When I saw the headline of a TIME article that read “Why U.S. Infants Die Too Often“, I clicked over thinking that it would be something about prenatal care or this test or that test that we’re not running but should be or maybe this procedure or that procedure that we are or are not performing. Instead, I got something that made me want to throw something at my computer monitor. Here is the logic of the article and of Marian MacDorman, the statistician that they consulted:

One of the main [factors] is whether the baby is delivered too small or too soon, which increases its chances of death. About two-thirds of all of our infant deaths occur among the 8.2% of babies that are born at low birth weight. Most developed countries have lower rates of preterm and low birth weight deliveries [than the U.S.] and that makes a difference in infant mortality rates. {…}

There are a lot of doctors who say it’s O.K. to take a baby out a little bit early because they’re going to do well — and it’s true. It’s only seven per 1,000 that are dying. Most of them do well. But still I think it’s important to note that the infant mortality rate for late-preterm infants is three times what it is for [full-]term infants.

One gets the image of doctors saying “I am just booked solid next week, so let’s deliver this baby a week early cause I don’t want to have to work late.”

In reality, when babies are delivered preterm, it’s because there is already some sort of problem and not because doctors don’t know as much about medicine as do statisticians. Granted, I am the husband of a doctor (who has done a lot of work in obstetrics) and that influences my perspective. Not because I believe doctors are perfect just cause my wife happens to be, but rather because I get to hear a lot about the ins and outs of following pregnancy and delivering babies. My wife is more conservative than most doctors and has in the past complained about the pro-active attitude some doctors take about inducing labor. What she hasn’t complained about, though, are doctors purposefully delivering babies that they believe to be healthy ‘just cuz’.

Doctors and hospitals make the determination about whether to deliver early based on the baby’s chances of survival in the whom and out of it. It’s quite possible that these calculations are flawed and they overestimate the threat to the baby in utero. If MacDorman has statistics that suggest that our efforts to avoid miscarriages and stillborns and all that are overly aggressive, you are going to have to look at alot more than infant death rates. Without information about miscarriages under this scenario or that, the numbers that McDorman cites are not particularly helpful. When it comes to infant mortality, there have to be infants involved. Delivering a baby preterm that dies counts as a strike against us, but a baby that dies before being born doesn’t count either way.

American doctors and American hospitals are much, much more conscientious of pre-birth deaths than a lot of other countries. A lot of it you can chalk up to the fact that a dead fetus leaves them financially vulnerable than doctors in other countries. To the extent that doctors may jump the gun, it’s because it’s a lot easier to get sued for being perceived as doing too little than it is for being perceived as having done too much. It’s this far more than anything else that might lead to this error. But we also live in a culture with a more protective attitude towards fetuses than many others. Sometimes, as in the case of jury awards, too much so. Also, though, because it leads us to deliver babies using resources that might better be directed elsewhere.

The hospital that Clancy worked at down here had very, very aggressive fetus-saving policies. It lead to babies being delivered earlier than any baby has even a remote chance for survival beyond a few days. But nonetheless they deliver the baby. They do everything they can within (and beyond) reason to prolong the life for as long as they can. The result is a dead baby and a slightly higher infant mortality rate. When working in Deseret, one of the higher ups was a doctor from Britain who commented with astonishment the lengths that American health care goes for (seemingly) lost causes.

While it’s quite possible that we don’t have a greater need for preterm deliveries than other countries, it’s possible that we do for at least a couple reasons that come to mind:

1. Heroic measures: As mentioned above, we deliver babies that other countries may not even try to. This may be unwise on our part, but not necessarily for the reasons that MacDorman implies.
2. Poor prenatal care: A lack of prenatal care can mean that little problems that go unaddressed earlier in the pregnancy become bigger problems later on. We also have higher instances of drug use, which can not only cause natural preterm labor and complications that require induced labor or cesarians, but it also leads to mothers failing to seek out prenatal care because they don’t want to get caught with drugs in their system. This one wouldn’t have occurred to me, but Clancy has reported it on more than a few occasions. It’s probably worthy of a post.
3. Fertilization drugs: Fertilization drugs are very common in the US. Moreso, I’d imagine, than many other developed countries because our religions more vigorously promote procreation than a lot of other countries do. It’s noteworthy that multiple-births are more common in religious conservative states than in blue ones. Fertility drugs cause multiple-births. Multiple-births shorten the expected length of the presidency pregnancy by something like 4 weeks per extra baby.

MacDorman seems to recognize that there may be contributing factors in the last couple of paragraphs but only as they pertain to comparing the demographics of which babies are prematurely delivered most often. Would that she were interested in contributing factors in comparing the US to other nations beyond the simple conclusion that she’s smarter than the doctors.