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It’s getting increasingly dangerous to be a newborn in the US

How maternity care deserts are leading to a spike in infant syphilis and mortality rates.

Newborn baby lying on a digital scale and crying.
A newborn being weighed in Fridley, Minnesota.
Education Images/Universal Images Group via Getty Images
Keren Landman is a senior reporter covering public health, emerging infectious diseases, the health workforce, and health justice at Vox. Keren is trained as a physician, researcher, and epidemiologist and has served as a disease detective at the US Centers for Disease Control and Prevention.

For two weeks in a row, the Centers for Disease Control and Prevention (CDC) has released data with a clear and dismal message: It’s getting increasingly dangerous to be a newborn in the United States.

First, last week, the agency published statistics showing that in 2022, the death rate for American infants increased for the first time in 20 years. Then, on Tuesday, the agency released a report showing rates of congenital syphilis — that is, syphilis infections acquired in the womb — have risen tenfold over the past decade.

Although a lot of different risk factors drive each of these trends, there’s an important one they have in common: bad — and worsening — health care access for mothers and babies.

In the US, the obstacles mothers face in accessing health care are too often insurmountable — and as this latest data shows, the consequences to American children are dire. Things might only get worse, some experts fear, as financial, political, and social pressures drive providers further from many of the places where they’re needed most.

“We only are hearing about more [obstetricians] leaving and more maternity wards closing,” said Tracey Wilkinson, a pediatrician who specializes in reproductive health issues at Indiana University’s medical school. “I am terrified about what the data is going to look like next year.”

Congenital syphilis and infant mortality are on the rise

Both the syphilis data and the infant mortality data represent stunning setbacks after years of progress.

Syphilis is a sexually transmitted infection caused by a spiral-shaped bacterium that leads to skin rashes in its early stages and, in its later stages, complications ranging from neurologic problems to cardiovascular disease. It can be lethal if untreated, but in its early stages, syphilis has been curable with penicillin since the 1940s.

Babies can catch syphilis from their parents while in the womb, and the infection has high rates of complication: In different studies, anywhere from 7 to 31 percent of babies with congenital infection die as a result, and another third develop health problems that can include liver disease and bone and neurologic abnormalities.

For decades, congenital syphilis was a rarity in the US. An intensive syphilis eradication campaign in the late 1990s and high rates of condom use due to concerns about HIV transmission led to a syphilis low at the turn of the millennium. Over the next decade, the CDC identified 300 to 400 cases of congenital infection every year.

As HIV treatment became more widely available and condom use dropped over that period, syphilis transmission increased, with the highest rates of transmission among gay men and people in their sexual networks. But around 2014, syphilis cases began rising in women, too, and as they did, rates of syphilis infections in babies also began to rise.

Yesterday, scientists in the CDC’s STD (sexually transmitted disease) branch reported that in 2022, more than 3,700 cases of congenital syphilis were reported across the US — a 1,000 percent increase from 2012.

As with syphilis, the story on infant mortality in the US had been largely a positive one, with rates decreasing steadily for at least 30 years. But in 2022, there were 600 more infant deaths than in 2021 — a 3 percent increase in the age group’s death rate.

A range of factors can contribute to infant mortality, such as congenital abnormalities and sudden infant death syndrome, or SIDS. But in last week’s report, CDC authors singled out bacterial bloodstream infections and maternal complications of pregnancy as particularly notable rising threats.

Neither congenital syphilis nor infant mortality is evenly distributed across the US. In 2021, babies born to Black, Hispanic, or American Indian/Alaska Native mothers were up to 8 times more likely to have congenital syphilis (the same analysis has not yet been performed on the 2022 numbers).

And when it comes to infant mortality, Black newborns had the highest death rate, with nearly 11 deaths per 1,000 live births — about twice the average rate. American Indian babies had the most dramatic rise in deaths — a 20 percent increase, from 7.5 to 9 deaths per 1,000 births. And the uptick in deaths was particularly pronounced in four states: Georgia, Iowa, Texas, and Missouri.

How pregnancy care deserts amplify threats to babies

The risks for both infant mortality and syphilis are directly related to what happens during pregnancy.

Because the stakes are so high for maternal syphilis infection, all but eight states require syphilis testing during pregnancy. That means prenatal care is a key opportunity for preventing congenital syphilis for babies born in the US.

But that system only works if people are reliably getting prenatal care and if everyone who tests positive during pregnancy gets treated. According to the newborn health nonprofit organization March of Dimes, about 15 percent of American women get inadequate care during pregnancy.

And that’s contributing to the syphilis trend. According to the CDC’s latest data, nine out of every 10 congenital syphilis cases in 2022 were born to women who didn’t get adequate syphilis care during pregnancy. Four out of 10 were born to women who didn’t get prenatal care at all, and an additional five out of 10 were born to women tested while pregnant but not treated. (Confirming a current syphilis infection usually requires two tests done several days apart. It’s possible some of these women who initiated testing never followed up.)

Lapses in maternal care are likely contributing to the infant mortality trends, too. Although the CDC’s report on infant mortality did not explore how maternal care access is related to risk, other research suggests they are closely linked.

Many of the leading causes of infant death are related to premature birth, i.e. birth before 36 weeks of gestation, which is more likely to happen when a pregnant person doesn’t get adequate prenatal care.

And pregnant people are increasingly finding themselves facing barriers to adequate prenatal care: Nearly 11 percent of American women of childbearing age live in counties with inadequate maternity care — meaning they lack the obstetric providers and labor wards necessary to meet people’s needs.

So, just as maternal care deserts are on the rise, so are premature births and the risks associated with them.

To make things worse, at the same time people’s access to premature birth prevention care is falling, many of the social and health risk factors for prematurity are rising, like obesity and lack of health insurance.

The big picture: Better access to maternal care could reduce premature birth rates and, potentially, infant mortality. But so long as prenatal care remains scarce for many Americans, they’ll be more likely to have their baby early, without the advantage of managing any risk factors they have that might affect their baby’s health.

Notably, congenital syphilis transmission is probably itself contributing to rising infant mortality rates. In 2022, there were 610 more total infant deaths and 62 more syphilis-related infant deaths than in 2021.

Although these numbers come from different sources, this suggests that congenital syphilis, and the prenatal care failures that are fueling its rise, may have accounted for about 10 percent of the increase in infant deaths.

A broken insurance system, abortion restrictions, and punitive policies on pregnancy are driving a wedge between maternal care providers and the patients who need them

Why are so many American women not getting the maternal care they need?

A big part of the problem is related to the hollowing out of rural health care. As rural fertility declines and rural areas lose maternity wards and hospitals — largely because of the high cost of maternity care, the difficulty of recruiting and retaining staff, and several states’ refusal to expand Medicaid — pregnant people in rural areas are finding it increasingly hard to find care. According to the March of Dimes 2022 report, two-thirds of maternity care deserts are rural.

But urban hospitals with labor and delivery wards are also shutting down or cutting services, especially safety-net hospitals that care for cities’ most vulnerable populations. These closures, which are also generally blamed on financial reasons, mean parents in urban areas also have less access and lower-quality pregnancy care than they once did.

There’s another important reason some states may soon see their maternal care capacity further hollowed out. In the wake of the Supreme Court decision eliminating the constitutional right to abortion, maternal care providers are leaving red states that have chosen to tighten abortion restrictions due to concern they won’t safely be able to provide the full spectrum of maternity care. Additionally, medical trainees are avoiding these states because they know that in a state that does not permit abortion, they won’t get training in a key part of pregnancy care.

“Maternity care deserts are widening,” said Wilkinson, the Indiana pediatric reproductive health specialist. “We are seeing the experts in maternity care, such as OB-GYN and maternal-fetal medicine doctors, leave — they’re just leaving states. And we’re seeing hospitals close because of the costs of that. It’s almost like a double hit.”

“We knew there was a train crash coming, and Dobbs actually just took the train off the rails completely,” she said.

Even when they can access prenatal care, women who live on the margins of society — in particular, women who use drugs — may avoid contact with health care providers out of concern that punitive policies around drug use in pregnancy could lead to bad consequences for themselves or their kids. Unfortunately, these women are among those whose babies are at highest risk for congenital syphilis infection and other conditions that could lead to death in infancy.

Authors of the infant mortality report did not suggest solutions in their publication. But on syphilis, CDC representatives articulated a strategy centered on broadening testing to more people and places and treating people who test positive during their first office visit.

Problems with multiple causes require multiple solutions, said Laura Bachmann, the chief medical officer of the CDC’s Division of STD Prevention, in an interview. “There’s a lot of work to be done,” she said.