counties lines or multiple county lines to find a birthing hospital or an obstetrician.”

Another significant cause of infant death is suffocation and unsafe sleep deaths, which Siela said “are 100 percent preventable.” Medical providers advise that babies should sleep on their backs, parents or caregivers should avoid using soft bedding and placing items like blankets, pillows and other soft objects in the baby’s crib and not sharing a bed with the baby.

The Centers for Disease Control estimates that there are around 3,500 sleep-related infant deaths each year in the United States. Approximately one in five mothers reported placing their baby on his or her side or stomach before sleeping between 2009 and 2015, and three out of five reported sharing a bed with their baby.

Infant mortality is “a tough thing to fix,” Siela said. “You’re talking about system changes, insurance changes. At the end of the day, this is a societal issue. Infant mortality is a huge lens into the health of a nation.”