The Public Health Enigma of U.S. Infant Mortality

When 23-year-old Elaine Beaty left the hospital last week with her newborn daughter, Samantha, it was--for her and her husband, John--a milestone surely characterized by hope and joy, but fear, paranoia and heartbreak, too.

These latter emotions are the aftereffect of a memory--too fresh for the pain to have faded--of a Saturday morning last May when the Beatys awoke in their San Pedro home and looked at the clock. Panic-stricken when they saw it was 7 a.m., they hurried to the crib of their then 7-week-old son, John, and found him dead.

“He had awakened at 3 a.m. and we fed and diapered him and put him back to bed,” Elaine recalled one day recently at her sister’s house in Torrance. “He usually woke up at 6 in the morning. He was our alarm clock. But that Saturday morning, he never woke up. I knew something was wrong as soon as I looked at the clock. He was blue. He was already gone.

The boy, the coroner’s office later ruled, had died of Sudden Infant Death Syndrome, a longstanding clinical mystery. But SIDS isn’t why the child’s death is a telling social commentary.

It is an individual tragedy--a parting with which Elaine Beaty is not yet at peace and whose memory still provokes fear in her because, she said, of “the guilt, the: ‘Did I do it?’ I was still feeling like it was my fault or something when I found out I was pregnant (again, with Samantha). I guess that was the best thing for me to do or else I would have had a nervous breakdown.”

Eventually, Elaine said, the coroner’s office wrote her a sensitive letter emphasizing that SIDS generally cannot be anticipated and she should not heap guilt on herself because her little boy was dead.

But to observers concerned with such things, John’s death was only one example of a frustrating national problem--the U.S. infant mortality rate is far higher than in many countries that are less advanced. And in California and perhaps the nation at large, even modest progress of the last few years in controlling infant mortality shows growing signs of being reversed.

Significant Concerns

A definite trend is not yet clear, but a variety of observers agree the stagnation in infant mortality has raised significant concerns that the U.S. may be seeing the start a reversal of modest gains in the field achieved in the last 22 years.

Moreover, the infant mortality quagmire in the United States has political implications as well as medical ones. Among the perplexing elements is the fact that black American babies die at a rate double that of whites. And a range of experts from Dr. Myron Wegman, of the University of Michigan School of Public Health in Ann Arbor to Sen. Lawton Chiles (D-Fla.) contend that the national public health system subordinates proven prevention techniques that could avert many of the fatalities of all races.

In Los Angeles County last year, scenes like the death of Elaine Beaty’s little boy--babies dying at a year old or less--were played, according to provisional statistics just assembled by the Department of Health Services, a total of 1,402 times.

Some critics believe stagnation of the infant mortality rate may be one of the first tangible results of Reagan Administration cuts in the Medicaid, Medicare and food assistance programs, although none of those was a factor in the case of Elaine Beaty’s baby.

In a statement released Thursday, the U.S. Department of Health and Human Services said it “does not believe that Administration policies in this area are having any negative effect.” In fact, a spokesman said the agency is not yet convinced the infant mortality rate has stagnated or may be about to increase--rather, the department believes the situation is only one in which “the infant mortality rate continues to decline, although at a slower rate than at some times in the past.”

The department said Secretary Otis Bowen believes the slowdown may be due to such factors as the teen-age pregnancy rate with young mothers giving birth to underweight babies, childbirth among drug abusers and even the increasing incidence of babies born to AIDS-infected mothers. “There are a number of factors besides money that affect the performance of these statistics,” the agency statement said.

Prevention Programs

Some other experts--particularly those in government who do not hold politically appointed health posts--say that technology has lowered the American infant mortality rate about as far as it can at this time and the focus should turn to prevention programs.

Many experts say that preventing low birth weight--5.5 pounds or less--would significantly cut the rate of complications after birth. Increasing birth weights requires little in the way of sophisticated technology. Instead, said Wegman and Dr. Robert Prentice, who organized an American Academy of Pediatrics strategy to deal with the problem, preventing low birth weight can be achieved by improving nutrition among pregnant women and providing counseling programs to cut smoking and drinking during pregnancy and to promote regular exercise and other forms of healthful behavior. Low birth weights are far more closely associated with teen-age mothers than with women over 20.

Sara Rosenbaum, of the Washington-based Children’s Defense Fund, said her calculations show an effective nutrition and health education program, with welfare aid to purchase correct foods and a complete program of health care--including prenatal care and the costs of normal delivery--would cost about $2,500 per baby.

Enormous Disadvantage

Blacks are at an enormous disadvantage in low birth weight, according to both government and private researchers, with black women--especially those 19 and under--recording low weights in 12.4% of their pregnancies, as opposed to 5.6% of white births. But while the association between being black and being poor is generally seen as critical to an understanding of high rates of infant mortality among blacks, other researchers say that while poverty is an important aspect of the problem, genetic and other factors may be crucial. Blacks are unique even among the poor in their low birth weight rates.

In fact, a 1986 study of pregnancy outcomes among California women found that while black women recorded the predictable higher rates of low birth weight, Mexican-born women, who are generally poor, and wealthier Anglos had nearly identical birth weight and infant mortality rates. The study, by researchers in California and at the federal government’s Centers for Disease Control in Atlanta, was unable to determine why Latinas born in Mexico fare so well compared to black mothers. The situation “is a contemporary public health enigma,” the researchers concluded.

In a telephone interview, Dr. Nancy Binkin of the Centers for Disease Control said no progress has been made in solving the riddle of the disparity between poor black and Latina mothers and infant mortality rates. “It may be that Latinas smoke less or that they have fewer of the risk factors that predispose them to having premature births,” Binkin said in a telephone interview.

Dr. Quentin Young, head of the Chicago-based Health and Medicine Policy Research Group, noted that while both black and white mortality rates have dropped in the last 30 years, the race disparity has remained. He said he also wonders whether the American technique of relying on high-technology treatment centers to save badly underweight or sick babies after they are born instead of preventing many such births has reached the limits of its usefulness.

‘A Hundred Dilemmas’

Observed Young: “The issue is now, ‘How small a baby can you keep alive?’ ” A cynic would say (in view of developmental problems that leave many extremely premature babies handicapped for life), ‘How small a baby do you want to (have to) keep alive?’ Our technology has gotten us into a hundred dilemmas. This is one.”

Wegman has for many years conducted an annual statistical analysis of infant mortality trends for the academy of pediatrics. Chiles last year successfully pushed through a rider to a budget bill that created a National Commission on Infant Mortality. The commission, when all of its 15 members are named in a few weeks, will conduct a yearlong review intended to produce a national action plan for reducing infant deaths so the United States can approach such countries as Japan (6 deaths per 1,000 live births) and East Germany (10) and even Singapore (8.8) and Hong Kong (8.8) as compared to 10.7 for the United States.

National Objective

Surgeon Gen. C. Everett Koop has set a national objective of cutting the rate to nine deaths by 1990, but there has been no indication the Administration is prepared to channel additional money into prevention programs. In fact, the Administration actively opposed the Chiles bill to create the strategy-producing commission, saying no additional programs were necessary.

“You tend to think, ‘How can we be behind Singapore and Hong Kong ?’ We are not behind in such areas as technology and medical care techniques,” said Chiles in a telephone interview. “We are behind in the information (disseminated to the public on issues like nutrition and prenatal care for pregnant women) and the fact that we have a high rate of pregnancies in teen-agers.”

In fact, the U.S. has the highest teen-age pregnancy rate of any the 25 nations figured in annual international summaries of infant mortality. In 1984, the U.S. recorded 13.7% of all births to women under 20--a rate higher than any of the 24 other geographic entities including Hong Kong, Singapore, Greece, Spain, Italy and Japan. Japan’s birth rate to women under 20 was the lowest in the world--just 1.2%--and only Communist East Germany approached the United States in this category with a rate of 13.4%.

For a crazy quilt of reasons, the U.S. infant mortality rate, which had been in a continuous decline from 1965 to 1985 (following a trend with roots as early as 1930), has stopped going down. Moreover, in some states--including California--the infant mortality rate for 1986 actually went up --albeit slightly.

By 1984, California’s infant mortality rate was 9.4 deaths per 1,000 live births. It was 58.7 in 1930, according to federal government figures, a year when the national rate was 64.6. But in 1985, for the first time in 20 years, California’s rate reversed course, rising just a tenth of a percentage point to 9.5 deaths. “That’s not what would be considered statistically significant,” said Anthony Oreglia, a state analyst, “but it’s of significant concern. You interpret this as, at best, a stagnation.”

Of major counties, Los Angeles is even with Alameda County, each of which had a 1985 infant mortality rate of 10.3, with all others trailing. San Francisco’s rate is 8.4; Sacramento, 8.9; Orange, 8.4, and San Diego, 8.8.

Moreover, there there are indications from preliminary federal government data that the national rate may have risen, too, according to the Children’s Defense Fund. Final 1986 statistics will not be available for some time, but Rosenbaum, an analyst for the private foundation, said government figures imply that, late last year, the national death rate, which ended 1985 at an estimated 10.6 deaths per 1,000 infants born, dropped a tenth of a percent early last year but then reversed course in the fall with a tenth of a point ascent. The Children’s Defense Fund recently released a new national report decrying the inability of the United States to make significant progress.

Statistical Quibbling

But such statistical quibbling, argue a wide variety of experts interviewed by The Times, is almost to trivialize a pervasive national problem whose details are at once predictable and surprising--especially for California.

Before about 1960, noted Wegman and other experts, babies often died in the first 28 days after birth because effective treatment technology to keep them alive simply did not exist. But with development of neonatal intensive care units, great progress has been made, though such deaths still account for the biggest share of the death rate--seven of the total 1984 death rate of 10.8, for instance, according to the Children’s Defense Fund. Major progress has also been made in the category from 28 days to one year of age, which accounts for 3.8 of the 10.8 death rate.

But while the United States has seen its infant mortality rate drop steadily, other countries whose rates once were much higher have achieved far greater reductions. Japan, for instance, which had an infant mortality rate of 124 of every 1,000 births in 1930, now has a rate of 6. Sweden dropped from 58.5 deaths to 6.4 and Finland dropped from 97.6 to 6.5--though a small part of the discrepancies are thought to be based on statistical inconsistencies. The huge disparity in rates between blacks and other Americans underlies much of the poor American showing.

The disparity between the United States and other countries significantly predates President Reagan’s election in 1980, but cutbacks in federal programs that benefit poor pregnant women are seen by some experts as worrisome.

“I think that with the changes in public policy and financing (that have occurred) since 1981, poor and young families have had much less in the way of benefits and eligibility for health care and social supports,” said Dr. C. Arden Miller, chairman of maternal and child health at the University of North Carolina School of Public Health. Miller was an influential member of a 1985 Institute of Medicine low birth weight task force.

Function of Economics

Miller said some observers have sought to explain deterioration in progress against infant mortality as a function of economic problems brought on by the 1981 to 1983 recession. But Miller said he recently concluded an analysis of that downturn measured against the recession of 1974 and 1975, finding that government responded to the earlier situation by increasing such programs as Medicaid and the Supplemental Food Program for Women, Infants and Children, otherwise known as “WIC.” No such assistance materialized in the most recent recession.

But program cuts in the early 1980s, Miller said, have brought deterioration in baby death rates today. “I think it (the stagnation of the infant mortality rate) is a very dramatic indication of what has happened,” he said.

A small supplement to the Medicare program passed Congress last year--the result of pressure generated by the Southern Regional Task Force on Infant Mortality in 1985. It would direct $20 million in new federal aid to nutrition and prevention programs. States must equal the federal share. The Southern Governors Assn., which sponsored the task force, also is expected to announce soon formation of a business coalition to develop private initiatives in the field.

“We’re trying to show the corporate community the investment they need to make if they’re going to look at the work force of the future as a solid one or (made up of) economically healthy consumers,” said Rae Grad, the task force project director. “We feel this is a very important business issue.”

Dr. Heinz Berendes, director of infant mortality research at the National Institute of Child Health and Human Development, asserted that infant mortality rates can reach a point below which further improvement is extremely difficult. “The maximum that can be gained from technology has been achieved,” he said in a telephone interview from Bethesda, Md. “I don’t think it’s a political issue. When you look around the world, it’s a good question (how countries like Sweden have achieved rates far lower than the U.S.). I think one possible major effect is behavior. Women at highest risk in this country are not necessarily the ones seeking prenatal care the earliest or changing to behavior that is beneficial.

“We’re trying to motivate women who are pregnant to change. I’m sort of guardedly optimistic.”

The University of Michigan’s Wegman agreed, however, that program cutbacks have combined with an over-reliance on high-tech alternatives like neonatal intensive care units to doom contemporary attempts to cut the baby death rate and bring U.S. rates in line with those of other Western countries.

Better Regional Planning

“Part of our problem has to do with the philosophy of public versus private enterprise,” Wegman said. “I don’t believe we’re going to make much progress until we do better regional planning (of health services, a program dropped by the administration). Without some control, the money is going to be invested (by private health care institutions) inevitably in high-tech programs.

“But the point is, we don’t need to have all (the ICUs) we have. We could do better planning (and perhaps even close some such facilities in urban areas where such programs are often overabundant), freeing money for nutrition and well baby care programs out in the ghetto. Why should Canada (8.1) have a lower infant mortality rate than we do? It’s the business of duplication of services and unnecessary expenditure.”

To Dr. Birt Harvey, a Palo Alto neonatologist and member of the academy of pediatrics’ board of directors, the ongoing disparity in infant mortality between the United States and other countries underscores basic differences in attitudes that pervade American society. “The issue is political,” he said in a telephone interview. “It (comes down to) the emphasis that’s placed in this country versus others on prenatal care, on assisting pregnant mothers so they are in the best shape to maintain their pregnancy to term and not deliver prematurely.”

To Harvey and other experts, the American system is an egregious example of squandered money, since a few hundred dollars worth of preventive care can avoid a bill for intensive care unit services that can total as much as $300,000 for an infant born dangerously premature and who suffers from other complications related to his or her mother’s nutrition, drug-taking or life style.

To David Stewart, head of the Missouri-based organization, National Assn. of Parents and Professionals for Safe Alternatives in Childbirth, even the American predilection for Caesarean childbirth plays a role in the frustration of continuing high infant mortality rates. He contended Caesareans are often performed when doctors aren’t certain of the length of the pregnancy--creating a premature, low-weight birth where one might not otherwise occur.

A Matter of Training

He argued that other countries with significantly lower infant mortality rates rely more on midwives and nurses to act as birth attendants--restricting the role of physicians. “Physicians don’t have the right training for prevention,” Stewart contended. “If you look at the countries that do better than we do, you have to ask, ‘What’s different?’ Every year, the same countries are on top (in terms of the lowest rates). They include Finland, Sweden, Switzerland, Norway, Denmark and the Netherlands. What’s different turns out to be the midwife.”

The Children’s Defense Fund’s Rosenbaum thinks the problem is rooted even more centrally in the American psyche--and is so deep that change may be nearly impossible. “There’s a serious attitudinal problem. People do not like to think ahead particularly here in this country. They want to be left alone and they think it’s up to everybody else to be left alone or suffer. We don’t have any history of seeing things as community responsibilities and here’s an issue (infant mortality) that’s just absolutely crying out for the national as well as a community commitment. You need a national policy.

“It’s different in Europe. There is not some sort of frontier cowboy mentality.”

INFANT MORTALITY AND BIRTHS BY NATION

Infant % Births to Mortality Women Younger Country Rate* than 20** Japan 6.0 1.2 Sweden 6.4 3.8 Finland 6.5*** 4.3 Switzerland 7.1 3.2 Denmark 7.7 4.2 France 8.0*** 4.3 (1981) Canada 8.1 7.8 (1982) Norway 8.3 6.3 Netherlands 8.4 2.7 Hong Kong 8.8 3.0 (1982) Singapore 8.8 3.2 Australia 9.2 6.9 West Germany 9.6 4.4 United Kingdom 9.6*** 8.6 East Germany 10.0 3.4 Ireland 10.1 4.4 Belgium 10.7 5.9 (1981) United States 10.7 13.7 Austria 11.5 10.4 New Zealand 11.6 9.5 Italy 11.6 6.9 (1980) Spain 12.3 6.9 (1979) Israel 12.8 5.1 Greece 14.1*** 12.2 (1982) Czechoslovakia 15.3 11.8 (1982)

* Rate is number of deaths of children one year old or younger per 1,000 births in 1984.

** Unless otherwise indicated, data is from 1983, the latest year for which

figures are available.

*** Provisional data.

1980 data.

Source: Pediatrics, published by the American Academy of Pediatrics.