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What’s killing American babies before their first birthday?

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(Bloomberg) — The number of infants who die before their first birthday is an important measure of a nation’s health, and the U.S. performs poorly. This isn’t just compared with Western Europe. The U.S. ranks below dozens of other countries, including Cuba, Lithuania and South Korea, by one measure.

It’s difficult to untangling the reasons behind the gap in infant mortality, or even the extent of the problem. Nations measure and report births and deaths in different ways. For instance, a death shortly after delivery that is counted toward the tally in the U.S. may be excluded as a stillbirth elsewhere.

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A new economic paper attempts to explain some of this dissonance. Differences in reporting methodology do inflate America’s infant mortality rate, compared with those in some countries, economists from Brown University, the University of Southern California, and Massachusetts Institute of Technology found. But that’s not the whole story.

When they compared data on U.S. births with those in Austria and Finland — two countries with similarly detailed reporting — the authors found that America’s mortality rate deviated after the first month of life.

In other words, American infants are more likely to die between one month and one year than babies in Austria and Finland. “We know something’s happening after the baby leaves the hospital,” said Alice Chen, a health economist at USC and co-author of the paper. “It’s happening mostly among low socioeconomic groups.”

One theory is that European systems provide more social support for new mothers, often including home visits by nurses or other professionals in the first months after birth. (Finns famously get a gift package from the government upon the arrival of a new child.)

David Olds has spent decades studying just such interventions. A professor of pediatrics at the University of Colorado, he’s led long-term randomized control trials to measure the effect of nurse visits targeted to disadvantaged mothers from pregnancy to age two. Studies in Elmira, N.Y., Memphis, and Denver, have found some health and social benefits for families, including reductions in infant mortality.

Olds is founder of the Nurse-Family Partnership, which provides such services to about 33,000 families in the U.S. He estimates that the need for them is in the hundreds of thousands. Poverty and troubled circumstances can make it challenging to provide safe environments for children, he said. “If the mother is living in a household where she is essentially homeless, and she’s there couch-surfing with a newborn baby, her ability to protect that child is really limited,” Olds said.

The Affordable Care Act created a federal home visit program, currently funded at about $400 million a year. The program served more than 145,000 parents and children in the 2015 fiscal year, according to the Health Resources Services Administration.

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“Most European countries have basically more or less universal home visiting programs,” said Emily Oster, a co-author of the paper and associate professor of economics at Brown University. “It is among the relatively few things that differs in a way that we can see that link.”

Still, Oster and other researchers caution against reading too much into the effect of visits on infant mortality. Olds said that it’s unlikely to fully explain the differences between the U.S. and other wealthy nations.

And comparing infant mortality across countries is exceedingly difficult, said Wally Carlo, a professor of pediatrics at the University of Alabama-Birmingham and spokesman for the American Academy of Pediatrics. One example: Pregnancies with congenital defects that could hurt the child’s chances of survival in the first year are more frequently terminated in other countries than in the U.S. “A lot of even good investigators have limited understanding of what biases mortality rates,” he said.

In general, the U.S. spends less on social support — and more on medical care — than other developed nations. The case that a stronger safety net could improve the country’s standing on infant mortality and other measures of health seems clear, said Paul E. Jarris, senior vice president for maternal child health at the March of Dimes Foundation.

“Why is it that these people are exposed to this poverty?” he said. “What can we do to change our situation so we don’t have so much poverty?”

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