Northeast Mississippi Birthing Project

As a local group of Birthing Project USA, the Northeast Missisippi Birthing Project [blog] has as its goal improving maternal outcomes and reducing infant mortality. By providing at-risk pregnant women with a sister-friend to help them during pregnancy, mothers and babies have better outcomes. [“At-risk” includes teen moms, single moms, moms without insurance, etc., not necessarily a medical risk.] Our primary goal is the reduction of infant mortality. For more information, click the links I’ve already given, because the work is really wonderful and the results have been astounding. If you’ve been looking for something concrete to do to help pregnant women, this is something you really should look into. There are branches all over the United States, so you may be able to find out already started; or you may be able to start one in your area. For a brief overview of what we do, please watch the video below [btw, I made it, so of course I like it! :-)] —

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Don’t just do something — stand there!

We’re used to the saying, “Don’t just stand there — do something!” and many times it’s true. Many times, however, it’s not. We value action — as measured by clichés like “He who hesitates is lost.” But we also understand the value of assessing a situation, to determine the best course of action — “Look before you leap.”

The father of a former coworker is a good example of not rushing into doing the first thing that pops into your mind. One time, there was a small kitchen fire that somehow started and caught the window curtains on fire. He rushed in, saw the fire, and pulled the curtains down. With his bare hands. Severely burning his hands, and if I remember correctly, requiring hospitalization. Far better would it have been for him to pause half a second longer, and grab a broom or some other object to get the burning curtains away from the walls and into the sink. Other similar stories abound of people throwing water on a grease fire, and spreading the fire instead of stopping it. They just reacted to the immediate situation… and reacted wrongly.

A great medical example is that of a nurse, pharmacist, or anyone else handling medication to double-check to verify that the medication they are dispensing is the medication they are intending to dispense to that patient. Or do an ultrasound to make sure that the baby really is breech before doing a C-section for a supposed breech baby (who may have flipped sometime in the past few minutes or few days).

Sometimes, it is better to pause, take a breather, and really think before acting. Or not to act at all.

What is commonly trumpeted by obstetricians is that maternal, neonatal and infant mortality dropped during the 20th century, for which they claim sole credit; what is not commonly told is that in the first part of the century, maternal and infant mortality increased under the care of doctors and particularly with births in the hospital. There are numerous quotes which demonstrate this, and show that it was known by some of “the powers that be” at the time, but I’ll just include a few [emphases mine]:

~ “Why bother the relatively innocuous midwife, when the ignorant doctor causes many more absolutely unnecessary deaths”. [1911-B; Dr.Williams,MD,p.180]

~ “In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives’”. [Dr. Ira Wile, 1911-G, p.246]

And from the same source, later quotes from a 1975 study on the topic:

~ “Whether because midwives provided more skilled care or because obstetricians were too eager to interfere in labor and birth, obstetric mortality rates often rose as … midwife practice declined.” [DeVitt, MD; 1975]

And then from this document, quoting a conclusion made about midwives, a report presented to the White House,

“…untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child.

On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.”

While the doctors’ motto was, “First, do no harm,” the reality was that oftentimes, they caused harm by acting, when less harm would have come to mother and/or child had they not acted. “Well,” you might say, “that was then! A lot of things have changed since then.” Yes, and no.  Sometimes waiting patiently is still the best course of action:

Sometimes acting and intervening and speeding things up is the best course of action; but how often is slowing down and waiting on nature to take its course much better! When you have technology and gadgets and other things at hand, it’s easy to use them even when unnecessary. “When all you have is a hammer, everything looks like a nail.” And the ever-excellent quote from Jurassic Park via Jeff Goldblum, “Yeah, but your scientists were so preoccupied with whether or not they could, they didn’t stop to think if they should.”

First make sure you’re right, then go ahead. — Davy Crockett

Pregnancy and Infant Loss Remembrance Day

It was October 15, so I’m a little late. I didn’t realize there was even such a worldwide day of remembrance, until a few of my facebook friends posted it (mostly those who had miscarriages), and some of the blogs I read likewise mentioned it.

Many women experience miscarriage — I’m not sure of the exact percentage. It seems like I’ve heard that one in six pregnancies end in miscarriage, but I’m not sure how accurate that figure is. I know a lot of women who had miscarriages; many women have multiple miscarriages — my sister had three prior to her two successful pregnancies, and others have none. Many women experience babies who are stillborn, or who die in their first year of life.

Some women grieve as much over an early miscarriage as other women grieve over a full-term or infant loss. However, many people seem to judge women who grieve over early pregnancy losses, as if they were somehow less connected to their child, or they ought to have loved him or her less. Many infertile women grieve over their menstrual cycle, with every month being like a pregnancy loss, since it is evidence that there will be no child born from this month’s attempt at conception.

If you’re on facebook, I think you will be able to read this note (My Forever Child), with multiple links to information websites.

Mary Breckinridge, the first American CNM

At a time when maternal mortality was 800/100,000 and infant mortality claimed one in ten lives, Mary Breckinridge was a true life-saver. She established Frontier Nursing Service in 1925, which brought quality care to rural (and typically, impoverished) Kentucky women. Frontier still trains nurse midwives. Here are a few articles about Mary Breckinridge, in honor of National Midwifery Week:

In many ways, Ms. Breckinridge was to nurse-midwifery what Ina May Gaskin is to non-nurse midwifery. Most of us are probably more familiar with Ina May than Mary Breckinridge, for many reasons — we home-birthers tend to hire CPMs rather than CNMs (who many times cannot legally attend home births); we’ve read her engaging books; she’s still alive and giving interviews, and working hard promoting midwifery and awareness of maternal mortality, etc. But there are many similarities between the two women — both saw a need and filled it; both popularized midwifery; it’s possible that without Mary Breckinridge, there would be no “CNM” at all, and perhaps without Ina May Gaskin there would be no CPM either. There have been many other influential figures, and many other necessary players, in the realm of midwifery; but in each of these cases, they were at least the starting point in their respective fields, and in so doing, saved midwifery and/or home birth. In some ways, Ms. Breckinridge had a harder role, perhaps, living at a time when doctors were on a full-court press to eliminate midwives as dirty and incompetent (in contrast to their sterile hospitals and/or sterile technique, in addition to their high-falutin’ education). The fact that maternal mortality increased with the increase in hospital births was not widely known; and the fact that these “dirty” and “incompetent” midwives had lower maternal mortality attending home births than doctors attending home births; and home birth had lower maternal mortality (and morbidity) than hospital birth, was actively suppressed by obstetricians of the day, in their PR campaign to drive out midwives and midwifery. For a woman to consciously and willingly step into a demonized role, roll up her sleeves, and get to work, should be recognized and given full credit. In some ways, I think it might be like the wife or daughter of a plantation owner going to live in a slave hut, and working the fields, instead of living a pampered life of ease and enjoyment.

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Abortion and Preterm Birth — a new study

Sidney Midwife, one of the blogs I read, had this as her most recent post: Study Showing Abortion-Premature Birth Risk Points to Cerebral Palsy. Since this is National Infant Mortality Awareness Month, and since premature birth increases infant mortality, this newest study has implications for this topic.

When I read about the study, I read the article, and then decided to find the abstract. Since the article mentioned that the study was published in the BJOG, and mentioned the study’s lead author, I had a good head-start. So, I went to the BJOG website, did a search for the author’s name, and came up with a pod-cast. Then the abstract. Then — wishful thinking! — I clicked on “fulltext,” fully expecting to go to a login screen, where I would have to pay $38 to view the report. What a pessimist realist! But, lo and behold, the full study is available! [Yeah, I’m a nerd — excited about being able to read a full study. :-)]

Here is the abstract:

Background History of induced termination of pregnancy (I-TOP) is suggested as a precursor for infant being born low birthweight (LBW), preterm (PT) or small for gestational age (SGA). Infection, mechanical trauma to the cervix leading to cervical incompetence and scarred tissue following curettage are suspected mechanisms.

Objective To systematically review the risk of an infant being born LBW/PT/SGA among women with history of I-TOP.

Search strategy Medline, Embase, CINAHL and bibliographies of identified articles were searched for English language studies.

Selection criteria Studies reporting birth outcomes to mothers with or without history of induced abortion were included.

Data collection and analyses Two reviewers independently collected data and assessed the quality of the studies for biases in sample selection, exposure assessment, confounder adjustment, analytical, outcome assessments and attrition. Meta-analyses were performed using random effect model and odds ratio (OR), weighted mean difference and 95% confidence interval (CI) were calculated.

Main results Thirty-seven studies of low–moderate risk of bias were included. A history of one I-TOP was associated with increased unadjusted odds of LBW (OR 1.35, 95% CI 1.20–1.52) and PT (OR 1.36, 95% CI 1.24–1.50), but not SGA (OR 0.87, 95% CI 0.69–1.09). A history of more than one I-TOP was associated with LBW (OR 1.72, 95% CI 1.45–2.04) and PT (OR 1.93, 95% CI 1.28–2.71). Meta-analyses of adjusted risk estimates confirmed these findings.

Conclusions A previous I-TOP is associated with a significantly increased risk of LBW and PT but not SGA. The risk increased as the number of I-TOP increased.

To be honest, the study does not even mention cerebral palsy, nor does it mention infant mortality — those are conclusions drawn by other readers of the study, based on the known facts of the risks of preterm birth and low birthweight. For instance, this cerebral palsy website says, in part,

Extremely low birth weight infants are 100 times more likely to develop CP than a full term infant. In one large overview of 6399 very low birth weight children that survived neonatal intensive care, childen that were evaluated up to age 3, the rate contracting CP was 77 per 1000. 2.5 per 1000 is the normal rate.

The CDC says,

Being born preterm is the greatest risk factor for infant mortality (death within the first year of life). Recent analyses of infant death data by CDC researchers demonstrate that preterm-related deaths accounted for more than 1/3 of all deaths during the first year of life, and more infants died from preterm causes than from any other cause.

Thinking of this sad topic always brings to mind a woman’s blog I read over a year ago. I forget how I even stumbled across it — some word search on Google or WordPress or something. Anyway, she told the story of her pregnancies. Midway through her first pregnancy, she found out that the baby had some defect of some sort — I can’t remember what it was, if it was genetic like Down Syndrome or physical like spina bifida  (probably neither one; it may have even been lethal) — and chose to terminate the pregnancy, rather than to give birth to a deformed child. The abortion took place sometime around 20-24 weeks. Then she got pregnant again; tests showed that everything was fine for this baby, and then a few weeks of gestation after the time of the first abortion, she went into preterm labor that was not (could not be?) stopped, and her baby died. I wondered at the time if her first abortion caused (or at least was a factor in) the early birth of her second baby — that her body having been forced to open too soon for the abortion (an induction abortion, I think, rather than a D&C or D&X), was traumatized by it, and opened too soon during the second pregnancy. This study strengthens that thought. I wonder if women are given true informed consent prior to undergoing abortions, that if they have an abortion, they might later put a wanted child at risk of preterm birth, cerebral palsy, or even death.

Here is a good article that includes more information on preterm birth, including other causes and factors.

September is National Infant Mortality Awareness Month

Infant mortality is how many live-born children die within 365 days of their birth. It is not necessarily a measure of how good a country’s prenatal or birth skills are, since many children die from car accidents and household accidents and such every year. It can be a useful comparative tool (for instance, is a country better off at keeping its infants from dying from gunshot wounds, or drowning, or cancer, or…?), but it is far from perfect. Especially, as I recently noted, if other countries use different data for their official statistics — for instance, not counting births prior to 26 weeks as live births.

GA 17-47

Still, as you can see, from the chart, there is a huge drop in infant mortality for babies born in each different gestational age bracket, up until “term.” This means a huge difference for babies — the longer they stay in until term, the better their outcomes will be. Here is a partial chart, which shows mortality by gestational age at birth:

imr by gest week

Again, there is a precipitous decline in infant mortality nearly every preterm week, with a majority of babies who were born prior to 24 weeks gestation dying, and a bit better than 50/50 at 24 weeks, with steep drops after that, for each week of gestation. Obviously, the longer these little “buns” can “bake,” the better. That is one reason why this midwife’s work is so astounding and beneficial. Some excerpts from this article include:

Lubic and her team of midwives run a birthing clinic in one of the city’s poorest areas. After 800 babies in eight years, they have never lost a child in childbirth, and has cut the rate of premature births – the biggest risk factor for infant mortality – in half

Her approach is simple. She believes low-income women, many on Medicaid, need the prenatal education that midwives provide. Everything from posture, to nutrition, to how the baby grows…

“Do you think it boils down to just the time you spend with them,” Andrews asked Lubic.

“I think so,” she replied. “I’m convinced that’s what it is. It’s time, respect, its treating people with dignity.”

Here is another chart I put together from the CDC statistics — comparing preterm birth rates by race (black and white only, to keep it simple):

IMR by gest week and race

Up to half of all births (and therefore half of the deaths) in the early weeks were babies born to black women; even though the rate decreased, so that black babies were born at half the rate of white babies by 27 weeks, that’s still disproportionately high. “Preterm birth is the leading cause of death and disability among African American infants.” However, while death rates are still disproportionately high for black babies at term, compared to white babies, they are less dramatic, since the percentage of term births is closer to the national population average (about 13% African-American).

Midwives have better results than doctors, with so-called disadvantaged populations in the U.S., though. Ruth Lubic may may have achieved phenomenal results, but she is not an exception to the rule that midwifery results in better outcomes. So, one question is, why do doctors put up such roadblocks to increasing midwifery care? These are CNMs not CPMs that were studied in this link — yes. But there are still significant difficulties for any midwife to practice. Many are legally restricted, or are politically restricted, from increasing their sphere of influence. For instance, some would want to attend home births, but if they do that, their hospital privileges will be terminated. We don’t see this in Canada, where, in fact, midwives are required to attend both hospital and home births. Obstetricians still attend about 90% of all births in this country, whereas in most other developed countries, midwives are the norm, and OBs are called in only when necessary.

But there is a factor for preterm birth that it not frequently talked about. That factor is previous induced abortion. First, according to the Alan Guttmacher Institute, black women obtain abortions at five times the rate of white women. Although African-Americans comprise only about 13% of the U.S. population, they have 21.4% of all preterm births. This may explain some of the disparity noted above.

Now, for the studies. I did a search through Google Scholar for “‘induced abortion’ and ‘preterm birth'”, and went through the first one hundred studies returned (ten pages, with ten results apiece). Not all of the studies returned were actually about this topic — many only included the search terms tangentially, with the studies themselves being about things as diverse as periodontal disease and smoking — not really about abortion at all. Here is what I found:

  • this abstract from a French study from 1995: “Previous induced abortion was associated with an increased risk of preterm birth (OR 1.4; 95% CI 1.1–1.8); the risk of preterm delivery increased with the number of previous induced abortions (OR 1.3; 95% CI 1.0–1.7 for one previous abortion and OR 1.9; 95% CI 1.2–2.8 for two or more). The relationship was the same for very preterm and moderately preterm deliveries and for spontaneous and indicated preterm deliveries”
  • History of induced abortion as a risk factor for preterm birth in European countries: results of the EUROPOP survey, March 2004 (full study): “Previous induced abortions were significantly associated with preterm delivery and the risk of preterm birth increased with the number of abortions. Odds ratios did not differ significantly between the three groups of countries. The extent of association with previous induced abortion varied according to the cause of preterm delivery. Previous induced abortions significantly increased the risk of preterm delivery after idiopathic preterm labour, preterm premature rupture of membranes and ante-partum haemorrhage, but not preterm delivery after maternal hypertension. The strength of the association increased with decreasing gestational age at birth.”
  • From the Journal of Reproductive Medicine, Feb. 2009: “Induced and spontaneous abortion are associated with similarly increased ORs for preterm birth in subsequent pregnancies, and they vary inversely with the baseline preterm birth rate, explaining some of the variability among studies.”
  • From October 2005, Obstetrical and Gynecological Survey: “A history of induced abortion correlated with an increased risk of very preterm birth (odds ratio, 1.6; 95% confidence interval, 1.2-2.1). There was little change when controlling for maternal characteristics or without adjusting for a history of preterm deliveries. In addition, the association remained the same when women with previous preterm delivery were excluded. The risk tended to increase with the number of previous induced abortions. The adjusted risk of preterm delivery associated with induced abortions tended to be highest for extremely preterm deliveries. The major complications leading to very preterm birth were premature rupture of membranes and idiopathic spontaneous preterm labor, and these occurred more often in connection with extremely preterm birth. Hypertension and fetal growth restriction were more common when infants were born at 28 to 32 weeks gestation. An association between previous induced abortion and very preterm delivery related to fetal growth restriction was apparent in infants born at 28 to 32 weeks gestation.
    “This study shows that a history of induced abortion increases the risk of very preterm birth, particularly extremely preterm deliveries. It appears that both infectious and mechanical mechanisms may be involved.”
  • And again from the Alan Guttmacher Institute, from 2000, a Danish study: “Danish women whose first pregnancy ended in abortion are about twice as likely as those who did not terminate their first pregnancy to subsequently deliver an infant at less than 37 weeks’ gestation, according to results of a population-based cohort study; they have a somewhat elevated risk of having a subsequent delivery at 42 or more weeks of gestation. Analyses of the same cohort also suggest that women who have undergone abortion have twice the risk of other women of later bearing a low-birth-weight infant…
    “When age, residence, interpregnancy interval and number of previous miscarriages were taken into account, women with one previous abortion were 1.9 times as likely as women in the comparison group, those with two previous abortions were 2.7 times as likely and those with three or more previous abortions were 2.0-2.2 times as likely to have a preterm birth. In general, the risk varied slightly according to the method of abortion used, but it was sharply higher (odds ratio, 12.6) among women who had had two abortions by dilation and evacuation. Increases in the risk of preterm birth were significant mainly among women whose interpregnancy interval was 12 months or more; the pattern of risk among this subgroup was similar to the overall pattern. Previous abortion also was associated with a doubling of the odds of very preterm delivery (before 34 weeks’ gestation).”
  • The abstract of this study on precancerous changes in the cervix and subsequent preterm birth matter-of-factly states, “However, because many of the known risk factors for preterm birth, such as sexually transmitted disease, smoking, or prior induced abortion, also are associated with an increased risk of precancerous changes in the uterine cervix, it has been difficult to determine the degree risk due solely to cervical treatment from the degree of risk due to the other risk factors for preterm birth.”
  • The abstract of this Danish study begins, “We have previously shown that induced abortions result in a slightly increased risk of spontaneous abortion and preterm delivery in subsequent pregnancies.” [The study looked at whether the increased risk was perhaps due to a complication from the abortion, but they found that was not the case.]
  • This 2007 study looked at cervical length/shortening in women with multiple prior induced abortions, and found that, “A cervical length of < 25 mm on transvaginal ultrasound is predictive of preterm birth in women with more than one prior induced abortion. Women with multiple prior induced abortions and a short cervix have a 3.3-fold greater chance of spontaneous preterm birth compared with those with a cervical length of 25mm.”

And now more articles and studies that some might question due to pro-life bias, but I think worth reading nonetheless: Endeavour Forum, “Induced Abortion and Later Risk of Preterm Birth,” “Does Induced Abortion Account for the Racial Disparity in Preterm Births, and Violate the Nuremburg Code?“, Open Letter to the U.S. Surgeon General, and AAPLOG’s “Induced Abortion and Subsequent Preterm Birth: General Comments and Summary of the Pertinent Literature.”

In the interest of fairness, not all studies noted the above — perhaps the differences may be part of the reason why midwives have much lower rates of preterm birth among at-risk populations than doctors have. This 1998 study from Hong Kong looked at 118 teenage girls who had had one or more induced abortions.  However, the study was small, and the “control group” (i.e., those who had not had a prior abortion) had a higher-than-average rate of preterm birth, which is more common among teenagers than the pregnant population at large.  It also notes that D&C abortions had been shown to increase rates of future preterm births, and most of these young ladies had suction or medical abortions.

Another Chinese study, this time published in 2001, noted that prior induced abortion (the abstract didn’t note the type of abortion performed) “did not significantly increase the risk of LBW or preterm birth,” although the authors cautioned that this was with a low-risk population, and may not be generalizable.

Next, yet another study from China, this one from 2004, which also found no difference, although there were some odd things I noticed in the discussion. The study looked at mifepristone-induced abortions (RU-486), surgical abortions, and no abortions. Most of the drug-induced abortions were early, about 7 weeks or so; with the majority of the surgical abortions (roughly 60%) performed after 7 weeks but still within the first trimester, and almost all of those were vacuum aspiration abortions. About 1/4 of women who had had drug-induced abortions also had D&Cs performed, and the study said, “The lower risk of preterm delivery among women with a previous mifepristone abortion compared with women with no abortion was confined to women who had mifepristone abortions without postabortion curettage.” I assume that is because the authors recognize and agree that a D&C increases the chance of future preterm birth. Even though this study seems to say that early abortions don’t play a role in future preterm birth, it says, “An early induced abortion with mifepristone and misoprostol without postabortion curettage may produce less trauma to the cervix and the uterus than the mechanical dilation of the cervix and curettage of the uterine wall that takes place in first-trimester vacuum aspiration or postabortion curettage.” That sounds logical — artificially or mechanically dilating the cervix sounds like it could be traumatic to the cervix, and scraping the walls of the uterus sounds fairly traumatic as well. The study noted that many other studies have found an association between prior abortion and subsequent low birthweight or preterm birth; and suggested that, “The age range of the women, the exclusion of women with previous spontaneous abortion and chronic diseases, and the low prevalence of smoking during pregnancy may have contributed to the low rates of preterm delivery and low birth weight in our study. Moreover, the study was undertaken in affluent cities in China; a large number of the participating women were professionals, and they had a level of education well above the Chinese average.

Finally — and the study I think most interesting, since it was 1) the only one that was not Chinese, in case ethnic or cultural differences come into play, or there was somehow biased research in China; and 2) it may actually give a clue as to how to reduce subsequent preterm birth and/or low birthweight in women who have already had abortions — is from this abstract. It said, preterm birth and low birthweight “appeared to be more common, but after logistic regression analysis, we found no evidence of adverse pregnancy outcomes. Induced abortion is not an independent risk factor for adverse obstetric outcome. Marked health behavioral pregnancy risks are associated with prior induced abortions. Health counseling of these women is a challenge, but this objective has not yet been achieved.” And perhaps it is in this that midwives excel, as mentioned above — in getting pregnant women to change their behavior, since they tend to view the pregnancy as a whole-woman condition, not a medical condition, as a life-changing, life-involving event, that needs to be supported with healthy practices, including nutrition and other lifestyle alterations. Midwives are more likely to actually sit down with their clients and talk with them, not just to them, and counsel them. You know how sometimes parents can talk and talk and talk to their kids, and not get any effective behavior changes? And them somebody else comes along, and connects with the kids, and has them eating out of his or her hand, obeying the slightest whim, just because they now want to? We’re human. We need human connections. We’ll do things for people we like and feel a connection or bond with, that we won’t do for others. Perhaps midwives befriend their clients, rather than remaining clinically cold and aloof. Perhaps that is how they get the better outcomes with the same (or worse) at-risk clientele.

Comparing Apples to Oranges

Imagine my surprise when reading this article about French health care, I read this quote:

Infant mortality rates are often cited as a reason socialized medicine and single-payer systems are better than what we have here. But according to Dr. Linda Halderman, a policy adviser in the California State Senate, these comparisons are bogus.

Official World Health Organization statistics show the U.S. lagging behind France in infant mortality rates — 6.7 per 1,000 live births vs. 3.8 for France. Halderman notes that in the U.S., any infant born that shows any sign of life for any length of time is considered a live birth. In France — in fact, in most of the European Union — any baby born before 26 weeks’ gestation is not considered alive and therefore doesn’t “count” in reported infant mortality rates.

This definitely makes a difference in infant mortality and neonatal mortality, n’est-ce pas? Most states have definitions of live and stillbirth which are similar to definitions used by the United Nations, namely, that if there is any sign of life (the umbilical cord still pulsing, the child taking even one breath, etc.), then the baby is considered to have been born alive. But if these extremely premature babies are just swept under the rug in most European statistics, then that is, at the least, disturbing. Sort of like counting up adult deaths but saying, “heart attacks don’t count, though.”

Since I recently learned how to do screen-shots, I’ll post the results of the CDC infant mortality rates (this is infant deaths from a live birth, as most broadly defined, up until one year of age), by gestational age for all mothers and babies  — as broad as I can make it — from 2003-2005:

GA 17-47

As you can see, it includes births from before 20 weeks of pregnancy (which no baby yet has survived, as far as I know), and combines all deaths from all gestational ages [from 17-47 weeks] into a single figure of 6.83/1000 deaths. Below is the same query, but limited to births from 28 weeks and above, including pregnancies of unknown gestation (which may also be below 28 weeks):

GA 28-42+This drops it to 3.76, a tad lower than the above-stated French infant mortality rate — although it’s not a perfect comparison, because it starts at 28 weeks, rather than at 26 weeks. [And if you exclude “unknown” gestational age, the rate drops a bit lower, to 3.64.] I wonder what the French (and other European nations’) infant mortality rate would be, if it were to include births as premature as what we count. So, it’s similar, if not identical.

This does change things in my mind. While as an absolute, we need to prevent premature births as much as possible (and I will note that the above figures do not include stillbirths; and many babies born so fragile and premature do not survive the birth process), so we can still do more and make our figures better; as a comparative measure, it’s simply inaccurate to say that the U.S. has worse infant mortality than European countries, if we include these high-mortality gestations in our figures, and they don’t. It’s apples and oranges.

Frankly, I’m a little irritated that I’ve not heard this before. I can understand impoverished countries not counting babies prior to 27 weeks, because they don’t have the technology of saving babies born so prematurely, while we do. But for France — which ought to have as much access to technology as we do — not to count babies that they could save in infant mortality rates is a little upsetting. Especially when it falsely makes us look worse by comparison.