Annual summary of vital statistics: 2000.

The birth rate in 2000 (preliminary data) was 14.8 births per 1000 population, an increase of 2% from 1999 (14.5). The fertility rate, births per 1000 women aged 15 to 44 years, increased 3% to 67.6 in 2000, compared with 65.9 in 1999. The 2000 increases in births and the fertility rate were the third consecutive yearly increases, the largest in many years, halting the steady decline in the number of births and fertility rates in the 1990s. Fertility rates for total white, non-Hispanic white, black, and Native American women each increased about 2% in 2000. The fertility rate for black women, which declined 19% from 1990 to 1996, has changed little since 1996. The rate for Hispanic women rose 4% in 2000 to reach the highest level since 1993. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women remained about the same at one third, but the number of births rose 3%. The birth rate for teen mothers declined again for the ninth consecutive year. The use of timely prenatal care (83.2%) remained unchanged in 2000, and was essentially unchanged for non-Hispanic white (88.5%), black (74.2%), and Hispanic (74.4%) mothers. The number and rate of multiple births continued their dramatic rise, but all of the increase was confined to twins; for the first time in more than a decade, the number of triplet and higher-order multiple births declined (4%) between 1998 and 1999 (multiple birth information is not available in preliminary 2000 data). The overall increases in multiple births account, in part, for the lack of improvement in the percentage of low birth weight (LBW) births. LBW remained at 7.6% in 2000. The infant mortality rate (IMR) dropped to 6.9 per 1000 live births (preliminary data) in 2000 (the rate was 7.1 in 1999). The ratio of the IMR among black infants to that for white infants was 2.5 in 2000, the same as in 1999. Racial differences in infant mortality remain a major public health concern. The role of low birth weight in infant mortality remains a major issue. Among all of the states, Utah and Maine had the lowest IMRs. State-by-state differences in IMR reflect racial composition, the percentage LBW, and birth weight-specific neonatal mortality rates for each state. The United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a record high of 76.9 years for all gender and race groups combined. Death rates in the United States continue to decline. The age-adjusted death rate for suicide declined 4% between 1999 and 2000; homicide declined 7%. Death rates for children 19 years of age or less declined for 3 of the 5 leading causes in 2000; cancer and suicide levels did not change for children as a group. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.

Association of human milk feedings with a reduction in retinopathy of prematurity among very low birthweight infants.

INTRODUCTION: With the increased survival of very low birthweight (VLBW) infants, weighing less than 1500 g at birth, the incidence of retinopathy of prematurity (ROP), a significant cause of blindness among children in the United States, is also increasing. Preterm infants with a positive diagnosis of ROP during the perinatal period are at increased risk for ocular abnormalities and for deficits in visual function during later periods of development. Human milk has many antioxidant constituents including inositol, vitamin E, and beta-carotene that may protect against the development of ROP. OBJECTIVE: The objective of this study was to examine the effect of human milk feedings on the incidence of ROP among VLBW infants. STUDY DESIGN: Observational cohort study. PARTICIPANTS: We identified 283 VLBW infants admitted to the Georgetown University Medical Center Neonatal Intensive Care Unit (NICU) from January 1992 through September 1993. All infants surviving to receive enteral feeding and ophthalmologic examinations for ROP (n=174) were included in the analysis. METHODS: Type of feeding (human milk versus exclusive formula), presence of ROP, and potential confounding variables were abstracted retrospectively from medical records. ROP was present if any stage of ROP was diagnosed at any age during the initial NICU hospitalization; each case was counted once based on the worse severity of ROP in either eye. Multiple logistic regression was used to control for confounders. MAIN OUTCOME MEASURE: ROP. RESULTS: Major predictors of ROP were similar in both feeding groups including gestational age, days on mechanical ventilation, and total number of days on supplemental oxygen. The incidence of ROP differed significantly by type of feeding (human milk -41.0% vs. formula -63.5%, p=0.005). Human milk feeding independently correlated with a reduced odds of ROP (OR: 0.42, 95% CI: 0.19 to 0.93) (p=0.03), controlling for gestational age, duration of supplemental oxygen therapy, 5-minute Apgar score, and race. Human milk feeding independently correlated with a reduced odds of ROP (OR: 0.46, 95% CI: 0.18 to 0.91) (p=0.03), controlling for birthweight, duration of supplemental oxygen therapy, 5-minute Apgar score, and race. CONCLUSION: Human milk feeding among VLBW infants was associated with a lower incidence of ROP compared to exclusively formula-fed VLBW infants after adjusting for confounding variables.

Annual summary of vital statistics: trends in the health of Americans during the 20th century.

The overall improvement in the health of Americans over the 20th century is best exemplified by dramatic changes in 2 trends: 1) the age-adjusted death rate declined by about 74%, while 2) life expectancy increased 56%. Leading causes of death shifted from infectious to chronic diseases. In 1900, infectious respiratory diseases accounted for nearly a quarter of all deaths. In 1998, the 10 leading causes of death in the United States were, respectively, heart disease and cancer followed by stroke, chronic obstructive pulmonary disease, accidents (unintentional injuries), pneumonia and influenza, diabetes, suicide, kidney diseases, and chronic liver disease and cirrhosis. Together these leading causes accounted for 84% of all deaths. The size and composition of the American population is fundamentally affected by the fertility rate and the number of births. From the beginning of the century there was a steady decline in the fertility rate to a low point in 1936. The postwar baby boom peaked in 1957, when 123 of every 1000 women aged 15 to 44 years gave birth. Thereafter, fertility rates began a steady decline. Trends in the number of births parallel the trends in the fertility rate. Beginning in 1936 and continuing to 1956, there was precipitous decline in maternal mortality from 582 deaths per 100 000 live births in 1935 to 40 in 1956. Since 1950 the maternal mortality ratio dropped by 90% to 7.1 in 1998. The infant mortality rate has shown an exponential decline during the 20th century. In 1915, approximately 100 white infants per 1000 live births died in the first year of life; the rate for black infants was almost twice as high. In 1998, the infant mortality rate was 7.2 overall, 6.0 for white infants, and 14.3 for black infants. For children older than 1 year of age, the overall decline in mortality during the 20th century has been spectacular. In 1900, >3 in 100 children died between their first and 20th birthday; today, <2 in 1000 die. At the beginning of the 20th century, the leading causes of child mortality were infectious diseases, including diarrheal diseases, diphtheria, measles, pneumonia and influenza, scarlet fever, tuberculosis, typhoid and paratyphoid fevers, and whooping cough. Between 1900 and 1998, the percentage of child deaths attributable to infectious diseases declined from 61.6% to 2%. Accidents accounted for 6.3% of child deaths in 1900, but 43.9% in 1998. Between 1900 and 1998, the death rate from accidents, now usually called unintentional injuries, declined two-thirds, from 47. 5 to 15.9 deaths per 100 000. The child dependency ratio far exceeded the elderly dependency ratio during most of the 20th century, particularly during the first 70 years. The elderly ratio has gained incrementally since then and the large increase expected beginning in 2010 indicates that the difference in the 2 ratios will become considerably less by 2030. The challenge for the 21st century is how to balance the needs of children with the growing demands for a large aging population of elderly persons.

Annual summary of vital statistics--1998.

Most vital statistics indicators of the health of Americans were stable or showed modest improvements between 1997 and 1998. The preliminary birth rate in 1998 was 14.6 births per 1000 population, up slightly from the record low reported for 1997 (14.5). The fertility rate, births per 1000 women aged 15 to 44 years, increased 1% to 65.6 in 1998, compared with 65.0 in 1997. The 1998 increases, although modest, were the first since 1990, halting the steady decline in the number of births and birth and fertility rates in the 1990s. Fertility rates for total white, non-Hispanic white, and Native American women each increased from 1% to 2% in 1998. The fertility rate for black women declined 19% from 1990 to 1996, but has changed little since 1996. The rate for Hispanic women, which dropped 2%, was lower than in any year for which national data have been available. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women remained about the same at one third. The birth rate for teen mothers declined again for the seventh consecutive year, and the use of timely prenatal care (82.8%) improved for the ninth consecutive year, especially for black (73.3%) and Hispanic (74.3%) mothers. The number and rate of multiple births continued their dramatic rise; the number of triplet and higher-order multiple births jumped 16% between 1996 and 1997, accounting, in part, for the slight increase in the percentage of low birth weight (LBW) births. LBW continued to increase from 1997 to 1998 to 7.6%. The infant mortality rate (IMR) was unchanged from 1997 to 1998 (7.2 per 1000 live births). The ratio of the IMR among black infants to that for white infants (2.4) remained the same in 1998 as in 1997. Racial differences in infant mortality remain a major public health concern. In 1997, 65% of all infant deaths occurred to the 7.5% of infants born LBW. Among all of the states, Maine, Massachusetts, and New Hampshire had the lowest IMRs. State-by-state differences in IMR reflect racial composition, the percentage LBW, and birth weight-specific neonatal mortality rate for each state. The United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth increased slightly to 76.7 years for all gender and race groups combined. Death rates in the United States continue to decline, including a drop in mortality from human immunodeficiency virus. The age-adjusted death rate for suicide declined 6% in 1998; homicide declined 14%. Death rates for children from all major causes declined again in 1998. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.

Characteristics of nurse-midwife patients and visits, 1991.

OBJECTIVES: This study describes the patient populations served by and visits made to certified nurse-midwives (CNMs) in the United States. METHODS: Prospective data on 16,729 visits were collected from 369 CNMs randomly selected from a 1991 population survey. Population estimates were derived from a multistage survey design with probability sampling. RESULTS: We estimated that approximately 5.4 million visits were made to nearly 3000 CNMs nationwide in 1991. Most visits involved maternity care, although fully 20% were for care outside the maternity cycle. Patients considered vulnerable to poor access or outcomes made 7 of every 10 visits. CONCLUSIONS: Nurse-midwives substantially contribute to the health care of women nationwide, especially for vulnerable populations.

Annual summary of vital statistics-1997.

Many positive trends in the health of Americans continued into 1997. In 1997, the preliminary birth rate declined slightly to 14.6 births per 1000 population, and the fertility rate, births per 1000 women 15 to 44 years of age, was unchanged from the previous year (65.3). These indicators suggest that the downward trend in births observed since the early 1990s may have abated. Fertility rates for white, black, and Native American women were essentially unchanged between 1996 and 1997. Fertility among Hispanic women declined 2% in 1997 to 103.1, the lowest level reported since national data for this group have been available. For the sixth consecutive year, birth rates dropped for teens. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women (32.4%) was unchanged in 1997. The trend toward earlier utilization of prenatal care continued for 1997; 82.5% of women began prenatal care in the first trimester. There was no change in the percentage with late (third trimester) or no care in 1997. The cesarean delivery rate rose slightly to 20.8% in 1997, a reversal of the downward trend observed since 1989. The percentage of low birth weight (LBW) infants rose again in 1997 to 7.5%. The percentage of very low birth weight was up only slightly to 1.41%. Among births to white mothers, LBW increased for the fifth consecutive year, to 6.5%, whereas the rate for black mothers remained unchanged at 13%. Much, but not all, of the rise in LBW for white mothers during the 1990s can be attributed to an increase in multiple births. In 1996, the multiple birth rate rose again by 5%, and the higher-order multiple birth rate climbed by 20%. Infant mortality reached an all time low level of 7.1 deaths per 1000 births, based on preliminary 1997 data. Both neonatal and postneonatal mortality rates declined. In 1996, 64% of all infant deaths occurred to the 7.4% of infants born at LBW. Infant mortality rates continue to be more than two times greater for black than for white infants. Among all the states in 1996, Maine, Massachusetts, and New Hampshire had the lowest infant mortality rates. Despite declines in infant mortality, the United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a new high in 1997 of 76.5 years for all gender and race groups combined. Age-adjusted death rates declined in 1997 for diseases of the heart, accidents and adverse affects (unintentional injuries), homicide, suicide, malignant neoplasms, cerebrovascular disease, chronic liver disease and cirrhosis, and diabetes. In 1997, mortality due to HIV infection declined by 47%. Death rates for children from all major causes declined again in 1997. Motor vehicle traffic injuries and firearm injuries were the two major causes of traumatic death. A large proportion of childhood deaths continue to occur as a result of preventable injuries.

Population differences affect the interpretation of fetal nonstress test results.

OBJECTIVE: The object of the study was to determine whether population differences exist with respect to outcomes of women with reactive and nonreactive nonstress test results. STUDY DESIGN: An epidemiologic evaluation was conducted on 2579 women who underwent nonstress tests in the Fetal Assessment Center of the Johns Hopkins Hospital within a week of delivery. Risk factors such as hypertension, diabetes, and postterm pregnancy were used in a logistic regression model to evaluate the ability of the nonstress test to predict outcomes including proxies of fetal distress and fetal and neonatal death. The sensitivities, specificities, and predictive values of the nonstress test for predicting these outcomes in cohorts of black and white women were also determined. RESULTS: The nonstress test was consistently more sensitive for black women than for white women in predicting several perinatal outcomes, but specificity and negative predictive value were consistently lower for black women. The positive predictive value for fetal and neonatal death was higher for white women than for black women. Although the nonreactive nonstress test result seemed to be predictive of certain perinatal events, the odds ratio for predicting perinatal mortality in any study population was no greater than when the nonstress test result was reassuring. CONCLUSIONS: Epidemiologic characteristics affecting test results, such as disease prevalence and population differences, may lead to clinically significant differences in outcome prediction when these tests' results are used. These differences should be considered in the implementation of antepartum fetal testing programs.

Human milk feedings and infection among very low birth weight infants.

BACKGROUND: Preterm infants are immunologically immature at birth. Previous studies have demonstrated that human milk protects against infection in full-term infants, but there are few studies of its effect for preterm infants. OBJECTIVE: To examine the effect of human milk feedings on infection incidence among very low birth weight (VLBW) infants during their initial hospitalization. STUDY DESIGN: The sample consisted of 212 consecutive VLBW infants admitted to the Georgetown University Medical Center neonatal intensive care unit (NICU) during 1992-1993 and surviving to receive enteral feeding. Type of feeding (human milk vs formula), presence of infection and sepsis/meningitis (clinical signs and positive cultures for pathogenic organisms), and potential confounding variables were abstracted from medical records. Multiple logistic regression was used to control for confounders. RESULTS: The incidence of infection (human milk [29.3%] vs formula [47.2%]) and sepsis/meningitis (human milk [19.5%] vs formula [32.6%]) differed significantly by type of feeding. Major risk factors for infection were similar in both groups. Human milk feeding was independently correlated with a reduced odds of infection (odds ratio [OR] = 0.43; 95% confidence interval [CI]: 0.23-0.81), controlling for gestational age, 5-minute Apgar score, mechanical ventilation days, and days without enteral feedings; and was independently correlated with a reduced odds of sepsis/meningitis (OR = 0.47, 95% CI:0.23-0. 95), controlling for gestational age, mechanical ventilation days, and days without enteral feedings. CONCLUSIONS: The incidence of any infection and sepsis/meningitis are significantly reduced in human milk-fed VLBW infants compared with exclusively formula-fed VLBW infants.

Effects of physical activity on preterm birth.

The authors conducted a cohort study of low income women to determine the effect of physical activity on the risk of preterm birth. Women were sampled prenatally from four clinic sites and were scheduled for delivery at the University of Maryland Medical Systems (UMMS). Women who delivered infants at UMMS but who had received no prenatal care were also eligible. Preterm delivery was defined as a delivery prior to 37 completed weeks gestation. After adjusting for confounders, the odds of preterm delivery were increased for women who climbed stairs > or = 10 times per day (odds ratio (OR) = 1.60, 95% confidence interval 1.05-2.46) and for women who engaged in purposive walking > or = 4 days per week (OR = 2.10, 95% CI 1.38-3.20). Leisure-time exercise (> or = 60 days in the first and second trimesters combined) had a protective effect on preterm delivery (OR = 0.51, 95% CI 0.27-0.95). Television viewing had a U-shaped relation with preterm delivery (ORs (95% CI): < 15 hours, 2.09 (1.21-3.61); 29-42 hours, 1.50 (0.84-2.67); > 42 hours, 3.05 (1.75-5.40)). While the results support current recommendations regarding leisure-time activities, activities of daily living appear to increase risk of preterm delivery among low income women. These findings and those for television watching warrant further investigation.

Annual summary of vital statistics--1996.

Several recent trends in the vital statistics of the United States continued in 1996, including an increase in life expectancy and declines in infant mortality, births to teenage mothers, age-adjusted death rates, and death rates for children and adolescents. In 1996, there were an estimated 3 914 953 births in the United States. The preliminary birth rate remained unchanged at 14.8 births per 1000 population, and the fertility rate, births per 1000 women 15 to 44 years of age, was essentially the same at 65.7. Fertility rates rose slightly for most racial and ethnic groups except black women, for whom the rate hit a historic low of 70.8. Overall, fertility remains particularly high for Hispanic women, although there is considerable variation within this heterogenous group. For the fifth consecutive year, birth rates dropped for teenagers. Birth rates for women >/=30 years of age continued to increase. The birth rate for unmarried women declined 1% in 1996 to 44.6 births per 1000 unmarried women, continuing the decline noted in 1995 for the first time in 2 decades. The percentage of women who began prenatal care in the first trimester rose in 1996 to 81.8%, whereas the percentage with late (third trimester) or no care dropped to 4.1%. The rise in timely prenatal care was greatest for black and Hispanic women. The percentage of low birth weight (LBW) infants reached 7.4% in 1996, its highest level since 1975. The very low birth weight rate remained unchanged at 1.4%. The rise in LBW occurred primarily among white women, whereas the LBW rate for black women dropped to 13.0%, the lowest rate reported since 1987. The rise among white women is only partially a result of increases in multiple births, because LBW rates have also risen among white singleton births. The multiple birth ratio rose again in 1996 by 2%, as it has since 1980. The rise was particularly large for higher-order multiple births. Infant mortality reached an all time low level of 7.2 deaths per 1000 births, based on preliminary 1996 data. Neonatal and postneonatal rates declined, as did rates for both black and white infants. National birth weight specific mortality rates are reported here for the first time. In 1995, 63% of infant deaths occurred to the 7.3% of the population that was born LBW. The four leading cause of infant death were congenital anomalies, disorders relating to short gestation and unspecified birth weight, sudden infant death syndrome, and respiratory distress syndrome, accounting for more than half of infant deaths in 1996. Despite the declines in infant mortality, the United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a new high in 1996 of 76.1 years for all gender and race groups combined. Age-adjusted mortality rates declined in 1996 for diseases of the heart, malignant neoplasms, cerebrovascular diseases, accidents and adverse effects, chronic liver disease and cirrhosis, and suicide. They rose, as in the past several years, for chronic obstructive pulmonary diseases, diabetes mellitus, and pneumonia and influenza. For the first time since human immunodeficiency virus infection was created as a special cause-of-death category in 1987, death rates for human immunodeficiency virus infection declined from 15.6 in 1995 to 11.6 in 1996. The homicide rate also declined, as it has since 1991. Death rates for children between 1 and 19 years of age declined in 1996, with an estimated 29 183 deaths to children. Unintentional injury mortality has dropped by approximately 50% among children and adolescents since 1979, although it remains the leading cause of death for all age groups of children from 1 to 19 years. Homicide was the fourth leading cause of death for children 1 to 4 and 5 to 9 years of age, the third leading cause for children 10 to 14, and the second leading cause for 15 to 19 year olds.

Annual summary of vital statistics--1995.

Recent trends in the vital statistics of the United States continued in 1995, including decreases in the number of births, the birth rate, the age-adjusted death rate, and the infant mortality rate; life expectancy at birth increased to a level equal to the record high of 75.8 years in 1992. Marriages and divorces both decreased. An estimated 3,900,089 infants were born during 1995, a decline of 1% from 1994. The preliminary birth rate for 1995 was 14.8 live births per 1000 total population, a 3% decline, and the lowest recorded in nearly two decades. The fertility rate, which relates births to women in the childbearing ages, declined to 65.6 live births per 1000 women 15 to 44 years old, the lowest rate since 1986. According to preliminary data for 1995, fertility rates declined for all racial groups with the gap narrowing between black and white rates. The fertility rate for black women declined 7% to a historic low level (71.7); the preliminary rate for white women (64.5) dropped just 1%. Fertility rates continue to be highest for Hispanic, especially Mexican-American, women. Preliminary data for 1995 suggest a 2% decline in the rate for Hispanic women to 103.7. The birth rate for teenagers has now decreased for four consecutive years, from a high of 62.1 per 1000 women 15 to 19 years old in 1991 to 56.9 in 1995, an overall decline of 8%. The rate of childbearing by unmarried mothers dropped 4% from 1994 to 1995, from 46.9 births per 1000 unmarried women 15 to 44 years old to 44.9, the first decline in the rate in nearly two decades. The proportion of all births occurring to unmarried women dropped as well in 1995, to 32.0% from 32.6% in 1994. Smoking during pregnancy dropped steadily from 1989 (19.5%) to 1994 (14.6%), a decline of about 25%. Prenatal care utilization continued to improve in 1995 with 81.2% of all mothers receiving care in the first trimester compared with 78.9% in 1993. Preliminary data for 1995 suggests continued improvement to 81.2%. The percent of infants delivered by cesarean delivery declined slightly to 20.8% in 1995. The percent of low birth weight (LBW) infants continued to climb in 1994 rising to 7.3%, from 7.2% in 1993. The proportion of LBW improved slightly among black infants, declining from 13.3% to 13.2% between 1993 and 1994. Preliminary figures for 1995 suggest continued decline in LBW for black infants (13.0%). The multiple birth ratio rose to 25.7 per 1000 births for 1994, an increase of 2% over 1993 and 33% since 1980. Age-adjusted death rates in 1995 were lower for heart disease, malignant neoplasms, accidents, and homicide. Although the total number of human immunodeficiency virus (HIV) infection deaths increased slightly from 42,114 in 1994 to an estimated 42,506 in 1995, the age-adjusted death rate for HIV infection did not increase, which may indicate a leveling off of the steep upward trend in mortality from HIV infection since 1987. Nearly 15,000 children between the ages of 1-14 years died in the United States (US) in 1995. The death rate for children 1 to 4 years old in 1995 was 40.4 per 100,000 population aged 1 to 4 years, 6% lower than the rate of 42.9 in 1994. The 1995 death rate for 5- to 14-year-olds was 22.1, 2% lower than the rate of 22.5 in 1994. Since 1979, death rates have declined by 37% for children 1 to 4 years old, and by 30% for children 5 to 14 years old. For children 1 to 4 years old, the leading cause of death was injuries, which accounted for for an estimated 2277 deaths in 1995, 36% of all deaths in this age group. Injuries were the leading cause of death for 5- to 14-year-olds as well, accounting for an ever higher percentage (41%) of all deaths. In 1995, the preliminary infant mortality rate was 7.5 per 1000live births, 6% lower than 1994, and the lowest ever recorded in the US. The decline occurred for neonatal as well as postneonatal mortality rates, and among white and black infants alike.

Annual summary of vital statistics-1994.

Recent trends in the vital statistics of the United States continued in 1994, including decreases in the number of births, the birth rate, the age-adjusted death rate, and the infant mortality rate. Life expectancy increased slightly to 75.7 years. Only marriages reversed the recent trend with a slight increase in 1994. An estimated 3,979,000 infants were born during 1994, a decline of < 1% from 1993. The birth rate was 15.3 live births per 1000 population, a 1% decline. These decreasing rates reflect a decline in the fertility rate to 67.1 live births per 1000 women aged 15 to 44 years. Final figures for 1993 indicate that fertility rates declined for all racial groups, by 1% for white women (to 65.4) and 3% for black women (to 80.5). The fertility rate for Hispanic women (106.9) was 84% higher than that for non-Hispanic white women and 31% higher than for non-Hispanic black women. Between 1991 and 1993, birth rates for teenage mothers remained virtually unchanged, and abortion rates have steadily declined, suggesting that teenage pregnancy rates are levelling off. The number and proportion of births to women over age 30, however, continued to rise. The rate of births to all unmarried women (45.3 per 1000 in 1993) has been stable for 3 years. Prenatal care utilization improved in 1993; 79% of women initiated care in the first trimester and < 5% had delayed care or no care. Improvements occurred among nearly all racial and ethnic groups. Reported smoking during pregnancy declined to 15.8% in 1993 from 16.9% in 1992. The proportion of babies delivered by cesarean section was 21.8% in 1993, a 2% decrease from 1992. Between 1992 and 1993, the rate of low birth weight (LBW) rose slightly to 7.2%, while very low birth weight (VLBW) remained stable at 1.3%. Most of the increase in LBW occurred among white infants and reflected, primarily, an increase in the proportion of multiple births. The black/white ratio in LBW continued to increase to more than two-fold with the largest difference recorded among term and postterm infants. Age-adjusted death rates in 1994 were lower for heart disease, malignant neoplasm, pulmonary diseases, other accidents, and homicides. The age-adjusted death rate for human immunodeficiency virus disease continued to rise to 15.1 in 1994. The infant mortality rate declined 4% in 1994, to 7.9 per 1000, the lowest rate ever recorded in the United States. The decline was primarily in neonatal mortality.(ABSTRACT TRUNCATED AT 400 WORDS)

Mechanisms for maternal age differences in birth weight.

The authors studied three hypothesized explanations for reduced birth weights of infants born to US adolescent mothers--social disadvantage, biologic immaturity, and unhealthy behaviors during pregnancy. A hierarchical regression analysis was pursued to evaluate these explanations using data from the National Longitudinal Study of Youth on 1,754 first births between 1979 and 1983 to women aged 14-25 years at the time of birth. The birth weights of infants of mothers aged 14-17, 18-19, and 20-23 years were 133, 54, and 88 g less than for infants of mothers aged 23-25. The regression results indicate that the reduced birth weights of infants born to young mothers, particularly women aged 14-17, were related to their disadvantaged social environment. When adjustment was made for poverty and minority status, there were no maternal age differences in birth weight. The reduced birth weights were not related to the young woman's health behaviors during pregnancy or her biologic characteristics. Ethnicity, poverty status, age at menarche, maternal height, net maternal weight gain, and smoking during pregnancy had an independent effect on birth weight in this sample of young women.

Risk factors for childhood burns: a case-control study of Ghanaian children.

STUDY OBJECTIVE: To study risk factors for childhood burns in order to identify possible preventive strategies. DESIGN: Case-control design with pair matching of controls to cases in relation to age, sex, and area of residence. The cases and controls were identified by a community based, multisite survey. The effects of host and socioenvironmental variables reported by mothers were investigated in a multivariate analysis using conditional logistic regression. SETTING: A developing country setting the Ashanti Region in Ghana. PARTICIPANTS: These comprised 610 cases aged 0-5 years who had been burned (as evidenced by a visible scar) and 610 controls with no burn history. MAIN RESULTS: The presence of a pre-existing impairment in a child was the strongest risk factor in this population (OR = 6.71; 95% CI 2.78, 16.16). Other significant risk factor included: sibling death from a burn (OR = 4.41; 95% CI 1.16, 16.68); history of burn in a sibling (OR = 1.79; 95% CI 1.24, 2.58); and storage of a flammable substance in the home (OR = 1.51; 95% CI 1.03; 2.21). Maternal education had a protective effect against childhood burns, although this effect was not strong (OR = 0.76; 95% CI 0.55, 1.05). CONCLUSIONS: Community programmes to ensure adequate child supervision and general child wellbeing, particularly for those with impairments, as well as parental education about burns are recommended, to reduce childhood burns in this region of Ghana. The public should bed advised against storing flammable substances in the home.

Determinants of modern health care use by families after a childhood burn in Ghana.

OBJECTIVES: This study examined determinants of modern health care use by families after their child aged 0-5 years sustained a burn injury in the Ashanti Region of Ghana. METHODS: A community based survey of children aged 0-5 years was conducted in 50 enumeration areas in the region. Mothers of all children with scars as evidence of a burn were selected for a follow up interview using a standard questionnaire two to three months later. Determinants of health care use were investigated through a multivariate logistic regression using interview responses from mothers of 617 children for whom report on some treatment was given. RESULTS: Overall, 48% of the burned children were taken to a modern health facility for treatment. Of those taken to a modern health facility, 68% were sent within 24 hours of the burn event. Factors with large adjusted odds ratios for modern health care use included wound infection, burns covering 6% or more of the body surface, and third degree burns. Compared with scalds, children with contact and flame burns were less likely to be taken to a health facility, as were burns to rural children, and those given first aid treatment at home. CONCLUSIONS: It is concluded that families, particularly rural residents, should be educated about appropriate health care seeking practices after a burn.

Day-care participation as a protective factor in the cognitive development of low-income children.

The impact of day-care participation during the first 3 years of life on the cognitive functioning of school age children was examined. 867 5- and 6-year-old children from the National Longitudinal Survey of Youth who completed the 1986 assessment were included in the sample. The dependent measures were scores on the Peabody Individual Achievement Test (PIAT) subtests of mathematics and reading recognition. In addition to day-care participation, the impact of the pattern of day-care was examined by analyzing the effect of the number of years in day-care, the timing of initiation of day-care, and type of day-care arrangement. After controlling for confounding factors, there were significant interactions between all 3 measures of day-care patterning and family income for reading recognition performance. This association was further examined by exploring the interaction between the pattern of day-care participation and the quality of the home environment. Initiation of day-care attendance before the first birthday was associated with higher reading recognition scores for children from impoverished home environments and with lower scores for children from more optimal environments. In addition, a significant interaction between the type of day-care arrangement and the quality of the home environment emerged for mathematics performance. Center-based care in particular was associated with higher mathematics scores for impoverished children and with lower mathematics scores for children from more stimulating home environments. These findings are discussed in the context of developmental risk.

Development of an index of maternal transport.

The authors used a decision-analytic approach to develop a Maternal Transport Index (MTI) from ACOG guidelines for maternal transport. Data were obtained from three questionnaires administered to five perinatologists, practicing in facilities with various casemixes. Each questionnaire was based on a given level of hospital and contained scenarios describing indications for maternal transport. The MTIs, ratios of the logs of the proportions with given outcomes in Level III hospitals relative to Level I (or II) hospitals, ranged from 1.0 to 26.3 for newborn outcomes. They were greater for Level I hospitals (than Level II) and when newborn outcomes included severe disability as well as death. Within gestational age categories, the MTI was generally greatest for active preterm labor and, within complication categories, for 24-26 or 27-31 weeks' gestation. It was large for maternal outcomes only for two rare acute medical conditions. The MTI has potential use in setting priorities for maternal transport.

Young motherhood and infant hospitalization during the first year of life.

We studied the relationship of young maternal age with infant hospitalization using data from the National Longitudinal Survey of Youth for 3,130 infants born between 1979 and 1983 to mothers aged 14-25 years. Data on the mothers were first collected in 1979 and yearly thereafter. Data on their children were collected starting in 1982. Logistic regressions of infant hospitalization rates were estimated for first and second and higher births. The odds of infant hospitalization during the first year of life increased with decreasing maternal age, even with adjustment for sociodemographic characteristics, preventive health-care practices, and newborn health status, factors hypothesized to explain the maternal age effect. The maternal age relationship with hospitalization differed by birth order; among second and higher births, the odds of hospitalization was increased only for infants of mothers aged 20-22 years. Male infants, infants with a first well-baby visit after the first month of life, with birth weights between 1501 and 2500 g, and with nursery stays longer than 1 week also had increased odds of hospitalization. Ethnicity, grandmother's education, poverty status, mother's school enrollment, and family composition were not related to the odds of hospitalization, nor was smoking during pregnancy when adjustment was made for birth weight and length of nursery stay.

Nurse-midwifery care to vulnerable populations. Phase I: Demographic characteristics of the National CNM Sample.

The purpose of this article is to describe the extent to which certified nurse-midwives (CNMs) provide care to vulnerable populations in the United States and the source of reimbursement for this care. The data were obtained from the first phase of a national study to address the characteristics of women served and cost of care provided by CNMs. Results were analyzed nationally and by American College of Nurse-Midwives regions. Certified nurse-midwives in all types of practices are providing care to women from populations that are vulnerable to poorer than average outcomes of childbirth because of age, socioeconomic status, refugee status, and ethnicity. Ninety-nine percent of CNMs report serving at least one group of vulnerable women, and CNMs in the inner city and rural practices serve several groups. The vast majority of CNMs are salaried; only 11% receive their primary income from fee-for-service. Fifty percent of the payment for CNM services is from Medicaid and government-subsidized sources whereas less than 20% comes from private insurance. Source of income varies by type of setting in which the CNM attends births. The results suggest that CNMs, as a group, make a major contribution to the care of vulnerable populations.

Differences in cause-specific infant mortality among Chinese, Japanese, and white Americans.

Although black-white differences in infant mortality have received much attention, information is limited about mortality differentials among Asian Americans. This study investigated racial differences in infant mortality in a sample of 21,288 Chinese, 11,882 Japanese, and 65,818 white resident singleton livebirths obtained from the National Center for Health Statistics 1983 and 1984 linked birth/infant death files. The crude infant mortality rates were 8.03, 6.56, and 8.46 per 1,000 livebirths for Chinese, Japanese, and white births, respectively. Cause-specific mortality varied considerably among the three racial groups. While the Japanese had lower rates of infant deaths and deaths from perinatal conditions for firstborn infants, they had higher rates of sudden infant death syndrome, as did Chinese females. The results of a logistic regression analysis indicate that the racial differences in total and cause-specific mortality persist when adjustment is made for demographic factors, use of prenatal care, infant sex, and birth weight. The effect of these latter variables on infant mortality varied by causes of death. The relations between infant mortality and variables such as marital status, maternal education, and birth interval appear indirect, operating partially through birth weight. While birth weight was the single strongest determinant of infant mortality, its relative importance varied by cause of death. The study findings suggest that policy decisions surrounding racial differences in infant mortality should not only be considered in light of specific races, but also with regard to cause-specific mortality. Moreover, additional research is needed to understand the cultural, biological, and behavioral factors that give rise to the racial differences.