I 042 LETTERS TO THE EDITOR
I wish to request that the title page be
changed hack to its previous format.
CHARLES M. SCHLOSSMAN, M.D.
Department of Pediatrics
Perinanente \iedical Group
900 Kiely Boulevard
Santa Clara, California 950.51
To TIlE EDIToR:
My sincere thanks and appreciation for the
new spine on PEDIATRICS-this 5 exactly what
‘as needed. As I have responsibility for filing
and finding my pediatrician husband’s journals, this vill save a great deal of time in often futile searches for just the right issue. I’ve even
color-coded the spines of back volumes as an aid,
and occasionally thought of writing to request
what flOW appears in 1970. Now if only all the other journals would simplify their spines in
bold, dark lettering. . .
Many smcere thanks-it was ai)out time we
had a i)reak.
Mns. HERBERT S. LEVIN
1368 W’oo(lruff Avenue
Los Angeles, California 90024
EDiToR’s REPLY:
\Ve wrote Dr. Horstmann of our dismay over
her dismay. The comment on page 8 of the
J
anuary issue was to express hope rather thanexpectation. Certainly we have no intention of
confronting subscribers with that which the majority dislike, either outside or within our covers .
In search of improved legibility, variations in the color, spacing, and size of the type used for
cover titles are now being introduced. We
fol-lov the “journals for readers” in printing such titles, and their authors; hopingthus.to interest
our own readers as they remove the mailing
wrapper. On this principle we expect to be
able to include the names of all contributors, in the newly added space, thus ending the Ct al.
listings which sometimes conceal the
better-known author who brings up the rear.
To 1)r. Schlossman we add that the seal of
the Academy is, indeed, on the present cover.
Its omission was never considered, but we
placed it l)elow the journals name to allow the name to appear in full above the top edge of a
lil)rary display rack.
To Mrs. Levin, the honor of being the first
pediatrician’s wife known to have appeared on
our Letters pages, and “many sincere thanks.”
Tm EDITOR
Factors Affecting Reports of Neonatal Deaths in United States and Elsewhere
To THE EDIT0II:
Again, I have read that the United States’
infant mortality rate is “a disgrace and totally
unacceptable,” that the Nation’s infant
mortal-ity rate is 21.7 per 1000 live births, and that
there are 12 countries which have lower infant
mortality rates than the United States.
I would very much like to challenge the
Edi-tonal Board of PEDIATRICS and the American
Academy of Pe&atrics to help clarify this somewhat mysterious l)ut often quoted figure.
I would like to see in print an authoritative
report outlining the criteria for neonatal death
as used in this country and its several states,
and also the coulltnies that are commonly listed Ill the forefront, in so far as infant mortality
rates are concerned. Which of these countries
have legalized abortion, and does this, in fact,
influence the mortality rate? What time period
is involved, what weights are involved, is it necessary to have one pulse beat or one
nespi-ratory effort in order to establish a diagnosis of
live birth, and so forth?
Your considerate attention is invited.
I and many practicing pediatricians eagerly
look forward to your communication.
LAURANCE N. NICKEY, M.D., F.A.A.P.
1515 North Oregon El Paso, Texas
EDIT0II’s NOTE: \Ve are grateful to two
an-thorities for the following replies to Dr.
Nickey. First, Dr. Moniyama:
Is the differential between the infant
mortal-ity rate for the United States (22.4 per 1,000
live births in 1967) and the corresponding rate for Sweden (13.7) , the Netherlands (13.4), Norway ( 14.8 ), and other countries of low mortality real?l2
One possible reason for the large differential
is the contribution that the nonwhite
popula-tion makes to the relatively high mortality rate
for the United States. Although the rate for
nonwhites is considerably higher than the rate
LETTERS TO THE EDITOR 1043
nonwhite population is a small proportion of
the total. Therefore, the infant deaths in the
nonwhite population do not account for the
large differentials between the infant mortality
rate for the United States and the rates for
other countries.
International comparisons of infant mortality
rates present problems of comparable
defini-tions of live birth and fetal death, and
registra-tion practices relating to these events. For
many countries of the world, the registration system is virtually nonexistent. However, the countries of low mortality, notably the
Scandi-navian countries, the Netherlands, United
Kingdom, Australia, New Zealand, and
Swit-zerland have had for many years a well
devel-oped vital registration system. The definitions
of live birth and fetal death, and the reporting
requirements for early infant deaths have been
stable. Even so, there are certain problems of
interpretation arising from differences in defini-tions of live birth and fetal death, and from
dif-ferences in statistical practice. However there
is no evidence to indicate that the international
differences in infant mortality can be
ac-counted for by differences in definitions or
sta-tistical practices.
In the international comparison of perinatal
and infant mortality which involved the United
States and six west European countries,3 a
number of demographic factors were examined
to assess their possible statistical effects on
in-fant mortality rates. It was concluded that fac-tors such as age of mother, birth order, and le-gitimacy would not account for the difference
ill rate for the United States and other
couii-tries of low mortality. Of the factors
consid-ered, only birth weight was thought to be a
possible factor which might account for a sig-nificant part of the difference in infant
mortal-ity rate. Unfortunately, national data on birth
weight are not available for many countries outside of the United States.
It is possible that special situations in certain
countries may have a favorable effect on the
infant mortality. Among these are free medical
care and hospital facilities which offer
advan-tages of early antenatal and obstetrical care.
However, there is no evidence to indicate that
the very low rates in the Scandinavian
coun-tries and the Netherlands result from their
medical care delivery system. Nor does it seem
likely that the liberal policy on abortions in certain of these countries would account for
the large international differentials in infant
mortality. For example, if one were to
hypothe-size that the infant mortality rate for the
abor-tuses in Sweden if carried to term would have
been twice that of those born alive, this would
have had the effect of increasing the total
in-fant mortality rate by about 10 to 15%. This is
not sufficient to account for the large difference in rate between Sweden and the United States.
Although the United States ranked more fa-vorably in the past than it now does, the infant
mortality rate for the United States has never
been so low as to be among the five or six
countries with the lowest infant mortality rate.
However, the United States began to lose
ground in the international standings in the early 1950’s. Because of the virtual halt in the
downward trend of the infant mortality rate in
the United States,4 an increasing number of
countries l)egan to record lower rates than the United States. The gap l)etween the rate for the United States and those for countries with
the more favorable mortality experience has
widened. Starting III 1966, a resumption of a
relatively large decline appeared to take place in the infant mortality rate for the United States. However, it is too early to tell if this
rate of decline will be sustained over any
length of time.
From the various studies that have been
made, it seems fair to state that the change in
trend of the infant mortality rate and the inter-national differentials in rates cannot be
attrib-uted to any known artefacts in the data.
Al-though the infant mortality rate for the United
States is now at an all-time low, there still
ap-pears to be room for further reduction in the
infant mortality rate. This is a point that is
dif-ficult to ignore.
I. M. MORIYAMA
Director, Office of Health
Statistics Analysis
United States Public Health Service
Health Services and
Mental Health Administration Rockville, Maryland 20852
REFERENCES
1. Progress in reducing infant mortality. Children,
9:201, 1962.
2. Chase, H. C. :Ranking countries by infant
mor-tality rates. Public Health Reports, 84, No. 1,
January, 1969.
Statis-1044 LETTERS TO THE EDITOR
tics: International comparison of perinatal and infant mortality: The United States and six vest European countries. Vital and Health Sta-tistics, Series 3, No. 6. Washington, D.C. :
Pub-lie Health Service, March, 1967.
4. Moriyama, I. M. : Recent change in infant mor-tality trend. Public Health Rep., 75:391, 1960.
EDITOR’S NOTE: Second, Dr. Yankauer:
“Disgraceful and totally unacceptable” are
inflammatory adjectives. They stir up
uncom-fortable feelings of personal guilt and blame. It
would be reassuring if the differences between
infant mortality rates in the United States and
those of several small European countries with
relatively homogenous populations and stable traditions could be explained away as statisti-cal artefacts.
Unfortunately the differences cannot be
ex-plained away. Clear evidence for their
sub-stance is the fact that infant death rates after
the first month of life are three times as high in
the United States as in Sweden. Reporting
re-quirements, abortions, and definitions of live
births cannot operate differentially at this time;
deaths from infectious diseases and accidents
account for the bulk of the differential by
cause.
In comparing early infant and perinatal
deaths, the relative magnitude of the rate
differ-entials is less although the absolute magnitude of the differences is greater. Here both legal
and customary reporting practice do serve to
narrow the gap somewhat. Yet, they still fail to
explain it away as a statistical artefact.
There is reason to believe that differences in
the characteristics of United States newborn
in-fants as compared to those of Western Europe
are related to the early perinatal mortality
dif-ferentials. During the period 1950 to 1960,
when the position of the United States vis a via
Western European countries deteriorated
sharply, there was actually an increase in the
proportion of low birth weight babies born in
this country.1 The weight-specffic neonatal or
first month death rates for both Caucasian and
Negro babies over 1,000 gm dropped during
these 10 years in all birth weight groups and of-ten quite substantially. Nevertheless, because
there were more small babies born (whose risk
was greater) the overall U.S. rates dropped
relatively little and considerably less than the
neonatal death rates of Western European
countries. Thus there is a strong implication
that one of the keys to the perinatal
differen-tials is to be found in the higher proportion of
U.S. babies who are small-for-date, or born
prematurely, or both. Unfortunately data on
birth weight-much less length of
gestation-comparable to those collected in the U.S. do
not presently exist in other countries so that the
assumption, though reasonable, cannot be
yen-fled.
It seems highly unlikely that these
differ-ences in early and late infant mortality rates
are traceable to genetic differences in the
pop-ulations compared. Almost everyone would
agree that they can reflect the operation of a
host of factors ranging all the way from the
health and growth of mothers during their own
fetal life and childhood to their current
knowl-edge and feelings about themselves and their
children-from the values expressed by the
workings of the society in which they live to
the distribution, accessibility, and capability of
those who provide medical care to them and
their children. Nutrition, family planning,
pov-erty, slums, pollution, high medical care costs
-take your pick of the headlines! No one
knows how to unscramble or weight this
multi-tude of factors. In a large country of
200,000,000 inhabitants it is probable that they
all play some part in explaining the picture.
Rather than using these comparisons to fix
the blame on some single scapegoat, perhaps
we should recognize that they really do
demon-strate that we can do better than we have been
doing. A physician can work to improve the
sit-uation within the limited sphere of his direct responsibilities, within the larger sphere of his
responsibilities as a member of a profession
and a community, and within the more global
sphere of his responsibilities as a citizen. Surely
anyone who looks can see the needs and
possi-bilities for constructive change in one or more of these spheres.
ALFRED YANKAUER, M.D.
Department Maternal and Child Health
Harvard School of Public Health and
Bunker Hill Health Center
Massachusetts General Hospital
Boston, Massachusetts
REFERENCE
1. Chase, H. C.: Infant mortality and weight at
birth: 1960 United States birth cohort. Amer.
