Health care debate - The forgotten issue: Infant Mortality

Health care debate - The forgotten issue: Infant Mortality
By Carlos T Mock, MD
August 24, 2009

One aspect the current debate on health care has failed to address is: Infant mortality.

Infant mortality is a true measure of health care well being of a nation, since it is not affected by accidents and homicides as life expectancy does. It is directly related to the ability of the country to provide good prenatal care.

Infant mortality is defined as the number of deaths of infants (one year of age or younger) per 1000 live births. In the United States, preterm delivery—births of babies born before 37 completed weeks of gestation or weighting less than 2500 grams—occurs in approximately 12% of all births in the United States and is a major factor contributing to perinatal morbidity and mortality. Despite extensive research in this area, the rate of preterm birth has increased by 38% since 1981. (Source American college of Obstetrics and Gynecology) Other causes of infant mortality include congenital malformation, infection, and SIDS.

The USA ranks number 46, behind to all socialized medicine countries and even Cuba in infant mortality. (Source: CIA - The World Factbook -- Country Comparison :: Infant mortality rates). This is a terrible statistic because for the most part it is preventable with good prenatal care—which lacks mostly in the poor, Hispanics, African American, and teenagers—thus their incidence of prematurity is much higher than in the white and affluent population of the US.

Premature Birth Rate in U.S. Reaches Historic High; Now Up 29 Percent Since 1981. (Source – March of Dimes). And yet, Medical Costs for One Premature Baby Could Cover A Dozen Healthy Births. The average medical cost for healthy full-term babies from birth through their first birthday was $4,551 in 2007 dollars, of which more than $3,800 is paid for by health plans, according to the new data. For premature and/or low birth weight babies (less than 37 completed weeks gestation and/or less than 2500 grams), the average cost was nearly $50,000, of which more than $46,000 was borne by the health plan.

More importantly, the survival rate for extremely preterm or extremely low-birth-weight (LBW) newborns born at the threshold of viability (25 or fewer completed weeks of gestation) improved in the early 1990s, largely as the result of a greater use of assisted ventilation in the delivery room and surfactant therapy. Increased use of antenatal and neonatal corticosteroids also may have influenced survival rates. However, this improvement in survival has not been associated with an equal improvement in morbidity. The incidence of chronic lung disease, sepsis, and poor growth remains high and may even have increased. There is concern that the treatment of extremely preterm and extremely LBW newborns may result in unforeseen effects into adulthood and that the neurodevelopmental outcome and cognitive function of extremely preterm and extremely LBW infants may be suboptimal. (American College of Obstetrics)

Two recent large, prospective studies addressing morbidity—one using gestational age and one using birth weight—provide useful data. A gestational-age-based population study of 811 extremely preterm newborns used data collected in 1995 and found that disabilities in mental and psychomotor development, neuromotor function, or sensory and communication function were present in about one half of the large cohort of survivors at 30 months of corrected age. Approximately one quarter met the criteria for severe disability. Male newborns had lower psychomotor scores and were significantly more likely to have cerebral palsy than female newborns. A similar disadvantage for male newborns has been reported by others. (ACOG)

Since prematurity is responsible for fifty percent of all cerebral palsy cases, it stems to assume that it will also add to the health care bill—not only in health care costs in the hundred of thousands of dollars, but also in litigation. Cerebral Palsy is responsible for the largest awards against obstetricians in litigation. On Feb. 24, 2008, a Stamford, CT jury's decision to award a record $38.5 million to the parents of a boy born with cerebral palsy reignited debates over medical malpractice rates, insurance company tactics and the cause of cerebral palsy. Obstetricians statewide were shocked by the verdict against a Harvard-trained obstetrician from Stamford who, in the jury's view, took too long to decide to do an emergency Cesarean section. The result of this case was higher malpractice premiums and forcing quality doctors to stop practicing Obstetrics. There are states in which women are forced to drive more than 300 miles just to get some sort of prenatal care because of the malpractice crisis.

The truth is the US is the richest country in the world, and even though has the best tools to fight disease than anyone else in the world, it spends almost 30% of its health care budget in the first year of life and another 30% in the last year of life (Source: CIA - The World Factbook — US medical expenses), thus leaving almost 60% of Americans unable to afford adequate health care insurance.

Dr. Mock has published four books with Floricanto Press, Berklety, CA. His articles have appeared on publications like The Chicago Tribune and several gay and lesbian newspapers. He was inducted in The Chicago GLBT Hall of Fame in 2007. He can be reached at: www.carlostmock.com