Infant Mortality in the U.S. and Canada
The U.S. National Center for Health Statistics reports that African American infants are nearly twice as likely as non-Hispanic white infants to be born prematurely.
In Canada, the disparity is most clearly defined by income, with those in the lowest income quintile having an infant mortality rate two-thirds higher than that of the highest income quintile. As infant mortality secondary to congenital anomalies and other causes has fallen significantly, the differential is largely a result of a higher rate of preterm birth in lower-income families.
Canada's First Nation and Inuit people face serious health problems, including infant mortality in many communities that is twice the national rate, as do America's Native American populations. Although Canada is an increasingly racially diverse country, other racial disparities are less obvious in measures of health care, such as prenatal care or preterm birth. Income is perhaps a more fitting measure of comparison, and deserving of a wider perspective.
One interesting study examined the gross national products and income distribution in 20 poor and 15 rich nations, determining, as one would expect, that overall infant mortality was inversely proportionate to income.
In rich countries, however, the main contributor to higher infant mortality was not income, but income disparity (Lancet 1999;354:2047).
The United Nations, in its annual Innocenti report card for 2000, explored child poverty in rich nations by using consistent indices to identify the percentage of children living in families with incomes below 50% of each nation's median income.
Child poverty levels ranged from 2.6% in Sweden to 26.6% in Mexico. Canada was 15.5%, and the United States was 22.4%.
Some governments, including those in Scandinavia, take a very active role in making sure that people don't live in poverty. Income disparity is low.
Conversely, income inequality is very high in the United States and may contribute to exceedingly elevated preterm birth rates and infant mortality among African Americans.
A related issue, of course, is access to medical care, which varies greatly among the industrialized nations of the world.
In Canada, where we have universal medical care, prenatal care is available at no cost, with no disincentives to seeking care in the system. Even pregnant women who do not have a primary care physician can walk into a clinic in any city and be seen that day.
As a result, in 2000, well over 95% of Canadian women received prenatal care beginning in the first trimester, compared with 83.7% of American women.
Once again, disparity is evident in the U.S. numbers, with only about 75% of African Americans and fewer than 70% of Native Americans receiving early prenatal care. Indeed, 3.6% of women delivered with no prenatal care, or with care initiated only in the last trimester.
Although the U.S. rate of early prenatal care has improved quite dramatically in the last 15 years, rising 10% since 1990, it still falls short of the care rates in most Western nations. Conversely, I should point out that the Swedes think that even Canada's prenatal care numbers are lousy. In Sweden, virtually 100% of women receive prenatal care throughout their pregnancy.
I would also be remiss if I left the impression that the Canadian health care system, the Swedish system, or any system, for that matter, is perfect. In Canada, one faces a long wait for a hip replacement. Far too many Canadians (about 10%) depend on walk-in clinics because they can't find a primary care physician of their own. Canadians who make more money tend to live longer, and certain groups, such as First Nation and Inuit people, have unequal health outcomes despite access to free care.
In Canada, we learn a lot from the United States, from the abundance of medical research and education to the excellent health care available to many. But in the spirit of learning from each other, U.S. physicians may be interested in studying a neighbor that spends less on health care yet produces not only lower preterm birth rates and infant mortality, but also lower mortality overall.
Sources
▸ The National Center for Health Statistics publishes regular reports on infant mortality. The final data for 2002 can be found in Natl. Vital Stat. Rep. 2003;52:1-113. The center's latest annual report on trends in health statistics is “Health, United States, 2004,” which includes a chartbook on trends in the health of Americans as well as interactive links (
▸ The Central Intelligence Agency publishes the World Factbook each year in printed and Internet versions. Data noted in this Master Class can be found online at
