TCS Daily

The Perils of Abundance?

By Sydney Smith - February 23, 2004 12:00 AM

The infant mortality rate has long been considered a measure of the state of a state's well-being. It is, it has been assumed, directly related to poverty, poor nutrition, and lack of healthcare. And at first glance this appears to be the case. Countries with the worst infant mortality rates are the war torn and impoverished, while those with the lowest are highly developed and politically stable.

No wonder then, that critics of the United States often point to our infant mortality rate -- 7 per 1,000 live born infants according to the latest figures -- as a disgrace. We consistently rank behind most Western European countries, Canada, Japan, and Hong Kong. And just above or below Cuba, depending on the year.

Now, how can this be? Intuitively, it makes no sense. Our healthcare system has its problems, certainly, but we haven't had the food shortages and medicine shortages that Cuba has had. At least not in recent memory. And is the state of our state really that much worse than England, Ireland, and Sweden? Part of the problem is that we're comparing very small numbers, at least among developed nations. The difference between 0.5% and 0.7% or 0.3% spread out over a large population is a very small difference, which means that the figures can be easily influenced by any number of factors from year to year. Or from country to country.

Take for example, the most recent numbers for the United States. When they were released last week, public health officials expressed surprise that our infant mortality rate had increased for the first time in four decades -- from a low of 0.68% to 0.7%. But the increase wasn't a measure of the failure of our healthcare system. It was rather a measure of its success.

More mothers than at any other time in the past four decades were over the age of thirty-five, thanks to advances in infertility treatment. In addition, the number of twins, triplets, and other multiple births have increased over 400% in the past twenty years, also thanks to advances in infertility treatment. Older mothers are at substantially higher risk for having babies with chromosomal and other congenital abnormalities, the number one cause of infant mortality in this country. And multiple births are at significantly increased risk of low birth weight and prematurity, the number two cause.

It isn't too much of a stretch to think that those demographics are also at work when comparing our infant mortality to that of other countries. Those bastions of socialized medicine -- Great Britain, Sweden, France, consistently outrank us in infant mortality rates. But is it because their healthcare system is superior to ours, or is it because they restrict access to reproductive technology?

In Britain, NHS funding for infertility treatment varies from region to region, but is often not covered at all, especially the expensive and risky in vitro fertilization techniques. (Although that may soon change.) And when it is covered, they limit the number of eggs or embryos that can be implanted. But in the United Stated, there are no limits. Physicians can implant as many embryos as they want in the hopes of improving the chance of success. It's no coincidence then that we have one of the highest rates of multiple births in the world. And with it, a higher infant mortality rate among developed nations.

That's not to say that our approach to conceiving and delivering babies is wrong. We are fortunate to live in a nation where technology can make dreams come true. But perhaps we should reconsider the significance of infant mortality as a measure of a nation's success, at least among nations with extremely low rates. A slightly higher rate may not represent a dearth of care, but rather an abundance of care.

Sydney Smith is a family physician who has been in private practice since 1991. She is board certified by the American Board of Family Practice, and is a Fellow of the American Academy of Family Practice. She is the publisher of MedPundit. She recently wrote for TCS about John Edwards and the healthcare system.


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