Whether an American baby lives or dies depends in part on where in the US it is born. Infant mortality—that is, a baby's ability to survive to its first birthday—varies greatly by state. The overall US infant mortality rate is 5.8 deaths per 1,000 live births—respectable, though below other wealthy developed nations—but individual states are another matter. Infants die at the highest rates in the deep south, with Mississippi, Louisiana and Alabama topping the list. Infant mortality rates in those states are on par with those in Botswana and Thailand. The safest place to have a baby? Along the coast and parts of the midwest, with Massachusetts, Iowa and Vermont leading the way, with rates closest to those of the United Kingdom or Canada.
Our healthcare system is known worldwide for being both state-of-the-art and extremely costly, so how can so much money yield such poor results in some regions? An analysis from economists Alice Chen, Emily Oster and Heidi Williams finds that it is not hospitals that are failing, but rather what happens after a baby leaves the sanitized, professional safety of a medical facility that differs from the rest of the developed world. For the poorest and most disenfranchised mothers in the US, something happens between taking a baby from the hospital and getting to that first-year milestone. The issue boils down to poverty—and policy.
David Olds first became interested in how to help babies and children on the fringes of society in the 1970s, when he worked at a Baltimore daycare. There, he met a little boy who was afraid to take a nap because when he slept, he would wet his bed. And wetting the bed at home meant being beaten. So the boy would do everything he could not to sleep. Another boy had been exposed to alcohol in the womb and then abandoned by his mother. Olds saw in these stories mothers who were ill-prepared for a child, with no money and no help, living under extreme stress.
Now professor of pediatrics and director of the Prevention Research Center for Family and Child Health at the University of Colorado, Olds has been looking for solutions ever since. For decades, he's been hot on the trail of one promising solution: having highly trained nurses regularly visit first-time mothers who live in poverty. While he was looking at the effects the nurses had on the overall health and cognitive development of the children, a decrease in mortality also showed up in his studies as a side effect of the nurses' work.
The visiting nurses in Olds' program worked on helping the mothers through pregnancy, making sure they quit smoking and drinking, helped teach the first-time mothers how to take care of their babies and provided support for the mothers to get back into the workforce or finish their education. The nurses also helped the mothers work on timing their next pregnancy, and avoid getting pregnant again immediately after their first child. For many of the mothers in the program, says Olds, it was the first time they met someone who treated them with respect and told them that they could be a good mother.
As the nurses gained the trust of their patients, visiting regularly and offering help, the incidents of accidental ingestions, falls and other preventable injuries to the infants decreased, and the home lives of both the mothers and children became more stable. Olds recalls one particular new mother who started out at a big disadvantage. She had fetal alcohol syndrome and had given birth to her first child as a teenager. Olds' visiting nurse worked with the mother on how to understand her baby's needs and how to react to inconsolable crying, a major concern with stressed, short-tempered and unprepared parents who sometimes shake or hit a baby to try to stop its crying, leading to skull fractures and death. The nurse taught the new mother that if the baby would not stop crying and there was nothing she could do to sooth the baby, it was okay to give the baby to another member of the household and go to her room to calm down, instead of reacting.
Visiting nurses were commonplace in the 1930s and 1940s, when many new moms had home visits from nurses who would come and talk to them, check for abuse in the home, make sure children were gaining weight, that the home was childproofed, and help mothers cope when they had no other support system. But in the 1950s and 1960s, as new medical breakthroughs allowed doctors to save the lives of premature babies, funding and focus shifted to hospital care and the visiting nurse system petered out.
The stressors faced by mothers like the ones in Olds' research come from a variety of factors. Poverty is one obvious cause. One in four women in the US who give birth are living below the poverty line, which is a paltry $16,020 a year for a household of two. Kelli Komro, a professor of epidemiology at Emory University, studies the link between minimum wage and infant mortality. Komro looked back at small historic increases in minimum wage and and found that an increase of $1 an hour above federal minimum wage resulted in a 4 percent decrease in postneonatal infant deaths. If an increase of just $1 an hour can improve security and decrease stress enough to have a noticeable impact on infant mortality, it puts the Fight for $15, the grassroots movement pushing for $15 minimum wage into stark perspective. "Based on the results of my study, plus others, I would expect an increase in the minimum wage would result in lower negative birth outcomes, including low birth weight and postneonatal mortality," Komro says.
Raising minimum wage is not the only way to reduce stress in an impoverished or marginalized household. Other research has found a link between access to abortion and infant mortality. Looking at historical data, researchers found significant drops in infant mortality, especially for babies born into poverty, when abortion was legalized. One explanation for the findings is the difference with which expectant mothers approach an unwanted and ill-timed pregnancy, which often is itself a source of great stress. As John Donohue and Steven Levitt point out in their study on crime rates and abortion access, "unintended pregnancies are associated with poorer prenatal care, greater smoking and drinking during pregnancy, and lower birth weights." All risks for infant mortality.
Of course, the single thing that encompasses all these issues—minimum wage, social support, access to abortion and others—is policy. On the presidential level, Republican administrations have a 3 percent higher infant mortality rate than Democratic administrations, according to a study by Arline Geronimus, professor of health behavior and health education at the University of Michigan, and co-investigators Javier M. Rodriguez and John Bound. Geronimus is now working on a study looking at the effects of Republican and Democratic legislation on a state-by-state level, which preliminary data suggests follows the same pattern, with Democratic legislation associated with greater decrease in infant mortality. This, of course, is likely inextricable from the economics question: "I would assume the variability in infant mortality by state is largely explained by variability in poverty—and social policies designed to support low-income populations," Komro says.
Policies that affect infant mortality are not limited only to those that touch on healthcare, explains Geronimus. Everything from housing policies and laws that allow exposure to pollution (like lead in public water) to laws that impact the overall stress level of a mother, such as those around immigration status, or any policy that makes one group feel excluded from society, can have an impact on infant mortality, Geronimus says.
As we move into a time with a Republican-majority senate and congress and a Trump-selected cabinet, there are likely to be more cuts to the types of social programs that support the most vulnerable, and more laws, like the proposed Muslim registry, that create great stress. Already there are promises to defund Planned Parenthood, cut Medicaid, repeal the Affordable Care Act (which, among other things, funded a trial of visiting-nurse programs in all 50 states but is contingent on a funding renewal in 2017), as well as threats of cuts to other safety-net programs and new challenges to abortion access. The impact of removing a social safety net on infant mortality, and child health is likely to be dire. As Geronimus puts it, looking into the future, "it does not look like it will be the best time for babies."