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Briefing – First-Day Mortality in Industrialised Countries.

In the industrialized world, the United States has by far the most first-day deaths. Only 1 percent of

the world’s newborn deaths occur in industrialized countries, but the newborn period is still the

riskiest time, no matter where a baby is born, with the first day being the riskiest time of all in most, if

not all, countries. The United States has the highest first-day death rate in the industrialized world. An

estimated 11,300 newborn babies die each year in the United States on the day they are born. This is

50 percent more first-day deaths than all other industrialized countries combined. When first-day

deaths in the United States are compared to those in the 27 countries making up the European Union,

the findings show that European Union countries, taken together, have 1 million more births each year

(4.3 million vs. 5.3 million, respectively), but only about half as many first-day deaths as the United

States (11,300 in the U.S. vs. 5,800 in EU member countries). In Australia, Austria, Canada,

Switzerland and the United States, 60 percent or more of babies who die in their first month die on

their first day. Current data do not allow for analysis of first-day death rates among disadvantaged

groups in wealthy countries, but newborn and infant mortality are often higher among the poor and

racial/ethnic minorities, and populations with high newborn mortality rates also tend to have high

first-day death rates. Poor and minority groups also suffer higher burdens of prematurity and low

birthweight, which likely lead to first-day deaths in the U.S. and elsewhere.

1. Why the disparity between EU and USA first day infant

mortality?

Preterm birth rates higher in USA than EU – The US

prematurity rate is higher than the industrialised country

average – infarct its twice that of Finland, Japan, Norway and

Sweden. This can be attributed to the high adolescent birth

rate in the USA – the highest of any industrialised country.

Teenage mothers in the U.S. tend to be poorer, less

educated,176 and receive less prenatal care than older mothers.

Because of these challenges, babies born to teen mothers are

more likely to be low-birthweight and be born prematurely178

and to die in their first month. They are also more likely to

suffer chronic medical conditions, do poorly in school, and

give birth during their teen years (continuing the cycle of

teen pregnancy).

Poverty, racism and stress are likely to be important

contributing factors to first-day deaths in the United States

and other industrialized countries. Current data do not allow

for analysis of first-day death rates among disadvantaged

groups in wealthy countries, but newborn and infant

mortality are often higher among the poor and racial and

ethnic minorities, and populations with high newborn

mortality rates also tend to have high first-day death rates.

Poor and minority groups also suffer higher burdens of

prematurity and low birthweight183 which likely lead to first-

day deaths in the U.S. and elsewhere. One recent analysis of

U.S. data found that most of the higher infant mortality

experienced by black and Puerto Rican infants compared

with white infants was due to preterm-related causes. These

groups are also less likely to receive the high-risk care they

need, which puts their babies at even higher risk.

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What can be done to reduce first-day deaths in the United States and elsewhere in the industrialized

world? Investments in education, health care and sexual health awareness for youth will help address

some of the root causes. Wider use of family planning will also improve birth outcomes and reduce

newborn deaths. In the United States, 49 percent of pregnancies are unplanned and these babies are at

higher risk of death and disability. Efforts to improve women’s health would also have a positive impact

on survival rates of babies. High-quality care before, during and after pregnancy (including home visits

by nurses or community health workers if appropriate) and access to the appropriate level of care at the

time of delivery can result in healthier mothers giving birth to healthier babies. More research is needed

to better understand the causes of prematurity in high-income settings and to develop better solutions to

prevent preterm births.

2. What policies can we infer have given the EU such a comparative advantage?

There is little data upon which to base hard and fast conclusions. But there are a number of areas where

the evidence would support greater investigation into the contributions played by particular differences

between US and EU public policy.

Social inclusion policies based on universal social

protection form a key component of public Policy in the

EU. It has ensured that the basic level of health and

nutrition for low income groups in the EU is higher than

in the USA – although the malnutrition problem of

obesity is increasingly prevalent for low income groups

in Europe as it is in the USA.

1. Universal access to quality healthcare is the norm in the

EU and this is particularly important for saving newborn

lives – with life saving interventions at birth being

dependent largely on access to quality health care

services.

2. The Education system in the EU has also played a role in

ensuring that the EU has a lower teenage pregnancy rate

than in the USA. Provision of both higher educational

attainment overall allied to sex education both play roles

in lowering teenage pregnancy rates. Births by teenage

mothers have higher risks for complications and so infant

mortality than those to older mothers.

3. This is the last internationally comparable data

from 2011 – what will be the effects of EU austerity?

As the major influences over maternal and child health

develop over time the State of the Worlds Mothers report

periodically adapts its methodology to reflect these

changes. This year’s State of the World’s Mothers

Report has adopted a new methodology that focuses on

newborn health. This is because as under 5 child

mortality has fallen around the world the significance of newborn deaths as a proportion of the total has

increased. With this new methodology over the coming years we will be able to track the performance of

the EU countries that have pursued austerity to establish the scale of any changes in maternal or infant

mortality that could be attributed to austerity. Given the stark differences between the EU and the USA in

Mother and newborn in the best place to be

a mother: Finland

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historic data such worrying changes could be thought reasonable to be expected and therefore it will be

especially important for EU leaders and decision makers to follow this data and correct any policies that

are endangering health in general and child survival in particular.

The report does highlight the dangers of recreating similar social problems that have given rise to the

higher newborn mortality rate in the USA. Public Policy decisions, and critically allocation of the

necessary finance for them, should therefore be advised by these findings now.

Beyond the large difference between the USA and the EU in the ranking of where is best to be a mother is

the large disparity between the best and worst place to be a mother in the EU. The best place in the EU is

infact the top ranked country in the world, Finland. In contrast the worst place to be a mother in the EU is

Romania that comes in 61st place, some 31 places lower than the USA. Clearly inequalities within the EU

are as strong and have as great an impact on maternal and child health as the differences between the EU

and the wider world.

4. Background on Child health inequalities in the EU:

Growing up in poverty can dramatically change children’s chances to enjoy their rights. Across Europe,

Save the Children is witnessing how poverty is depriving children from educational opportunities, access

to healthcare, healthy diets, adequate housing and living environments, family support and protection

against violence, abuse, neglect and exploitation. We see how children experience discrimination due to

their social status and how they are socially excluded, for example through limited opportunities to

participate in leisure, culture and sports activities.

Inequalities in child health and access to health care across Europe remain high and are increasing due to

the economic crisis. A child’s right to enjoy a healthy life is largely linked to the child’s socio-economic

background and the country in which he or she is born. A child born in France or Austria is much more

likely to benefit from the State’s health care system than a child born in Bulgaria. Health inequalities

often start during childhood, last and widen during life and might be passed on to the next generation.

Poor health is also a mechanism for intergenerational transmissions of poverty and risk factors for chronic

diseases are strongly correlated to social determinants of health. Health inequalities do not only vary

between EU Member States, but also between advantaged and disadvantaged socioeconomic groups

within all EU countries, mainly due to social, economic, environmental and behavioural factors such as

lack of awareness, unequal access to healthcare and poverty.

Beyond the major focus of the report on newborn mortality (deaths in the first 28 days after birth), major

differences within the EU also exist between infant mortality rates (Deaths in the first year after birth).

The highest infant mortality rates are five times higher than the lowest rates in the EU. Infant mortality

rates are found to be much higher in the lowest socio-economic groups within the EU. Data shows that

nearly three-quarters of infant deaths are due to conditions originating in the perinatal phase, mainly

prematurity and congenital anomalies. The remaining 25 % of deaths are in part due to infectious diseases

and accidental deaths, many of which are preventable. The highest rates of other causes are reported in

Bulgaria (48%), Romania and Cyprus (40 %) and Estonia (36 %). Statistics also indicate that while the

overall rate of infant mortality decreases, infant deaths during the first year of life due to perinatal causes

are on the rise. Research shows that reducing health inequality by 1% per year could increase a country’s

annual GDP growth rate by 0.15%, establishing that investment in health is a catalyst to reducing poverty.

Reducing poverty, in turn, is a catalyst for equality.

5. EU Poverty and Health

Health and poverty are strongly correlated with each other. Within countries for which statistics are

existing, 11% of the children at risk of poverty cannot eat fresh fruits or vegetables once a day, because

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the household cannot pay for it. Children at risk of poverty or who are materially deprived cannot always

consult a general practitioner or a dentist when needed. Even if universal access to healthcare is available,

many obstacles remain existing. These are amongst others poor supply in disadvantaged areas or for

disadvantaged communities, discrimination, or payment systems. The correlation between job instability

and mental ill-health becomes even more obvious in times of financial and economic crisis. Increasing

unemployment and poverty rates put great stress and pressure on parents which can lead to rise in suicide,

depression and psychological abuse. Children suffer from the impacts the crisis has on their parents.

Fuel poverty is another risk to children’s health: living in a cold home has negative impacts on children’s

physical and mental health. Cardiovascular and respiratory diseases can be attributable to living in cold

homes. Children living in cold homes are more than twice as likely to suffer from a variety of respiratory

problems as children living in warm homes. Moreover, living in cold homes can negatively affect

children’s educational attainment, emotional well-being and resilience.

6. The Impact of recession and austerity

The economic recession and austerity measures are worsening child poverty and social exclusion in many

EU Member States. Between 2008 and 2011 the at-risk-of-poverty or social exclusion rate for children

increased in 17 Member States and decreased in only 4. The situation is particularly worsening for groups

already at high risk such as children from an ethnic minority or migrant background, particularly

undocumented migrant children. Symptoms of the crisis are increasing demands for food aid and other

emergency services. Early childhood is the most critical phase in a person’s development. Poverty in this

age can increase the risk of poor physical and mental health. These children are more likely to experience

more illness during their lifetime and die younger than their financially better-off peers. They have a

higher risk of dying at birth or in infancy and are more likely to suffer chronic illness during childhood or

to have a disability.

Key risk factors: Parents being unemployed or employed in “poor” jobs; inadequate income support systems; poor access

to essential services; lack of good-quality and affordable social and other housing; lack of play,

recreation, sporting and cultural facilities; living in poor areas or districts; coming from an ethic minority

and/or migrant background; having a disability; being detached from family and support networks.

Some key facts:

• Currently around 25 million children, i.e. over 1 in 4 children, are at risk of poverty and/or social

exclusion; these rates are much higher in some countries than others (17% or less in Denmark,

Finland, Slovenia and Sweden compared to 40% or more in Hungary, Latvia, Romania and

Bulgaria).

• The severity of child poverty and social exclusion and the extent of child deprivation vary greatly

between Member States. Countries such as Sweden, Denmark, Netherlands, Finland and

Luxembourg have deprivation rates of under 10%, whereas Portugal, Latvia, Hungary, Bulgaria and

Romania have rates ranging from 40% to nearly 80%.

• Currently 1 in 5 (21%) children are materially deprived.

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References cited in text from the Report:

175 Santelli, John and Andrea Melnikas. “Teen Fertility in Transition: Recent and Historic Trends in the United States.”

Annual Review of Public Health. Volume 31. April 2010. pp.371-383. See also Emily Holcombe, Kristen Peterson and

Jennifer Manlove. Ten Reasons to Still Keep the Focus on Teen Childbearing. (Child Trends: Washington, DC: March 2009)

176 John Santelli, et al. “Teen Fertility in Transition: Recent and Historic Trends in the United States.” Annual Review of

Public Health. See also Carmen Solomon-Fears. Teenage Pregnancy Prevention: Statistics and Programs. Congressional

Research Service. 2012

177 Centers of Disease Control and Prevention. VitalStats (2012) cited in: Kaye, Kelleen. Teen Childbearing and Infant

Health. (The National Campaign to Prevent Teen and Unplanned Pregnancy: October 2012)

178 Ibid.

179 WHO. “Adolescent Pregnancy. ” MPS NOTES. Volume 1, Number 1. October 2008. p.3

180 Solomon-Fears, Carmen. Teenage Pregnancy Prevention: Statistics and Programs. Congressional Research Service. See

also: Urban Institute. Kids Having Kids: Costs and Social Consequences of Teen Pregnancy, edited by Saul Hoffman and

Rebecca Maynard. 2008 (second edition)

181 See examples from Australia, Belgium, Sweden and the United States in State of the World’s Mothers 2006: Saving the

Lives of Mothers and Newborns. (Save the Children: Westport, CT: 2006) p.38

182 See, for example: MacDorman, Marian. “Race and Ethnic Disparities in Fetal Mortality, Preterm Birth, and Infant

Mortality in the United States: An Overview.” Seminars in Perinatology. Volume 35, Number 4. August 2011. pp.200-208

183 See, for example: Teitler, Julien, Nancy Reichman, Lenna Nepomnyaschy and Melissa Martinson. “A Cross-National

Comparison of Racial and Ethnic Disparities in Low Birthweight in the United States and England.” Pediatrics. Volume

120, Number 5. November 2007. pp.1182–1189.

184 MacDorman, Marian and T.J. Mathews. Understanding Racial and Ethnic Disparities in U.S. Infant Mortality Rates.

NCHS Data Brief. Number 74. September 22, 2011. pp.1–8

185 See, for example: Marlene Bengiamin, John Capitman and Mathilda Ruwe. “Disparities in Initiation and Adherence to

Prenatal Care: Impact of Insurance, Race-Ethnicity and Nativity.” Maternal and Child Health Journal. Volume 14, Issue 4.

July 2010. pp.618-634; Norma Gavin, Kathleen Adams, Ketherine Harmann, Beth Benedict and Monique Chireau. “Racial

and Ethnic Disparities in Use of Pregnancy-Related Health Care Among Medicaid Pregnant Women.” Maternal and Child

Health Journal. Volume 8, Issue 3. September 2004. pp.113-126; Ian Paul, Erik Lehman, Alawia Suliman and Marianne

Hillemeier. “Perinatal Disparities for Black Mothers and Their Newborns.” Maternal and Child Health Journal. Volume 12.

2008. pp.452-460; and Elizabeth Howell, Paul Hebert, Samprit Chatterjee, Lawrence Kleinman and Mark Chassin.

“Black/White Differences in Very Low Birth Weight Neonatal Mortality Rates Among New York City Hospitals.”

Pediatrics. Volume 121, Number 3. March 1, 2008. pp.e407-e415186 Handler, Arden. “Best Practices for Reducing Infant

Mortality.” HRSA Infant Mortality Region V COIN Talk. March 21, 2013

187 Finer, Lawrence and Mia Zolna. “Unintended Pregnancy in the United States: Incidence and Disparities, 2006.”

Contraception. Volume 84, Issue 5. November 2011. pp.478-485.

188 The Alan Guttmacher Institute. In Brief: Facts on Unintended Pregnancy in the United States. (New York and

Washington, DC: January 2012) 189 March of Dimes, Partnership for Maternal Newborn and Child Health, Save the Children

and WHO. Born Too Soon: The Global Action Report on Preterm Birth.

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The Best place to be a mother – 2013 rankings: