Monday, September 29, 2014

On US Infant Mortality

Why is the US infant mortality rate so high?  The international rankings place US somewhere in the vicinity of Croatia, despite the US being about three times as wealthy.  A new study by Alice Chen, Emily Oster and Heidi Williams uses microdata to compare the US with Finland (picked for having very low infant mortality rates) and Austria (picked for both representing the average in Europe and for data comparability). 

The study suggests a greater role for post-neonatal mortality (deaths in months one to  twelve) than earlier studies which focused more on neonatal mortality rates.  It  concludes that the post-neonatal disadvantage of the US is driven:
almost exclusively by excess inequality in the US: infants born to white, college-educated, married US mothers have similar mortality to advantaged women in Europe. Our results suggest that high mortality in less advantaged groups in the postneonatal period is an important contributor to the US infant mortality disadvantage.
In other words, the fates of infants born to less advantaged women in Austria and Finland are better, on average, than the fates of infants born to similarly less advantaged women in the US. 

Why that is the case isn't completely clear from the study.  For example, identifying the causes of death after the neonatal period is helpful, but not completely so.  My guess is that part of the difference lies in the fact that the less advantaged groups in the US are less likely to have low-cost access to health care or a permanent relationship with a health care provider. 

The concrete recommendation the authors of the study make focus on the idea of home nurse visits for new parents:

Identifying particular policies which could be eff ective is beyond the scope of this paper and is an area that deserves more research attention. One policy worth mentioning is home nurse visits. Both Finland and Austria, along with much of the rest of Europe, have policies which bring nurses or other health professionals to visit parents and infants at home. These visits combine well-baby checkups with caregiver advice and support. While such small scale programs exist in the US, they are far from universal, although provisions of the A ffordable Care Act will expand them to some extent. 
Randomized evaluations of such programs in the US have shown evidence of mortality reductions, notably from causes of death we identify as important such as SIDS and accidents.
At least in Finland (I'm not sure about Austria) these operate in conjunction with the ante-natal clinics, as part of a process which begins before the woman gives birth and continues with checkups by specialized nurses, first at the home of the family and later at the same clinics that were used for ante-natal care.  Put in another way, all this is an example of accessible health care.