Infant Mortality Rate in the US Compared to Sweden

Running Head: INFANT MORTALITY RATE COMPARISON 1
Infant Mortality Rate in the United States Compared to Sweden
Karissa Braden
Purdue University

INFANT MORTALITY RATE COMPARISON 2
Infant Mortality Rate in the United States Compared to Sweden
The United States is the seventh richest country in the world, spends the most money on
health care, and yet ranks only 56th out of 224 territories for lowest infant mortality rate (Central
Intelligence Agency, 2014). To put this in perspective, even though 1 million less babies are born
in the U.S. each year, twice as many will die on their first day of life than in all the 27 European
Union nations combined (Williams, 2013). More specifically, a baby born in the U.S. is almost
2.5 times more likely to die within their first year of life compared to a baby in Sweden, which
ranks 6th for lowest infant mortality rate (Central Intelligence Agency, 2014). How do two
highly developed countries, United States and Sweden, have such drastically different infant
mortality rates? The United States’ high inequality and preterm birth rate play a large part in
their high infant mortality rate, while Sweden’s low rate of inequality and universal health care
coverage play resilient roles to the same risk factors that affect the U.S. so harshly.
Background on Infant Mortality
The Central Intelligence Agency (2014) defines infant mortality rate as “the number of
infant deaths under one year old in a given year, per 1,000 live births in the same year”.
According to MacDorman and Mathews (2008), it is one of the most important indicators of a
nation’s health because it is associated with multiple factors such as quality of and access to
healthcare (p. 1). Factors that are impacting the death of an infant in a country are also affecting
the health of the entire population. We expect industrialized countries to have the lowest rates
because they have advanced technology, cutting-edge research, high incomes, and access to
resources, even resources as simple as clean water. The United States is one of the most
developed countries, yet has one of the highest infant mortality rates of the industrialized world.

The U.S. did have a consistent downward trend between 1935 to 2000, with the infant
mortality rate declining from 55.7 per 1,000 live births to 6.9. However, over the past fourteen
years, the rate has only dropped to 6.17 (Singh & van Dyck, 2010). Also, all of the major causes
of infant death have had a downward trend in mortality, except for a recent upturn in mortality
from prematurity. In the U.S., the occurrence of preterm births before 37 weeks gestation
increased 36% from 1984 to 2006. The U.S. now ranks 6th for the greatest number of preterm
births worldwide (World Health Organization, 2013). Many other countries are also showing an
increase in preterm birth rate over the past 20 years, and it remains the leading cause of newborn
deaths worldwide (Williams, 2013).
Risk Factors for Infant Mortality
According to Williams (2013), there are five main causes of infant mortality: “birth
defects, sudden infant death syndrome, maternal health complications, unintentional injuries, and
preterm-related causes of death.” There are multiple risk factors that certain countries, such as
the U.S., are more susceptible to because of the characteristics of their population and economy.
Key risk factors contributing to infant mortality include: maternal smoking, secondhand smoke,
inadequate nutrition of the mother, street drugs and alcohol during pregnancy, infections during
pregnancy, and an overall less than optimal health of the mother (North Carolina Healthy Start
Foundation, 2013). Many of these risk factors lead to a low birth weight baby and a shorter
gestation, which are two of the most important determinants of survival in a newborn (Singh and
van Dyck, 2010).
Wennemo (1993) states, “a country’s level of economic development reflects its capacity
to reduce infant mortality” (p. 431). Here, economic development not only means whether a
country is considered rich or poor, but also includes the extent of distribution of economic

resources, social security, and health care throughout the country. A country, such as the U.S.,
can have an abundance of economic resources, but if the distribution is not equal there can be a
large portion of the population that is unemployed, uninsured, uneducated, or living below the
poverty line. All of these characteristics put an individual at high risk for infant mortality.
Therefore, on a macro-level, an important risk factor for infant mortality is increased social and
income inequality throughout the country (Wennemo, 1993).
Factors Affecting the United States’ Infant Mortality Rate
High Inequality
Income inequality. As stated previously, the United States has high levels of social
inequality, one of the highest among the developed countries to be specific. According to Noah
(2012), "among the industrial democracies where income inequality is increasing, it's much
worse in the United States than it is almost anywhere else.” Among the 34 highly developed
countries surveyed by the Organization for Economic Co-operation and Development (OECD),
only Turkey, Mexico, and Chile had a higher income inequality than the U.S, and all three are
much less economically developed than the U.S.
Many indicators are used to measure income inequality including the Gini coefficient and
household income after taxes and government transfers. The Gini coefficient, measuring income
distribution, is the most commonly used measure of inequality because it summarizes inequality
in a single number: 0 representing complete equality, everyone has the same income, and 1
representing complete inequality (World Bank, 2011). The U.S. ranks 31 out of the 34 countries
in the OECD, with a Gini coefficient of 0.45. This is the highest the U.S. has been since 1967
when inequality first started to be measured. The Gini coefficient differs drastically from state to
state, which could play a role in the United States’ high value. For example, in 2011 the state

with the lowest inequality was Wyoming with an estimated coefficient of 0.437, and the highest
inequality was in District of Columbia with an estimated coefficient of 0.5338 (U.S. Department
of Commerce, 2011).
The household income measurements for the U.S. are also concerning. According to the
Congressional Budget Office’s (2011) study from 1979 to 2007, income rose by 275% for the
top 1 percent and only 18% for the bottom 20 percent of the population. When comparing the
U.S. to the other 21 richest countries in 2006, the U.S. had the second highest ratio of top 20%
income to the bottom 20% income (20/20 ratio). This illustrates that there is a very large gap
between the rich and the poor, in other words high inequality (Pizzigati, 2009). Also, the poverty
rate in the U.S. is 39th in the world with 15% of the population living below the national poverty
line. (Central Intelligence Agency, 2010). If this trend continues, the gap between the rich and
poor in the United States will become even larger and income inequality will rise further.
Income inequality negatively impacts infant mortality because of limited resources to a
large portion of the population and limited cohesiveness throughout a country. Decreased
cohesiveness leads to more social aggressiveness, stress, and ultimately a divide between the
community, with each side prioritizing different wants and needs. David (2011) argues that a
national policy in favor of income redistribution would improve the overall population health by
“relieving the fate of the poor” (p. 4). The U.S. may be the seventh richest country in the world,
but when the poverty rate and 20/20 ratio are so high compared to other developed countries, the
infant mortality rate begins to reflect the bottom 20% instead of the top 20%
Health insurance inequality. The number of uninsured also adds to the level of
inequality in the United States. Of the 34 countries in the OECD, 20 countries have 100% of
their population insured. The U.S. is second to last with only Chile behind the U.S. (OECD,

2013). Overall, 15.4% of the U.S. population is uninsured, but the percentage of uninsured from
state to state differs greatly. For example, only 4% of the population is uninsured in the state of
Massachusetts, but 24% of Texas is uninsured (Henry J. Kaiser Family Foundation, 2012). Texas
not only has the highest percentage of people uninsured in the U.S. but also the largest number of
children uninsured and the highest rate of adults under the poverty line that are uninsured
(Aaronson, 2013).
Having no health insurance forces people to postpone necessary health services, like
prenatal care. A study by the Institute of Medicine (2002) showed a correlation between lack of
insurance, fewer prenatal care visits, low birth weight infants, and infant mortality. A mother can
have a treatable condition, such as hypertension or gestational diabetes, that when goes
untreated, causes her to go into preterm labor or leads to health complications for her newborn.
Racial inequality. Even though the income gap between races is smaller than in the past,
there are still racial differences, according to the U.S. Census Bureau. In 2012, the median
income for Asian Americans was $68,636, White Americans was $57,009, Hispanics was
$39,005, and African Americans was $33,321 (DeNavas-Walt, Proctor, & Smith, 2012). African
Americans are not only paid the least, but they also have the highest infant mortality rate among
racial groups. Racial income inequality has been a significant predictor of African American
infant mortality rate in nation-wide studies (Jesmin, 2008). According to a report by Stanford
Medicine, “African Americans had — and continue to have — almost double the rate of infant
deaths as Caucasians” (Williams, 2013).
From 1935 to 2007, the infant mortality rate for black infants compared to white infants
went from 38% higher to 134% higher (Singh & van Dyck, 2010). Currently, the infant mortality
rates in the U.S. range from 3.57 per 1,000 live births in Alaska, with only 4% of their

population African American, to 9.62 per 1,000 live births in Mississippi, with 37% of their
population African American (CDC, 2010). Mississippi has the largest percentage of African
Americans and also the highest infant mortality rate in the U.S. There are multiple factors
complicating the causes of their increased mortality rate including the highest rates of obesity,
preterm birth rates, teen pregnancies, and poverty in the country (Landau, 2012). The state of
Mississippi has the greatest racial inequality in the U.S. when it comes to infant mortality rates.
Overall, there are multiple factors leading to the higher infant mortality rate among
African Americans in the U.S. African American women have a higher stillbirth and preterm
birth rate, on average have lower income and less education, are more often uninsured, and are
less likely to breastfeed compared to White American mothers (Braunstein, 2012). The increased
African American infant mortality rate has a larger affect on the U.S. rate since they make up
approximately 13% of the United States population, while African Americans comprise only 1%
of the total population in all of Europe (Central Intelligence Agency, 2011).
High Premature Birth Rate
According to Stanford Medicine, when comparing infant mortality rate between the
United States and other industrialized countries, the factor making the most significant difference
is premature births. In the U.S., almost one in eight babies is born premature, between 22 and 37
weeks gestation, which is the second highest rate in the industrialized world (Williams, 2013).
There are multiple reasons for the United State’s increased preterm birth rate. There is a
high proportion of African Americans in the U.S. compared to other developed countries, and
their preterm birth rate is 5.3% above the national rate (Braunstein, 2012). Also, in an attempt to
lower the U.S. stillbirth rate, physicians are inducing mothers before their due date more often
than in the past. This leads to a premature birth. Lastly, the United States has the highest teenage

birth rate in the industrialized world. It is four times the European Union average. Teenagers are
more likely to have low birthweight babies, and majority of these babies are born premature
(March of Dimes Foundation, 2012).
As one can see, there are many factors contributing to the increased preterm birth rate in
the United States. If the U.S. decreased it’s preterm birth rate to the same rate as Sweden, the
infant mortality rate would decrease by 33% (Williams, 2013). This shows how large the role of
preterm births affects the infant mortality rate in the U.S.
Sweden Infant Mortality Rate
Sweden is ranked 6th in the world for lowest mortality rate and 11th in the world for
lowest preterm birth rate. Compared to the United States, they have almost 49% less of a class
divide, spend almost 53% less money on health care, and have 55% less chance of infant
mortality (Lintner, 2010). There are multiple reasons why Sweden has a much lower infant
mortality rate than the United States including social equality and their universal health care
system.
Equality
According to Arntzen and Nybo Andersen (2004), social equity in health is a vital goal of
public health policies in Nordic countries, including Sweden. The statistics regarding their
population and economy confirm they are achieving that goal. With the most recent data on
Sweden’s Gini coefficient from 2005 being 0.23, they have the lowest inequality in the world
(World Bank, 2011). To add to their equality, the top 20% of earners only have an income four
times that of the bottom 20% of earners, compared to the U.S. where the difference is eight times
(Jones, 2012). Also, even with the mere 3.7% of their population who lives below the poverty
line, 100% of their population has health insurance (Central Intelligence Agency, 2010).

Health Care System
Sweden has universal healthcare coverage where health services are uniform for
everyone. The county councils at the regional level are responsible for delivering healthcare to
their residents, and only 10% of Sweden’s GDP goes towards healthcare costs (Wright, 2004).
There are small fees to help avoid abuse of their inexpensive healthcare system such as 100
kronor (USD 14) to visit a primary care provider or 80 kronor (USD 11) for a hospital stay per
day. If a citizen cannot afford the costs, the government will provide financial assistance
(Swedish Institute, 2013). Also, the majority of Swedish physicians are salaried and thus have no
incentive for performing more procedures or ordering unnecessary tests. Sweden will also only
provide treatments if there is evidence of its effectiveness. People can spend privately on
unproven treatments if they wish. There is also a large focus on trained midwives, which is
thought to play an important role in Sweden’s low maternal and infant mortality rates (Swedish
Institute, 2013).
Caregiver credit. In recent years, caregiver credits have become nearly universal in the
higher-income OECD countries. In Sweden, the caregiver credit is for any parent caring for a
child four years or younger. The parent can receive one of three options, whichever is most
favorable at that time for the individual’s situation: earnings equal to their income the year
before childbirth, 75% of the average earnings in Sweden, or a fixed amount of 52,1000 kronor
(USD 8,028). Sweden’s caregiver credit is unique because it offers three different options that
fits three different types of workers: those who had a high income before childbirth, those who
had a low income before childbirth, and those who are still working after childbirth. Also, the
program only uses 2% of total pension expenditures for the country (Jankowski, 2011). One
might not think that caregiver credits after a newborn’s birth can decrease infant mortality rate,

but social security systems such as this function as safety nets. They compensate for losses of
income that can impact a family’s risk for poverty, which would increase income inequality in
the country, and thus increase the infant mortality rate (Wennemo, 1993).
Conclusion
The high rates of inequality and preterm birth have a large impact on the United States’
high infant mortality rate. In comparison, Sweden’s low rates of inequality and universal health
care coverage make them resilient to the same risk factors that affect the U.S. so harshly. The
United States has made strides, but it is still falling behind the other industrialized countries.
When discussing the United States’ infant mortality rate, Paul Wise, a health policy analyst at
Stanford, stated, “The infant mortality rate in many ways is a synoptic judgment on our health-
care system and our society. It’s telling us that we must do better — and we can do better,
especially when it comes to eliminating social disparities in medicine” (Williams, 2013, p. 46).
Sweden may have the perfect recipe: income redistribution and increasing social security for
vulnerable groups (Wennemo, 1993). But will the United States’ large and diverse population
continue to act as a barrier to decreasing their high infant mortality rate, or will they finally find
a way to overcome it?

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Infant Mortality Rate in the US Compared to Sweden

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