• The zombie infant mortality explanation

    There is it, in the lead of an editorial in the WSJ:

    Those Misleading World Health Rankings

    The numbers are distorted because, for instance, U.S. doctors try so hard to save premature babies.

    And from later in the piece:

    Another major gauge of health is infant mortality. As the report’s authors point out, the U.S. has the highest infant-mortality rate among high-income countries. Again, this isn’t a good indicator of the quality of the American health-care system. The elevated U.S. rate is a function of both the technological advancement of American hospitals and discrepancies in how different countries define a live birth.

    Doctors in the U.S. are much more aggressive than foreign counterparts about trying to save premature babies. Thousands of babies that would have been declared stillborn in other countries and never given a chance at life are saved in the U.S.

    If only someone had addressed this issue in a public venue. Perhaps at CNN.com?

    When compared to peer countries, the United States was the absolute worst with respect to still births, infant mortality, and low birth weight. Some have tried to blame this on “coding” differences. In other words, they will claim that other countries will refuse to define a premature birth as we do, resulting in artificially high numbers in the US. But when this report recalculated the rates to exclude such births equally in all countries, we still ranked last.

    See, this is something people trot out all the time to try and explain our bad infant mortality. They cherry pick a country or a year and say we do things differently. But let’s use a little common sense here. We’re giving our data to these studies. They aren’t stealing it in the middle of the night. So if we really think we’re being cheated, we should change how we measure things. Moreover, it’s not us versus the rest of the world. Each country does things differently. The United States is not the only developed country that tries to save premature babies.

    Let me quote directly from the study (page 66-7):

    The high rate of adverse birth outcomes in the United States does not appear to be a statistical artifact, such as a difference in coding practices for very small infants who die soon after birth (MacDorman and Mathews, 2009). Indeed, country rankings remained identical even when Palloni and Yonker (2012) recalculated the rates to exclude preterm births (less than 22 weeks of gestation).

    There are lots of reasons why our infant mortality is terrible. This isn’t one of them. It’s a zombie idea.


    Comments closed
    • I suspected this was the case. I read the WSJ every morning. Usually I avoid the Opinion pages, but today curiosity got the better of me. Now I’m going to have this woman’s lies buzzing around my head all day. :/

    • Zombie infants? I’m scared, though at least they are mortal.

    • I’ve always viewed this “argument” with a bit of trepidation when I’ve seen it.

      I’ve thought first of all that it seemed to me that even if completely true & relevant, it would have to be a small part of the big picture equation in regards to health outcomes as a whole.

      But mostly, I’ve often gotten the vibe, when I’ve seen this argument… That there was the sort of innuendo… perhaps as an appeal to something or other fallacy in an “us vs. them” framing… That what one should imagine from this argument is the idea that other countries, including ones with advanced medical technology, just don’t love their babies as much as Americans do!

      Perhaps that isn’t what everyone who uses this argument is going for… or even thinking about.

      But I bet a quick internet search could bring up some web sites (albeit not respectable ones you’d ever want to subject yourself to), that would demonstrate that kind of prejudice very plainly, in the context of other bizarre “us vs. them” attitudes regarding how other nations, or other cultures, or other religions, just don’t “value life like we do”.
      I wouldn’t like to guess whether it started with such people, or if they just found this argument complimentary to their prejudiced worldview.

    • “Indeed, country rankings remained identical even when Palloni and Yonker (2012) recalculated the rates to exclude preterm births (less than 22 weeks of gestation).”

      and then you follow with: “There are lots of reasons why our infant mortality is terrible. This isn’t one of them.”

      The data mentioned in the first quote seem to indicate that this isn’t THE reason for the differences in IM between countries. Your quote seems to indicate it is not A difference. The first is clearlytrue; the second, to me, is clearly false.

      In the MacDorman and Mathews paper mentioned above (http://www.cdc.gov/nchs/data/databriefs/db23.pdf), they do, indeed, show that when 22-23 GA births are excluded, the rankings do remain more or less unchanged, supporting the statement it is not THE difference; but the difference bewteen the US and the median does shrink. The US vs median for comparable countries is 7 vs 4, per 1000; when 22-23 GA is excluded, it’s more like 6 vs 4. That’s not the whole difference, but it’s not nothing, thus it’s harldy a “zombie” idea, and you are wrong to say so.

      Further, the same data show that the difference between countries is almost entirely due to the increased number of preterm births in the US. When broken down by GA groupings, the US jumps to or above the median within each. Other studies also attribute part of the difference to the higher percentage of low-weigth births, as well as the much different racial composition in the US versus individual European countries. None of these three factors alone explains the differece, but taken together, they do. Now, our higher prevalance of premature and/or low-birth weight babies might be a social problem, but it not a problem due to our particular health care system, per se.

      The botton line is that IM is about the poorest measure for health care quality bewteen countries because it is so coarse (it does serve good purpose as a measure over time in one country). It’s measured in units that are low in an absolute sense, and this makes it very sensitive to composition prolems described above. If there is a zombie idea here, at all, it is the notion that our health care system lags because of a slightly higher IM.

      • Sorry, but the claim is that our relative rank is due to differences in coding. That’s not true, and it’s a zombie idea.

        The rest is just noise here. If the WSJ wants to write a piece saying that infant mortality is bad in the US, but not how you judge the system, that’s fine. That’s not what they did.

      • I’ve been familiar with this zombie for a while now. As far as I can tell, it was just made up out of thin air by the WSJ editorial page in January, 2005. I say made up because it was not suggested or theorized, just baldly stated as a fact;; which makes it a lie, not a bad hunch or incorrect hypothesis. And despite being roundly debunked in the ensuing 8 years, they apparently are so proud of this fantasy that they have trotted it out again.

        As you point out, it doesn’t meet the sanity test, a priori; it requires the belief that in Canada, for instance, they just stand by and allow a late term fetus in difficulty to die, rather than making an effort to save it (despite caesarean sections being known to medicine since, well, since the time of Caesar); and it fails to explain why, for instance, the mortality rate in the second year of life for American babies is higher than in other developed countries.

        And in fact, the question was raised in the public health community long before the WSJ thought of it; measures such as perinatal mortality, defined as the rate of stillbirths within the last few weeks prior to birth or deaths in the early weeks after birth have been tabulated internationally, and, as you might expect after following the debate this far, it imporves the US ranking only marginally.

        Of course, the other shibboleth raised by the rightwing is that the reason our healthcare system is unfairly painted as performing relatively poorly is because of the great problems with violent death and/or drug-related deaths in America. Even before checking and confirming that eliminating these deaths doesn’t help, again it doesn’t meet the sanity test, unless our society is so troubled that our newborns are likely to take drugs and get into gunfights.

        There is no evidence whatsoever for those who insist on the superiority of American medical care to lean on, other than an implicit belief that it would be unthinkable for it to be otherwise. Meanwhile, for those familiar with the function of American healthcare, it seems obvious that it would be this way. The breakdown of relative performance of the US system vs other countries shows an interesting pattern; it is worst at birth but improves relatively as age of the patient rises, so that by age 70 or so it actually is best in the world. This is not coincidentally similar to the much greater rewards in terms of money and prestige given in America to practioners of “heroic” medicine, compared to simple primary care. Meaning, that we put our money where it will deliver the least bang for the buck, giving postponing death by half a year for people whose bodies are completely falling apart at a cost of hundreds of thousands of dollars, while neglecting to ensure that uneducated and impoverished pregnant teenagers, both inner city black or rural white, have access to proper nutrition and/or vitamin supplements, and keep away from toxins, teratogens, and infections. Many of these girls have never seen a doctor in their life, including at their birth. (I can personally attest to this fact) and need outreach; they wouldn’t know how to arrange for prenatal care even if they could get it for free.

        The same goes when you examine our health care system, sliced by type of disease, rather than age; we do excel in one field: cancer care, arguably the most expensive, invasive, and “heroic” field. Otherwise, even in cardiac/circulatory medicine, our outcomes fall below those of other countries.

        The sad punch line is that it’s not even that this is “where we choose to spend the money.” Of course, there’s no reason we couldn’t cover both ends of this spectrum; the small extra expenditure for extending proper prenatal and postnatal care to all the “preborn”, as the advocates for the rights of the fetus term them, wouldn’t make a significant dent into what we now spend on end of life care, and would in all probability end up saving money, as the data on medical resources used by low birth weight babies shows.

    • I think Trent McBride’s work here is done now. Ouch!

    • “There are lots of reasons why our infant mortality is terrible”

      Let’s take the position that the international IM comparisons are flawless, just for the sake of this discussion

      The only possible explanations for the performance of the US on this metric are problems with the way our doctors and nurses provide care, access to care, or variations in maternal behavior.

      There is no support for the first factor in the literature that I am aware of, but there is plenty of support for variations in access and behavior causing excess infant mortality.

      The excess mortality arising from access and behavior are complex, linked, and tragic. There is very little that doctors and nurses can do on their own to tackle excess mortality arising from deficient access to care, and they have far less control over variations in patient behavior.

      It’s worth noting that even under a single payer regime, variations in underlying infant mortality persist:

      Canada (figure 3B)

      • Okay, I’m sure your comment is well laid out, and it’s me that’s the problem here. So please tell me if I’m understanding this properly.
        Your comment means :

        1) ? There is evidence that there are variations in access (to labor & delivery & infant health care)
        And if so, is there somewhere I can read more about this issue? (I’m not disputing anything, I’m just interested in learning more about this issue.)

        2) ? There is evidence that there are variations in behaviour causing excess infant mortality…
        Behaviour by who? Behaviour of providers of medical services, or behaviour of patients? (“they have far less control over variations in patient behavior” – sounds like the previous statement was referencing patient behaviour, but I’d like to be sure.)

        3) ? The variations are not caused by the health care system per se?
        “It’s worth noting that even under a single payer regime, variations in underlying infant mortality persist:”

        So if I’m to understand this correctly (thank you for those pdf links btw)…

        An infant mortality problem similar to that of the U.S. is also seen in Canada & the UK ?
        Or just that all 3 countries have variations in infant mortality that are not seen in other similar nations?

        I’m not sure if I’m understanding this correctly. (Thanks for your patience!)

        And as for the single payer vs. whatever health system…

        Any problem of higher infant mortality in the U.S. is:
        a) perhaps caused by access issues
        b) the access issues are not necessarily caused by the type of health care system
        And from this it could be related to patient behaviour? And the causes of this variation in patient behaviour are not about the health care system, but are caused by something else, and that cause is not firmly settled in Canada or the UK?
        I’m getting that from reading those PDFs that there’s some theories as to why though.

        Are there any similar papers regarding the U.S. on the issue of infant mortality?

        Sorry if I sound a bit greedy for more literature & links!!!

        • DOH! JayB posted what looks to be a good pdf link for that. *thumbs up*

          • All good questions.

            Hopefully someone more qualified will answer, but my sense of what the literature actually shows is that most of our excess mortality is driven by pre-term births, which are more frequent amongst women who are on one extreme of childbearing age or the other (old or young), and those who have poor prenatal care. AFAIK the data shows that the geographic and racial variation in infant mortality rates within the US is largely driven by these factors.

            What I meant by the comments regarding access and behavior is that the cohort of women who are least likely to have all of the attributes that lead to being either privately insured or pro-actively seeking out public health services when they become pregnant (and thus get good prenatal info/care) are also often the most likely to engage in behaviors or experience hardships that elevate the risks of preterm birth (this is just my opinion).

            The data from Canada and the UK demonstrate that these geographic/racial variations persist under single payer regimes.

            • After reading all 3 of those reports, I want that hour of my life back, please.
              Sorry, just kidding.
              But it was rather Soylent-Green moment-ish.

              Thinking of variations of demographics between countries was rather disturbing.

    • Good recent summary of the literature here:

      “The U.S. Infant Mortality Rate: International
      Comparisons, Underlying Factors, and Federal


    • Canadian Medical Association Journal, Feb 19, 2013 Headline: Rates of stillbirth by gestational age and cause in Inuit and First Nations populations in Quebec

      Results: Rates of stillbirth per 1000 births were greater among Inuit (6.8) and First Nations (5.7) than among non-Aboriginal (3.6) residents. Relative to the non- Aboriginal population, the risk of stillbirth was greater at term (≥ 37 wk) than before term for both Inuit (OR 3.1, 95% CI 1.9 to 4.8) and First Nations (OR 2.6, 95% CI 2.1 to 3.3) populations. Causes most strongly associated with stillbirth were poor fetal growth, placental disorders and congenital anomalies among the Inuit, and hypertension and diabetes among the First Nations residents.

      Interpretation: Stillbirth rates in Aboriginal populations were particularly high at term gestation. Poor fetal growth, placental disorders and congenital anomalies were importantcauses of stillbirth among the Inuit, and diabetic and hypertensive complications were important causes in the First Nations population. Prevention may require improvements in pregnancy and obstetric care.

      Canadian media doesn’t resort to Zombie-ish refutations of bad international comparisons but seeks to understand what’s wrong and what needs to be done. Here’s CBC, for example. http://www.cbc.ca/news/health/story/2013/02/19/stillbirth-first-nation-inuit.html
      (Neither mentions the emotional toll on the family when a child is stillborn, particularly at or close to term.)

    • I seems to me it would be useful to have this data:

      life expectancy at:
      20 weeks gestation
      age 1 year
      age 18 years
      age 40
      age 60

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