Poverty Contributes to Higher Infant Mortality in Rural Areas

By Will Boggs MD

October 21, 2020

NEW YORK (Reuters Health) - Socioeconomic disadvantages are a major contributor to the disparity in infant mortality between rural and nonrural parts of the U.S., and greater government investment in public health and non-healthcare services is associated with lower infant mortality rates, according to a pair of new reports.

"Though there is often a focus on investment in healthcare and strategies to improve individual health behaviors, our analysis suggests that economic factors, such as a lower average household income of families living in rural counties, may explain the higher rates of infant mortality in rural counties," said Dr. Deborah B. Ehrenthal of the School of Medicine and Public Health at the University of Wisconsin-Madison.

"This implies that while access to high quality health care is important, investment in communities beyond health care is needed," she told Reuters Health by email.

Dr. Ehrenthal and colleagues investigated the association of infant mortality with county urban-rural classification, as well as county health system resources and measures of socioeconomic advantage.

Among the 11.9 million live births included in the study, the infant mortality rate was lowest among infants born to mothers living in large fringe metropolitan counties, and infant mortality rates increased as counties became more rural.

The odds of neonatal death were also lowest in large fringe metropolitan counties, but there was an inconsistent trend with increasing rurality. Postneonatal mortality, however, increased progressively as counties became more rural.

Including health system characteristics in multilevel models did little to attenuate the disparity in infant mortality across rural and urban classification groups.

In contrast, including socioeconomic status (as measured by a previously developed advantage index) in the models eliminated virtually all of the disparity in the infant mortality between rural and urban counties.

Household income and median value of owner-occupied housing units were the biggest drivers of infant mortality, among the individual components of the advantage index.

While race and ethnicity were significantly associated with infant mortality, these factors had little impact or on the overall differences across the rural-urban classification groups.

"While access to high-quality healthcare is essential, healthcare alone cannot eliminate the adverse outcomes, such as infant mortality," Dr. Ehrenthal said. "Policies that address the social determinants of health in rural counties, such as those that reduce poverty, are also needed to address the high rates of infant mortality."

In a separate longitudinal study, published along with the first in Pediatrics, Dr. Neal D. Goldstein of Dornsife School of Public Health at Drexel University, in Philadelphia, and colleagues investigated how U.S. state and local government spending affects infant mortality rates.

From 2000 to 2016, infant deaths per 1,000 live births averaged 6.6 and ranged from a low of 3.5 (Vermont in 2016) to a high of 13.7 (Washington, D.C. in 2005).

Infant mortality rates were more than twice as high among Black infants (mean, 12.2) as among White (mean, 5.5), Asian American (mean, 5.1), or Hispanic (mean, 6.0) infants.

State and local government expenditures averaged $9.03 per person per state, but there was wide variation.

In regression models, each $0.30 increase in environmental spending per person was associated with a significant decrease of 0.03 deaths per 1,000 live births, and each $0.73 increase in social spending was associated with a significant decrease of 0.02 deaths per 1,000 live births.

The benefit was even greater among infants born to mothers younger than 20 years (with decreases of 0.08 and 0.06 deaths per 1,000 live births for the same increases in environmental and social spending, respectively).

In terms of environmental factors, higher spending on solid-waste management, housing, and parks and recreation showed the strongest association with decreases in infant mortality rate. For social expenditures, spending on public health, public welfare and hospitals showed the strongest associations with decreases in infant mortality rate.

"These findings suggest that targeted investment strategies for specific populations, particularly younger mothers, within communities may have differential impact on infant mortality rates and vary by state over time," the authors conclude.

Dr. Michele Kiely and Dr. Woodie Kessel, who wrote an accompanying editorial, told Reuters Health by email, "This study reinforces the importance of investing in children, like Head Start, that integrates child development with child health with family well-being, or like the WIC program improving nutrition for moms and infants. Whether it is education, social services, the environment, or family-support services, these investments in areas like these will save the lives of infants and many of our citizens."

"The health and well-being of Americans would be substantially improved by investing its healthcare dollars in prevention - both in terms of morbidly and mortality," said Dr. Kiely, of the Graduate School of Public Health and Health Policy at the City University of New York, and Dr. Kessel, of Dartmouth College in Hanover, New Hampshire, and the University of Maryland in College Park.

"In the U.S., we spend approximately a trillion dollars annually on healthcare, mostly direct medical care," they explained. "If we effectively incorporated Goldstein et al.'s 'non-healthcare' with quality medical care into an over-arching comprehensive systems approach, we would enjoy the improvements across the population spectrum and, of course, save infant lives and improve their well-being. Coupling the social determinants of health with the biological determinants and collectively investing would achieve health equity and all of the Healthy People goals."

Dr. Goldstein did not respond to a request for comments.

SOURCE: https://bit.ly/3ke6gSy, https://bit.ly/3jdMVj6 and https://bit.ly/3o6b4vW Pediatrics, online October 19, 2020.