The United States loses more babies before their first birthday than nearly every other wealthy nation. Across OECD countries, infant mortality averages 4.0 deaths per 1,000 live births. The US rate is significantly higher, and the gap persists even after accounting for differences in how countries count births. The reasons are layered: high preterm birth rates, deep racial and economic disparities, uneven access to maternal care, and preventable sleep-related deaths all contribute.
How the US Compares Globally
Among the 38 OECD member nations, the US consistently ranks near the bottom for infant survival. Part of this gap is real, and part is inflated by a reporting difference. The US registers extremely premature births (before 22 weeks or under 500 grams) as live births more consistently than many European countries, which may classify those same births as miscarriages or stillbirths. Since these infants rarely survive, counting them raises the US mortality rate on paper.
But reporting differences don’t explain the problem away. When researchers restricted comparisons to singleton births at 22 weeks or later and weighing at least 500 grams, the US still had 1.1 to 2.1 excess deaths per 1,000 births compared to European baselines. That translates to a 27% to 76% higher death rate even on an apples-to-apples basis. Something beyond bookkeeping is going wrong.
The Leading Causes of Infant Death
In 2023, the top five causes accounted for more than half of all US infant deaths. Birth defects led the list at 19.9% of deaths, followed by complications of prematurity and low birth weight at 14.5%. Sudden infant death syndrome (SIDS) made up 7.2%, unintentional injuries 6.4%, and complications from the mother’s pregnancy 5.7%.
The dominance of prematurity on this list is especially telling. The US delivers a substantially higher share of babies before term than Canada, the UK, and Western Europe. Premature infants face higher risks of breathing problems, infection, and organ immaturity. When a country has more preterm births, it will inevitably have more infant deaths, even with excellent neonatal intensive care units.
Racial Disparities Are Stark
The national average obscures enormous variation by race and ethnicity. In 2023, the infant mortality rate for Black infants was 10.93 per 1,000 live births, more than double the rate for white infants (4.48) and more than triple the rate for Asian infants (3.44). American Indian and Alaska Native infants died at a rate of 9.20, and Native Hawaiian or Other Pacific Islander infants at 8.21. Hispanic infants fell in between at 5.03.
These gaps don’t simply reflect income. Research from Stanford found that the infant mortality rate among the highest-income Black mothers is on par with that of the lowest-income white mothers. That finding points to something beyond individual wealth: chronic stress from discrimination, differences in the quality of hospitals where Black women deliver, and disparities in how seriously providers take Black women’s symptoms during pregnancy all play a role.
Poverty and Insurance Coverage
Income still matters enormously in its own right. Infants born to parents in the bottom 5% of the income distribution die at more than twice the rate of those born to parents in the top 5%. Low-income families are more likely to live in areas with fewer obstetricians, less access to prenatal care, and higher exposure to environmental hazards like air pollution and lead.
Insurance coverage has a measurable effect. States that expanded Medicaid saw a 15.2% decline in infant mortality between 2014 and 2016, compared to just 11.0% in states that did not expand. The difference was even more dramatic for Black infants: Medicaid expansion states saw a 14.5% decline in Black infant deaths, more than double the 6.6% decline in non-expansion states. When pregnant women can access prenatal visits, manage chronic conditions, and deliver in better-resourced hospitals, fewer babies die.
Maternal Health Drives Infant Outcomes
The health of the mother before and during pregnancy is one of the strongest predictors of whether a baby survives. The US has rising rates of chronic conditions among women of childbearing age, including obesity, hypertension, and diabetes, all of which increase the risk of preterm birth and delivery complications.
Severe maternal complications carry an outsized risk. In a population-based study spanning two decades in Massachusetts, infants born to mothers who experienced severe pregnancy complications died at a rate of 15.7 per 1,000, roughly four times the state’s overall infant mortality rate. These infants also faced a 57% greater risk of hospitalization in their first year of life. The US maternal mortality rate is itself an outlier among wealthy nations, and the two crises are deeply connected. Mothers who are sicker have babies who are more vulnerable.
Sleep-Related Deaths Remain Stubbornly High
About 3,700 infants died from sudden unexpected causes in 2022. Of those, 1,529 were classified as SIDS, 1,131 as deaths from unknown causes, and 1,040 as accidental suffocation and strangulation in bed. These deaths overwhelmingly happen in the postneonatal period, after the first month of life, and many are tied to unsafe sleep environments: soft bedding, bed-sharing on adult mattresses, or placing babies on their stomachs.
Most other high-income countries have lower rates of these deaths. The persistence of unsafe sleep practices in the US is linked to factors ranging from lack of education to housing instability. A family living in a single room with limited furniture may have fewer options for creating a separate, safe sleep space. Public health campaigns have reduced SIDS rates significantly since the 1990s, but progress has plateaued.
No Single Fix
The US infant mortality problem is not caused by one failure but by a cluster of them reinforcing each other. A woman without insurance misses prenatal visits, develops unmanaged high blood pressure, delivers prematurely, and her baby enters an underfunded NICU. A Black mother with excellent insurance still faces implicit bias that delays treatment for a dangerous complication. A family in a rural county drives 90 minutes to the nearest hospital with a labor and delivery unit.
Countries with lower infant mortality tend to share a few features the US lacks: universal access to prenatal care, stronger social safety nets for new parents, and more consistent standards for maternal health screening. The gap between the US and its peers is not about medical technology. American NICUs are among the best in the world. The gap is about who gets care, when they get it, and what their lives look like outside the hospital walls.