The Poverty/Health Connection in US Children

Laurie Scudder, DNP, NP; Andrew D. Racine, MD, PhD


June 02, 2015

In This Article

Editor's Note: Save the Children recently released its 2015 State of the World's Mothers report, [1] which examines the relative health of women and young children in countries around the world. This year's report focused on the impact of rapid urbanization on the poorest women and children.

Despite the overall wealth of the United States, the country as a whole performed poorly, slipping two places to number 33 out of 179 countries surveyed. The US capital—Washington, DC—was highlighted as having the highest infant mortality rate of all the world's richest capitals; 6.6 babies die per 1000 live births in Washington, in comparison with 1.6 infant deaths per 1000 live births in the Czech capital Prague, which topped the charity's index measuring child survival in the world's wealthiest capitals. The United States also had the highest maternal death rates in the developed world: American women face a 1 in 1800 risk for maternal death compared with less than 1 in 19,000 in Poland.

Medscape spoke with Andrew D. Racine, MD, PhD, Chairperson of the American Academy of Pediatrics Poverty and Child Health Leadership Work Group, to discuss the results of the Save the Children report and the work group's plan to combat the health effects of poverty here in the United States.

Medscape: The findings reported in the State of the World's Mothers report[1] with respect to Washington, DC, are sobering. The outcomes for women and children in Washington masked huge disparities between rich and poor kids and generated international headlines. Were these results incongruent with what you see in New York City, or other major US urban centers?

Dr Racine: I'm not sure that Washington, DC, is unique, because other cities in the United States have equally troubling statistics with respect to infant mortality—Detroit, Baltimore, and others. In contrast, New York City has had a different experience for infant mortality. When you have large variation among cities in a single country, it is worth paying attention to the variation.

In New York City, the infant mortality rate is only 4.6 per 1000 live births. If you compare that with the data provided in the Save the Children report, you'll note that New York City is not on par with Germany, France, or the Scandinavian countries, but it's significantly better than either Washington, DC, or the US national average. Because the sociodemographics of New York are not all that different, it's worth asking why we have that kind of variation.

The Bronx is one of the poorest areas of the city. In fact, the Bronx is the poorest urban county in the country. The infant mortality rate in the Bronx, according to the most recent data, is about 5.7 per 1000 live births.[2] It's higher than that of the city in general, but considerably lower than in other places around the country, given the concentration of poverty in that borough and also the concentration of minorities (Latinos and African Americans).

There are obvious differences in what is happening in these different parts of the country. We need to be thinking about that. The comparisons between the United States and developing countries that are highlighted in the Save the Children report are very different. We are talking about apples and oranges. The infant mortality rates in the United States are the result of a very different set of conditions with a very different set of causes from what is causing infant and child mortality in the developing world. That has to do with living conditions and where these countries are with respect to their transition to both urbanization and industrialization.

Most children in the United States, if they are dying in the first year of life—which is what we mean when we are talking about infant mortality—are dying of prematurity and congenital conditions. In the developing world, children are dying of infections and malnutrition—the lack of access to clean water and sanitation. Those are different things.

If you want to look at what is driving infant mortality in the United States, then you are looking at what drives rates of premature birth. That is very nettlesome, because we probably are among the best in the world at saving babies who are born at less than 1500 g—the really small premature babies. Our neonatal intensive care units are on par with anywhere in the world.

The problem is we have so many more of those babies than everywhere else, and even with the best of care, a baby born at 1500 g has a much different prognosis than a full-term baby. If you have a lot of these babies, even if you are very good at taking care of them, your infant mortality rate is going to be significantly higher than places that don't have such numbers.

The question that we have to confront in the United States is why the birthweight distribution in our country is so different from elsewhere. We don't have a great answer for that. Some of it has to do with the fact that we have higher rates of teenage pregnancies, and those mothers are at high risk for adverse outcomes.

We see higher rates of obesity than in many areas of the world, and mothers who are substantially overweight, especially if they are morbidly obese, have more difficulties in terms of their newborn's outcomes. There also seems to be a difference in birthweight distribution among African Americans and Caucasians in the United States, even after controlling for such factors as education and income. We don't quite understand that, and it does play a role. It's a complex issue.


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