Date Published: March 20, 2018
Publisher: Public Library of Science
Author(s): Neha Bairoliya, Günther Fink, Gordon C. Smith
Abstract: BackgroundWhile the high prevalence of preterm births and its impact on infant mortality in the US have been widely acknowledged, recent data suggest that even full-term births in the US face substantially higher mortality risks compared to European countries with low infant mortality rates. In this paper, we use the most recent birth records in the US to more closely analyze the primary causes underlying mortality rates among full-term births.Methods and findingsLinked birth and death records for the period 2010–2012 were used to identify the state- and cause-specific burden of infant mortality among full-term infants (born at 37–42 weeks of gestation). Multivariable logistic models were used to assess the extent to which state-level differences in full-term infant mortality (FTIM) were attributable to observed differences in maternal and birth characteristics. Random effects models were used to assess the relative contribution of state-level variation to FTIM. Hypothetical mortality outcomes were computed under the assumption that all states could achieve the survival rates of the best-performing states. A total of 10,175,481 infants born full-term in the US between January 1, 2010, and December 31, 2012, were analyzed. FTIM rate (FTIMR) was 2.2 per 1,000 live births overall, and ranged between 1.29 (Connecticut, 95% CI 1.08, 1.53) and 3.77 (Mississippi, 95% CI 3.39, 4.19) at the state level. Zero states reached the rates reported in the 6 low-mortality European countries analyzed (FTIMR < 1.25), and 13 states had FTIMR > 2.75. Sudden unexpected death in infancy (SUDI) accounted for 43% of FTIM; congenital malformations and perinatal conditions accounted for 31% and 11.3% of FTIM, respectively. The largest mortality differentials between states with good and states with poor FTIMR were found for SUDI, with particularly large risk differentials for deaths due to sudden infant death syndrome (SIDS) (odds ratio [OR] 2.52, 95% CI 1.86, 3.42) and suffocation (OR 4.40, 95% CI 3.71, 5.21). Even though these mortality differences were partially explained by state-level differences in maternal education, race, and maternal health, substantial state-level variation in infant mortality remained in fully adjusted models (SIDS OR 1.45, suffocation OR 2.92). The extent to which these state differentials are due to differential antenatal care standards as well as differential access to health services could not be determined due to data limitations. Overall, our estimates suggest that infant mortality could be reduced by 4,003 deaths (95% CI 2,284, 5,587) annually if all states were to achieve the mortality levels of the best-performing state in each cause-of-death category. Key limitations of the analysis are that information on termination rates at the state level was not available, and that causes of deaths may have been coded differentially across states.ConclusionsMore than 7,000 full-term infants die in the US each year. The results presented in this paper suggest that a substantial share of these deaths may be preventable. Potential improvements seem particularly large for SUDI, where very low rates have been achieved in a few states while average mortality rates remain high in most other areas. Given the high mortality burden due to SIDS and suffocation, policy efforts to promote compliance with recommended sleeping arrangements could be an effective first step in this direction.
Partial Text: Despite some progress made in recent years, infant mortality rates in the US continue to be high compared to other high-income countries . According to the latest estimates, the US currently ranks 44th among 199 countries of all income levels, with an infant mortality rate of 5.6 deaths per 1,000 live births in 2015, about 3 times the rate observed for countries at the very top of the ranking .
A total 10,175,481 children born full-term in the US between January 1, 2010, and December 31, 2012, were analyzed. FTIMR was 2.19 (95% CI 2.16, 2.22) per 1,000 full-term live births in the pooled sample. At the state level, estimated FTIMR ranged between 1.29 (95% CI 1.08, 1.53) in Connecticut and 3.77 (95% CI 3.39, 4.19) in Missouri. No state was classified as excellent in terms of their FTIMR; 10 states including Connecticut were classified as good, 17 as average, 11 as fair, and 13 as poor FTIMR (see Fig 2 and S2 Table for details).
The results presented in this paper show a large gap in the survival probabilities of full-term infants born in the US compared to European countries with low under-5 mortality rates. Pooling all available data between 2010 and 2012, we found that no single US state or territory achieved the full-term survival rates currently reported in leading European countries, with children born full-term in the 10 best-performing states facing about 50% higher risks of infant mortality, and children born in states with poor FTIMR facing almost 3 times the infant mortality risk of European countries with low infant mortality rates.