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Infant Mortality: Trends and Disparities
Marian MacDorman and T.J. MathewsDivision of Vital Statistics
National Center for Health Statistics
Presented to the Secretary’s Advisory Committee on Infant Mortality
March 26, 2015
Vital Statistics Infant Mortality Data• Based on all birth and death certificates filed in state vital
statistics offices, and transmitted to NCHS.• National data files currently available:
– Birth (natality) data – 2013 final– Mortality data – 2013 final
– Fetal death data – 2012 final
– Linked birth/infant death data set (linked file) – 2012 period file • Links birth and death certificate data for all infant deaths.
• Purpose: To use more detailed data from the birth certificate for infant mortality analysis. Linked file provides more accurate data by race and ethnicity than mortality data.
• For this presentation, black and white = non-Hispanic black and non-Hispanic white
4.62 4.54 4.46 4.42 4.29 4.18 4.05 4.06 4.02 4.04
2.27 2.32 2.22 2.33 2.32 2.21 2.10 2.01 1.96 1.93
0
1
2
3
4
5
6
7
8
2000 2005 2006 2007 2008 2009 2010 2011 2012 2013
Rate
per
1,0
00 li
ve b
irths
Neonatal Postneonatal6.89
6.07 5.98 5.966.39 6.14
6.68 6.75 6.86 6.61
Infant, neonatal and postneonatal mortality rates, US, 2000 and 2005-2013
Source: 2000-2012 data are from the linked birth/infant death data set. 2013 data are from the main mortality file.
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VAWV
OH
MI
NY
PA
MDDE
NJ
CT RI
MA
ME
VTNH
AK
HI
DC
Decline in infant mortality rates by state, 2005-2013
Source: CDC/NCHS, National Vital Statistics System, main mortality file.
No significant changeStatistically significant decline of <20%
Statistically significant decline of 20% or more
U.S. change = -13.1
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VAWV
OH
MI
NY
PA
MDDE
NJ
CT RI
MA
ME
VTNH
AK
HI
DC
Infant mortality rates by State, 2013
Source: CDC/NCHS, National Vital Statistics System, main mortality file.
5.00 to 5.99
Less than 5.00
6.00 to 6.99
7.00 to 7.99
More than 8.00
U.S. rate = 5.96
6.86
13.63
8.06 8.30
5.62 5.76 5.53
4.42 4.68 4.89
5.98
11.19
8.40
6.86
5.11 5.04 5.02 5.004.14 4.06
0
5
10
15
TOTAL Non-Hispanic
black
AmericanIndian orAlaska
native /1
PuertoRican
TotalHispanic
Non-Hispanic
white
Mexican Cuban Central andSouth
American
Asian orPacific
Islander
Rat
e pe
r 1,0
00 li
ve b
irths
2005 2012
-17%
Infant mortality rates by race and Hispanic origin of mother: US, 2005 and 2012
1/ Includes persons of Hispanic and non-Hispanic origin. Note: Percent change indicates statistically significant change between 2005 and 2012. SOURCE: National Vital Statistics System, NCHS, CDC.
-18%
-13%
-12% -17%
-9% -13% -9%
Infant mortality rates for the five leading causes of infant death by maternal race and Hispanic origin, US, 2012
125.7106.6
42.4 38.4 29.4
116.8
75.1
42.528.7 28.4
148.2
263.2
76.8 80.259.0
136.6
85.6
24.7 33.815.9
0
50
100
150
200
250
300
Congenitalmalformations
Short gestation/low birthweight
SIDS Maternalcomplications
Unintentionalinjuries
Rate
per
100
,000
live
birt
hs
Total White Black Hispanic
Source: CDC/NCHS linked birth/infant death data set.
250.4
626.1
344.2
191.9 182.6 184.5 173.5 159.4
214.1
487.4
287.3
214.8
167.9 158.9 148.1 140.4
0
50
100
150
200
250
300
350
400
450
500
550
600
650
TOTAL Non-Hispanicblack
Puerto Rican AmericanIndian or
Alaska native*
Mexican Non-Hispanicwhite
Asian orPacific
Islander*
Central andSouth
American
Rat
e pe
r 100
,000
live
birt
hs
2005 2012
-14%
-22%
-8% -14% -15% -12%
Preterm-related infant mortality rates by race and Hispanic origin of mother: US, 2005 and 2012
*Includes persons of Hispanic and non-Hispanic origin. Rates per 100,000 live births. Source: CDC/NCHS linked birth/infant death data set.
-17%
New variables available from states that have revised their birth certificates
• educational attainment of father• birth interval• receipt of WIC food• exact time of birth• source of payment for the delivery• mother’s body mass index (BMI) (including height and weight)• cigarette smoking before and during pregnancy • infertility treatment• maternal infections• maternal morbidity• 10-minute Apgar score• infant breastfed Available in birth file from 2009 data onwards, and in linked file from 2011 data onwards.
New Data of Variable Quality • 1 study out, 1 underway
Infant mortality rates by source of payment for the delivery and smoking status, 36 states and DC, 2012
5.99
7.38
4.44
6.916.04
10.30
5.43
0
2
4
6
8
10
12
Total Medicaid Privateinsurance
Self-pay Other Yes No
Rate
per
1,0
00 li
ve b
irths
(uninsured)Source of Payment for the Delivery
Mother smoked during pregnancy
Note: Smoking reported for 35 states and DC. Source: CDC/NCHS: 2012 linked birth/infant death data set.
Infant mortality rates by maternal educational attainment, 36 states and DC, 2012
5.98
7.837.09
5.59
3.803.33
0
1
2
3
4
5
6
7
8
9
Total < High school High schooldiploma
Some college Bachelor'sdegree
Masters orDoctorate
Rate
per
1,0
00 li
ve b
irths
Source: CDC/NCHS: 2012 linked birth, infant death data set.
Infant mortality rates by pre-pregnancy Body Mass Index (BMI), 36 states and DC, 2012
5.99 5.89
4.81
5.66
6.83
7.76
9.10
0
1
2
3
4
5
6
7
8
9
10
Total Underweight Normalweight
Overweight Obese I Obese II Obese III
Rate
per
1,0
00 li
ve b
irths
Underweight = BMI<18.5, normal weight = BMI 18.5-24.9, overweight = BMI 25.0-29.9, obese I = BMI 30.0-34.9, obese II = BMI 35.0-39.9, obese III = BMI 40+. Source: CDC/NCHS: 2012 linked birth/infant death data set.
Components of infant mortality
• The overall infant mortality rate can be partitioned into two key components:1) The distribution of births by gestational age;2) Gestational age-specific infant mortality rates (i.e. the mortality rate for infants at a given gestational age).
Percentage of preterm births by maternal race/ethnicity, 2006, 2011, 2012 and 2013
12.811.7
18.5
12.211.710.5
16.8
11.711.610.3
16.5
11.611.410.2
16.3
11.3
0
2
4
6
8
10
12
14
16
18
20
Total Non-Hispanic white Non-Hispanic black Hispanic
2006 2011 2012 2013
-11%
-13%
-12%
-7%
Sources: Martin et al. Births: Final Data for 2013.
Infant mortality rates by gestational age, US, 2005 and 2012
6.86
183.24
16.697.30 3.08 2.07 2.13 2.665.98
163.14
16.237.10 3.05 1.84 1.87 2.63
0
20
40
60
80
100
120
140
160
180
200
Total <32 32-33 34-36 37-38 39-40 41 42+
Rate
per
1,0
00 li
ve b
irths
2005 2012
-11% -12%
-11%
Source: CDC/NCHS, linked birth/infant death data set.Completed weeks of gestation
-13%
Kitagawa analysis• Used to quantify the relative contribution of
changes in the two components, to the 2005-2012 infant mortality decline.
• Analyzed separately for the total population and for non-Hispanic white, non-Hispanic black, and Hispanic women.
Percent contribution of two components to decline in US infant mortality rate 2005-2012, by race/ethnicity
31
82
44
17
69
18
56
83
0%
20%
40%
60%
80%
100%
TOTAL Non-Hispanicwhite
Non-Hispanicblack
Hispanic
Gestational age-specific infantmortality ratesDistribution ofbirths bygestational age
Source: CDC/NCHS, linked birth/infant death data set.
Fetal mortality
Fetal mortality rates by race and Hispanic origin of mother, US, 2006-2012
6.05
4.81
10.73
5.296.05
4.91
10.67
5.33
0
2
4
6
8
10
12
Total Non-Hispanic white Non-Hispanic black Hispanic
2006 2012
No statistically significant differences 2006-2012
Source: National vital statistics system, fetal death data set.
Prospective fetal mortality rate by gestational age: US, 2006 and 2012
0.0
0.2
0.4
0.6
0.8
1.0
1.2
20 22 24 26 28 30 32 34 36 38 40 42
Rate
per
1,0
00 w
omen
stil
l pre
gnan
t at e
ach
gest
atio
nal a
ge
Gestational age (weeks)
2006
2012
No statistically significant differences at 21-42 weeks of gestation.
Note: The prospective fetal mortality rate is the number of fetal deaths at a given gestational age per 1,000 live births and fetal deaths at that gestational age or greater. Source: CDC/NCHS, fetal death file.
Conclusions • After a plateau from 2000-2005, the US infant mortality rate
declined by 13%, to 5.98 infant deaths per 1,000 live births in 2012, and 5.96 in 2013.
• Infant mortality rates were much higher for women who were:
- Uninsured or on Medicaid- Smokers- High school education or less- Overweight or obese.
• After more than two decades of increase, the percent of preterm births declined by 13% from 2006-2013. Still, preterm birth rates were 60% higher for black than for white women.
• Fetal mortality rates plateaued from 2006-2012.
Conclusions (cont.)• From 2005-2012, the black infant mortality rate fell by 18% from
13.63 to 11.19; however the 2012 black infant mortality rate was still 2.2 times the white rate (5.04).
• Preterm-related infant mortality rates were 3 times higher for black than for white women. Rates for SIDS and unintentional injuries were also higher for black than for white women.
• About 2/3 (69%) of the overall infant mortality decline from 2005-2012 was due to declines gestational age-specific infant mortality rates, and less than 1/3 (31%) was due to declines in preterm births.
- However, patterns were very different for white women, with 82% of their infant mortality decline due to decreases in preterm births.
