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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 firstday 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
Mother and newborn in the best place to be
Report has adopted a new methodology that focuses on
a mother: Finland
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
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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
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)
180
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:
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