A child born in Guilford Country, North Carolina or Baltimore, Maryland has about the same chances of dying on her first day as a child in Namibia.

Save the Children’s new Birth Day Risk Index ranks countries by the chances that a child born will die on her day of birth. Somalia and the DR Congo rank at the very bottom with a birth day mortality ratio of 18/1,000 and 17/1,000 live births respectively.  Luxembourg and Iceland are on top of the charts, with a ratio of less than 0.5.

The USA ranks decidedly poorly on this index, at least compared to other wealthy countries. The USA’s ratio as a whole is 2.6. But when you break down the numbers by county, the figures are downright shameful for a country as wealthy as the USA.

Guilford County, North Carolina,  has a birth day mortality ratio of 6.5, putting it on par with sub-saharan African countries Rwanda and Namibia, which have ratios of 7 and 6 respectively. Baltimore, Maryland is about the same. As is Mercer County, New Jersey.

Here’s a list of the top 20 countries in the USA with the highest birth day mortality ratios.

And here’s a selection of countries that have birth day mortality rates between 7 deaths and 4 deaths per 1,000 live births:

Countries with 1st-day death rate of close to 7/1,000
Iraq
South Africa
Morocco
Rwanda
Cambodia
Azerbaijan
Kyrgyzstan
Guyana
Kiribati

Countries with rate of 6/1,000
Algeria
Korea, Democratic People’s Republic of
Paraguay
Lao People’s Democratic Republic
Namibia
Suriname
Micronesia, Federated States of

Countries with rate of 5/1,000
Indonesia
Iran, Islamic Republic of
Uzbekistan
Guatemala
Kazakhstan
Dominican Republic
Occupied Palestinian Territory
Trinidad and Tobago
Saint Vincent and the Grenadines

Countries with rate of 4/1,000
Brazil
Philippines
Vietnam
Colombia
Ecuador
Honduras
Jordan
Nicaragua
Mongolia
Jamaica
Georgia
Botswana
Armenia
Solomon Islands
Barbados
Dominica
Marshall Islands

Here’s Save the Children’s explantion of why the USA ranks so poorly. It boils down to poverty, racism, and poor access to reproductive healthcare.

Many babies in the United States are born too early. The U.S. preterm birth rate (1 in 8 births) is one of the highest in the industrialized world (second only to Cyprus). In fact, 130 countries from all across the world have lower preterm birth rates than the United States. The U.S. prematurity rate is twice that of Finland, Japan, Norway and Sweden. The United States has over half a million preterm births each year – the sixth largest number in the world (after India, China, Nigeria, Pakistan and Indonesia). According to the latest estimates, complications of preterm birth are the direct cause of 35 percent of all newborn deaths in the U.S., making preterm birth the number one killer of newborns. Preterm birth is a major cause of death in most industrialized countries and is responsible for up to two-thirds of all newborn deaths in countries such as Iceland and Greece. 

The United States also has the highest adolescent birth rate of any industrialized country. Teenage mothers in the U.S. tend to be poorer, less educated, and receive less prenatal care177 than older mothers. Because of these challenges,

babies born to teen mothers are more likely to be low-birthweight and be born prematurely178 and to die in their first month. They are also more likely to suffer chronic medical conditions, do poorly in school, and give birth during their teen years (continuing the cycle of teen pregnancy).

Poverty, racism and stress are likely to be important contributing factors to first-day deaths in the United States and other industrialized countries. Current data do not allow for analysis of first-day death rates among disadvantaged groups in wealthy countries, but newborn and infant mortality are often higher among the poor and racial and ethnic minorities, and populations with high newborn mortality rates also tend to have high first-day death rates. Poor and minority groups also suffer higher burdens of prematurity and low birthweight which likely lead to first-day deaths in the U.S. and elsewhere. 

One recent analysis of U.S. data found that most of the higher infant mortality experienced by black and Puerto Rican infants compared with white infants was due to preterm-related causes. These groups are also less likely to receive the high-risk care they need, which puts their babies at even higher risk. What can be done to reduce first-day deaths in the United States and elsewhere in the industrialized world? Investments in education, health care and sexual health awareness for youth will help address some of the root causes.186 Wider use of family planning will also improve birth outcomes and reduce newborn deaths. In the United States, percent of pregnancies are unplanned187 and these babies are at higher risk of death and disability. Efforts to improve women’s health would also have a positive impact on survival rates of babies.

High-quality care before, during and after pregnancy (including home visits by nurses or community health workers if appropriate) and access to the appropriate level of care at the time of delivery can result in healthier mothers giving birth to healthier babies. More research is needed to better understand the causes of prematurity in high-income settings and to develop better solutions to prevent preterm births.