Neighbors a World Apart Nfant Mor- Reflection of National Health
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34 O B .GYN. NEWS • April 1, 2005 M ASTER C LASS Neighbors a World Apart nfant mor- reflection of national health. we may do well to learn from other coun- the University ofOttawa. He has studied tality is one Leaders in the medical community and tries’ successes. The Scandinavian coun- infant mortality as an international issue, Iofthe government have long recognized that tries, which boast very low infant mortal- publishing on such topics as population- dominant the United States has unacceptably high in- ity, have homogeneous populations that based approaches to prevention of measures by fant mortality in comparison with other are difficult to compare with our own. But preterm birth, an important contributor to which a na- nations. I served, in fact, on the Depart- right next door is Canada, a country with infant mortality. BY E. ALBERT REECE, tion’s health is ment ofHealth and Human Services’ Sec-an increasingly diverse population that We hope his thoughts will provide fresh M.D., PH.D, M.B.A. judged. Many retary’s Committee on Infant Mortality may serve as a more analogous example of insight into a very important health mea- factors con- under President George H.W. Bush, as how programs can work to reduce infant sure that we continue to try to improve.■ tribute to the number ofbabies who sur-part ofa major effort to reduce by halfour mortality. vive in a given country, making infant infant mortality. We still have not suc- For a commentary on this important is- DR. REECE, who specializes in maternal- mortality a rather unrefined gauge of ceeded, despite concerted efforts. sue, we turn to C. Robin Walker, M.D., fetal medicine, is the vice chancellor and overall health. Yet it has been accepted Because this is a complex issue that will Ch.B., president ofthe Canadian Paedi-dean of the college of medicine at the worldwide as a generally fair and realistic be solved only by using multiple strategies, atric Society and professor of pediatrics at University of Arkansas in Little Rock. Infant Mortality in the U.S. and Canada nfant mortality is a complex issue, in- ing to two basic contributors: neonatal We understand that older women have hardly ever see quads, although triplets are fluenced by social, statistical, political, deaths occurring within the first month of a higher risk ofhaving a preterm baby, stillin not a rarity. Iand geographic factors as well as med- life, and postneonatal deaths occurring part because they have a higher risk of All over Canada, rates ofmultiple birth ical ones. Looking at a chart ofinterna-later in the first year. having multiples, having pregnancy com- are lower than in the United States, con- tional infant mortality, one can see that the Postneonatal deaths have not increased; plications, and having babies with con- tributing to lower rates ofpreterm birth. United States, as well as my native Cana- in fact, tremendous advances in the under- genital anomalies, three factors that con- However, in looking at overall preterm da, are light-years better off than politically standing and prevention ofsudden infant tribute to infant mortality. birth statistics, it is worth noting that unstable regions such as Angola, which death syndrome have substantially reduced Older mothers also are more likely to re- both nations have unequal rates across leads the world at more than 191 infant postneonatal deaths over the past decade. quire assisted reproductive technology populations. deaths per 1,000 live births, or Afghanistan The neonatal increases noted in 2002— (ART). The U.S. National Center for Health Sta- (163 per 1,000), by estimates ofthe Cen-and indeed the disparity between the Although ART procedures are similar in tistics reports that African American infants tral Intelligence Agency’s United States and Canada— the United States and Canada, and are ba- are nearly twice as likely as non-Hispanic “World Factbook 2004.” have occurred in the early sically patient-funded in both countries, white infants to be born prematurely. However, we’re far from weeks oflife, when the most reproductive technology is increasingly In Canada, the disparity is most clear being the best in the world. common causes ofdeath in- subject to oversight in Canada. A bill that when looking at income, with those in Forty nations surpass the clude congenital anomalies, recently passed both the House ofCom-the lowest income quintile having an in- United States in infant mor- problems oftransition, and mons and the Senate would strictly regu- fant mortality rate two-thirds higher than tality, including Singapore complications ofpreterm late clinics and procedures, for example. that ofthe highest income quintile. As in- (2.29 per 1,000), Sweden birth. Among these factors, A great many ART centers in Canada fant mortality secondary to congenital (2.77 per 1,000), and Japan only preterm birth stands are university-affiliated, not-for-profit pro- anomalies and other causes has fallen (3.26 per 1,000). out as a significant contribu- grams, rather than independent clinics. As significantly, the differential is largely a re- Because we are neighbors tor to rising infant mortality. a result, a controversial issue—such as the sult ofa higher rate ofpreterm birth in and share a border, similar In the United States, implantation ofmultiple embryos—is de- lower-income families. economies, and comparable BY C. ROBIN preterm births increased to bated within the wide academic commu- Canada’s First Nation and Inuit people levels oftechnologic sophis- WALKER, M.D. 12.1%, from 11.9% the pre- nity ofendocrinologists, ob.gyns., neona- face serious health problems, including in- tication, it may be ofinter- vious year. tologists, pediatricians, and ethicists. fant mortality in many communities that is est that Canada’s infant mortality is fully But here is a telling statistic: Although When three sets ofquadruplets weretwice the national rate, as do America’s Na- 30% lower than that ofthe United States,the preterm birth rate also rose slightly in born in 1 year at the University ofOttawa,tive American populations. Although Cana- which was optimistically estimated by the Canada, it was 7.6% in 2002, nearly 40% the university-affiliated fertility center da is an increasingly racially diverse coun- CIA to be 6.5 per 1,000 in 2004. lower than in the United States. demonstrated its responsibility by revising try, other racial disparities are less obvious In both ofour nations, 2002 infant mor- Why is the preterm birth rate trending its policies to limit the number ofembryosin measures ofhealth care, such as prena- tality worsened slightly, prompting re- upward? The evidence is fairly clear that transferred during each cycle. Now, we Continued on following page newed scrutiny ofan ever-important issue. it is driven by the use ofreproductive tech- The Centers for Disease Control and nology leading to multiple births, by Prevention reported that in 2002, U.S. in- mothers having babies at later ages, by ob- Sources fant mortality edged upward to 7.0 per stetricians intervening to deliver babies 1,000 live births from 6.8 per 1,000 in 2001. earlier when the fetus is in jeopardy, and Ǡ The National Center for Health Canada has published the 2003 Canadi- That’s the first rise in 44 years, and even by complications attributed to a lack of Statistics publishes regular reports on an Perinatal Health Report online at if—as preliminary reports suggest—it was early, consistent prenatal care. infant mortality. The final data for www.phac-aspc.gc.ca/publicat/ a one-time blip, it’s concerning to see even Not all ofthese factors are things we2002 can be found in Natl. Vital Stat. cphr-rspc03. a 0.02% increase in the context ofmorecan, or would want to, control. Rep. 2003;52:1-113. The center’s latest Ǡ The United Nations Children’s Fund than 4 million births. Early delivery to attempt to save an in- annual report on trends in health sta- (UNICEF) uses data collected in annu- The same trend occurred in Canada, fant in trouble is a good thing. Some of tistics is “Health, United States, al report cards from its Innocenti Re- where infant mortality rose from 5.2 per these preemies will not live, but would 2004,” which includes a chartbook on search Centre. The first report card 1,000 in 2001 to 5.4 per 1,000 in 2002 after have been stillborn in years past. trends in the health ofAmericans as was published in June 2000, and— progressively falling since the 1960s. Social trends influence the ages at which well as interactive links (www.cdc. along with more recent report cards— I’d like to suggest a number offactorswomen decide to have their children. In gov/nchs/hus.htm). can be accessed at www.unicef-icdc. that may help to explain this troubling Ottawa, where I practice, over 60% of Ǡ The Central Intelligence Agency pub- org/publications. Click on the link trend, which at the very least indicates we moms in 2003 gave birth when they were lishes the World Factbook each year in “For a briefdescription ofour series,” are not making the progress we would like older than 30 years, and 23.2% when they printed and Internet versions. Data not- and then click on “Innocenti Report to make in addressing one ofthe most im-were older than 35 years. Although ed in this Master Class can be found on- Cards.” portant measures ofa nation’s health. women have a right to be informed about line at www.cia.gov/cia/publications/ Ǡ Simon Hales, M.B., and colleagues I’ll also put forth some suggested ex- their chances ofconceiving and delivering factbook/rankorder/2091rank.html.