A Report from the Healthy Start National Evaluation 2006

Racial and Ethnic Disparities in Infant Mortality

Evidence of Trends,

Risk Factors,

and

Intervention Strategies

Evidence of Trends, 

Risk Factors, 

and 

Intervention Strategies 

U.S. Department of 

Health and Human Services 

Health Resources and Services Administration 

Maternal and Child Health Bureau 
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Contents 

Chapter Page
 

EXECUTIVE SUMMARY 

INTRODUCTION 

RACIAL/ETHNIC DISPARITIES IN BIRTH OUTCOMES 

RACIAL/ETHNIC TRENDS IN INFANT MORTALITY 

Overall Trends 

Neonatal and Postneonatal Mortality 

CAUSES OF INFANT DEATH 

RISK FACTORS FOR POOR BIRTH OUTCOMES 

BEHAVIORAL RISK FACTORS 

Preventive Behaviors 

Risky Behaviors 

BIOLOGICAL/SOCIAL RISK FACTORS 

Perinatal Depression 

Stress 

Bacterial Vaginosis 

Domestic Violence 

Maternal Birthweight 

DISCUSSION 

APPENDIX A: DETAILED TABLES 

APPENDIX B: GLOSSARY 

REFERENCES 

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Tables 

Table Page
 

I.1 INFANT MORTALITY RATE, BY RACE/ETHNICITY 

AND EDUCATIONAL ATTAINMENT OF MOTHER: 

UNITED STATES, 2002 

INFANT MORTALITY RATE, BY RACE/ETHNICITY: 

UNITED STATES, 1995 – 2002 

INFANT, NEONATAL, AND POSTNEONATAL MORTALITY RATE, 

BY RACE/ETHNICITY: UNITED STATES, 2002 

LOW BIRTHWEIGHT, BY RACE/ETHNICITY: 

UNITED STATES, 1995 – 2002 

BEHAVIORAL AND BIOLOGICAL/SOCIAL RISK FACTORS 

FOR POOR BIRTH OUTCOMES 

INFANT MORTALITY RATE, BY TRIMESTER 

PRENATAL CARE BEGAN: UNITED STATES, 1995 – 2002 

WOMEN BEGINNING PRENATAL CARE IN THE FIRST TRIMESTER 

AND WITH LATE OR NO PRENATAL CARE, BY RACE/ETHNICITY: 

UNITED STATES, 2002 

INFANT MORTALITY RATE, BY RACE/ETHNICITY AND TRIMESTER 

BEGAN PRENATAL CARE: UNITED STATES, 2002 

SIDS RATE, BY RACE/ETHNICITY: UNITED STATES, 1995 – 2002 

VACCINATION COVERAGE AMONG CHILDREN 19 – 35 MONTHS OF AGE, 

BY RACE/ETHNICITY: UNITED STATES, 1999 

REPORTED TOBACCO USE BY RACE/ETHNICITY: 

UNITED STATES, 2003 

REPORTED ALCOHOL USE DURING PREGNANCY, 

BY RACE/ETHNICITY: UNITED STATES, 2002 

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Figures 

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INFANT MORTALITY RATE: UNITED STATES, 1960 – 2000 

INFANT MORTALITY RATE BY RACE/ETHNICITY: 

UNITED STATES, 2002 

INFANT MORTALITY RATE (IMR), BY STATE, 2001 

INFANT MORTALITY RATES FOR THE FIVE LEADING 

CAUSES OF INFANT DEATH, BY RACE/ETHNICITY: 

UNITED STATES, 2002 

NTD-SPECIFIC INFANT MORTALITY, BY RACE/ETHNICITY: 

UNITED STATES, 1996 – 1998, AGGREGATED 

WOMEN WHO REPORTED SMOKING DURING PREGNANCY, 

BY RACE/ETHNICITY: UNITED STATES, 1999 

INFANT MORTALITY RATE, BY MATERNAL SMOKING STATUS 

AND RACE/ETHNICITY: UNITED STATES, 2002 

INFANT MORTALITY AMONG TEENAGERS YOUNGER THAN 20 

BY RACE/ETHNICITY: UNITED STATES, 2002 

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1
 
2
 
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Executive Summary 

The rate of infant mortality in the United States 

declined by 74 percent between 1960 and 2000, but 

the degree of decline has slowed in the past decade. 

Experts believe that eliminating racial/ethnic 

disparities in birth outcomes is key to the continued reduction in the overall rate of infant mortality 

in the United States. Blacks, American Indian/ 

Alaska Natives, and Puerto Ricans, in descending 

order, have notably higher rates of infant mortality 

than other races/ethnicities. 

Several programs have been implemented to 

address racial/ethnic disparities in birth outcomes. 

Healthy Start, a national initiative begun in 1991 by 

the Health Resources and Services Administration, 

Maternal and Child Health Bureau, is the largest of 

these programs. Healthy Start is a community-based 

program targeted to eliminating or reducing racial/ 

ethnic disparities in birth outcomes in high-risk 

communities. The goals of Healthy Start are to 

improve the quality of the local perinatal system of 

care, to enhance the cultural competence of providers who work within the system, and to improve 

women’s access to the system of care. These objectives are accomplished through outreach, health 

education, case management, and enhanced community collaboration within the local perinatal 

health system. The activities of the Healthy Start 

program are designed to encourage pregnant and 

interconceptional women, providers, and other 

community stakeholders to address the risk factors 

associated with poor perinatal health outcomes.

 In this paper, an evidence base is provided to support the targeted interventions implemented by the 

national Healthy Start program and other perinatal health initiatives to reduce racial/ethnic disparities in birth outcomes. In light of this objective, the 

racial/ethnic disparities in birth outcomes are 

described and the evidence on behavioral, 

biological, and social risk factors for poor perinatal 

outcomes in the context of such racial/ethnic 

disparities is reviewed. The risk factors reviewed are 

prenatal care, folic acid use, periodontal care, infant sleep position, breastfeeding, well-child care, 

interconceptional care, maternal smoking, alcohol 

and other drug use, adolescent pregnancy, perinatal depression, stress, bacterial vaginosis, domestic 

violence, and maternal birthweight. Key findings 

are: 

Compared to women of other races/ethnicities, Black women have the lowest rates of 

preventive behaviors associated with 

improved birth outcomes. These behaviors 

include entering prenatal care during the 

first or second trimester, using folic acid, 

receiving periodontal care, putting infants to 

sleep on their back, breastfeeding, completing child vaccinations, and spacing births a 

year or more apart. Black women also have 

higher rates of adolescent pregnancies, 

stress, bacterial vaginosis, and domestic 

violence during pregnancy. These risk 

factors are recognized as being associated 

with preterm birth/low birthweight, the 

cause of infant mortality for which Blacks 

are at highest risk. 

3

Compared to other races/ethnicities, Ameri­ These findings provide an evidence base for 

can Indian/Alaska Natives have the highest designing and evaluating initiatives – such as 

prevalence for risk factors associated with Healthy Start – that are intended to reduce or elimisudden infant death syndrome, such as smok­ nate disparities in maternal and infant health outing and alcohol use during pregnancy, and comes. 

putting infants to sleep in the prone position.

4
 
Deaths per 1,000 Live Births

Chapter I 

Introduction 

Infant mortality often is used as an international 

indicator of the health and well-being of a nation. It 

provides a quick measure of the quality of food and 

water, housing and clothing, health care, and education available in a population (Reidpath and 

Allotey 2003). The United States, despite being the 

largest, most technologically advanced economy in 

the world, ranks 37th of 191 countries in infant mortality (Appendix A, Table A.1) (World Health Organization 2004). Although the rate of infant mortality in the United States declined by 74 percent over 

the four decades between 1960 and 2000, to 6.9 infant deaths per 1,000 live births (Figure I.1), the 

degree of decline has slowed in the past decade (Centers for Disease Control and Prevention 2004b). In 

the 1990s, the rate of infant mortality decreased by 

22 percent, compared to 27 percent and 37 percent 

in the 1980s and 1970s, respectively (Figure I.1). 

Much of the decrease in the 1970s and 1980s was 

due to technological advances in high-risk obstetrics and neonatal intensive care (Wise 2003). More 

recently, technological strides in neonatal health 

Figure I.1. 

Infant Mortality Rate: United States, 1960 – 2000 

30 

26.0 

25 

20.0 20
 

15
 12.6 

9.2 10 

6.9 

5
 

0
 

1960 1970 1980 1990 2000 

Source: Centers for Disease Control and Prevention 2004b. 

have slowed, making it more challenging to create 

the large rates of decline seen previously in the 

United States. 

Although it is more difficult to achieve the magnitude of decreases in infant mortality today that 

occurred in previous decades, the United States’ 

world ranking in infant mortality suggests that there 

is still progress to be made. Experts in neonatal 

health attribute this ranking to the prevalence of 

poor birth outcomes among certain racial and ethnic groups in the United States, particularly Black, 

American Indian/Alaska Native, and Puerto Rican 

populations. The rate of infant mortality is notably 

higher among these three racial/ethnic groups than 

the national average (Figure I.2). For example, in 

2002, infants born to Black women were twice as 

likely to die in their first year than infants overall in 

the United States. In that same year, American Indian/Alaska Natives and Puerto Ricans had infant 

mortality rates 15 percent above the national average. Hawaiians also had a rate above the national 

average. However, as shown in Table II.2, the rate 

for Hawaiians fluctuates below and above the national average from year to year, likely due to small 

sample size. 

In response to these racial/ethnic disparities, the 

U.S. Department of Health and Human Services has 

set a goal to reduce infant mortality to less than 4.5 

infant deaths per 1,000 births among all racial/ethnic groups in its Healthy People 2010 objectives 

(U.S. Department of Health and Human Services 

2000a). Although infant mortality rates for people 

in the United States of Cuban and Chinese ancestry 

5
 
Asian/Pacific

Islander

Hispanic Origin

Figure I.2. 

Infant Mortality Rate by Race/Ethnicity: U.S. 2002 

Healthy People 

2010 Objective 

4.5 Deaths per 

1,000 Live Births 

All Races 7.0 

White 5.8 

Black 13.8 

Chinese 3.0 

Japanese 4.9 

Hawaiian 9.6 

Filipino 5.7 

American Indian 8.6 /Alaska Native 

Mexican 5.4 

Puerto 8.2 Rican 

Cuban 3.7 

Central & 

South 5.1 

American 

Source: Mathews et al. 2004. 

are already below the Healthy People 2010 goal, 

those who are Black, Puerto Rican, Hawaiian, and 

American Indian/Alaska Native have a rate of 8.2 infant deaths per 1,000 births or higher (Figure I.2). This 

relationship holds at the State level as well. For all 

States in 2001, Blacks and American Indian/Alaska 

Natives consistently have higher infant mortality rates 

than Whites, while Asian/Pacific Islanders consistently 

have lower rates (Appendix A, Table A.2). 

High rates of infant mortality tend to be concentrated in the South and North Central regions of the 

United States (Figure I.3). Those States with higher 

overall rates of infant mortality also tend to have larger 

racial/ethnic disparities in infant mortality. For example, when States are divided into thirds by infant 

mortality rate, States in the lowest tertile (less than 

6.5 infant deaths per 1,000 live births) had an average 

difference in rate between Whites and Blacks of 6.3 

infant deaths per 1,000 live births. In comparison, 

States with rates greater than 7.4 infant deaths per 

1,000 live births (highest tertile) had an average difference in rate between Whites and Blacks of 8.4 infant deaths per 1,000 live births (Appendix A, Tables 

A.2 and A.3). 

The Institute of Medicine’s (IOM) report, Unequal 

Treatment: Confronting Racial and Ethnic Disparities in Healthcare, offers some insight into the causes 

of the racial/ethnic disparities in infant mortality (Institute of Medicine 2003). In this report, the IOM attributed the racial/ethnic disparities in health care and, 

consequently, health to lower health care quality and 

access for minorities. The IOM reviewed more than 

100 studies assessing the health care quality for various minority groups. It consistently found evidence 

that minorities are less likely than Whites to receive 

needed services and are more likely to receive less desirable services. The research also showed that disparities are present even when controlling for clinical factors. Although minorities are disproportionately represented among the uninsured and those of lower socioeconomic status, the IOM noted that these factors 

are not the cause of poorer quality of health care 

Figure I.3. 

Infant Mortality Rate by Race/Ethnicity: U.S. 2002 

District of 

Columbia 

High IMR 

(>7.4 per 1,000) 

Medium IMR 

(6.5 - 7.4 per 1,000) 

Low IMR Source: Data from Mathews et al. 2003 were used 

(<6.5 per 1,000) to create State tertiles. Note: Detailed data are 

shown in Appendix A, Table A.2. 

among minorities. Even when minorities have the
 

same health insurance as nonminorities, and similar access to care, minorities still tend to receive a
 

6
 
 

 

 

 

Table I.1. 

Infant Mortality Rate, by Race/Ethnicity and Educational Attainment of Mother: United States, 2002 

Rate per 1,000 Live Births 

Educational Attainment of Mother 

Race and Ethnicity 0 to 8 9 to 11 12 13 to 15 16 years 

years years years years & more 

All Races and Ethnicities 6.6 9.6 7.8 6.0 4.2 

RACE
 

• White

• Black

• Asian/Pacific Islander

• American Indian/Alaska Native 

ETHNICITY 

• All Hispanics 

–Mexican 

–Puerto Rican 

–Cuban 

–Central & South American 

• White non-Hispanic 

• Black non-Hispanic 

Source: Mathews et al. 2004. 

6.1 8.0 6.5 4.9 3.7 

14.7 15.8 13.4 11.7 9.9 

4.0 5.9 5.6 4.7 3.7 

* 8.3 9.1 8.6 * 

5.3 6.1 5.6 4.9 4.0

5.1 5.7 5.3 5.0 4.1 

11.5 9.7 8.8 6.0 3.9 

* * * * * 

5.8 6.0 4.7 4.3 4.4 

9.9 9.9 6.9 4.8 3.7 

15.2 15.9 13.6 11.9 10.0 

*Figure does not meet standard of reliability or precision, based on fewer than 20 deaths in the numerator.
 

lower quality of care and have poorer outcomes than 

Whites (Institute of Medicine 2003). When education is used as a proxy for socioeconomic level, 

Blacks, American Indian/Alaska Natives, and Puerto 

Ricans continue to have the highest rates of infant 

mortality compared to other races/ethnicities, 

regardless of socioeconomic level (Table I.1). 

The IOM proposes that the sources of racial/ethnic disparities in health are “complex, rooted in historic and contemporary inequities, and involve many 

participants at several levels, including health systems, health professionals, and patients” (Institute 

of Medicine 2003). Many factors other than socioeconomic and clinical ones contribute to the problem. These factors include minority behavior and 

attitudes, cultural and language barriers within 

health systems, and patients’ and providers’ lack of 

knowledge. As a result, the IOM promotes a comprehensive, multilevel approach to eliminating 

disparities that targets patients, providers, and 

health care systems. This approach includes (1) raising awareness of the problem among the public and 

health care professionals; (2) employing health systems interventions to equalize and promote highquality care for all patients; (3) implementing legal, 

policy, and regulatory improvements to increase 

minority access to care and reduce cultural barriers 

to care; and (4) increasing the education of patients 

and providers.

 Healthy Start is a federally-sponsored, commu7 
nity-based program that works on many levels to 

eliminate racial/ethnic disparities in infant mortality. The program recognizes the complex nature of 

racial/ethnic disparities in health and the need to 

address other factors besides socioeconomic and 

clinical ones. The goal of Healthy Start is to improve 

perinatal system access and knowledge by providing culturally competent services, including outreach, health education, and case management, and 

by enhancing the local perinatal health system. The 

activities of the Healthy Start program are designed 

to encourage pregnant and interconceptional 

women, providers, and other community stakeholders to address the risk factors associated with poor 

perinatal health outcomes. Healthy Start relies on 

community involvement to lead to better access to 

care and knowledge of perinatal risks for high-risk 

women, which should in turn bring about improved 

birth outcomes and ultimately eliminate racial/ethnic disparities in infant mortality.

 In this paper, an evidence base for Healthy Start 

and other perinatal health initiatives is provided by 

describing in detail the racial/ethnic disparities in 

birth outcomes and the risk factors that may be the 

underlying causes of differences in birth outcomes. 

To gather this information, a literature review of infant mortality trends and risk factors among various racial/ethnic groups was conducted. The National Vital Statistics Reports was used, and 

Pubmed, Ovid, and the Internet were searched 

using key words related to racial/ethnic disparities 

in infant mortality, causes of infant mortality, and 

its associated risk factors. Data were amassed from 

many sources, including vital statistics, peer-reviewed journal articles, and press releases and reports from organizations such as the Centers for 

Disease Control and Prevention (CDC), National 

Institutes of Health (NIH), and the IOM.

 Because data cited in this paper are from different sources, categorizations of race and ethnicity on 

the tables and figures vary. While some sources categorized race and ethnicity separately (for example, 

White and Black, Hispanic and non-Hispanic), others grouped race and ethnicity together (for example, 

White non-Hispanic, Black non-Hispanic, and Hispanic). Unless explicitly stated as non-Hispanic, 

White and Black include both Hispanics and nonHispanics. When possible, race and ethnicity are 

presented separately. For consistency, African 

Americans are referred to as Black, and Caucasians 

are referred to as White.

 For comparison and consistency, year 2002 data 

are presented whenever possible, because, in most 

cases, 2002 is the most recent year for which data 

are available. In a few cases, however, data are 

shown for years before 2002 and are aggregated over 

several years. Appendix A contains tables with detailed data used to create the figures in the paper. 

Appendix B provides a glossary defining terms used 

in the paper that relate to birth outcomes. 

8
 
Chapter II 

Racial/Ethnic Disparities 

in Birth Outcomes 

Racial/ethnic differences in infant mortality are 

evident in trends over time and in the leading causes 

of infant death. Investigating these patterns can provide insight into these disparities. This chapter first 

presents racial/ethnic trends in rates of infant mortality. It then describes infant mortality rates during the neonatal and postneonatal period by race and 

ethnicity to offer a deeper understanding of how 

racial/ethnic disparities in birth outcomes show up 

at different times in an infant’s life. Infant mortality 

trends are examined from 1995 to 2002; 1995 is the 

earliest year with racial/ethnic infant mortality data 

publicly available through the National Center for 

Health Statistics, while 2002 is the latest year with 

data available by racial/ethnic groups, including 

White, Black, Asian/Pacific Islander, American 

Indian/Alaska Native, and Hispanic. 

RACIAL/ETHNIC TRENDS 

IN INFANT MORTALITY 

OVERALL TRENDS 

Decreases in infant mortality rates were observed for most racial and ethnic groups from 1995 

to 2002, but the magnitude of the change varied by 

group. Significant decreases were observed for 

White (7.9 percent), Black (5.5 percent), Asian/Pacific Islander (9.4 percent), and Hispanic (11.1 percent) populations (Table II.1). The infant mortality 

rate decreased among American Indian/Alaska Natives by 4.4 percent during this period, although the 

change was not statistically significant. The large 

decrease in infant mortality among the Hispanic 

population was driven by those of Cuban (30.2 percent) and Mexican (10.0 percent) descent. Although 

Hispanics as a group had a lower rate of infant mortality than the overall U.S. rate, women of Puerto 

Rican descent had an infant mortality rate higher 

than the national average for all years reported. 

Despite significant declines in the rate of infant 

mortality for most racial/ethnic groups, the racial/ 

ethnic disparity in rates did not change between 1995 

and 2002 (Table II.1). For each year during this period, the rate of infant mortality for Blacks overall 

and Black non-Hispanics was 2.3 times that of 

Whites. In addition, for each year during this period, American Indian/Alaska Natives had an infant 

mortality rate ranging from 1.4 to 1.7 times that of 

Whites, while Puerto Ricans had a rate ranging from 

1.3 to 1.5 times that of Whites. The ratio between 

White non-Hispanic and Hispanic infant mortality 

rates was similar and remained stable for all years.1 

1

As shown in Table II.1 (page 10), the infant mortality rate increased 

slightly from 2001 to 2002. The increase was spread among most 

race and Hispanic origin groups. The increase is attributed, in large 

part, to an increase in the number of very low birthweight infants 

(less than 750 grams). Among the other possible explanations for 

the slight rise in infant mortality are: (1) increase reporting of early 

fetal deaths; (2) extent of mothers’ medical risk factors (including 

maternal anemia, diabetes, and chronic hypertension); and (3) 

changes in the medical management of pregnancy (such as cesarean deliveries) (MacDorman et al. 2005). 

9
 
 

 

 

 

 

 

 

 

Table II.1. 

Infant Mortality Rate, by Race/Ethnicity: United States, 1995 - 2002 

Rate per 1,000 Live Births 

Percent 

Change 

1995 to 

Race and Ethnicity 1995 1996 1997 1998 1999 2000 2001 2002 2002 

All Races and Ethnicities 7.6 7.3 7.2 7.2 7.0 6.9 6.8 7.0 -7.9* 

RACE
 

• White

• Black

• Asian/Pacific Islander

 –Chinese 

 –Japanese 

 –Hawaiian 

–Filipino 

• American Indian/ 

Alaska Native 

ETHNICITY 

• All Hispanics 

 –Mexican 

 –Puerto Rican 

 –Cuban 

 –Central

 & South American 

• Non-Hispanic White

• Non-Hispanic Black 

Source: Mathews et al. 2004. 

6.3 6.1 6.0 6.0 5.8 5.7 5.7 5.8 -7.9* 

14.6 14.1 13.7 13.8 14.0 13.5 13.3 13.8 -5.5* 

5.3 5.2 5.0 5.5 4.8 4.9 4.7 4.8 -9.4*

3.8 3.2 3.1 4.0 2.9 3.5 3.2 3.0 -21.1

5.3 4.2 5.3 3.5 3.4 4.5 4.0 4.9 -7.5

6.6 5.6 9.0 10.0 7.1 9.0 7.3 9.6 45.5

5.6 5.8 5.8 6.2 5.8 5.7 5.5 5.7 1.8 

9.0 10.0 8.7 9.3 9.3 8.3 9.7 8.6 -4.4 

6.3 6.1 6.0 5.8 5.7 5.6 5.4 5.6 -11.1*

6.0 5.8 5.8 5.6 5.5 5.4 5.2 5.4 -10.0*

8.9 8.6 7.9 7.8 8.3 8.2 8.5 8.2 -7.9

5.3 5.1 5.5 3.6 4.7 4.6 4.2 3.7 -30.2

5.5 5.0 5.5 5.3 4.7 4.6 5.0 5.1 -7.3 

6.3 6.0 6.0 6.0 5.8 5.7 5.7 5.8 -7.9* 

14.7 14.2 13.7 13.9 14.1 13.6 13.5 13.9 -5.4* 

*Significant difference at p<0.05. Note: Hispanic includes both White and Black Hispanics.
 

10
 
 

 

 

 

 

 

 

 

 

NEONATAL 

AND POSTNEONATAL MORTALITY 

Racial/ethnic trends for neonatal and postneonatal death rates are similar to overall rates of 

infant mortality–Blacks, American Indian/Alaska 

Natives, and Puerto Ricans continue to have the 

highest rates of all races and ethnicities (Table II.2). 

American Indian/Alaska Natives have one of the 

highest rates of postneonatal mortality while they 

have a neonatal mortality rate lower than the rates 

for all races/ethnicities combined. These results indicate that racial/ethnic disparities in infant mortality among American Indian/Alaska Natives are 

largely driven by infant deaths occurring after the 

first month of birth. The opposite is true for Puerto 

Ricans–they have a neonatal infant death rate 23 

percent higher than the overall rate for all races and 

ethnicities and a postneonatal rate only 4 percent 

above the overall rate. For Blacks, the racial/ethnic 

disparities in infant mortality are equally attributable to neonatal and postneonatal mortality rates– 

both neonatal and postneonatal mortality rates for 

Blacks are nearly twice the rates for all races/ 

ethnicities combined. 

Table II.2. 

Infant, Neonatal, and Postneonatal Mortality Rate, by Race/Ethnicity: United States, 2002 

Rate per 1,000 Live Births 

INFANT NEONATAL POSTNEONATAL
 

All Races and Ethnicities 7.0 4.7 2.3 

RACE
 

• White

• Black

• Asian/Pacific Islander

 –Chinese 

 –Japanese 

–Hawaiian 

–Filipino 

• American Indian/
 

Alaska Native
 

ETHNICITY 

• All Hispanics 

 –Mexican 

 –Puerto Rican 

 –Cuban 

 –Central

 & South American 

• Non-Hispanic White

• Non-Hispanic Black 

Source: Mathews et al. 2004. 

5.8 3.9 1.9 

13.8 9.3 4.5 

4.8 3.4 1.4

3.0 2.4 0.7

4.9 3.7 *

9.6 5.6 4.0

5.7 4.1 1.7 

8.6 4.6 4.0 

5.6 3.8 1.8

5.4 3.6 1.8

8.2 5.8 2.4

3.7 3.2 *

5.1 3.5 1.6 

5.8 3.9 1.9 

13.9 9.3 4.6 

*The figure does not meet standard of reliability or precision, based on fewer than 20 deaths in the numerator.
 

11
 
CAUSES OF INFANT DEATH 

In 2002, the five principal causes of infant mortality accounted for 55 percent of all infant deaths 

(Mathews et al. 2004). The five leading causes, in 

descending order, are: (1) congenital malformations, 

(2) preterm birth/low birthweight, (3) sudden infant death syndrome, (4) maternal complications, 

and (5) cord complications. Congenital malformations, the leading cause of infant mortality, contribFigure II.1. 

Infant Mortality Rate for the Five Leading Causes 

of Infant Death, by Race/Ethnicity: U.S. 2002 

All Races 

& Ethnicities 

White 

Black 

Asian/Pacific 

Islander 

American 

Indian 

/Alaska Native 

Hispanic 

140 

115 

57 

42 

25 

131 

77 

55 

35 

21 

Congenital 

malformations 

Preterm 

birth/LBW 

SIDS 

Maternal 

complications 

Cord 

complications 

171 

316 

111 

95 

53 

107
 

76
 

24
 

32
 

15
 

188
 

108
 

123
 

53
 

146 

87
 

30
 

28
 

18 

Source: Mathews et al. 2004. 

Notes: For American Indian/Alaska Natives, infant mortality rates 

due to cord complications were not reported because there were fewer 

than 20 deaths in the numerator. “Black” and “White” categories exclude women of Hispanic origin. Detailed data are shown in Appendix A, Table A.5. 

uted to 20 percent of all deaths. The second largest 

cause, disorders relating to short gestation (less than 

37 weeks) and low birthweight (less than 2500 

grams), accounted for another 17 percent of mortality. Eight percent of deaths were attributable to 

sudden infant death syndrome (SIDS). Newborns 

affected by maternal complications of pregnancy and 

complications of placenta, cord, and membrane explained another six and four percent of infant deaths, 

respectively. 

Cause of death varied by race/ethnicity. Congenital malformations were the leading cause of 

death for White, Hispanic, Asian/Pacific Islander, 

and American Indian/Alaska Native populations in 

2002, but preterm birth/low birthweight was the 

leading cause among the Black population (Figure 

II.1). Unlike other races/ethnicities, American Indian/Alaska Natives had SIDS as the second leading cause of infant mortality. 

The variability in cause of infant death across 

racial/ethnic groups may help identify the areas 

where interventions to reduce disparities and improve birth outcomes would be most effective. For 

example, although Black women had higher infant 

mortality rates than White women for all five leading causes of infant mortality, the largest difference 

in rates between the two groups was for preterm 

birth/low birthweight infants–infants born to Black 

women had an infant death rate due to preterm 

birth/low birthweight four times higher than those 

born to White women (Figure II.1). This infant mortality pattern is consistent with the prevalence of 

preterm birth/low birthweight among the two races; 

Black infants are almost two times more likely than 

White ones to be born preterm/low birthweight 

(Martin et al. 2002b) (Appendix Table A.6). Preterm 

birth/low birthweight accounted for 30 percent of 

the disparity in infant mortality rates between White 

and Black infants, while SIDS and maternal complications accounted for seven percent each 

12
 
 

 

 

 

 

 

 

(Mathews et al. 2004). In addition, although the among Blacks remained stable during this period 

rate of infant mortality decreased for Blacks between (Table II.3), as did deaths attributable to low 

1995 and 2002, the rate of low birthweight births birthweight/preterm births (data not shown). 

Table II.3. 

Low Birthweight, by Race/Ethnicity: United States, 1995 - 2002 

Percent of Live Births 

Percent 

Change 

1995 to 

Race and Ethnicity 1995 1996 1997 1998 1999 2000 2001 2002 2002 

All Races and Ethnicities 7.3 7.4 7.5 7.6 7.6 7.6 7.7 7.8 6.8 

RACE
 

• White

• Black

• Asian/Pacific Islander

–Chinese 

–Japanese 

–Hawaiian 

–Filipino 

• American Indian/ 

Alaska Native 

ETHNICITY 

• All Hispanics 

 –Mexican 

–Puerto Rican 

 –Cuban 

 –Central

 & South American 

• Non-Hispanic White

• Non-Hispanic Black 

6.2 6.3 6.5 6.5 6.6 6.5 6.7 6.8 9.7 

13.1 13.0 13.0 13.0 13.1 13.0 13.0 13.3 1.5 

6.9 7.1 7.2 7.4 7.4 7.3 7.5 7.8 13.0

5.3 5.0 5.1 5.3 5.2 5.1 5.3 5.5 3.8

7.3 7.3 6.8 7.5 7.9 7.1 7.3 7.6 4.1

6.8 6.8 7.2 7.2 7.7 6.8 7.9 8.1 19.1

7.8 7.9 8.3 8.2 8.3 8.5 8.7 8.6 10.3 

6.6 6.5 6.8 6.8 7.1 6.8 7.3 7.2 9.1 

6.3 6.3 6.4 6.4 6.4 6.4 6.5 6.5 3.1

5.8 5.9 6.0 6.0 5.9 6.0 6.1 6.2 6.9

9.4 9.2 9.4 9.7 9.3 9.3 9.3 9.7 3.2

6.5 6.5 6.8 6.5 6.8 6.5 6.5 6.5 0.0

6.2 6.0 6.3 6.5 6.4 6.3 6.5 6.5 4.8 

6.2 6.4 6.5 6.6 6.6 6.6 6.8 6.9 11.2 

13.2 13.1 13.1 13.2 13.2 13.1 13.1 13.4 1.5 

Source: MacDorman et al. 1998a, MacDorman et al. 1998b, Ventura et al. 1999, Ventura et al. 2000, Ventura et al. 2001, Martin et al. 2002a, 

Martin et al. 2002b, Martin et al. 2003. 

Note: See Appendix A, Table A.7 and A.8 for trends in preterm birth and very low birthweight by race and ethnicity. 

13
 
This pattern suggests that focusing on the prevention of preterm birth/low birthweight among Black 

infants could have a large impact on reducing racial/ethnic disparities in infant mortality. 

Similarly, American Indian/Alaska Natives had 

the highest proportion of infant deaths attributable 

to SIDS; the infant death rate among this group was 

2.2 times that of Whites (Figure II.1). This implies 

that concentrating on the reduction of SIDS among 

American Indian/Alaska Natives could decrease the 

disparity in infant mortality between the two groups 

by 24 percent (Mathews et al. 2004). Likewise, if 

Puerto Rican infant deaths due to congenital malformations, preterm birth/low birthweight, and maternal complications were reduced to the levels of 

White infants, the difference in their infant mortality rates would be cut in half (data not shown). In 

Chapter III the risk factors underlying poor birth 

outcomes, and the racial/ethnic disparities in these 

risk factors, are discussed. 

14 
Chapter III 

Risk Factors for Poor Birth Outcomes 

Eliminating racial/ethnic disparities in perinatal 

outcomes requires thorough knowledge of their 

causes. Researchers suggest that several factors contribute to racial/ethnic disparities in perinatal 

health: stress, environment, genetics, economic resources and socioeconomic status, health behavior, 

access to and availability of health care services, and 

quality of health care (Hogan et al. 2001). In this 

chapter, evidence on the behavioral, biological, and 

social risk factors for poor perinatal outcomes in the 

context of racial/ethnic disparities is presented. 

Table III.1 lists the risk factors discussed. In categorizing risk factors as behavioral, biological, and social, the interdependent nature of risk factors between and within categories is recognized. For example, a biological risk factor such as depression can 

lead to behavioral risk factors, such as alcohol use 

and smoking during pregnancy. As a result, the risk 

factors in relationship to each other are discussed 

whenever possible. The inter-related quality of these 

risk factors also makes it challenging to pinpoint the 

direct contribution of each factor to poor birth outcomes. Adding to this challenge is women’s possible 

self-selection to certain risk groups (such as those 

receiving late or no prenatal care). Therefore, no attempt is made to draw direct causal relationships 

between risk factors and adverse birth outcomes, but 

a link between the two, acknowledging the influence 

of other factors is illustrated. 

This chapter provides insight into areas where 

targeted maternal and child health interventions 

through programs, such as Healthy Start, could help 

reduce racial/ethnic disparities in birth outcomes. 

Therefore, issues related to socioeconomics, clinical practice, genetics, and access to health care are 

not directly discussed. However, these issues in relation to the risk factors presented in the chapter is 

acknowledged. For example, some behavioral factors, such as getting early prenatal care and obtaining well child visits, can be influenced by a woman’s 

ability to access this care and her knowledge about 

such care. Despite these multiple influences on a 

Table III.1. 

Behavioral and Biological/Social Risk Factors for Poor Birth Outcomes 

Biological/Social

Behavioral Risk Factors Risk Factors

PREVENTIVE BEHAVIORS RISKY BEHAVIORS 

Prenatal Care Maternal Smoking Perinatal Depression 

Folic Acid Use Alcohol & Other Drug Use Stress 

Periodontal Care Adolescent Pregnancy Bacterial Vaginosis 

Infant Sleep Position Domestic Violence 

Breastfeeding Maternal Birthweight 

Well-Child Care 

Interconceptional Care 

Biological/Social Behavioral Risk Factors Risk Factors 

15
 
woman’s ultimate behavior, this discussion emphasizes the need for interventions and systems to encourage, support, and reinforce positive perinatal 

behaviors. 

BEHAVIORAL 

RISK FACTORS 

PREVENTIVE BEHAVIORS 

Prenatal Care 

The American College of Obstetricians and 

Gynecologists recommends that all pregnant women 

initiate prenatal care in the first trimester and continue care at specified intervals throughout pregnancy (Beck et al. 2002). Lack of prenatal care is 

associated with an increased risk of preterm birth, 

low birthweight, and infant death (Beck et al. 2002). 

From 1995 to 2002, women who had no prenatal 

care consistently had approximately five times the 

risk of infant death of women who received prenatal care during any trimester (Table III.2). 

The link between prenatal care and adverse birth 

outcomes is not fully understood, but research indicates that early, regular prenatal care is associated 

with a decreased risk of poor birth outcomes 

(Vintzileos et al. 2002a, 2002b). Examination of trimester when prenatal care began by race/ethnicity 

demonstrates that Whites and Asian/Pacific Islanders had the highest percentages of women who initiated prenatal care in the first trimester; American 

Indian/Alaska Natives and Blacks had the highest 

proportions of women who received late or no prenatal care in 2002 (Table III.3). 

The racial/ethnic pattern of late or no prenatal 

care parallels infant mortality rates; Blacks and 

American Indian/Alaska Natives have both the highest rates of late or no prenatal care and the highest 

rates of infant mortality. When infant mortality is 

stratified by when trimester of pregnancy when 

prenatal care began, however, Blacks and American 

Indian/Alaska Natives have higher rates of infant 

mortality, regardless of timing of prenatal care 

(Table III.4). This suggests that differences in 

prenatal care only partially explain differences in 

infant mortality. Regardless of the causal link, 

prenatal care offers an opportunity for early risk 

assessment, intervention, and monitoring among 

those at risk for adverse birth outcomes. 

Folic Acid Use 

Neural tube defects (NTD) occur in approximately one per 1,000 births in the United States. It 

is estimated that adequate levels of folic acid one 

month before conception and through the first trimester of pregnancy could prevent 50 to 70 percent 

of these defects (Centers for Disease Control and 

Table III.2. 

Infant Mortality Rate, by Trimester Prenatal Care Began: United States, 2002 

Infant Death Rate per 1,000 Live Births 

1995 1996 1997 1998 1999 2000 2001 2002
 

• First Trimester 

• Second Trimester 

• Third Trimester 

• No Prenatal Care 

6.6 6.5 6.3 6.3 6.2 6.1 6.2 6.2 

8.0 7.7 7.6 7.7 7.2 7.2 6.9 7.3 

7.5 6.7 6.6 6.1 6.2 6.1 6.0 6.0 

37.9 35.2 35.6 35.2 34.6 33.8 34.8 38.4 

Source: MacDorman and Atkinson 1998a, MacDorman and Atkinson 1998b, MacDorman and Atkinson 1999,
 

Mathews et al. 2000, Mathews et al. 2002a, Mathews et al. 2002b, Mathews et al. 2003, Mathews et al. 2004.
 

16
 
 

 

Table III.3. 

Women Beginning Prenatal Care in the First Trimester and with Late or No Prenatal Care, 

by Race/Ethnicity: United States, 2002 

PERCENT

 RACE ETHNICITY 

American 

Asian/ Indian/ White Black 

Pacific Alaska Non- NonAll White Black Islander Native Hispanic Hispanic Hispanic 

• First Trimester

• Second Trimester

• Late* or No

Prenatal Care 

• Unknown 

83.7 85.4 75.2 84.8 69.8 76.7 88.6 75.2 

12.4 11.3 18.1 n/a n/a 17.4 9.0 18.1 

3.6 3.1 6.2 3.1 8.0 5.5 2.2 6.2 

0.3 0.2 0.5 n/a n/a 0.4 0.2 0.5 

Source: Martin et al. 2003. *Care beginning in the third trimester.

Table III.4. 

Infant Mortality Rate, by Race/Ethnicity and Trimester Began Prenatal Care: United States, 2002 

PERCENT

 RACE ETHNICITY 

American 

Asian/ Indian/ White Black 

Pacific Alaska Non- NonAll White Black Islander Native Hispanic Hispanic Hispanic 

• First Trimester

• Second Trimester

• Third Trimester

• Late* or No 

Prenatal Care 

6.2 5.2 12.8 4.4 7.9 5.3 5.2 12.9 

7.3 6.5 10.5 4.3 8.9 5.2 7.4 10.5 

6.0 4.9 9.3 4.5 ** 3.4 6.1 9.5 

38.4 29.9 58.0 30.5 ** 23.0 36.4 57.9 

Source: Martin et al. 2004. *Care beginning in the third trimester. **The figure does not meet standard 

of reliability or precision, based on fewer than 20 deaths in the numerator. 

Prevention 1999a). NTDs were responsible for 1.4 

percent of all infant deaths in 2000 (Williams et al. 

2003). In addition, they are associated with spontaneous abortions and low birthweight/prematurity. 

Between 1996 and 1998, 74 percent of NTD-specific 

deaths were low birthweight, and 58 percent were 

preterm (Davidoff et al. 2002). 2 

The Healthy People 2010 goal is for 80 percent of 

women of child-bearing age to consume at least 400 

micrograms of folic acid daily. Approximately only one 

in three women in the United States consume this 

amount (American Academy of Pediatrics 1999, Centers for Disease Control and Prevention 2005). Folic 

acid use was highest among White non-Hispanic 

women and lowest among Black non-Hispanic women 

2Reported infant mortality rates do not account for spontaneous abortions.

17
 
(Centers for Disease Control and Prevention 2002a). 

Despite having lower levels of folic acid use, 

Black women had a lower NTD-specific infant mortality rate than White, Asian/Pacific Islander, and 

American Indian/Alaska Native women (Figure 

III.1). Black women had a rate of NTD-specific infant death of 8.6 per 100,000 live births, compared 

to 11.6, 9.8, and 11.5 for White, Asian/Pacific Islander, and American Indian/Alaska Native women, 

respectively. Infant mortality rates do not take into 

account spontaneous abortions that could be associated with NTD (Petrini et al. 2002). Therefore, the 

discrepancy in NTD-specific mortality rates between 

Blacks and Whites, in particular, could be connected 

to Black women having a higher rate of spontaneous 

fetal loss than White women; in 1999, 19.4 of 1,000 

Black non-Hispanic women experienced fetal loss, 

compared to 14.8 of 1,000 White non-Hispanic women 

(Ventura et al. 2003). Further research is needed to 

examine this potential explanation. 

Periodontal Care 

Studies have shown that pregnant women with 

periodontal disease may be up to seven times more 

likely to deliver a preterm/low birthweight infant 

than those without such disease (American Academy of Periodontology 2004). Hormone changes 

during pregnancy, especially in the second and third 

trimesters, can cause a greater reaction to dental 

plaque, resulting in increased swelling, bleeding, and 

redness of the gums leading to periodontal disease. 

The disease may contribute to as many as 45,000 

(18 percent) of the preterm births that occur every 

year (Offenbach et al. 1996). This is more than the 

preterm births attributed to alcohol consumption 

and tobacco use combined. 

Figure III.1. 

NTD-Specific Infant Mortality, by Race/Ethnicity: United States, 1996-1998 

15.4 

11.1 11.6 

8.6 

9.8 

11.5 

10.3 

8.6 

Rate per 100,000 Live Births 

All Races Asian/Pacific American Indian/ White Black 

and Ethnicities White Black Islander Alaska Native Hispanic Hispanic Hispanic 

Source: Davidoff et al. 2002. Note: Detailed data are shown in Appendix A, Table A.9. 

Lower socioeconomic and minority status are 

associated with untreated periodontal disease. For 

example, Blacks and American Indian/Alaska Natives 

have a higher prevalence of periodontal disease than 

Whites, with Blacks having the highest rate of periodontal disease of all races/ethnicities (Skrepcinski and 

Niendorff 2000). In addition, the disparity in the rate of 

disease between White and Black populations has 

increased since 1971 (Borrell et al. 2002). In general, 

Blacks are less likely to use dental services, which may 

increase the rate of periodontal disease or exacerbate its 

severity (Doty and Weech-Maldonado 2003). 

Infant Sleep Position 

SIDS is the leading cause of postneonatal mortality and the third leading cause of all infant 

18
 
 

 

 – – –

 – – –

 

– – –

mortality in the United States, accounting for approximately eight percent of all infant deaths (Mathews et 

al. 2004). Infant sleep position and sleep environment 

have been identified as modifiable factors that can help 

reduce the risk of SIDS. Although SIDS declined almost 35 percent between 1995 and 2002 to 57.1 per 

100,000 live births, experts are concerned about disparities in the rate of SIDS among different racial/ethnic groups (Table III.5) (Centers for Disease Control 

and Prevention 1996). As noted in Chapter II, American Indian/Alaska Native infants are more than twice 

as likely as White infants to die of SIDS, and Black 

infants have a SIDS rate more than twice the national average and that of Whites. The rate of SIDS 

among Blacks has also decreased at a lower rate than 

in the overall population. Despite having a SIDS rate 

below that of Blacks and American Indian/Alaska 

Natives for all years between 1997 and 2001, Puerto 

Ricans were the only racial/ethnic group for which 

the rate of SIDS increased during this time period. 

Variations in infant sleep position may explain 

some of the disparity in the SIDS rate. A study conducted between 1994 and 1998 showed that 32 percent of Black mothers, compared to 17 percent of 

other mothers, place their infants to sleep in the 

prone position (on the stomach) (Willinger et al. 

2000). Black infants who die of SIDS also have a 

higher prevalence of bed sharing and using bed surfaces other than those specifically designed and approved for infant use, as well as other risk factors 

for SIDS, such as smoking in the home, than White 

infants (Unger et al. 2003). Among American Indian/Alaska Natives, 16 to 24 percent put their babies to sleep on their stomach (U.S. Department of 

Health and Human Services 1998). American Indian/Alaska Native infants also have an increased 

risk of SIDS because their mothers are more likely 

than other mothers to binge drink during the first 

trimester of pregnancy; binge drinking increases the 

risk of SIDS eightfold among American Indian/ 

Alaska Natives (Iyasu et al. 2002). 

The Back to Sleep campaign, started in 1994, 

spreads awareness about the importance of sleep 

position in the reduction of SIDS and racial/ethnic 

Table III.5. 

SIDS Rate, by Race/Ethnicity: United States, 1995 - 2002 

Rate per 100,000 Live Births 

Percent 

Change 

1995 to 

Race and Ethnicity 1995 1996 1997 1998 1999 2000 2001 2002 2002 

All Races and Ethnicities 87.2 78.5 77.2 71.7 66.8 62.1 55.5 57.1 -34.5 

RACE
 

• White 

• Black 

• Asian/Pacific Islander 

• American Indian/ 

Alaska Native 

ETHNICITY 

• All Hispanics

 –Mexican 

 –Puerto Rican 

 –Central

 & South American 

72.3 64.3 64.8 59.5 55.6 51.8 45.6 55.2 -23.7 

166.6 153.8 143.2 137.9 129.9 122.1 113.5 110.9 -33.4 

49.9 44.0 51.2 39.4 31.0 29.4 18.5 24.3 -51.3 

206.6 203.3 155.6 151.5 146.9 120.0 145.7 123.3 -40.3 

47.7 48.5 46.5 37.4 37.2 34.3 27.1 29.7 -37.7

46.9 38.0 33.3 31.8 23.2 28.8

59.5 41.8 66.5 63.7 76.4 54.3

40.0 20.4 * 26.5 * 20.8 

*The figure does not meet standard of reliability or precision, based on fewer than 20 deaths in the numerator. — Data not available.
 

Source: MacDorman and Atkinson 1998a, MacDorman and Atkinson 1998b, MacDorman and Atkinson 1999, Mathews et al. 2000, Mathews et al.
 

2002a, Mathews et al. 2002b, Mathews et al. 2003, Mathews et al. 2004. Notes: “Black” and “White” categories exclude women of Hispanic origin.
 

19
 
disparities in SIDS. Providers also play an important role in SIDS reduction by influencing the 

behavior of new mothers. In examining the relationship between information sources and SIDS risk 

behavior, specific instruction by a nurse or doctor 

in the hospital about how to properly place the 

infant for sleep positively influenced behavior after 

the mother left the hospital (Rasinski et al. 2003). 

Breastfeeding 

Breastfeeding provides nutritional and immunological benefits to the baby during and after the 

first year of life (U.S. Department of Health and 

Human Services 2000b). The American Academy 

of Pediatrics and the World Health Organization 

recommend that women breastfeed their infants for 

at least 1 year to reduce the incidence of acute 

illnesses (such as diarrhea, ear infections, pneumonia, and meningitis) and chronic diseases (such as 

SIDS, obesity, childhood leukemia, and asthma) 

(American Academy of Pediatrics 2004; Wolf 2003). 

Data from the 1988 National Maternal and Infant 

Health Survey of women with a live birth or infant 

death in 1988 showed that infants who were ever 

breastfed3

 had a 21 percent decreased odds of postneonatal death, compared to infants who were not 

ever breastfed (Chen and Rogan 2004). After controlling for demographic and socioeconomic characteristics, the study also found that breastfeeding 

reduced the odds of postneonatal deaths regardless 

of race. However, the magnitude of breastfeeding’s 

impact on postneonatal death differed between 

Black and non-Black populations. Breastfeeding 

decreased the odds of postneonatal death by 31 percent among Black infants, while it reduced the odds 

by 19 percent among non-Black infants. 

Between 1971 and 2001, breastfeeding rates 

increased in the early postpartum period from 25 

percent to 70 percent and at 6 months postpartum 

from 5 percent to 33 percent (Ryan et al. 2002). 

However, these breastfeeding rates are still below 

Healthy People 2010 objectives of 75 percent of 

women breastfeeding in the early postpartum 

period and 50 percent at 6 months (U.S. Department of Health and Human Services 2000a). The 

breastfeeding rate at 1 year in 2001 was 12 percent, 

which also is lower than the Healthy People 2010 

goal of 25 percent at 1 year (Li et al. 2003; U.S. 

Department of Health and Human Services 2000a). 

In particular, Black women have consistently 

lower rates of breastfeeding than do White and Hispanic women. A report based on the 2004 National 

Immunization Survey indicated that 71.5 percent of 

non-Hispanic White children were ever breastfed in 

comparison to 50.1 percent of non-Hispanic Black 

children (Centers for Disease Control and Prevention 2006). Continuing to breastfeed until at least 6 

months of age was also higher among White nonHispanic women (53.9 percent) than Black non-Hispanic women (43.2 percent). In addition, the 1988­

1994 National Health and Nutrition Examination 

Survey of women with children ages 12 to 71 months 

found that 26 percent of Black women had ever 

breastfed their infant, compared to 60 percent of 

White women and 55 percent of Mexican American 

women (Li and Grummer-Strawn 2002). Results 

from the 2001 Ross Laboratory Mothers Survey of 

women with infants ages 6 to 12 months and the 

2001 National Immunization Survey of women with 

children ages 19 to 35 months showed that Black 

women had lower rates than White and Hispanic 

women of ever breastfeeding in hospital, at 6 

months, and at 12 months (Ryan et al. 2002; Li et 

al. 2003).

 According to results from the 1988 National Maternal and Infant Health Survey, Black women in 

the Special Supplemental Nutrition Program for 

Women, Infants, and Children (WIC) were also less 

likely than White women to receive breastfeeding 

3Infants were considered “ever-breastfed” if their mother answered “yes” 

to the 1988 National Maternal and Infant Health Survey Question, “Did 

you ever breastfeed this infant?” 

20
 
 

advice from WIC counselors and more likely to 

receive bottle-feeding education from them (Beal et 

al. 2003). The disparity in breastfeeding behavior 

between Blacks and Whites who received 

breastfeeding advice was smaller than that between 

Blacks and Whites who did not receive advice, 

suggesting that increased education may help narrow the gap in breastfeeding practices. 

Well-Child Care (Up to Two Years Old)

 Health maintenance and preventive health care 

are important to a child’s well-being after birth. Due 

to a combination of medical advances and public 

Table III.6. 

Vaccination Coverage Among Children 19-35 Months of Age, by Race/Ethnicity: United States, 1999 

health measures, the overall health status of children in the United States has improved considerably during the past several decades. Mortality 

between 1950 and 1987 was reduced by 63 percent 

for children ages 1 to 4, and well-child visits 

promoting vaccinations and other preventive health 

measures significantly contributed to this improvement (Middleton and Schroeder 2002).

 The American Academy of Pediatrics and the 

American Board of Family Practice recommend 11 

well-child visits from birth to age 2 on the following 

schedule: at birth; at one week; and at 1, 2, 4, 6, 9, 

PERCENT
 

White Black Asian/Pacific American Indian/
 

All non-Hispanic non Hispanic Islander Alaska Native Hispanic
 

DTP (3 doses)a 

DTP (4 doses)b 

Polioc 

MMR/MCVd 

Hibe 

Hepatitis Bf 

Varicellag 

DTP (3 doses)a , 

polioc

, MCVd 

DTP (4 doses)b , 

polioc, MCVd 

DTP (4 doses)b , 

polioc, MCVd, Hibe 

DTP (4 doses)b , 

polioc

, MCVd , 

Hibe, Hep Bf 

95.9 96.6 94.4 96.5 94.7 95.1 

83.3 85.5 79.0 86.8 80.2 80.2 

89.6 90.3 87.0 90.1 88.2 89.4 

91.5 92.4 89.8 92.7 91.7 90.2 

93.5 94.8 91.8 90.2 91.4 92.0 

88.1 88.9 86.5 88.2 * 87.3 

57.5 56.0 57.6 84.0 * 60.5 

86.1 87.2 83.2 86.5 84.0 85.1 

79.9 82.0 75.1 82.4 77.6 77.3 

78.4 81.0 73.8 77.4 75.0 74.9 

73.2 75.6 69.4 73.4 * 69.6 

Source: Lumen ET et al. 2001. 

Notes:	 *Estimate was not available because the unweighted sample size for the numerator was <30 or (confidence interval half wid th)/ 

Estimate<0.5 or (confidence interval half width)>10. Combined Hispanic and Non-Hispanic White and Black rates were not 

available. a	 Three or more doses of any diphtheria and tetanus toxoids and pertussis vaccines including diptheria and tetanus toxoids, and any 

acellular pertussis vaccine (DTP/DTa/DT). 

b	 Four or more doses of any diphtheria and tetanus toxoids and pertussis vaccines including diptheria and tetanus toxoids, and any 

acellular pertussis vaccine (DTP/DTa/DT). 

c Three or more doses of any poliovirus vaccine. 

d One or more doses of measles-mumps-rubella vaccine, previous reports of vaccination were for measles-containing vaccine (MCV). 

e Three or more doses of Haemophilus influenza type B (Hib) vaccine. 

f Three or more doses of hepatitis B vaccine. 

g One or more doses of varicella at or after child’s first birthday, unadjusted for history of varicella illness. 

21
 
 

12, 15, 18, and 24 months. Childhood vaccinations 

given during these visits have had a major impact 

on the reduction and elimination of many causes of 

childhood morbidity and mortality. For example, 

smallpox has been eradicated, and polio has been 

eliminated in the United States. Measles and 

Haemophilus influenza type b (Hib) have also been 

reduced to record low numbers (Centers for Disease 

Control and Prevention 1999b).

 Currently, the CDC recommends that all infants 

finish the series of vaccinations shown in Table III.6 

by age 2 (Centers for Disease Control and Prevention 2004c). In 1999, 73 percent of children ages 19 

to 35 months met these recommendations (Table 

III.6, last row). Compliance with vaccination varies 

by race/ethnicity; in general, White non-Hispanic 

and Asian/Pacific Islanders had slightly higher rates 

of vaccination than Black non-Hispanics and American Indians/Alaska Natives. Researchers also found 

that racial/ethnic disparities in childhood vaccination were not driven by socioeconomic status; regardless of income level, Black non-Hispanics had 

the lowest rates of vaccination for DTP, polio, MMR, 

and hepatitis B compared to other populations 

(Barker and Lumen 2001; Lumen et al. 2001). They 

also had the lowest completion rate of the vaccination series. No racial/ethnic group has met the 

Healthy People 2010 objective to have 90 percent 

of all children ages 19 to 35 months complete the 

vaccination series which indicates that there is room 

for improvement for all groups (U.S. Department of 

Health and Human Services 2000a). 

Interconceptional Care 

The IOM notes, “One of the best protections 

available against low birthweight and other poor pregnancy outcomes is to have women actively plan for 

pregnancy, enter pregnancy in good health with as few 

risk factors as possible, and be fully informed about 

her reproductive and general health” (Institute of 

Medicine 1985). Experts suggest that, to restore the 

maternal nutritional resources necessary for a healthy 

pregnancy, it is essential to have one or more years 

between the birth of one infant and the conception of 

another (Klerman et al. 1998). Studies have shown that 

nearly a quarter of pregnant women have an 

interpregnancy period of less than a year (Zhu et al. 

2001; James et al. 1999; Russo et al. 1993). Short 

interpregnancy intervals are associated with late entry into prenatal care, low birthweight, premature 

birth, and other poor pregnancy outcomes. Williams 

et al. (2003) found that, compared to infants born following an interpregnancy interval of less than 6 

months, infants born to women who became pregnant 

18 to 59 months after a prior birth had a lower risk 

of dying, being born preterm, being small for gestational age, or having low birthweight. Another study 

showed that infants born to women who become pregnant less than 6 months after delivery have three times 

the risk of infant death due to intentional injury, a 74 

percent increased risk of unintentional injuries, and a 

55 percent increased risk of SIDS (Easton 1999). 

Black and Native American women have the highest rates of short interpregnancy intervals, compared 

to other racial/ethnic groups. From 1981 to 1989, 30 

percent of Native American pregnancies were conceived less than a year after a prior birth, compared to 

19 percent of pregnancies among White non-Hispanics (Khoshnood et al. 1998). Studies have shown that 

Black women are twice as likely as White women to 

have an interpregnancy period of 6 months or less 

(James et al. 1999; Zhu et al. 2001). Even among Black 

and White women with interpregnancy periods of 6 

months or less, Blacks still had a higher rate of preterm 

birth than Whites. Although this suggests that other 

risk factors may act in conjunction with a short 

interpregnancy period to cause disparities in birth 

outcomes, having an adequate interpregnancy period 

may protect against poor birth outcomes for all 

women. 

22
 
Risky Behaviors 

Maternal Smoking 

Research suggests that infants born to women 

who smoke cigarettes during pregnancy have a 40 

percent higher risk of death in their first year than 

infants whose mothers did not smoke (Salihu et al. 

2003). In the United States, an estimated five percent of infant mortality is attributable to smoking, 

with variation among different races and ethnicities. 

Smoking during pregnancy contributes to many 

adverse outcomes, including ectopic pregnancy, 

fetal death, stillbirth, spontaneous abortion, low 

birthweight, preterm delivery, SIDS, intrauterine 

growth retardation, placenta previa, abruptio placenta, and premature rupture of membranes. Morbidity and mortality increase with the amount of 

cigarettes consumed prenatally (Salihu et al. 2003). 

Although the overall rate of smoking during 

pregnancy declined 33 percent between 1990 and 

1999, more than 10 percent of women reported 

smoking during pregnancy in 1999 (Figure III.2). 

Rates of reported smoking were the highest among 

American Indian/Alaska Natives, who also had the 

lowest rate of decrease in reported smoking during 

pregnancy between 1990 and 1999. All other races and 

ethnicities reduced the reported rate of smoking 

during pregnancy by more than 20 percent, while 

American Indian/Alaska Natives reduced their 

reported rate by 11 percent. 

The high rate of smoking during pregnancy among 

American Indian/Alaska Natives may contribute to 

their high rate of SIDS. However, due to the interaction of smoking with other factors that contribute to 

adverse birth outcomes, the direct impact of smoking 

during pregnancy on infant mortality is difficult to 

tease out. For example, why does smoking during pregnancy differentially affect infant survival across racial/ 

ethnic groups? Smoking among Whites is associated 

with a 85 percent increased risk of infant mortality, 

while it is associated with an increased risk of 53, 147, 

and 57 percent among Blacks, Asian/Pacific Islanders, and American Indian/Alaska Natives, respectively 

(Figure III.3). It is difficult to understand the direct 

effect of smoking on birth outcomes, but it is clear that, 

for all racial/ethnic groups, women who smoked 

during pregnancy had higher rates of infant mortality 

than women who did not smoke.

 In addition to the adverse effect that smoking 

during pregnancy has on infants, smoke exposure after birth also has negative impacts on infant health. 

22.4 In Percent 

Figure III.2. 

Women Who Reported Smoking During Pregnancy, by Race/Ethnicity: United States, 1999 

18.4 

12.3 

21.0 

15.7 15.9 

9.1 

5.5 

2.9 

20.0 

6.7 

3.7 

1990 

1999 

White Black Asian/Pacific American Indian/
 

All Races Non-Hispanic Non-Hispanic Islander Alaska Native Hispanic
 

Source: Mathews 2001.
 

Notes: Excludes California, Indiana, New York State, and South Dakota. Combined Hispanic and Non-Hispanic White and Black percents
 

were not available. Detailed data are shown in Appendix A, Table A.10.
 

23
 
 

Figure III.3. 

Infant Mortality Rate, by Maternal Smoking Status and Race/Ethnicity: United States, 2002 

Rate per 1,000 Live Births 20.0 20.1

11.1 

6.6 

9.8 

5.3 

13.1 

11.6 

4.7 

12.1 

7.7 

10.7 

5.6 

9.7 

5.2 

13.2 

Smoker 

Non-Smoker 

Asian/Pacific American Indian/ White Black 

All Races White Black Islander Alaska Native Hispanic Non Hispanic Non Hispanic 

Source: Mathews et al. 2004. Notes: Detailed data are shown in Appendix A, Table A.11. 

Research has shown that secondhand cigarette smoke 

exposure increases the risk of respiratory illnesses 

among infants. Such illnesses, including asthma and 

lower respiratory tract infections, can lead to respiratory distress, the sixth leading causes of infant mortality in 2002 (DiFranza and Lew 1996). Although the 

overall rate of secondhand smoke exposure among 

infants has not been precisely measured, examination 

of smoking behavior by race shows that American 

Indian/Alaska Natives have the highest rate of tobacco 

use in comparison to other races and ethnicities 

(Table III.7). 

To encourage pregnant and non-pregnant 

women of all races/ethnicities to stop smoking, the 

U.S. Public Health Service sponsors a best practice 

guideline called the “5 A’s” (U.S. Surgeon General 

2005). The “5 A’s” guideline includes five steps to 

identify tobacco users and implement appropriate 

interventions based on their willingness to quit. The 

five major steps to intervention are: (1) ask about 

smoking status; (2) advise in a clear, strong, and personalized manner why the person should quit; (3) 

assess the willingness of the person to quit; (4) assist the person using counseling and pharmacotherapy if they are willing to quit; and (5) arrange 

for follow-up with the person. This guideline provides a conceptual framework for interventions to 

motivate pregnant and non-pregnant women to quit 

smoking. 

Alcohol and Other Drug Use 

During Pregnancy 

Drinking alcohol during the first seven months 

of pregnancy is associated with preterm delivery and 

low birthweight (Lundsberg et al. 1997). Though the 

risk of having poor birth outcomes rises with increasTable III.7. 

Reported Tobacco Use by Race/Ethnicity: United States, 2003 

PERCENT WITH TOBACCO USE
 

Ever During Past Year During Past Month
 

All Races and Ethnicities 72.7 35.1 29.8 

78.1 37.0 31.6 

63.3 34.0 30.0 

45.3 18.3 13.8 

60.6 42.0 37.0 

79.4 48.4 41.8 

59.9 29.8 23.7 

• White non-Hispanic 

• Black non-Hispanic 

• Asian 

• Native Hawaiian/Pacific Islander 

• American Indian/Alaska Native 

• Hispanic 

Source: U.S. Department of Health and Human Services 2004. Note:Tobacco use is reported for those age 12 and older. 

24

 

 

 

 

 

 

 

 

ing alcohol use, any fetal alcohol exposure puts a 

fetus at risk for developing fetal alcohol syndrome.4 

Fetal alcohol exposure is the leading cause of preventable birth defects and developmental disorders 

in the United States. As many as 1 in 100 children in 

the United States are believed to be affected by fetal 

alcohol exposure, although fetal alcohol syndrome 

is 100 percent preventable (Meschke et al. 2003). 

Data from the CDC’s Birth Defects Monitoring 

Program showed that fetal alcohol syndrome increased fourfold between 1979 and 1992, to 3.7 cases 

per 10,000 live births (Centers for Disease Control 

and Prevention 2003a). In 1992, Behavioral Risk 

Factor Surveillance System data indicated that more 

than 12.4 percent of women reported drinking alcohol during pregnancy (Centers for Disease Control 

and Prevention 2002b). Since 1992, the prevalence 

of reported alcohol use among pregnant women has 

increased slightly, to 12.8 percent in 1999, and 

Table III.8. 

Reported Alcohol Use During Pregancy, 

by Race/Ethnicity: United States, 2002 

Percent Reporting 

Alcohol Use 

Race and Ethnicity During Pregnancy 

All Races and Ethnicities 0.8 

RACE 

• White

• Black

• Asian/Pacific Islander

–Chinese
 

–Japanese
 

–Hawaiian
 

–Filipino
 

• American Indian/Alaska Native 

ETHNICITY 

• All Hispanics

–Mexican
 

–Puerto Rican
 

–Cuban
 

–Central and South American
 

• White non-Hispanic 

• Black non-Hispanic 

0.8 

0.9 

0.3 

0.1 

0.8 

1.1 

0.4 

2.5 

0.5

0.5 

0.7 

0.3 

0.3 

0.9 

0.9 

Source: Martin et al. 2003. 

decreased slightly, to 12.5 percent in 2001 (Centers 

for Disease Control and Prevention 2002b; Floyd 

and Sidhu 2004). According to data reported on 

birth certificates, alcohol use during pregnancy was 

more frequent among American Indian/Alaska Natives than any other racial/ethnic group (Table 

III.8); they had three times the alcohol use rate during pregnancy of any other racial/ethnic group. 

Black and White women had the second-highest rate 

of alcohol use, while Hispanics had the lowest rate. 

The rate of fetal alcohol syndrome among different racial/ethnic groups follows a pattern similar to that of alcohol use among these groups during pregnancy. In 1994, the CDC’s National Institute of Alcohol Abuse and Alcoholism reported that 

American Indian/Alaska Natives had more than four 

times the rate of fetal alcohol syndrome (30 cases 

per 10,000 births) than any other group; Black 

women had the second-highest rate (6 cases per 

10,000 births) (Meschke et al. 2003). In contrast, 

Whites had an incidence of 0.9 cases per 10,000 

births, followed by Hispanics (0.8 cases per 10,000 

births) and Asian/Pacific Islanders (0.3 cases per 

10,000 births). 

Use of other substances, such as cocaine, marijuana, or other illicit drugs5

, during pregnancy is 

another risk factor for preterm, low birthweight, and 

very low birthweight births (Blatt et al. 2000). 

Women who use drugs such as cocaine during pregnancy have more than twice the odds of delivering a 

4Fetal alcohol syndrome is defined as a group of symptoms caused by a 

pregnant woman’s consumption of alcohol. These symptoms include 

abnormal facial features, growth impairment, problems with learning, 

memory, attention span, problem solving, speech, and hearing. 

5Illicit drugs are controlled substances that possess a high potential for 

abuse, have no currently accepted medical use in the United States, and 

demonstrate a lack of accepted safety for use under medical supervision 

(U.S. Department of Health and Human Services 2004). Controlled 

substances so defined fall under seven headings: marijuana (marijuana, 

hashish); stimulants (amphetamines, cocaine); depressants (barbiturates, 

tranquilizers, hypnotics); hallucinogens (acid, PCP); opiates, or narcotics 

(heroin, morphine, opium, codeine); inhalants (sprays, solvents, glue); 

and designer drugs (synthetic drugs similar in effect to stimulants, 

hallucinogens, and narcotics). To be used legally and safely, some of these 

drugs must be prescribed by a physician. This list is not comprehensive; 

omitted substance may be illegal and may fall under the designation of 

controlled substances. 

25
 
preterm, low birthweight, or very low birthweight baby 

as pregnant women who do not use any substances 

(Blatt et al. 2000; March of Dimes 2004). Women who 

use cocaine during pregnancy are also twice as likely 

as women who do not to have an infant die of SIDS 

and five times more likely to have a baby with a birth 

defect. Substance users are more likely than non-users to miss prenatal care appointments (Funai et al. 

2003). 

According to the Substance Abuse and Mental 

Health Services Administration’s 2000 and 2001 National Household Survey on Drug Abuse, 3.7 percent 

of women reported using illicit drugs during pregnancy 

(U.S. Department of Health and Human Services 

2002). Of the women who reported any illicit drug use 

during pregnancy, 70 percent reported using marijuana, and 8 percent reported using cocaine. Of those 

who used illicit drugs during pregnancy, more than 

half also smoked cigarettes or drank alcohol (Shahul 

and Gfroerer 2003). 

Drug use varies by race/ethnicity, with non-White 

women being almost twice as likely as White women 

to use illicit drugs (Kelly et al. 2002). Drug use during 

pregnancy has a differential impact on racial/ethnic 

groups; Black women who report illicit substance use 

had approximately a twofold increase in odds of delivering a preterm, low birthweight, or very low 

birthweight infant, compared to White women who 

reported illicit substance use (Kelly et al. 2002; March 

of Dimes 2004). This implies that drug use, like smoking, may be associated with other risk factors for poor 

perinatal outcomes. 

Adolescent Pregnancy 

Every year in the United States, more than 

800,000 adolescent girls ages 15 to 19 become pregnant (Ventura et al. 2004). The rate of teenage pregnancy declined by nearly 10 percent between 1990 and 

2000, to 104 pregnancies per 1,000 teenagers. However, the rate of births to adolescents in the United 

States still ranks much higher than that of most other 

developed countries, such as Sweden, France, Canada, 

and Great Britain (Darroch et al. 2001). In 2001, there 

were 43.5 births per 1,000 teenagers in the United 

States (Hamilton et al. 2003). Children born to teenagers have an increased risk of low birthweight, prematurity, intrauterine growth retardation, congenital 

malformations, and infant death (Cunnington 2001). 

Before controlling for demographic factors, adolescents have an infant mortality rate 1.6 times that of 

women older than age 20 (Mathews et al. 2004). When 

controlling for race and ethnicity, White and Asian/ 

Pacific Islander teenagers have more than two times 

the infant mortality rate of their older counterparts, 

while Black and American Indian/Alaska Native teenagers have rates of infant mortality comparable to 

those of their older counterparts; Hispanic teenagers 

have 1.4 times the rate of their older counterparts 

(Mathews et al. 2004) (Appendix A, Table A.12). Although these results indicate that the risk of teenage 

pregnancy varies by race, pregnant teenagers are more 

likely than pregnant adults to have health behaviors 

that lead to poor birth outcomes, regardless of race 

(Elfenbein and Felice 2003). For example, they are 

less likely to gain adequate weight during pregnancy, 

take recommended daily vitamins during pregnancy, 

have good eating habits, and seek prenatal care. They 

are also more likely to smoke, drink alcohol, or take 

drugs and to have a shorter interpregnancy interval. 

Black teenagers have nearly three times the pregnancy rate of White teenagers, and Hispanic teenagers have twice the rate of White teenagers (Ventura et 

al. 2004). Infants born to Black teenagers also have a 

higher rate of infant mortality than those born to White 

teenagers (Figure III.4). However, Hispanic teenagers have lower rates of infant mortality than White 

teenagers, although they had a higher number of pregnancies. The high teenage Hispanic birth rate and 

low infant mortality rate suggest that the risky behaviors associated with teenage pregnancy may be 

mitigated by other factors, such as culture. For example, one study found that the Mexican culture had 

26
 
Figure III.4. 

Infant Mortality Rate Among Teenagers Younger than 20 by Race/Ethnicity: United States, 2002 

15.2 15.2 Rate per 1,000 Live Teenage Births 

10.4 

8.8 9.2 9.1 9.7 

7.3 

All Asian/Pacific American Indian/ White Black 

Teenagers White Black Islander Alaska Native Hispanic Non Hispanic Non Hispanic 

Source: Mathews et al. 2004. 

a positive impact on birth outcomes (Jenny et al. 

2001). That study also found that Mexican American infants born in counties with a high concentration of Mexican births to women of Mexican descent 

that is, a higher exposure to those with traditional 

Mexican pregnancy and child-rearing practices had 

lower mortality rates than Mexican American 

women without such exposure. 

BIOLOGICAL/SOCIAL 

RISK FACTORS 

PERINATAL DEPRESSION

 Untreated depression during pregnancy is associated with adverse fetal outcomes. These include 

spontaneous abortion, preterm delivery, need for 

special neonatal care, increased uterine artery resistance, small head circumference, low APGAR 

scores, neonatal growth retardation, high cortisol 

levels at birth, maternal hypertension, and preeclampsia (Bonari et al. 2004). Mental illness can affect a pregnant woman’s functional status and her 

ability to obtain prenatal care, eat properly, take 

prenatal vitamins, and avoid dangerous behavior, 

such as smoking, drinking alcohol, and using illicit 

drugs (Bonari et al. 2004; Zuckerman et al. 1989). 

In addition, research has shown that depression can 

negatively affect women’s parenting behavior, which 

has implications for their children’s health 

(Kavanaugh et al. 2006). 

Approximately 10 percent of women in the 

United States have depressive symptoms during 

pregnancy. For a third of these women, it represents 

their first episode of major depression (Nonacs and 

Cohen 2003). The prevalence of depression is higher 

among those of low socioeconomic status (Hobfoll 

and Ritter 1995). Studies have not conclusively 

shown a relationship between race and depression 

during pregnancy; however, one study found that, 

in general, Blacks and Hispanics exhibit elevated 

rates of depression compared to Whites (Dunlop et 

al. 2003). 

STRESS 

Stress during pregnancy has been shown to significantly increase rates of prematurity and low 

birthweight (Copper et al. 1996). According to a 

study of 2,593 pregnant women performed through 

the Maternal-Fetal Medicine Units Network of NIH, 

women who experience stress during pregnancy, as 

measured by a 28-item Likert scale, are at 1.16 and 

1.08 higher odds for delivering premature and low 

27
 
birthweight infants, respectively, than women who 

do not experience stress during pregnancy. Behaviors further increasing the risk of prematurity and 

low birthweight, such as smoking, substance abuse, 

and poor weight gain during pregnancy, have been 

reported to be more prevalent among women who 

are under stress. In addition, it has been hypothesized that psychological distress may cause the 

secretion of placental corticotropin, releasing hormone (CRH) that can lead to increased susceptibility to infections, such as bacterial vaginosis (Kramer 

et al. 2001). 

Exposure to psychosocial stressors among Black 

women in an urban setting has been shown to significantly increase the occurrence of low birthweight 

(Orr et al. 1996). This may be due to factors such as 

smoking, substance abuse, prevalence of infection, 

or poverty; the exact mechanism is not well understood. 

BACTERIAL VAGINOSIS

 Between 25 and 60 percent of preterm births are 

attributable to maternal infections that can lead to 

infant morbidity and mortality (Flynn et al. 1999). 

One such infection, bacterial vaginosis (BV), is estimated to be prevalent in 16 percent of pregnant 

women and 10 to 30 percent of nonpregnant women 

(Hillier et al. 1995). The vaginal flora imbalance that 

occurs with BV has been associated with preterm 

delivery, low birthweight, premature rupture of 

membranes, infection of the chorion and amnion, 

and infection of the amniotic fluid. Women with BV 

during pregnancy have 1.4 times the odds of delivering a low birthweight infant of pregnant women 

who do not have BV (Hillier et al. 1995). Preterm 

delivery among those with BV can be reduced by 18 

percent with antibiotic prophylaxis (Hauth et al. 

1995). 

Abstaining from douching and reducing stress 

during pregnancy can also significantly decrease BV 

(Culhane et al. 2001; Holzman et al. 2001). A study 

conducted through the NIH and the CDC’s National 

Survey of Family Growth found that Black women 

have higher rates than White and Hispanic women 

of vaginal douching, and have higher levels of stress 

(Copper et al. 1996; Centers for Disease Control and 

Prevention 2003b). Both douching and stress may 

contribute to pregnant Black women having three 

times the prevalence of BV than White women 

(Fiscella 2004; Paige et al. 1998). 

DOMESTIC VIOLENCE 

Research conducted in the United States 

between 1963 and 1995 reveals that up to 20 

percent of women experience domestic violence during pregnancy (Gazmararian et al. 1996; Coker et 

al. 2004). The Pregnancy Risk Assessment Monitoring System found that, in 17 States surveyed, nonWhite women, Hispanic women, and women with 

Medicaid were consistently at higher risk of physical abuse by a husband or partner than their White, 

non-Hispanic, and non-Medicaid counterparts 

(Centers for Disease Control and Prevention 2002c). 

Physical abuse at this time can cause maternal and 

infant morbidity and mortality. Research suggests 

that physical violence during pregnancy is associated with an increased risk of antepartum hemorrhage, intrauterine growth restriction, and perinatal death. Rates of low birthweight among battered 

women are also 1.5 to 2.5 times higher than those of 

nonbattered women, and rates of preterm birth are 

2.5 to 4.0 times higher (Gazmararian et al. 1996; 

Neggers et al. 2004). A recent study shows that 

women who experienced intimate partner violence 

during pregnancy had 3.8 times the odds of antepartum hemorrhage, 3.1 times the odds of intrauterine 

growth restriction, and 8.1 times the odds of perinatal death of women who did not experience such 

violence (Janssen et al. 2003). Physical abuse during pregnancy has also been found to be associated 

with many other risk factors for infant mortality, 

such as inadequate prenatal care, smoking, substance abuse, mental health-related illness, and 

28
 
short interpregnancy interval (Curry et al. 1998; 

Lipsky et al. 2004). 

MATERNAL BIRTHWEIGHT 

Maternal birthweight has been suggested as a 

determinant of low infant birthweight and preterm 

delivery. Research has shown that women who were 

themselves born at a low birthweight or preterm are 

at significantly higher risk for having low 

birthweight or preterm infants than women who 

were not low birthweight or preterm (Coutinho et 

al. 1997; Porter et al. 1997; Sanderson et al. 1995; 

Wang et al. 1995). One study in Buffalo, New York, 

found that, compared to women who weighed 8.0 

pounds at birth, women who weighed 6.0 to 7.9 

pounds at birth and women who weighed 4.0 to 5.9 

pounds at birth had 1.7 and 3.5 greater odds of delivering a low birthweight infant, respectively 

(Klenbanoff et al. 1984). Sanderson et al. (1995) 

found that, although both White and Black women 

who were low birthweight themselves were at higher 

risk of delivering low birthweight infants, only Black 

women who weighed less than 4.0 pounds at birth 

had significantly greater risk of delivering a normal 

birthweight infant who subsequently died before 

reaching 1 year of age. These researchers also demonstrated that higher prepregnancy weight and 

height among women born low birthweight reduced 

the risk of low birthweight deliveries. Such results 

suggest that, although low maternal birthweight 

plays an important role in birth outcomes, other factors may also mitigate the effects of maternal low 

birthweight and prematurity. 

Birthweight may appear to be a genetically 

transmitted characteristic because of its seeming 

intergenerational trend; however, recurring and 

similar social and environmental stress across generations could cause familial clustering of low 

birthweight. Lu and Halfron (2003) examined the 

link between poor maternal and infant birth outcomes in the context of a life course perspective. 

These researchers proposed a model where there 

are critical periods in a woman’s reproductive life 

when she is more vulnerable to risk factors and more 

amenable to protective factors. The earliest of these 

sensitive periods occurs when the baby grows in the 

mother’s womb. Consequently, if a woman is exposed to risks during her time in utero, her reproductive potential will be adversely affected and could 

result in poor birth outcomes for herself and her 

own infant. In addition, if she continues to experience other stresses during her life, which are likely 

similar to the stresses her mother experienced, her 

risk of having an infant with poor birth outcomes 

may increase. 

This life course perspective suggests that, 

because a woman’s birth outcome and subsequent 

pregnancies are influenced by the accumulated life 

exposure of her mother and female ancestors before her, a short period of intervention during the 

pregnancy period may not be able to cause a dramatic decrease in the risk of poor birth outcomes. 

According to this model, the racial/ethnic disparities in birth outcomes we see today can be explained 

by many lifetimes of amassed racism, poverty, and 

stress. Many social and environmental risk factors 

need to be addressed during the birth, childhood, 

puberty, and young adulthood of a woman to influence her infant’s birth outcome, but intervening 

during the pregnancy and interpregnancy period 

remains key to improving birth outcomes; targeting women during, and immediately after, pregnancy is a way to identify high-risk women and address their risks to improve outcomes for future generations (Kotelchuck 2003). 

29
 
30
 
Chapter IV 

Discussion 

Trends in racial/ethnic disparities in infant mortality are consistent with the racial/ethnic patterns found 

in causes of infant mortality. Blacks and American 

Indian/Alaska Natives had the highest rate of infant 

mortality in 2002. Blacks had the highest rate of neonatal mortality while American Indian/Alaska Natives 

had one of the highest rates of postneonatal deaths. 

During the same year, preterm birth/low birthweight 

was the leading cause of neonatal mortality and Blacks 

had the highest rate of preterm birth/low birthweight. 

SIDS was the leading cause of postneonatal deaths in 

2002; American Indians had the highest rate of SIDS. 

The congruency in the data does not end with the 

racial/ethnic trends in infant mortality and causes of 

death. The racial/ethnic trends in causes of infant 

mortality correspond to the patterns of the risk factors for poor birth outcomes. For example, risk factors associated with preterm birth and low birthweight, 

such as late or no prenatal care, drug abuse, stress, 

depression, and bacterial vaginosis, are more prevalent among Blacks. Similarly, American Indian/Alaska 

Native women have the highest rates for risk factors 

associated with SIDS, such as smoking and binge 

drinking during pregnancy. Such data suggest that 

targeted interventions for these risk factors can help 

improve birth outcomes in the target population and 

reduce racial/ethnic disparities in infant mortality. 

This paper has the same limitations as many literature reviews. For example, among the sources used 

for the paper, there were variations in research methods, categorizations of race/ethnicity, and years of information available. Moreover, using data from different sources made it difficult to isolate the direct 

contribution of each behavioral, biological, and social 

factor to the racial/ethnic disparities in infant mortality. For example, it would be interesting to further 

investigate the role that discrimination, genetic predisposition, life course, culture, or behavior play in producing the long-standing racial/ethnic disparities in 

birth outcomes. 

Shiono et al. (1997) have studied the influence of 

many factors on ethnic differences in birthweight. Few 

researchers, however, have conducted similar studies 

that further the understanding of how behavioral, biological, and social factors affect racial/ethnic disparities in birth outcomes. The study by Shiono et al. (1997) 

controlled for 21 social, medical, socioeconomic, and 

psychological factors. It found that impoverished 

living environments, feelings of helplessness, and 

unstable social support were negatively associated with 

birthweight (that is, better living environments, feelings of hope, and stable social supports were associated with higher birthweight). Future studies to support such findings or provide further information 

about the mechanisms through which these factors 

affect birth outcomes will help researchers, health care 

providers, and other stakeholders to better understand 

the interplay between risk factors and birth outcomes. 

Nevertheless, the data presented in this paper 

provide insight into the racial and ethnic trends in birth 

outcomes and the risk factors contributing to these 

outcomes. By showing how the factors associated with 

poor birth outcomes are associated with racial/disparities in birth outcomes, this information offers evidence 

to support targeted maternal and child interventions, 

such as those performed by Healthy Start and other 

perinatal health initiatives, to reduce racial and 

ethnic disparities in infant mortality. 

31
 
32
 
Appendix A 

Detailed Tables 

A1
 
A2
 
TABLES 

Table Page
 

INFANT MORTALITY RATE, BY COUNTRY, 2002 

INFANT MORTALITY RATE, BY RACE/ETHNICITY: 2001 

LIVE BIRTHS, BY RACE/ETHNICITY: UNITED STATES, 2001 

STATE RANK IN INFANT MORTALITY RATE AND DIFFERENCE 

BETWEEN BLACK AND WHITE RATES: UNITED STATES, 2001 

FIVE LEADING CAUSES OF INFANT DEATH, BY RACE/ETHNICITY: 

UNITED STATES, 2002 

PRETERM BIRTH/LOW BIRTHWEIGHT, BY RACE/ETHNICITY:

 UNITED STATES, 2002 

PRETERM BIRTH, BY RACE/ETHNICITY: 

UNITED STATES, 1995 - 2002 

VERY LOW BIRTHWEIGHT, BY RACE/ETHNICITY: 

UNITED STATES, 1995 - 2002 

NTD-SPECIFIC INFANT DEATHS, BY RACE/ETHNICITY: 

UNITED STATES, 1996 – 1998 AGGREGATED 

WOMEN WHO REPORTED SMOKING DURING PREGNANCY, 

BY RACE/ETHNICITY: UNITED STATES, 1990 - 1999 

INFANT MORTALITY RATE, BY MATERNAL SMOKING STATUS AND 

RACE/ETHNICITY: UNITED STATES, 2002 

INFANT MORTALITY RATE, BY AGE AND RACE/ETHNICITY: 

UNITED STATES, 2002 

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Table A.1. 

Infant Mortality Rate, by Country, 2000 

Rank Country IMR Rank Country IMR 

1 Iceland 2.4 49 Brunei Darussalam 9.9 

2 Sweden 2.4 50 Costa Rica 10.0 

3 Singapore 2.6 51 Ukraine 10.4 

4 Finland 3.2 52 Bulgaria 10.7 

Luxembourg 3.2 53 Seychelles 11.1 

6 Czech Republic 3.4 54 Dominica 11.6 

7 Japan 3.4 55 Nauru 11.8 

8 Norway 3.5 56 Jamaica 11.9 

9 Spain 3.9 57 The Former Yugoslav Republic of Macedonia 12.4 

Switzerland 4.1 58 Yugoslavia 12.5 

11 Austria 4.2 59 Qatar 13.2 

12 Slovenia 4.3 60 Mauritius 13.4 

13 France 4.5 61 Uruguay 13.7 

14 Germany 4.5 62 Saint Lucia 14.3 

Canada 4.6 63 Sri Lanka 15.3 

16 Belgium 4.6 64 Saint Kitts and Nevis 15.4 

17 Andorra 4.8 65 Samoa 15.6 

18 Italy 4.8 66 Russian Federation 15.9 

19 New Zealand 4.9 67 Jordan 16.5 

Australia 5.0 68 Saint Vincent and Grenadines 16.6 

21 Denmark 5.1 69 Republic of Moldova 16.8 

22 Netherlands 5.2 70 Bosnia and Herzegovina 17.0 

23 Monaco 5.4 71 Trinidad and Tobago 17.5 

24 Bahrain 5.6 72 Argentina 17.6 

Republic of Korea 5.6 73 Grenada 17.7 

26 Ireland 5.8 74 Cook Islands 17.8 

27 United Kingdom 5.8 75 Palau 8.1 

28 Greece 5.9 76 Antigua and Barbuda 18.2 

29 Portugal 5.9 77 Barbados 18.6 

Malta 6.0 78 Oman 18.8 

31 San Marino 6.0 79 Tonga 18.9 

32 Israel 6.1 80 Panama 19.2 

33 Cyprus 6.4 81 Venezuela (Bolivarian Republic of) 19.5 

34 Poland 6.7 82 Colombia 20.4 

Malaysia 6.9 83 Lebanon 21.7 

36 Cuba 7.5 84 Tunisia 21.7 

37 United States of America 7.5 85 Belize 22.7 

38 Slovakia 7.5 86 Syrian Arab Republic 23.5 

39 Kuwait 7.7 87 Saudi Arabia 23.7 

Lithuania 7.7 88 Fiji 23.9 

41 Hungary 8.1 89 Georgia 24.0 

42 Croatia 8.2 90 Mexico 24.5 

43 Bahamas 8.3 91 Niue 24.5 

44 Chile 8.5 92 Libyan Arab Jamahiriya 25.0 

Belarus 9.2 93 Suriname 25.2 

46 Estonia 9.2 94 Marshall Islands 25.5 

47 United Arab Emirates 9.3 95 Romania 26.0 

48 Latvia 9.4 96 Albania 26.4 

A4
 
 

 Rank Country IMR Rank Country IMR 

97 Paraguay 26.7 145 Pakistan 84.2 

98 Ecuador 27.1 146 Eritrea 84.7 

99 Armenia 27.6 147 Nepal 85.9 

100 Viet Nam 27.6 148 Haiti 88.9 

101 El Salvador 28.0 149 Kenya 90.1 

102 Philippines 29.4 150 Congo 91.7 

103 Democr. People’s Republic of Korea 33.1 151 Gambia 91.8 

104 Turkey 34.3 152 Yemen 96.6 

105 Honduras 35.1 153 Zimbabwe 97.7 

106 Nicaragua 35.1 154 Lesotho 98.1 

107 Cape Verde 35.3 155 Cameroon 102.5 

108 Algeria 35.7 156 Iraq 102.6 

109 Thailand 35.8 157 Senegal 103.7 

110 Iran (Islamic Republic of) 36.9 158 Togo 104.7 

111 Peru 37.2 159 Lao People’s Democratic Republic 105.8 

112 China 37.9 160 Sao Tome and Principe 106.6 

113 Egypt 38.1 161 Sudan 107.2 

114 Tuvalu 38.1 162 Myanmar 111.5 

115 Maldives 38.3 163 Uganda 120.2 

116 Brazil 38.4 164 United Republic of Tanzania 123.4 

117 Guatemala 38.5 165 Equatorial Guinea 125.4 

118 Indonesia 39.5 166 Madagascar 131.4 

119 Kazakhstan 40.5 167 Benin 132.3 

120 Dominican Republic 41.1 168 Nigeria 133.7 

121 Uzbekistan 41.7 169 Cambodia 37.2 

122 Guyana 45.2 170 Djibouti 138.2 

123 Vanuatu 49.8 171 Cote d’Ivoire 141.1 

124 Micronesia (Federated States of) 49.9 172 Burundi 142.0 

125 Turkmenistan 52.3 173 Ethiopia 142.6 

126 Kyrgyzstan 54.4 174 Mauritania 148.4 

127 Morocco 56.3 175 Mozambique 148.6 

128 Mongolia 57.2 176 Rwanda 152.0 

129 Botswana 58.6 177 Guinea 153.1 

130 Kiribati 60.5 178 Somalia 157.1 

131 Solomon Islands 65.9 179 Central African Republic 159.6 

132 Bolivia 66.4 180 Chad 163.4 

133 Bhutan 68.3 181 Burkina Faso 167.3 

134 Namibia 69.1 182 Zambia 168.1 

135 Ghana 69.6 183 Democratic Republic of the Congo 175.7 

136 South Africa 73.3 184 Afghanistan 176.2 

137 Papua New Guinea 73.7 185 Guinea-Bissau 176.7 

138 Gabon 74.3 186 Malawi 198.8 

139 Tajikistan 74.8 187 Mali 204.8 

140 Comoros 75.1 188 Liberia 231.1 

141 India 76.2 189 Niger 239.0 

142 Bangladesh 76.6 190 Sierra Leone 257.7 

143 Azerbaijan 78.3 191 Angola 261.5 

144 Swaziland 80.4 

Table A.1. 

Infant Mortality Rate, by Country, 2000 (continued) 

Source: World Health Organization 2004. Note:IMR = Infant Mortality Rate, number of infant deaths per 1,000 live births. 

A5 
 

 

Table A.2. 

Infant Mortality Rates, by Race/Ethnicity: United States, 2001 

INFANT DEATH RATE PER 1,000 LIVE BIRTHS 

American Asian/ 

Indian/ Pacific White Black

 State Total White Black Alaska Native Islander Hispanic Non-Hispanic Non-Hispanic 

United States 6.9 5.7 13.6 9.1 4.8 5.6 5.7 13.7 

Alabama 9.5 6.8 15.3 * * * 7.3 10.0 

Alaska 7.0 5.6 * 11.9 * 5.7 5.9 16.0 

Arizona 6.8 6.3 16.6 9.3 5.2 6.1 5.1 13.6 

Arkansas 8.2 7.2 12.3 * * 4.4 6.3 15.2 

California 5.4 5.0 11.5 7.9 4.5 6.1 5.7 12.7 

Colorado 6.2 5.8 12.7 * 6.2 6.6 6.4 * 

Connecticut 6.2 5.3 13.1 * * 8.1 6.6 * 

Delaware 9.2 7.0 16.1 * * * 5.7 * 

District of Columbia 13.0 5.3 16.9 * * * 6.4 * 

Florida 7.1 5.5 12.7 * 4.9 * 5.9 * 

Georgia 8.4 5.9 13.4 * 6.2 6.3 6.5 16.0 

Hawaii 7.1 6.8 * * 7.2 7.6 6.1 13.2 

Idaho 6.9 6.8 * * * 6.8 5.0 11.4 

Illinois 8.2 6.3 16.4 * 6.7 * 6.2 * 

Indiana 7.8 7.0 14.4 * * * 7.0 * 

Iowa 5.9 5.6 15.8 * * 8.5 * 16.9 

Kansas 7.1 6.6 14.1 * * 5.5 5.2 11.9 

Kentucky 6.8 6.5 10.4 * * 5.5 4.1 11.1 

Louisiana 9.4 6.4 13.7 * * 4.9 4.9 10.3 

Maine 5.3 5.3 * * * 4.2 7.5 12.2 

Maryland 8.0 5.2 13.6 * 4.8 4.9 7.6 14.3 

Massachusetts 4.9 4.4 9.9 * 3.8 7.0 6.8 15.2 

Michigan 8.1 6.2 16.7 * 6.0 9.0 5.7 15.0 

Minnesota 5.7 5.1 11.7 10.8 7.4 8.2 6.8 16.3 

Mississippi 10.4 6.9 14.7 * * 6.4 5.7 16.8 

Missouri 7.4 5.9 16.0 * * 5.8 4.8 11.4 

Montana 6.6 5.9 * 11.7 * * 6.5 10.5 

Nebraska 6.9 6.3 13.0 17.3 * * 6.9 14.6 

Nevada 6.2 5.6 11.7 15.8 5.4 6.9 6.1 16.4 

New Hampshire 5.2 5.1 * * * 6.3 6.3 16.5 

New Jersey 6.4 5.0 13.5 * 3.7 6.3 6.7 14.1 

New Mexico 6.6 6.5 14.6 7.1 * 5.3 6.5 13.7 

New York 6.2 5.1 10.9 * 3.6 6.8 7.0 14.5 

North Carolina 8.7 6.6 15.1 11.6 6.9 5.9 4.8 * 

North Dakota 8.0 7.3 * 15.2 * 6.4 5.4 7.5 

Ohio 7.8 6.6 15.1 * 4.2 7.5 6.6 14.9 

Oklahoma 8.1 7.4 14.3 8.4 * 7.9 4.6 13.0 

Oregon 5.5 5.5 7.3 9.5 4.0 7.5 4.7 13.3 

Pennsylvania 7.2 6.0 15.1 * .7 6.3 4.4 14.0 

Rhode Island 6.3 5.5 12.8 * * 6.6 5.5 15.8 

South Carolina 9.3 6.2 15.2 * * 4.9 5.5 13.0 

South Dakota 7.1 6.2 * 11.7 * * 4.5 * 

Tennessee 8.5 6.5 16.0 * 5.8 5.1 5.4 10.9 

Texas 5.9 5.3 10.9 * 3.9 5.0 5.6 12.8 

Utah 5.0 5.0 * * 7.0 * 5.3 * 

Vermont 5.9 5.9 * * * 5.1 6.0 13.5 

Virginia 7.2 5.5 13.0 * 4.6 6.3 6.9 14.7 

Washington 5.3 5.0 10.8 8.9 4.4 5.1 4.7 11.6 

West Virginia 7.4 7.3 9.9 * * 5.9 6.7 15.1 

Wisconsin 6.8 5.7 16.8 10.1 5.0 6.5 5.9 16.7 

Wyoming 6.6 6.7 * * * * 5.3 * 

Source:Mathews et al. 2003. *Figure does not meet standard of reliability or precision, based on fewer than 20 deaths in the numerator. 

A6 
 

Table A.3. 

Live Births, by Race/Ethnicity: United States, 2001

 NUMBER OF LIVE BIRTHS 

American Asian/ 

Indian/ Pacific White Black

 State Total White Black Alaska Native Islander Hispanic Non-Hispanic Non-Hispanic 

United States 5,025,933 3,177,626 66,156 41,872 200,279 851,851 2,326,578 589,917 

Alabama 60,454 40,604 19,199 182 469 2,254 38,342 19,183 

Alaska 10,003 6,383 441 2,542 637 652 5,567 388 

Arizona 85,597 75,219 2,762 5,498 2,118 36,183 38,878 2,560 

Arkansas 37,010 28,836 7,435 244 495 2,649 26,082 7,422 

California 527,750 428,238 33,774 2,926 62,827 261,071 167,025 32,551 

Colorado 67,007 61,056 2,971 651 2,329 19,730 41,764 2,830 

Connecticut 42,648 35,612 5,134 164 1,738 6,913 28,434 4,929 

Delaware 10,749 7,668 2,710 26 345 1,083 6,598 2,684 

District of Columbia 7,625 2,570 4,860 9 186 895 1,667 4,805 

Florida 205,793 152,207 47,186 1,230 5,170 49,629 104,068 45,954 

Georgia 133,526 85,648 43,727 275 3,876 15,699 69,306 43,076 

Hawaii 17,072 3,815 527 183 12,547 2,237 3,119 495 

Idaho 20,688 19,944 86 360 298 2,753 16,855 78 

Illinois 184,064 142,474 33,203 261 8,126 40,973 101,660 32,995 

Indiana 86,459 75,393 9,649 168 1,249 5,898 69,242 9,575 

Iowa 37,619 35,324 1,266 232 797 2,232 33,068 1,237 

Kansas 38,869 34,622 2,781 458 1,008 4,906 29,363 2,747 

Kentucky 54,658 48,968 4,930 102 658 1,509 47,485 4,905 

Louisiana 65,352 36,899 27,058 380 1,015 1,557 35,383 27,010 

Maine 13,759 13,280 153 110 216 173 13,074 142 

Maryland 73,218 45,068 24,252 212 3,686 5,301 39,798 24,046 

Massachusetts 81,077 67,786 8,205 144 4,942 9,444 59,405 6,552 

Michigan 133,427 105,235 23,613 641 3,938 7,335 96,346 23,399 

Minnesota 67,562 57,982 4,767 1,312 3,501 4,543 53,141 4,685 

Mississippi 42,282 22,808 18,817 265 392 719 22,073 18,809 

Missouri 75,464 62,504 11,134 342 1,484 2,981 59,513 11,084 

Montana 10,970 9,442 42 1,369 117 377 8,798 38 

Nebraska 24,820 22,496 1,373 433 518 2,946 19,056 1,355 

Nevada 31,382 26,284 2,518 482 2,098 10,855 15,323 2,414 

New Hampshire 14,656 13,954 208 4 454 509 12,849 159 

New Jersey 115,795 85,110 20,583 167 9,935 23,497 63,266 18,709 

New Mexico 27,128 22,810 511 3,404 403 14,126 8,776 485 

New York 254,026 182,191 52,190 710 18,935 54,544 130,637 46,709 

North Carolina 118,185 85,315 28,393 1,689 2,788 14,539 70,863 28,250 

North Dakota 7,629 6,625 102 806 96 140 6,299 101 

Ohio 151,570 125,507 22,994 313 2,756 4,598 20,869 22,769 

Oklahoma 50,118 39,218 4,612 5,258 1,030 4,942 34,360 4,574 

Oregon 45,322 41,284 944 792 2,302 7,902 33,388 908 

Pennsylvania 143,495 119,015 20,238 356 3,886 8,192 10,501 19,615 

Rhode Island 12,713 10,960 1,112 127 514 2,196 7,676 994 

South Carolina 55,756 35,866 18,927 153 810 2,988 32,932 18,878 

South Dakota 10,483 8,475 101 1,776 131 257 8,254 97 

Tennessee 78,340 60,216 16,603 181 1,340 3,905 56,363 16,568 

Texas 365,410 311,979 40,750 854 11,827 172,354 139,104 40,221 

Utah 47,959 45,440 342 742 1,435 6,543 38,682 325 

Vermont 6,366 6,237 31 7 91 35 6,014 29 

Virginia 98,884 70,946 22,272 120 5,546 9,143 61,871 22,082 

Washington 79,570 67,437 3,334 1,897 6,902 12,140 54,468 3,219 

West Virginia 20,428 19,576 704 19 129 83 19,446 698 

Wisconsin 69,072 59,383 6,567 989 2,133 5,152 54,346 6,515 

Wyoming 6,115 5,717 65 271 62 569 5,161 64 

Source: Martin et al. 2002b. 

A7 
Table A.4. 

State Rank in Infant Mortality Rate and Difference Between Black and White Rates: United States, 2001 

 INFANT DEATH RATE PER 1,000 LIVE BIRTHS 

Black-White 

Rank State All Races White Black Difference 

United States 6.9 5.7 13.6 7.9 

1 Massachusetts 4.9 4.4 9.9 5.5 

2 Utah 5.0 5.0 * * 

3 New Hampshire 5.2 5.1 * * 

4 Maine 5.3 5.3 * * 

5 Washington 5.3 5.0 10.8 5.8 

6 California 5.4 5.0 11.5 6.5 

7 Oregon 5.5 5.5 7.3 1.8 

8 Minnesota 5.7 5.1 11.7 6.6 

9 Iowa 5.9 5.6 15.8 10.2 

10 Texas 5.9 5.3 10.9 5.6 

11 Vermont 5.9 5.9 * * 

12 Colorado 6.2 5.8 12.7 6.9 

13 Connecticut 6.2 5.3 13.1 7.8 

14 Nevada 6.2 5.6 11.7 6.1 

15 New York 6.2 5.1 10.9 5.8 

16 Rhode Island 6.3 5.5 12.8 7.3 

17 New Jersey 6.4 5.0 13.5 8.5 

18 Montana 6.6 5.9 * * 

19 New Mexico 6.6 6.5 14.6 8.1 

20 Wyoming 6.6 6.7 * * 

21 Arizona 6.8 6.3 16.6 10.3 

22 Kentucky 6.8 6.5 10.4 3.9 

23 Wisconsin 6.8 5.7 16.8 11.1 

24 Idaho 6.9 6.8 * * 

25 Nebraska 6.9 6.3 13.0 6.7 

26 Alaska 7.0 5.6 * * 

27 Florida 7.1 5.5 12.7 7.2 

28 Hawaii 7.1 6.8 * * 

29 Kansas 7.1 6.6 14.1 7.5 

30 South Dakota 7.1 6.2 * * 

31 Pennsylvania 7.2 6.0 15.1 9.1 

32 Virginia 7.2 5.5 13.0 7.5 

33 Missouri 7.4 5.9 16.0 10.1 

34 West Virginia 7.4 7.3 9.9 2.6 

35 Indiana 7.8 7.0 14.4 7.4 

36 Ohio 7.8 6.6 15.1 8.5 

37 Maryland 8.0 5.2 13.6 8.4 

38 North Dakota 8.0 7.3 * * 

39 Michigan 8.1 6.2 16.7 10.5 

40 Oklahoma 8.1 7.4 14.3 6.9 

41 Arkansas 8.2 7.2 12.3 5.1 

42 Illinois 8.2 6.3 16.4 10.1 

43 Georgia 8.4 5.9 13.4 7.5 

44 Tennessee 8.5 6.5 16.0 9.5 

45 North Carolina 8.7 6.6 15.1 8.5 

46 Delaware 9.2 7.0 16.1 9.1 

47 South Carolina 9.3 6.2 15.2 9.0 

48 Louisiana 9.4 6.4 13.7 7.3 

49 Alabama 9.5 6.8 15.3 8.5 

50 Mississippi 10.4 6.9 14.7 7.8 

51 District of Columbia 13.0 5.3 16.9 11.6 

Source: Mathews et al. 2003. Black-White difference was calculated using data from Mathews et al. 2003. 

*Figure does not meet standard of reliability or precision, based on fewer than 20 deaths in the numerator. 

A8 
 

 

Table A.5. 

Five Leading Causes of Infant Death, by Race/Ethnicity: United States, 2002 

INFANT DEATH RATE PER 1,000 LIVE BIRTHS 

Preterm Sudden 

Congenital Birth/Low Infant Death Maternal Cord 

Race and Ethnicity All Causes Malformations Birthweight Syndrome Complications Complications

 All Races and Ethnicities 7.0 1.4 1.2 0.6 0.4 0.3 

RACE

 White 5.8 1.3 0.8 0.6 0.3 0.2

 Black 13.9 1.7 3.2 1.1 0.9 0.5

 Asian/Pacific Islander 4.8 1.1 0.8 0.2 0.3 0.2

 American Indian/

 Alaska Native 8.6 1.9 1.1 1.2 0.5 * 

ETHNICITY

 All Hispanics 5.6 1.5 0.9 0.3 0.3 0.2

 Mexican 5.4 1.5 0.8 0.3 0.2 0.2

 Puerto Rican 8.2 1.7 1.7 0.5 0.5 *

 Central and


 South American 5.1 1.4 0.7 0.2 0.2 *
 

Source: Mathews et al. 2004.
 

Note: “Black” and “White” categories exclude women of Hispanic origin.
 

* Figure does not meet standard of reliability precision, based on fewer than 20 deaths in the numerator. 

Table A.6. 

Preterm Birth/Low Birthweight, by Race/Ethnicity: United States, 2002 

Race and Ethnicity 

PE

Preterm Births 

RCENT OF LIVE BIRTH

Low Birthweight 

S 

Very Low Birthweight 

All Races and Ethnicities 12.1 7.8 1.5 

RACE

 White 11.1 6.8 1.2

 Black 17.6 13.3 3.2

 Asian/Pacific Islander 10.4 7.8 1.1

 • Chinese 7.7 5.5 0.7

 • Japanese 9.2 7.6 1.0

 • Hawaiian 13.5 8.1 1.6

 • Filipino 12.7 8.6 1.3

 American Indian/Alaska Native 13.1 7.2 1.3 

ETHNICITY

 All Hispanics 11.6 6.5 1.2

 • Mexican 11.4 6.2 1.1

 • Puerto Rican 14.0 9.7 2.0

 • Cuban 10.5 6.5 1.2

 • Central and South American 11.2 6.5 1.2

 White Non-Hispanic 11.0 6.9 1.2

 Black Non-Hispanic 17.7 13.4 3.2 

Source: Martin et al. 2003. 

A9 
Table A.7. 

Preterm Birth, by Race/Ethnicity: United States, 1995-2002 

PERCENT OF LIVE BIRTHS 

% Change 

Race and Ethnicity 1995 1996 1997 1998 1999 2000 2001 2002 1995 to 2002 

All Races and Ethnicities 11.0 11.0 11.4 11.6 11.8 11.6 11.9 12.1 10.0 

RACE 

White 9.7 9.8 10.2 10.5 10.7 10.6 11.0 11.1 14.4 

Black 17.7 17.4 17.5 17.5 17.5 17.3 17.5 17.6 -0.6 

Asian/Pacific Islander 9.9 10.0 10.2 10.4 10.4 9.9 10.3 10.4 5.1

 • Chinese 7.2 7.4 7.4 7.6 7.6 7.3 7.7 7.7 6.9

 • Japanese 8.3 8.2 8.1 8.7 9.3 8.3 8.8 9.2 10.8

 • Hawaiian 11.0 11.5 11.0 12.0 12.3 11.7 14.2 13.5 22.7

 • Filipino 11.7 11.5 11.9 11.8 12.4 12.2 12.5 12.7 8.5 

American Indian/Alaska Native 12.4 11.9 12.2 12.2 12.9 12.7 13.2 13.1 5.6 

ETHNICITY 

All Hispanics 10.9 10.9 11.2 11.4 11.4 11.2 11.4 11.6 6.4

 • Mexican 10.6 10.5 10.9 11.0 11.1 11.0 11.2 11.4 7.5

 • Puerto Rican 13.4 13.2 13.7 13.9 13.7 13.5 13.7 14.0 4.5

 • Cuban 10.1 10.3 11.0 11.4 11.5 10.6 10.6 10.5 4.0

 • Central and South American 10.7 10.9 11.2 11.6 11.4 11.0 11.2 11.2 4.7

 Non-Hispanic White 9.4 9.5 9.9 10.2 10.5 10.4 10.8 11.0 17.0

 Non-Hispanic Black 17.8 17.5 17.6 17.6 17.6 17.4 17.6 17.7 -0.6 

Source: MacDorman and Atkinson 1998a, MacDorman and Atkinson 1998b, MacDorman and Atkinson 1999, Ventura et al. 1999,
 

Ventura et al. 2000, Ventura et al. 2001, Mathews et al. 2000, Mathews et al. 2002a, Mathews et al. 2002b, Mathews et al. 2003,
 

Mathews et al. 2004.
 

Note: Hispanic includes both White and Black Hispanics.
 

Table A.8. 

Very Low Birthweight, by Race/Ethnicity: United States, 1995-2002 

PERCENT OF LIVE BIRTHS 

% Change 

Race and Ethnicity 1995 19961 997 1998 1999 2000 2001 2002 1995 to 2002 

All Races and Ethnicities 1.3 1.4 1.4 1.4 1.5 1.4 1.4 1.5 15.4 

RACE 

White 1.1 1.1 1.1 1.1 1.2 1.1 1.2 1.2 9.1 

Black 3.0 3.0 3.0 3.1 3.1 3.1 3.0 3.2 6.7 

Asian/Pacific Islander 0.9 1.0 1.1 1.1 1.1 1.0 1.0 1.1 22.2

 • Chinese 0.7 0.6 0.7 0.7 0.7 0.8 0.7 0.7 0.0

 • Japanese 0.9 0.8 0.8 0.8 0.9 0.7 0.7 1.0 11.1

 • Hawaiian 0.9 1.0 1.4 1.5 1.4 1.4 1.5 1.6 77.8

 • Filipino 1.1 1.2 1.3 1.3 1.4 1.4 1.2 1.3 18.2 

American Indian/Alaska Native 1.1 1.2 1.2 1.2 1.3 1.2 1.3 1.3 18.2 

ETHNICITY

 All Hispanics 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.2 9.1

 • Mexican 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.1 10.0

 • Puerto Rican 1.8 1.7 1.8 1.9 1.9 1.9 1.8 2.0 11.1

 • Cuban 1.2 1.3 1.4 1.3 1.5 1.2 1.3 1.2 0.0

 • Central and South American 1.1 1.1 1.2 1.2 1.1 1.2 1.2 1.2 9.1

 Non-Hispanic White 1.0 1.1 1.1 1.1 1.2 1.1 1.2 1.2 20.0

 Non-Hispanic Black 3.0 3.0 3.1 3.1 3.2 3.1 3.1 3.2 6.7 

Source:MacDorman and Atkinson 1998a, MacDorman and Atkinson 1998b, MacDorman and Atkinson 1999, Ventura et al. 1999,
 

Ventura et al. 2000, Ventura et al. 2001, Mathews et al. 2000, Mathews et al. 2002a, Mathews et al. 2002b, Mathews et al. 2003,
 

Mathews et al. 2004.
 

Note: Hispanic includes both White and Black Hispanics.
 

A10
 
–

 

Table A.9. 

NTD-Specific Infant Deaths, by Race/Ethnicity: United States, 1996-1998, Aggregated 

Relative Risk 

Race and Ethnicity Rate per 100,000 Live Births (95 Percent Confidence Interval) 

ALL RACES AND ETHNICITIES 11.1 

RACE

 White 11.6 –

 Black 8.6 0.73 (0.62-0.87)

 Asian/Pacific Islander 9.8 0.85 (0.64-1.12)

 American Indian/Alaska Native 11.5 0.96 (0.55-1.65) 

ETHNICITY 

ALL HISPANICS 15.4 1.49 (1.31-1.69)

 • Mexican 17.0 1.64 (1.42-1.89)

 • Puerto Rican 10.4 0.98 (0.61-1.59)

 • Central and South American 11.9 1.15 (0.82-1.62)

 White Non-Hispanic 10.3 –

 Black Non-Hispanic 8.6 1.49 (1.31-1.69) 

Source: Davidoff et al. 2002. 

Note: White and White non-Hispanic are the reference groups for the relative risk ratios. 

Table A.10. 

Women Who Reported Smoking During Pregnancy, by Race/Ethnicity: United States, 1990-1999 

PERCENT 

% Change 

Race and Ethnicity 1990 1999 1990-1999 

ALL RACES AND ETHNICITIES 18.4 12.3 -33.1 

RACE

 White Non-Hispanic 21.0 15.7 -25.2

 Black Non-Hispanic 15.9 9.1 -42.8

 Asian/Pacific Islander 5.5 2.9 -47.3

 • Chinese – 0.5 –

 • Japanese – 4.5 –

 • Hawaiian – 14.7 –

 • Filipino – 3.3 –

 American Indian/Alaska Native 22.4 20.0 -10.7 

ETHNICITY 

ALL HISPANICS 6.7 3.7 -44.8

 • Mexican – 2.6 –

 • Puerto Rican – 10.5 –

 • Cuban – 3.3 –

 • Central and South American – 1.4 – 

Source: Mathews et al. 2003.
 

Notes: Total Hispanic and non-Hispanic White and Black percents were not available.
 

– Data not available. 

A11
 
 

 

Table A.10. 

Infant Mortality Rate, by Maternal Smoking Status and Race/Ethnicity: United States, 2002 

INFANT DEATH RATE PER 1,000 LIVE BIRTHS 

Race and Ethnicity Smoker Nonsmoker % Difference (Smoker-Nonsmoker) 

ALL RACES AND ETHNICITIES 11.1 6.6 68.2 

RACE

 White 9.8 5.3 84.9

 Black 20.0 13.1 52.7

 Asian/Pacific Islander 11.6 4.7 146.8

 American Indian/Alaska Native 12.1 7.7 57.1 

ETHNICITY 

ALL HISPANICS 10.7 5.6 91.1

 • Mexican 9.8 5.4 81.5

 • Puerto Rican 12.4 7.9 57.0

 • Cuban * 3.5 *

 • Central and South American * 4.9 *

 White Non-Hispanic 9.7 5.2 86.5

 Black Non-Hispanic 20.1 13.2 52.3 

Source: Mathews et al. 2004.
 

*Figure does not meet standard of reliability precision, based on fewer than 20 deaths in the numerator.
 

Table A.12. 

Infant Mortality Rate, by Age and Race/Ethnicity: United States, 2002 

YEARS OF AGE 

Race and Ethnicity Under 20 Over 20 20 to 24 25 to 29 30 to 34 35 to 39 40 to 54 

ALL RACES AND ETHNICITIES 10.4 6.5 7.8 6.0 5.6 6.5 8.5 

RACE

 White 8.8 5.5 6.4 5.1 4.7 5.5 7.3

 Black 15.2 13.5 13.9 12.4 13.4 14.5 16.1

 Asian/Pacific Islander 9.2 4.6 5.2 3.9 4.3 5.4 8.2

 American Indian/Alaska Native 9.1 8.5 9.4 7.6 7.6 8.5 * 

ETHNICITY 

ALL HISPANICS 7.3 5.3 5.3 5.1 5.0 6.2 8.9

 • Mexican 6.8 5.2 5.0 4.8 5.1 6.3 9.2

 • Puerto Rican 10.6 7.7 8.2 7.4 7.2 7.6 *

 • Cuban * 9.7 * * * * *

 • Central and South American 6.8 4.9 4.8 4.9 4.4 5.1 8.2

 White Non-Hispanic 9.7 5.5 6.9 5.1 4.6 5.3 6.8

 Black Non-Hispanic 15.2 13.6 14.0 12.5 13.4 14.6 16.3 

Source: Mathews et al. 2004. 

* Figure does not meet standard of reliability precision, based on fewer than 20 deaths in the numerator. 

A12
 
Appendix B 

Glossary 

B1
 
B2
 
TERM DEFINITION 

•Abruptio Placenta A disorder of pregnancy in which the placenta prematurely separates from the 

wall of the uterus. 

•Amnion The tissue membrane that expands to enclose the fetus and form the amniotic 

sac, protecting and cushioning the fetus during pregnancy, within which is the 

amniotic fluid (bag of water). 

•Antenatal The time period from conception until the onset of labor–about 40 weeks. 

•Antepartum Occurring or existing before birth; the prenatal period; antenatal care. 

•APGAR Designed in 1952 by Dr. Virginia Apgar at Columbia University’s Babies Hospital, 

the APGAR (appearance, pulse, grimace, activity, respirations) score is a quick 

test performed at 1 and 5 minutes after birth to determine the physical condition 

of the newborn. The rating is based on a scale of 1 to 10. Ten suggests the healthiest infant, and scores below 5 indicate that the infant needs immediate assistance 

in adjusting to his or her new environment. 

•Bacterial Vaginosis An inflammation of the vagina caused by one or more bacteria that has replaced 

the normal flora of the vagina. Signs and symptoms include vaginal discharge– 

thin, creamy, and grayish, often unpleasant and fishy in odor, and vulval 

irritation, rather than itching. 

•Chorion The outermost membranous sac enclosing the embryo. 

•Congenital Malformations Physical and/or neurological defects that are present at delivery. 

•Domestic Violence Any physical abuse or threat or pattern thereof, between intimately involved 

partners, roommates, or family members. 

•Eclampsia Coma and convulsions during or immediately after pregnancy, characterized by 

edema, hypertension, and proteinuria. 

•Ectopic Pregnancy A pregnancy in which a fertilized egg begins to develop outside the uterus (for 

example, in a fallopian tube). Ectopic pregnancy can lead to tubal rupture, 

hemorrhage, and death. 

•Fetal Alcohol Exposure Exposure to alcohol of the developing fetus. 

•Fetal Alcohol Syndrome Refers to a group of symptoms exhibited by an infant or child resulting from a 

woman’s consumption of alcohol during pregnancy. The symptoms may include 

differing levels of mental retardation, low birthweight, small size, and underdevelopment of the upper lip. 

•Fetus The clinical name for an unborn child after the eighth week of pregnancy. 

•First Trimester Time period extending from the first day of the last menstrual period through 12 

weeks of gestation. 

•Folic Acid A nutrient found in some green, leafy vegetables, nuts, beans, citrus fruits, 

fortified breakfast cereals, and some vitamin supplements. Folic acid can help 

reduce the risk of birth defects of the brain and spinal cord (also called neural 

tube defects). 

•Gestation Period The period during when the embryo develops. 

B3
 
The age of an embryo counting from the time of fertilization. 

Health education includes instructional activities and other strategies to 

increase knowledge/awareness of an individual/group/community and to 

change individual health behavior. 

A comprehensive, nationwide health promotion and disease prevention agenda 

launched by the U.S. Department of Health and Human Services in January 

2000. Healthy People 2010 contains 467 objectives designed to serve as a road 

map for improving the health of all people in the United States during the first 

decade of the 21st century. 

In the uterus; typically refers to events that occur in the womb before birth. 

Death during the first year of life. 

Relating to the care recommended to women between pregnancies or up to 24 

months postpartum. Interconceptional care generally consists of interventions 

to ensure that medical conditions, poor personal behaviors, and negative 

environmental conditions are treated and eliminated before conception, thus 

decreasing the likelihood of poor birth outcomes. 

A fetus whose weight is below the 10th percentile for gestational age. 

Refers to an infant weighing less than 2,500 grams (five pounds, eight ounces) 

at birth. 

Refers to maternal depression occurring during the period shortly before or 

after birth. 

The first four weeks after birth. 

A congenital defect of the central nervous system, including the spinal cord, 

skull, and brain, resulting from failure of the neural tube to properly close 

during fetal development. Defects may include absence of the skull, and 

protrusions of the brain or spinal cord. Most such defects can be detected 

before birth through amniotic fluid or blood levels of alpha-fetoprotein and by 

ultrasonic scanning. 

Pertaining to or occurring in the period shortly before and after birth, 

variously defined as beginning with completion of the 20th to 28th week of 

gestation and ending 7 to 28 days after birth. 

Refers to an infant born before 37 weeks of gestation. 

The period from 4 weeks to 52 weeks after birth. 

The sudden death of an infant under 1 year of age that remains unexplained 

after a thorough case investigation, including performance of a complete 

autopsy, examination of the death scene, and review of the clinical history. 

Refers to an infant weighing less than 1,500 grams (three pounds, four ounces) 

at birth. 

TERM DEFINITION 

•Gestational Age 

•Health Education 

•Healthy People 2010 

•In Utero 

•Infant Mortality 

•Interconceptional Care 

•Intrauterine Growth 

Retardation 

•Low Birthweight 

•Maternal Perinatal 

Depression 

•Neonatal Period 

•Neural Tube Defect 

•Perinatal 

•Preterm/ Premature 

•Postneonatal Period 

•Sudden Infant 

Death Syndrome (SIDS) 

•Very Low Birthweight 

B4
 
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