In 1960, Singapore’s infant mortality rate was 36 out of every 1,000 babies born alive. That same year the rate in the United States was significantly better: 26 out of every 1,000 live births.
In 1973, the infant mortality rate of the two countries were the same but the rate in Singapore improved every year thereafter. In 2017, U.S. infant mortality rate was higher than Singapore’s: 5.7 per 1,000 live births versus 2.2 per 1,000 live births, or more than 2.5 times higher, according to the World Bank.
The infant mortality rate (deaths per 1,000 live births) used to be much higher in Singapore than in the U.S. Now it is the reverse, and the U.S. and the Russian rates are nearly the same.
Source: World Bank Open Data
While overall U.S. infant mortality is lower than it was in the ’60s, how can the country that spends more per person on health care than any other in the entire world by far have made so little progress while rates in Singapore and elsewhere have improved? Indeed, the U.S. rate is now higher than infant mortality rates in Antigua or Cuba. Furthermore, the overall U.S. rate masks significant disparities. The infant mortality rate of non-Hispanic black infants is 11.2 per 1,000 live births, which is comparable to the rate in Libya or Tunisia.
Differences in mortality rates also extend to mothers. Mothers in the United States are five to six times more likely to die as a result of pregnancy and delivery than in any comparable country, and the gap between non-Hispanic black women and other women is staggering. According to the CDC, black women are three to four times more likely to die from a pregnancy-related complication than non-Hispanic white women. The overall U.S. rate has been rising over two decades, while in the rest of the world it’s been going down. Though some researchers have ascribed some of that increase to better data capture, it’s absurd to think that causes of death in the U.S. are more precise than in European countries where everyone has a unique national identification card.
The sad reality is that infant and maternal health is comparatively bad in this country—and getting worse, not better. At the same time the cesarean section rate has been increasing, and there’s a clear relationship between that increase, maternal mortality, and nonlethal complications from birth.
So much for “managed care.”
Several responses from the field have emerged to address the combination of factors that cause these avoidable deaths and complications.
François de Brantes
First, with funding from the CDC and many state-based health care foundations, perinatal quality collaboratives (PQCs) have sprung up. Amazingly, only 43 states are participating so far when all should. These PQCs include formal data collection and reporting to participating providers, although in many states, fewer than half of birthing facilities participate because the programs are voluntary when, given the current state of maternal outcomes, they should be mandatory. They also share best practices and encourage strong action, even though they have no means of enforcing any action.
Second, states, through their Medicaid agencies, are instituting changes in how facilities and obstetricians are paid that should help end the perverse incentives in the current payment system that reward doctors and hospitals for performing unnecessary and potentially harmful C-sections.
Third, employers are teaming with charitable organizations such as the March of Dimes to educate mothers, engage communities, and reform payment.
Still, the lack of broader engagement by provider systems and managed care organizations is disgraceful, as evidence of poor outcomes and low-value care mounts. For example, ACOs with total-cost-of-care contracts from Medicaid MCOs have been reticent to act on maternity, focusing on other savings opportunities. It’s almost as if they’ve given up on the hope of influencing obstetricians and facilities, even though professional societies such as the American College of Obstetricians and Gynecologists are strongly voicing their support for improving birth outcomes.
In 2016, the Medicare-sponsored Health Care Payment Learning and Action Network issued a report detailing a global maternity case rate that would include all services from womb to crib and that would very clearly encourage better management of the pregnancy, delivery, and postpartum care. The report was the result of an effort by me and a number of other health care experts to define a novel way to pay for maternal care that would lead to better outcomes.
A few employers wanted to adopt the model but were unable to find any carrier that would implement it. They had to turn to third parties for implementation help, paying extra for something that every payer should be able to do as a routine course of business. More recently, employers in a number of states (Florida, Colorado, Pennsylvania, Wyoming), supported by their local health care purchasing coalitions, have banded together to get payers on board. Some are responding, but the progress is slow.
The bottom line here is simple. It’s not as if Singapore, every country in the European Union, and numerous other countries around the world have healthier mothers or far better social, demographic, or economic conditions for all child-bearing women. But they don’t have payment systems that can end up rewarding physicians and facilities for bad outcomes and that allow them to extract the highest rent possible from all other economic actors.
High U.S. infant and maternal mortality rates are a completely solvable problem. There is simply no excuse for letting this circumstance continue. Those who continue to make excuses can’t claim there’s nothing to be done. There is much that can be one, and their failure to act puts the blood of innocents squarely on their hands.