A separate WHO Bulletin in 2008 noted that registration of stillbirths, live births, and neonatal deaths is done differently in countries where abortion is legal compared with countries where abortion is uncommon or illegal, and these discrepancies generate substantial differences in infant-mortality rates. Jan Richardus showed that the perinatal mortality rate “can vary by 50% depending on which definition is used,” and Wilco Graafmans reported that terminology differences alone among Belgium, Denmark, Finland, France, Germany, Greece, the Netherlands, Norway, Portugal, Spain, Sweden, and the U.K. — highly developed countries with substantially different infant-mortality rates — caused rates to vary by 14 to 40 percent, and generated a false reduction in reported infant-mortality rates of up to 17 percent. These differences, coupled with the fact that the U.S. medical system is far more aggressive about resuscitating very premature infants, mean that very premature infants are even more likely to be categorized as live births in the U.S., even though they have only a small chance of surviving. Considering that, even in the U.S., roughly half of all infant mortality occurs in the first 24 hours, the single factor of omitting very early deaths in many European nations generates their falsely superior neonatal-mortality rates.
An additional major reason for the high infant-mortality rate of the United States is its high percentage of preterm births, relative to the other developed countries. Neonatal deaths are mainly associated with prematurity and low birth weight. Therefore the fact that the percentage of preterm births in the U.S. is far higher than that in all other OECD countries — 65 percent higher than in Britain, and more than double the rate in Ireland, Finland, and Greece — further undermines the validity of neonatal-mortality comparisons. Whether this high percentage arises from more aggressive in vitro fertilization, creating multiple-gestation pregnancies, from risky behaviors among pregnant women, or from other factors unrelated to the quality of medical care, the U.S. National Center for Health Statistics has concluded that “the primary reason for the United States’ higher infant mortality rate when compared with Europe is the United States’ much higher percentage of preterm births.” (M. F. MacDorman and T. J. Matthews, 2007)
Throughout the developed world, and regardless of the health-care system, infant-mortality rates are far worse among minority populations, and the U.S. has much more diversity of race and ethnicity than any other developed nation.
Whether in wholly government-run health-care systems — like Canada’s, or the U.K.’s NHS — or in the mixed U.S. system, racial and ethnic minorities have higher infant-mortality rates, roughly double those of the majority. While these disparities are among the most perplexing problems in society, they are extremely complex, identifiable even when other risk factors (including maternal age, marital status, and education) are taken into account, and often entirely separate from health-care quality. Population heterogeneity specifically distorts mortality rates in the U.S., because the racial-ethnic heterogeneity of the U.S. is far higher, four to eight times that found in Western European nations like Sweden, Norway, France and the UK.
The fact is that for decades, the U.S. has shown superior infant-mortality rates using official National Center for Health Statistics and European Perinatal Health Report data — in fact, the best in the world outside of Sweden and Norway, even without correcting for any of the population and risk-factor differences deleterious to the U.S. — for premature and low-birth-weight babies, the newborns who actually need medical care and who are at highest risk of dying.
In summary, the analysis and subsequent comparison of neonatal- and infant-mortality rates have been filled with inconsistencies and pitfalls, problematic definitions, and inaccuracies. Even the use of the most fundamental term, “live births,” greatly distorts infant-mortality rates, because often the infants who die the soonest after birth are not counted as live births outside the United States. In the end, these comparisons reflect deviations in fundamental terminology, reporting accuracy, data sources, populations, and cultural-medical practices — all of which specifically disadvantage the U.S. in international rankings. And unbeknownst to organizations bent on painting a picture of inferior health care in the U.S., the peer-reviewed literature and even the WHO’s own statements agree.
— Scott W. Atlas, M.D., is a senior fellow at the Hoover Institution and a professor at Stanford University Medical Center. He is the author of the forthcoming book In Excellent Health: Setting the Record Straight on America’s Health Care (Hoover Press).