Intranational and International Comparisons

Large variations in infant mortality rates exist among different geographical regions as well as among racial and ethnic groups (Alexander et al., 1999; Allen et al., 2000; Carmichael and Iyasu, 1998; Joseph et al., 1998) (Chapters 1 and 2 and Appendix B). The United States ranked 28th of 37 industrialized nations in infant mortality in 2001 and has a higher rate of low birth weight. Although increasing preterm birth rates and racial and ethnic disparities in the rates of preterm birth have been implicated, methodological factors are contributors to these differences (Chapter 2 and Appendix B). For example, efforts at resuscitating infants born at the lower limit of viability, thereby classifying them as live births (not stillbirths), increases the rate of infant mortality because so many infants born before 24 weeks of gestation die (Alexander et al., 2003; Martin et al., 2005; MacDorman et al., 2005). The dearth of international comparisons of preterm birth rates is due to similar methodologic concerns about how gestational age, live births, and fetal deaths are recorded and reported (Appendix B).

The rate of infant mortality among African-American populations in the United States in 2000 was 14.1 per 1,000 live births, more than twice the national average of 6.9 per 1,000 live births (NCHS, 2002). The rate of access to high-quality neonatal intensive care varies by race and ethnicity (Alexander et al., 2003; Morales et al., 2005; Wise, 2003). Preterm birth rates for African Americans are more than twice those for Hispanic or white infants (Alexander et al., 2003). Although African-American infants born preterm have had a survival advantage over white infants born preterm, this gap is narrowing, and the higher proportion of African-American infants born preterm and the higher mortality rate among African-American infants born full term play a greater role in the disparity in African-American and white infant mortality rates (Alexander et al., 2000, 2003; Allen et al., 2000) (Appendix B).

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