NATIONAL CENTER Series 3 

For HEALTH STATISTICS Number 4 

PROPERWOF~f


VITAL and HEALTH STATISTICS p(l~f!c,~/0ti5f3R4~~ 

ANALVTICALSTUDIES moRi&u-f 

InfantandPerinatalMortality 

intheUnitedStates 

Analysis of long- and short-term trends in infant mortality 

in the United States by age at death, cause of death, sex 

of child, color, and geographic area; fetal and perinatal 

mortality trends; role of various risk factors including 

birth weight, age of mother, birth order, mother’s history 

of prior pregnancy loss; changes during the 1950 decade 

in personnel and facilities and services related to obstetrical and pediatric care; discussion of health insurance 

crnd maternal and child health programs and services. 

Washington, D.C. October 1965 

U.S. DEPARTMENT OF 

HEALTH, EDUCATION, AND WELFARE Public Health Service 

John W. Gardner Luther L. Terry 

Secretary Surgeon General 
Public Health Service Publication No. 1000-Series 3-No. 4 

For sale by the Superintendent of Documents, U.S. Government Printing Office 

Washington, D.C., 20402 - Price U; cents 
NATIONAL CENTER FOR HEALTH STATISTICS 

FORREST E. LINDER, PH. D,, Director 

THEODORE D. WOOLSEY, Deputy Director 

OSWALD K. SAGEN, PH. D., ~f.fhta?zt Director 

WALT R. SIMMONS, M.A., stati~tical ~dvi~or 

ALICE M. WATERHOUSE, M.D., Medical Advi~or 

JAMES E. KELLY, D,D.s., Dental Advi~or 

LOUIS R. STOLCIS, M.A., Executive oj?cer 

OFFICEOF HEALTH STATISTICS ANALYSIS 

IWAO M. MORXYAMA,PH. D,, Chief 

DIVISIONOF VITAL STATISTICS 

ROBERTD. GROVE, PH. D., Chief 

DIVISIONOF HEALTH INTERVIEWSTATISTICS 

PHXLIPS. LAWRENCE, Sc. D., Chief 

DIVISION OF HEALTH RECORDS STATISTICS 

MONROE G. SIRKEN, PH. D., Chief 

DIVISIONOF HEALTH EXAMINATIONSTATISTICS 

ARTFiURJ. MCDOWELL, Chief 

DIVISIONOF DATA PROCESSING 

SIDNEY BINDER, Chit-f 

Public Health Service Publication No. 1000-Series 3-No. 4 

Library of Congress Catalog Card Number 6.5s62151 
----------------------------------------------------------

---------------------------------------------------

-----------------------

-------------------------------------------------

-------------------------------------

------------------

-------------------------------------

----------------------

------------------------------

--------------------------------------------------

-----

-----------------------------

-----------------------------------------

-----------------------------

-------------

-----------------------------------------------------

---------------------------------------------------------

-------------------------------------------------------

-------------------------------------------------------

-----------------------------------------------

--------------------

------------------------------------------

----------------

------------------------------------------------

------------------

---------------------------------------

-------------------------------

-----------------------------------------------------

-----------------------------------------------------------

-------------------------------------------------------

------------------------------------------------------

CONTENTS


Introduction


I. Mortality Rates


Trend	 in Infant, Fetal, and Perinatal Mortality


Infant Mortality


Fetal and Perinatal Mortality


The Current Status of Infant and Perinatal Mortality


Infant Mortali~-------------------------------------------------


Fetal and Perinatal Mortality


Other Selected Parameters of Infant Mortality


Total Suboptimal Pregnancy Outcome


The 1950Bcade


Changes in Parameters of Infant Loss and Their Effect on Trend


Changes in High MortalityRiskGroups


Summary—Mortality Rates


II. Medical Resources and HealthPrograms


Personnel,	 Facilities and Services, and Financing of Care


Physicians


Nurses


Midwives


Hospitals


Financing of Care


Maternal and Child Health Programs and Services


General HealthServices


Specialized Health Programs for Mothers andInfants


Patterns of Care


Summary—Medical Resources and Health Programs


Medical Manpower and Facilities---------------------------------,


Financing of Medical Care


Maternal and CMld Health Program


III. Perspective on Fumre Course of hfant Mortali~---------------------

Acknowledgments


References


Detailed Tables


Appendix Tables


Page 

1 

2 

2 

2 

10 

14 

14 

18 

19 

29 

32 

34 

36 

39 

40 

40 

40 

45 

46 

46 

48 

50 

50 

51 

53 

54 

54 

54 

55 

55 

57 

58 

60 

80 
------------------------ ---

------------------

----------------------------

--------------

IN THIS REPORT detailed statistics are provided on changes in infant 

and pevinatal mortality rates since the early 1930 ‘s. The analysis focuses on the lack of sizable decreases in these rates in the 1950’s and 

describes the current situation in the white and nonwhite groups and in 

various geo.graphic subdivisions. Statistics onfetal loss, congenital anomalies, and birth weight devived jkom special studies are given. Changes 

in parameters of infant loss that may explain the small decveases in this 

loss during the 1950’s are considered, and differences in rates of change 

in the infant mortality rate among high-risk gYoups aye analyzed. Statistics are presented on the vatios of general practitioners, obstetricians-gynecologists, pediatricians, nurses, and hospital beds to Yelevant 

segments of the population. Othey factors, includir@ obstetrical costs, 

health insurance, and mateynal and child health pyogvams, are discussed. 

The rate of decline in the infant moytality rate was 4.7 peycent pey year 

duying the 1940’s. Between 1951 and 1962 it was 1 percent pey yeay. The 

slowdown affected all segments of the population. The rate in many layge 

cities increased, and the gap between Yates in met~opolitan and nonmetropolitan ayeas decveased. High-Yisk gYoups such as childyen weighing 

2,500 gyams or less at biyth, children born to motheys who previously 

had a fetal death, and nonwhite infants showed almost no improvement 

duying the 1950 ‘s. 

Increased emphasis through special community-action pyograms on the 

problem of infant mortality is viewed as OYW of the elements that may 

help accelerate the rate of decline in infant mortality. 

I I 

SYMBOLS 

Data not available 

Category not applicable . . . 

Quantity. zero -

Quantity more than O but less than 0.05 ----- 0.0 

Figure does not meet standards of 

* reliability or precision----
INFANT AND PERINATAL MORTALITY


IN THE UNITED STATES


The following research repart was prepared by Sam Shapira, Edward R. Schlesinger, M. D., and Robert E. L. Nesbitt, Jr., M.D. a b 

The methadalagy, findings, and conclusions are those of the investigators. 

INTRODUCTION 

The relatively poor progress in reducing infant mortality since the early 1950’s has been 

a source of increasing concern in the United 

States. The subject has been examined previously 

in the context of international, national, and local 

changes in pregnancy loss rates; but it is clear 

that continued discussion based on the analysis 

of old and new data is very much the order of 

the day.1”5 

The tone and outlook of reports on infant 

mortality in the United States would be vastly 

different if, instead of being written in the present period, they were being presented 25-30 

years ago or as recently as 10-15 years ago. 

During the late 1930’s a backward glance at what 

had been accomplished in reducing the infant 

mortality rate had its rewards. The infant mortality rate had been cut at least in half in a matter of 20-25 years, and the country was apparently 

in the midst of further dramatic reductions in the 

loss rate. The decline continued at a rapid pace, 

and between 1940 and 1950 the infant mortality 

rate decreased by almost 40 percent. 

aThis study was supported in part by U.S. Public Health 

Service Cantract Na. PH 86-63-129 and in part by USPHS grant 

CH 00075 from the Division af Community Health Services h 

the American Public Health Association far a series of monographs on vital and health statistics. 

bMr. Shapiro is Director of Research and Statistics, Health 

Insurance Plan of Greater New York; Dr. Schlesinger is Assistant Commissioner far Special Health Services, N. Y., State DepartnrentofHealth; Dr. Nesbitt is Professor and Chairman, Department of Obstetri cs and Gynecology at the State University, 

Upstate Medical Center, Syracuse, New Yark. 

In 1950 the assessment of the performance in 

the immediate past could well have led to an expectation of additional impressive gains in the 

-future. Today the mood is quite different. For 

over a decade there has been no sizable decrease 

in the infant mortality rate. In fact, during the 

1950’s there were years in which the rate increased—a most unusual occurrence in half a 

century of vital statistics reporting in the United 

States. Events in the last few years give the definite impression that while the infant mortality 

rate will not remain stationary its downward 

movement will be slow indeed. 

The emphasis of the report that follows is on 

the current national situation with regard to both 

infant and perinatal mortality. In developing the 

subject, considerable attention is given to how we 

arrived at our present state and the extent to 

which significant parameters of pregnancy loss 

have been altered over the years. Long- and 

short-term trends are discussed; the basic 

variables of sex of child, color, geography, and 

risk factors such as age of mother, birth order, 

and prior pregnancy history of the mother are also 

considered. Although the focus is on infant and 

perinatal mortality, other components of pregnancy loss and damage among the offspring-including early fetal loss, low birth weight, and congenital malformations—are dealt with briefly. It 

has been apparent for some time that the attack 

on infant and perinatal mortality must concern 

itself with these types of loss and damage, and, 

indeed, serious efforts are being made to enlarge 

our limited knowledge about them. 
All of the information is derived from existing data or from special tabulations of data collected before the report was initiated. Official 

vital statistics are the yrimary source. Whenever 

possible, these data come from the Division of 

Vital Statistics, Public Health Service. In several instances where national data were unavailable, it proved feasible to examine important relationships on the basis of vital statistics for Upstate New York. c 

Although vital statistics are the most comprehensive source of information for examining the 

national picture on infant and perinatal mortality. 

C“Upstate New York” refers to New York State, excluding New York City. 

special studies conducted over the past two decades provide additional insights into the epidemiology of pregnancy loss. It is not the intent of the 

present report to incorporate all of these findings. 

The approach taken is to include a limited amount 

of data derived from special investigations which 

extend information about variables also found in 

vital statistics. 

While the analysis of mortality data is the 

focus of the present report, a major section is devoted to a review of medical and paramedical manpower, facilities, and medical care costs in the 

United States with particular emphasis on their 

relationship to obstetrical and pediatric services. 

The final section of the report provides a perspective on the future course of infant mortality 

in the United States. 

L MORTALITY RATES


TREND IN INFANT, FETAL, AND 

PERINATAL MORTALITY 

Infant Mortality 

General tvend. —The long-term trend in infant 

mortality in the United States and changes in rates 

of decline are examined in detail from the middle 

1930’s to the early 1960’s in this report. It was 

not until 1933 that data became available for the 

United States as a whole. In 1915, the Bureau of 

the Census established the birth registration area 

which included 10 states and the District of 

Columbia in which the registration of live births 

was relatively complete. d periodically other 

States were added as they met the minimum requirement of 90 percent completeness of birth 

registration. Generally the States that entered 

the Area late have had comparatively high infant 

mortality rates. 

Incompleteness of birth registration persisted as a serious problem in large sections of 

the country long after 1933, and it was not until 

‘The death registration area was established in 1900 for 

the annual collection of mortality statistics. 

the birth registration test of 1950 showed that 98 

percent of the live births were being registered 

that the issue could be dismissed as inconsequential for the United States as a whole.6 There 

is no direct evidence about the relationship between the completeness of live birth and infant 

death registration. The usual assumption is that 

they are of the same order of magnitude and, 

therefore, that the errors cancel each other when” 

rates are computed. However, this may be less 

true for very early infant deaths than for deaths 

later in infancy. 

Despite restrictions imposed by changes in 

registration completeness, it is believed that. inferences about the course of the infant mortality 

rate since the mid-1930’s can be drawn with a 

fairly high degree of accuracy from data based on 

reported events. The trend analysis in this report 

starts with these years. With regard to what happened prior to the mid-l 930’s, it is perhaps sufficient to recognize that 10-15 percent of the newborn babies died in infancy at the beginning of the 

20th century and that by the 1930’s the mortality 

rate had been cut at least in half. 

Between the mid- 1930’s and 1950 the rate was 

again greatly reduced. The annual rate of decline 

was 4.7 percent, but year-to- year changes were 

very uneven: a few years would go by with comparatively minor changes, and then there would be 

2 
--

a sharp drop. e Anextremee xampleofthisi sfound 

in the World War II period when the rates decreased only about 5 percent from 1942 to 1945. 

In the immediate postwar years the drop was three 

times as great. After 1950 the rate began to level 

off. At first it might have been assumed that this 

was another temporary situation, but, in time, it 

became clear that a fundamental change had 

occurred in the course of the infant mortality rate. 

Over the entire period of 1951-62 the rate of decline was 1.0 percent per year, or a small fraction 

of the annual rate of change in the preceding period. Furthermore, some of the year-to-year 

fluctuations involved important increases in the 

rate. 

Trends by age at death, sex of child, and 

CO1OY.—The trend in the infant mortality rate is 

the resultant of widely different trends in mortality 

at various ages during infancy. Selected for analysis are three age groupings in the neonatal period 

(under 1 day, 1-6 days, and 7-27 days) and two age 

groupings in the postneonatal period (l-5 months 

and 6-11 months). These provide a fairly complete basis for understanding the changes in 

mortality that have taken place throughout infant y. Other age groupings lead to inferences that 

differ in detail but do not alter the general conclusion (table 1 and fig. 1). 

Mortality in the first day of life decreased 

between 1935 and 1951 rather steadily but at a 

substantially slower rate than for the entire first 

‘Annual rates of decline were obtained by fitting straight 

lit-m by tho method of least squares to the logarithms of the 

death ratw, Fmm the slopes of these fitted lines the annual 

rates of duclina or increase (in percent) are derived. Changes 

in infant mortality rates are determined from rates computed 

conventionally, i.e., the number of deaths in a particular year 

is related b the number of live births in that year b obtain 

an infant mortality rate. During a period of stability in the 

annual numberof live births the rates closely approximate tbe 

risk of infant mortality in each of the years. When the number 

of livo births decreases sharply fmm one year to the next,-an 

accompanying docrwase in mortality would be understated by 

conventional rates; the reverse would occur if there were a 

sharp increaso in the number of live bkthe. The latter situation held during the immediate post-World War II period. The 

large dmp in the infant mortality rate between 1945 and 1946 

is duo, in part, to the changing number of births. Actually 

when infturt mortality rates are adjusted for tbe factor, the 

demwaso in tho rato between 1946 and 1947 appears tn be relaLI\dy greater than in the previous years. It should be noted 

that tho effect of changes in the number of births varies with 

ago at death; it is negligible during the first month following 

birth, but it becomes appreciable in the postneonatal period. 

100 

80 

60 ,*, \ .. Under I year 

‘*, % 

40 “e,.,, 

“$,& ,* 

“\.-, + .-,-,+,~,-,-

: ?.0 

~ 

z 

Lu 

> 

i 

0 10
 0
 0 * $*


cc % ~ 

6 m 

w

1-

<

K I-5 months 

4 B 

B 7-27 days ] 8 

* 

a

�,4’* 

\ 

2 

I I I I I 1 ,1,11,1111,,,,111,111,1 

1935 1940 1945 1950 1955 1960 

1 

From 1935 to 1948 this category refers to deaths at ages 7-29 days. 

NOTE2 Beginning in 1959 include Alaska and Hawaii. 

Sourc~ Annual volumes Vital Statistics of the United States, Natfonal 

Center for Healti Statistics, Public Health Service, Washington, U.S. 

Government Printing Office. 

Fiaure 1. Infant mortal i ty rates by age: Urrited 

States, 1935-62. 

year (2.9 percent). f ‘Then it leveled off, and, starting with 1955, it began to increase slightly. There 

is no indication yet that the rate of loss in the 

fAll percen~ge changes in this section are per annum. 

3 
--

100 

80 TOTAL MALE 80 — TOTALFEMALE r

— 

60 L

**

I

40 

\‘%,y’ ‘Ye”r 

8\‘*,­

‘s+ 

\ ‘-, *. +*-1**-a*,4’%-, -

: 20 1- 20


+
 a


z t
 w


>


i 

o 10 10—
 0


0


8 

En. I 6 mw1- 1-5 months 

a

z 

4 B 4 — I-5months 

1 

I 1 

I 1 

2 2 — 

I 

I I I I 1111111111111111111111111 

1935 1940 1945 1950 1955 1960 1965 

. 

‘From 1935to 1948 this category refers to deaths at ages 7-29 days. 

NOTE: Beginning in 1959 include Alaska and Hawaii. 

Source: Annual volumes Vifal Sfatisficsofflw Unifed Sfates, National Center for Health Statistics, Public Health Service, Washington, U.S. Government Printing Office. 

Figure 2. Infant mortality rates by age and sex: United States, 1935-62. 

first day after birthhasresumed itsformerdownward trend. In the balance of the first week of life 

(l-6 days) the mortality rate followed a course 

similar to that of the rate for under 1 day until 

the early 1950’s when, instead of increasing, it 

continued its slow downward movement (2.0 percent). After the first week the trend in the mortality rate showed great variability. At a:>es 7-27 

days there were three distinctly different patterns. 

4 

Between 1935 and 1945 themortality ratedeclined 

at a fairly rapid rate (4.5 percent). This was followed by even larger reductions in the immediate 

postwar period. After 1950 the rate of decrease 

slowed down and was not much greater than at 

ages 1-6 days (2.7 percent). 

The rate of decline in the mortality rate from 

1935 to 1945 was larger in the postneonatal period than at earlier ages. At ages 1-5 months the 
100 loot 

$%, 80 — 80 Is 

1-

WHITE ‘-** NONWHITE 

“\ 

60 — 60 — ‘+, � , 

c’+, 

\, 

\ 

“+ ,- s,, -,*, Under I year 

40 – 

-, *+ 

*8*,* 40 — 

+ .-,* *4’* ,+ 

.-

‘\ 

‘*, * 

‘\ J-, -

Under I year s.%,,,,$ 

‘- I-,-*-, -*- �. 

**’’’”?% I -5 months 

In 

x 20 - 20 – %,, �,,*..* ~ 

m Under I day 

u 

> 

z 

0


0 10 Under I day 10 —
 o


_.


K

Ill

L 

8 — 

I-6 days 

UJ6 

u 

t- 6 — \ 

* A 6-II months < 

a 1-5 months 

4 — 4 — 

1 

1 

1 

1 

6-11 months 

2 — 2 – 

I I I II I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 11111 

1;35 1940 1945 1950 [955 1960 1965 I935 I940 I945 1950 1955 1960 1965 

1

lVom 1935 to 1948 this category refers to deaths at ages 7-29 days. 

NOTE: Beginning in 1959 include Alaska and Hawaii. New Jersey excluded from data for 1962; race not reported. 

Suurcw Annual volumes Vital Statistics of the United States, National Center for Health Statistics, Public Health Service, Washington, U.S. Governmlmt Printing Office. 

Figure 3. Infant mortality rates by age and color: United States, 1935-62. 

annual rakofdecline was 5.4 percent. Following ever, there is some indication that the rate is 

a sharp decrease in mortality immediately after starting to decline again—thus far very slowly. 

World War II, the mortality rate at ages 1-5 The course of the mortality rate at ages 6-11 

months followed an erratic downward course until months resembles that at ages 1-5 months except 

the mid- 1950’s. The precise year when the down- that the decrease in each period has been greater. 

ward trend ended cannot be determined, but for The trend in the infant mortality rate has been 

purposes of the current discussion 1956 has been very similar for male and female births (table 2 

selected. For six successive years, 1957-62, the and figs. 2 and 3). It is clear that the circummortal ity rate has been higher than in 1956. How- stances that led to reductions in infant mortality 

7HH-lI%? O - G5 .2


5

bNDER I YEAR 

200 } PercenY’’%i’’oF%ang& 

I Period Total - Nonwhite 

I 1935-50 -4.7 -4.7 -5.0’ 1951-62 -1.0 -1.2 .’-0.7 

w 

: [00 c 

z 

w 80~ 

�* 

�* �-, ~ * A 

0


0


0 Nonwhite
 _. 

E 40 — & 

m 

w

$ 

cc J1ll,,,,,,,s*.,~J.,,J,,,,,,, 

White 20 -

UNOER I OAY I-6 DAYS 

‘“~ ‘“~ 

20 20 

t t Nonwhite 

�. ...---=. 4*, 

+=*.+= %.0-...* t %...* 

-** m Total Nonwhite i 

+ 10 — “’’’%,**, ,,,,,,,,,,”r,r,,,,,l$~lll,,,~@’ E 

z White


w 8 – 8 –


>


i


06 — 6 - White
 0


0


_.


ti4 _ 4 & 

~ t 

Under 1 day 1-6 days ‘2 

K Percent rate of changeL Percent rate of change’

Period Total = Nonwhite Period Total m- Nonwhite 

2 –	 L935-51 -2.9 -3.1 -L.9 2 1935-51 -2.0 -1.8 -2.9 1952-62 +0.8 +0.6 +1.2 1952-62 -2.0 -2.2 -L.9

1~ 1~ 

I 1935 5 1935 1965 

1

Annual rate of change Obtained befitting least square 1IIWS1Ologarithms of rates for specified time period andtaking antL.logofslo~ “f i!tt.dluw. 

2

Coefficient of variations is one-third or more. 

NOTE: Rates for 1959to1962 ticlude Akskmd Hawaii. New Jersey excIuded from &tabycoIor for1962; race not reported. 

Source Annual volumes Vi fat.%tisticsofthe United States, NatiaMCe nterforHe aUbStatistics, Fublic Health Service, Washington, U. S. Government Print fng Office. 

Figure !. [nfant mortality rates by color for each age group: IJnitecl states, l~s&Gz. 

6 
�

7-27 DAYS UNDER 28 DAYS 

I 

7-27days Under28 days 20 Percent rate of changd 100 Percentrate of changez 4 

Period Total * Nonwhite 80 Period Total = Nonwhite 

1935-f45-4.5 -4.5 -4.4 1935-51 -3.2 -3.2 -3.2


t 1951-62 -2.7 -3.3 -2.2 i 1952-62 -0.6 -0.8 2-0.4


�� 60 

10 — %... 1 1


8 - % �.W 

1’“+ w.,, %...* Nonwhite 

6 %.- - “%”,,,,+

Nonwhite � **. �-*.- . ...=. �

,.. Total 4 — 20 

White 

2 – 

White 

t --l 6 

5 I I I I 1111111111111111111111111 

1935 1940 1945 1950 1955 1960 1965 

I-5 MONTHS 6-11 MONTHS 

lnziizl 20~ 

1935-45 -5.4 -5.6 1947-56 -3.6 -4.9 ‘% 40 1957-62=1.0 ‘-1.2 2-1.3 

a


: 1

%*


5 ‘\***


y 20


i


0 

I-1 .4.*,A 

E- ~“%% 

*

%* 

\ : 

;*. Nonwhite II 

x 4 White 

t ~i White I I 

1

Annual rate of change obtained by fitting Ieast square Unes to logarithms of rates for specified time period and taking anti-log of slope of fitted line. 

2

Coefficient of variaUons is one-third or more. 

NOTE: Rates for 1959 to 1962 include Alaska and Hawaii. New Jersey excluded from data by color for 1962; race not reported. 

8ourcw Annual volumes VifaI Statistics @the Um”fed Sf4tes, National Center for Eealtb Statistics, Public Health Service, Washington, U.S. Government Printing Office. 

Figure W. Infant mortality rates by color for each age group: United States, 1935-62—Con.


7

have at no time favored one sexgroup over the 

other. Throughout the years 1935-62 the gap between the rates for males and females remained 

almost unchanged at every age level, with males 

having consistently higher rates. 

The rates for white and nonwhite groups present a far different situation. Mortality trends for 

white infants closely parallel the trends previously 

presented for all races combined (table 3 and figs. 

3 and 4). The only difference of any consequence 

is a slightly greater decrease in the death rate 

since 1950 for the white race than for the United 

States as a whole. 

Until 1950 the rate of decrease in the loss 

during the first year of life was at least as great 

among the nonwhite births as the white. Since then 

the slowdown in the rate of decline has been more 

severe in the mortality rate for the nonwhite group. 

Larger differences than those suggested by the 

total infant mortality rate are found in the trends 

by age at death. Between 1935 and 1951 substantial 

decreases in mortality in the first day of life were 

scored by the white group; among nonwhite infants the decrease in the rate of loss under 1 day 

stopped in 1943. More recently—since 1952—the 

rate of increase in mortality at this age has been 

greater for the nonwhite than the white infants. 

Question might be raised about the comparative accuracy of the mortality trends for under 1 

day among white and nonwhite children. Improvement in the reporting of live births could be accompanied by a more complete registration of 

deaths in early infancy and thereby artificially increase the mortality rate. It might be argued that 

this would be more significant for the rates among 

nonwhite babies in view of the reduction in the lag 

between nonwhite and white persons in the use of 

hospitals and in the completeness of registration 

of live births. These considerations are important, 

but it is unlikely that they completely explain 

events in the more recent period. The same situation is found in many areas of the country where 

the problems of underregistration and accuracy of 

reporting have been inconsequential for a long 

time. Another possibility is that with improvement 

in medical care there has been a shift in the timing of the death of some infants from the prenatal to the immediate postnatal period and that 

this has been more common among the nonwhite 

than the white births. This, too, is highly spec ­

ulative, and it might be more fruitful to seek other 

explanations for the difference in trends between 

the rates for white and nonwhite infants. 

Following the first day of birth and &mtinuing until the end of the neonatal period, comparisons between mortality trends for the two 

race groups show a somewhat different set of 

relationships from those observed in under 1 day. 

There is some indication that the rate of decline 

in the 1-6 day period was, at one time, greater 

for the nonwhite than the white infants and that in 

more recent years the change in the loss rate 

has been similar in both race groups. At 7-27 

days the decline in losses was almost identical 

for white and nonwhite infants from 1935 through 

1945. It has been more rapid among white births 

since 1947. 

Taking the neonatal period as a whole, the reduction in death rates among the nonwhite births 

kept pace with the rate of decline among the white 

births until about 1951. Subsequently the rates for 

both race groups decreased only slightly, with the 

rate among nonwhite infants leveling off somewhat 

more than the rate among white infants. 

Both race groups made substantial gains in 

lowering postneonatal mortality and at about the 

same rate until the mid- 1940’s. The sharp drop 

in the death rate immediately after the war was 

shared by both white and nonwhite infants. Since 

then the trends in the mortality rates for white and 

nonwhite births have differed. For almost a decade 

the rates among the white infants at ages 1-5 

months and 6-11 months continued to decline 

briskly. The tendency of the rates to level off 

started about 1954 or 1955. In contrast, among the 

nonwhite infants the rate at 1-5 months flattened 

out shortly after the war ended. This.situation has 

persisted through 1962. Mortality rates at 6-11 

months followed an erratic course among the nonwhite births after 1946. Increases in the rate were 

experienced for several years, and, while there 

have been decreases in the past few years, reversals still occur. 

Trends by cause of death. —The decline in 

the overall infant mortality rate during the period prior to 1950 is generally accepted as reflecting the global effect of advances in medicine, 

maternal and child care, and improvement in 

medical facilities and economic and sanitary conditions in the United States. About half of the de8 
--------

crease between 1939 and 1950gresulted from the 

lowering of mortality from infective andparasitic 

diseases, influenza and pneumonia, and infections 

of the digestive system (fig. 5). The large decrease 

in the rate soon after World War II is mainly due 

to the reduction in loss from these causes, a circumstance which is attributed to the increased 

availability of antibiotics in the postwar period. 

This is one of the few instances in which a 

decrease in the rate can be associated with a 

specific factor. Even here there is reason to moderate the conclusion. In the case of the rates for 

infective and parasitic diseases and for influenza 

and pneumonia the sharp drop after the war accentuated a decline that was already in progress. 

In the case of infections .of the digestive system 

the large size of the reduction in the rate that 

followed the end of the war could be traced in 

part to the elimination of the increase in mortality from these conditions that occurred during 

the war. 

Comparatively small but significant reductions in the mortality rate for certain diseases 

of early infancy also occurred prior to 1950. 

These are the causes of death that are heavily 

weighted with conditions related to the development of the child in utero and conditions affecting 

the delivery. Difficult as it is to identify the contributions toward the decrease in mortality from 

infectious diseases made by specific medical and 

economic circumstances, the problem becomes 

even more complex in dealing with this class of 

causes of death. Prenatal and postnatal programs 

would appear to be central factors although quantitative confirmation of the effectiveness of specific 

measures is not available. 

Since 1950 the rates for the infective diseases 

and infections of the digestive system have declined still further, but the rates for respiratory 

diseases have not. Actually the combined rate for 

acute upper respiratory infections, bronchitis, 

and other diseases of the respiratory system (excluding influenza and pneumonia) has increased. 

To a large extent this rise reflects interest stimulated in the late 1940’s and in the 1950’s in hyaline membrane disease and abnormal pulmonary 

~’1’rends of cause-of-death rates start with the year 1939 rather than 1935 to reduce the effect of changes in rules for 

classification of causes of death. 

1 All couses


2 Infective and por.asitic diseases


3 Influenzo, and pneumonio 1


4 All other dlseoses of respiratory system


5 Gastritis and duodenitis, etc.2


6 All other diseases of digestive system


7 Congenital malformations


8 symptoms and 1[1-defined cOnditiOn~


9 Certain diseoses of early infancy


1,000 

800 

600 

400 

- ‘~ 

200 ‘—--+-. 

100 m 

s 60 1-

m 

a 60 

Yz 40 

0 

0 

0. 

g 

~ 20 w 

a


W


P


g 10


8


6


4


2


I 1 I I I 111111111111111111111,11 

..—. — . —. o 

——— 

. . . . . . . . . . . .. . . . . . . . 

—.— 

1935 i940 1945 1950 1955 1960 196: 

1.Including pneumonia of newborn. 

2 

fncludes gastritis and duodenitfs; gastroenteritfs and colitis, except 

ulcerative colitis (4 weeks and over); chronfc enteritis and ulcerative 

colitis; diarrhea of the newborn. 

Source: Annual volumes Vital Statistics of tlze Um”tedStates, National 

Center for Health Statistics, Public Health Service, Wasbfngton, U.S. 

Government Printing Office. 

Figure 5. [nfant mortal i ty rates for selected 

causes of death: Un ited States, 1939-61. 

9 
ventilation as causes of death. In 1958 classification changes transferred hyaline membrane disease from the category other respiratory diseases 

to ill-defined diseases peculiar to early infancy, 

and the rate for other respiratory diseases was 

appreciably reduced. More time is needed to 

determine the course of the mortality rate for the 

latter set of conditions. At this point they still 

represent only one-sixth of the total loss attributed 

to all respiratory conditions. 

The infant mortality rate for the category of 

conditions, certain diseases of early infancy, decreased slowly and irregularly for several years 

after 1950 and then changed little. This is, of 

course, indicative of the general lack of progress 

in reducing mortality in early infancy. 

An interesting feature of the cause-of-death 

trends is that the rate for congenital anomalies 

has changed little in almost a quarter of a century. The rate of decline in this cause of death has 

consistently lagged behind the decline in the total 

infant mortality rate during both the period when 

the infant mortality rate declined rapidly and the 

past decade when it decreased only moderately. 

Trends in cause-of-death rates for white and 

nonwhite infants have some elements in common 

(fig. 6). In both race groups the loss rates from 

infective and parasitic diseases have dropped to a 

tenth of what they were 20-25 years ago. The longterm decline in mortality from pneumonia and influenza and infectious diseases of the digestive 

system has also been impressive for both white 

and nonwhite infants. However, the magnitude of 

the decline in the rates for these diseases has not 

been the same in the two race groups. During the 

period of rapid reduction in mortality from pneumonia and influenza (from 1939 until shortly after 

the war) the relative gain was greater among 

white infants. Subsequently the differences in rates 

of decline increased. The death rate due to pneumonia and influenza among nonwhite children 

leveled off several years before the rate among 

the white. As for the loss from diseases of the 

digestive system major decreases in the rate for 

the white infants, in contrast with periodic largescale increases in the rate for the nonwhite, were 

scored during the 1950’s. 

It is apparent that the rates for the more important causes of death reflecting the influence of 

postnatal environmental conditions have been substantially reduced in both race groups over the 

past 20-25 years. However, except for the infective 

and parasitic diseases the gap between the rates 

for white and nonwhite infants has widened. Today 

among the nonwhite births mortality due to pneumonia and influenza and infectious diseases of the 

digestive system is at least as high as the corresponding rates of loss among the white births 

20-25 years ago. This observation must be qualified because of the changes in the proportion of 

the deaths in the nonwhite group that were classified as caused by ill-defined diseases. In 1939 

about 1 in 7 were so classified; in 19.=51only 1 

in 20. The problem has been a minor one in the 

white group. 

Congenital malformation rnortalil y rates for 

white and nonwhite infants have undergone only 

slight changes over the years. The rates have 

been lower among the nonwhite group although 

racial differences in these rates are now much 

smaller than years ago. While the -rate among nonwhite infants has slowly increased, the rate among 

white has slowly decreased. The classification 

issue related to ill-defined diseases that was previously discussed may also apply to the longterm comparison of congenital malformation 

rates, but the more recent courses of these rates 

could hardly be affected. 

Generally trends in mortality rates among 

white children for certain diseases of early infancy provide the same insights as comparisons 

that involve all deaths in early infancy. This does 

not hold for the long-term trend among nonwhite 

infants. For example, between the early 1940’s 

and the present there has been no change in the 

mortality rate attributed to certain diseases of 

early infancy. But the total neonatal mortality rate 

among the nonwhite births decreased by about onefourth. This apparently anomalous situation resulted from the shift of large numbers of deaths 

from the category of ill-defined causes of death 

to categories included under certain diseases of 

early infancy. 

Fetal and Perinatal Mortality 

Much of the public concern about reproductive 

loss has been concentrated in the mortality among 

the live-born infants. However, the heavy concentration of infant deaths in the period immediately 

10 
------ -----

1.000 I 

800 — 

600 — 

400 — 

zoo — 

100 — 

n


c 60 –


:


n 60 —


L!


>


i 40 –


>


>


>“


~


~ 20 –


d


1. 

n


L1


z 10 —
 r


8 – 

6 — 

4 -

2 -

1~ 

1935 

I All causes


2 Infective and parasitic diseases


3 Influenza and pneumonial 

4 All other diseases of respiratory system 

5 Gastritis and duode nitis, etc.~ 

6 All other diseases of digestive system 

7 Congenital malformations 

8 Symptoms and ill-defined conditions 

9Certain diseases of early infancy 

, 1,000 

WHITE 600 

600 

‘\ 400 

200 ‘————=——
 1 

100 — 

60 — 

60 — 

40 — 

20 — 

10 — 

6 — 

6 — 

4 — 

2 — 

I -.ul~ 

1940” 1945 1950 1955 1960 [965 1935 

—.— .—. _ 

—— 

0 0 

.—— — . 

. . . . . . . . . . . . . . . . . . . . . . . . . . . 

—— 

%,. 

6 

4 

1940 [945 1930 1955 1960 19E 

1

Including pneumonia of newborn. 

2

fncludes gastritis and duodenitis; gastroenteritis and colitis, except ulcerative colitis (4 weeks and over); chronic enteritis and ulcerative colitis: 

IIarrhca of the newborn. 

Source Annual volumes Vital Statistics of the Urn’tedStates, National Center for Health Statistics, Public Health Service, Washington, U.S. GOve~­

nent Printing Office. 

Figure 6. Infant mortality rates for selected causes of death by color: United States, 1939-61. 

11

I


following birth has for along time indicated the 

desirability of simultaneously examining the problem of fetal mortality. The circumstances responsible for the overwhelming majority of the deaths 

in early infancy arise from conditions established 

before delivery or from stresses during the 

birth process itself. Although national data are not 

available on causes of fetal death, these same circumstances must, of course, also be responsible 

for the loss of viable fetuses. The various conditions may differ in their relative importance 

for neonatal and fetal deaths, but they are present 

in both mortality categories. This has led to the 

introduction of the concept of perinatal mortality, 

a concept which provides for combining fetal 

deaths with loss in early infancy. 

Another reason advanced for the use of the 

perinatal mortality measure is that it overcomes 

artifacts due to differences among physicians and 

hospitals in how they report a death that occurs 

immediately after birth. There is evidence that 

some of these births are reported as fetal deaths, 

but it is not at all certain how much this problem 

affects each of the components of the perinatal 

mortality rate. Also, as previously mentioned, 

there is the possibility that some of the pregnancies now terminating in live-born children who die 

soon after birth would formerly have terminated 

in fetal deaths. 

It should be realized that a penalty of unknown dimensions is incurred when the perinatal 

mortality rate is used. This arises from the underreporting of fetal deaths, which may vary in magnitude with time, place, and population subgroup. 

Fragmentary data available on the issue of under. 

reporting indicate that it is heavily influenced by 

an area’s reporting requirements and its special 

efforts to improve registration completeness. The 

problem of underreporting may vary in degree, 

but it is generally assessed as being a serious 

matter in most places even today. 7 

Turning first to fetal mortality, trends can be 

examined from 1942 for fetal deaths of 20 weeks 

or more gestation and for those of 28 weeks or 

more gestation (table 4 and fig. 7). Very much the 

same impression is obtained from the two sets of 

loss ratios. Between 1942 and the mid-1950’s 

large decreases occurred in fetal mortality; after 

that the trend lines leveled off. Compared with the 

neonatal mortality rates. the decline in fetal loss 

after 1942 extended into a more recent period and 

was steeper.. 

Fetal loss trend data by sex and race are 

available only from 1945 and are limited to rates 

for all fetal deaths of 20 weeks or more gestation. 

With regard to male-female comparisons the observation made about infant mortality trends holds 

for fetal loss trends. In both cases there has been 

no narrowing of the gap between the mortality 

rates for the two sexes. Males have consistently 

had the higher fetal loss rates although the margin 

has been far less than in the total infant mortality ‘ 

or neonatal mortality rates. 

Trends in the fetal mortality rates among the 

white and nonwhite populations were strikingly 

similar for the period 1945 to the mid-1950’s, 

when the rates declined sharply. The rate of decline since 1956 has been negligible for both 

groups. 

The perinatal mortality rate can be defined 

in a variety of ways, but conclusions about the 

rate of decline or when the trend changed directions are not materially altered by the definition used. Rates based on two definitions are 

given in this report. One definition is the most inclusive that has been proposed by any group; i.e., 

it includes fetal deaths of 20 weeks or more 

gestation and infant deaths under 28 days. For convenience it will be referred to as PMR II. The 

other definition, referred to as PMR 1, is restricted to fetal deaths of 28 weeks or more 

gestation plus infant deaths under 7 days. This definition has been recommended by the American 

Medical Association as coming closer than PMR 11 

to the theoretical purpose of a perinatal mortality 

rate. 8 

Ideally the perinatal mortality rate should be 

confined to fetal and infant deaths influenced by 

prenatal conditions and circumstances surrounding the delivery. Given the present stage of knowledge and the limited information of the vital records, the criteria for defining perinatal mortality 

rest on less certain grounds than is implied by 

this concept. In all statistical series derived from 

official records, the definition relies entirely on 

a time-of-death criterion. PMR I does have the 

advantage of limiting the infant death group to an 

age range (under 1 week) which is less affected 

than the balance of the neonatal period by postnatal environmental factors. Also, fetal deaths of 

12 
FETAL DEATH RATIO PERINATAL MORTALITY RATE 

80 I 

--in 

z i a 

10 ~ 

1940 1965 

Percent rate of change= 

~ 

1942-56 1957-62 

Fetal death ratio I--- -3.8 -0.9 

Fetal death rati-o II-- -3.3 -0.6 

-

1945-56 1957-62 

Fetal death ratio II-- -3.3 -0.9 

Nonwhite 

1945-56 1957-62 

Fetal death ratio II-- -4.1 S-0,.3 

1 ratio I is defines fetal deaths of 28 weeks gestation 

‘4 

10 I I I I I I I I I I I I I I I I I I I I I I I I 

1940 1945 1950 1955 1960 

Percent rate of changes 

Total 

1942-56 1957-62 

Perinatal 

Perin - cal mortality mortality rate rate I---II--

-2.6 

-2.7 -0.7 

-0.8 

a 

1945-56 1957-62 

Perinatal mortality rate II-- -3.0 -1.0 

Nonwhite 

1945-56 1957-62 

Perinatal mortality rate II-- -2.8 6-1.1 

Futiil death as or more and a proportionate number of fetal deaths of unknown gestation per 1,000 

IIVL births. 

2

Fetal death ratio II differs from fetal death ratio I in that it includes fetal deaths of 20 weeks or more gestation plus all not stated gestation age. 

3

Perinatul mortality rate I is defined as infant deaths under 1 week plus fetai deaths of 28 weeks or more gestation and a proportionate number of fetal 

dc:iths of unknown gestation per 1,000 live births plus specified fetai deaths. 

4Pcwinabal mortality rate 11 differs from perinatal mortality rate I in that it includes infant deaths undzr 26 days plus fetal deaths of 20 weeks or more 

~usb~tlon plus III not stated gestation age. 

5

AmlwJi rate of change obtained by fitting least square lines to logarithms of rates for specified time period and taking anti-log of slope of fitted line. 

6

Coufficicnt of variation is one-third or more. 

NOTE: 1959 hlcIudes Alaska; 1960 and 1961 include Alaska and Hawaii. New Jersey excluded from data by color for 1962. For 1942-44, data not 

AviIil.d21u by color. 

Smmcw Annual volumes Wtal statistics of Ihe united .$’tdes, National center fOr Health Statistics, public Health Service, Washingt% U.S. GOvern ­

mtmt Printing Office, and special tabulations. 

Figure 7. Fetal death ratios and perinatal mortality rates by color: United States, 1942-62. 

7UL3-0!!20-65 -3 

13


1965 
gestation ages 28 weeks ormoreare believed to 

be better reported than earlier fetal deaths. In 

favor of the PMR IIisthe fact that a longer time 

series of data is available for such variables as 

color, sex, and geographic area. This circumstancehasledto the more frequent useof PMRII 

in this report. 

In any event, wherever it is possible to examine 

trends by means of both PMR I and PMR II, the 

same conclusions are reached. The decreases in 

these rates paralleled each other between 1942 and 

1962. Both rates declined rapidly until 1956, when 

they leveled off (table 5 and fig. 7). The decline 

continued until 1956 in the face of a leveling off 

in the early infant mortality rates that started several years earlier. Fetal mortality decreased 

enough during this period to overcome the tendency 

of the mortality rate in early infancy to flatten out. 

No new insights are obtained about trends 

from the perinatal mortality rates by sex or 

race. There has been no reduction in the sex or 

racial differences in PMR II between 1945 and 

1962. Male births have been subject to a 20-23 percent higher risk of perinatal death than female 

throughout this period. Nonwhite births have consistently had close to a 70 percent higher risk 

than white. 

THE CURRENT STATUS OF INFANT 

AND PERINATAL MORTALITY 

Infant Mortality 

Age at death, S~X of cj~~l~, ad coLoy._~n 1962 

the infant mortality rate in the United States was 

25.3 per 1,000 live births. A large proportion of 

the deaths were concentrated in the first 24 hours 

after birth (41 percent) (table A). Another 24 percent of the deaths occurred during the balance of 

the first week; 7.5 percent occurred in the second 

through the fourth week of life. The mortality rate 

for the entire neonatal period was 18.3, or 72 percent of the total infant mortality rate. In later 

months the risk of dying decreased markedly, and 

the mortality rate differed little in the last 2 

months of the first year of life. 

A closer view of changes in mortality rates 

shortly after birth indicates that an important 

turning point in the rate of decline in the loss 

rate occurs when the newborn infant is 4 days old. 

Although there are decreases after this age, the!r 

are quite small compared with the sharp day-to.. 

day reductions in the mortality rate immediately 

following birth. 

Chances of dying during infancy are about 30 

percent greater among boys than girls. The mar-. 

gin between the mortality rates for boys and girh; 

varies appreciably as the newborn infant progresses through the first year of life, but at nc) 

point does the loss rate for females exceed the ratt: 

for males. In the immediate postpartum periocl 

(under 1 day) the margin is about 30 percent. The: 

differential increases substantially the very nex: 

day and reaches its peak (40-50 percent) in tht 

period 2-4 days after birth. Thereafter the margir~ 

decreases sharply to less than 7 percent in the 

last few months of infancy. 

The infant mortality rate for the nonwhitx 

population is almost double the rate for white (41 .L 

per 1,000 and 22.3 per 1,000 for the two races, respectively, in 1962). In the first 24 hours following, 

birth, the differential is approximately 50 percent. 

It drops to almut 30 percent at ages 2 and 3 days. 

But with each successive day to the end of the 

first week of life the differential increases 

sharply, and at the age of 6 days the mortalit~ 

rate among the nonwhite infants is more than twice 

the rate among the white. The differential continues to widen after the first week. From age 3 

to 8 months the rate for the former group is about 

three times that for the latter. The margin narrows only moderately in the balance of the first 

year. 

It is unlikely that the progression from comparatively small differentials soon after birth tc 

sizable differentials thereafter merely reflects 

the effect of reporting problems. Nationally it 

may well be that the early infant deaths are less 

completely reported as such for the nonwhite 

births than for the white. Nevertheless, the existence of a smaller racial differential during the 

neonatal period than later on in every part of the 

country and in large urban areas where underreporting of deaths is considered a minor problem suggests that the general picture obtained 

from official vital statistics is close to the true 

state of affairs. 

Geogvajhic a~eas. —Infant mortality differs 

greatlY among geographic areas of the country 

(table 6). When the comparison is restricted t,, 

14 

I 
----- -------

1

2 ------------- 3 ------------- 4 ------------- 5 ------------- 6 ------------- ----------

---------

---------

--------- -----------

-----------

-----------

-----------

-----------

-----------

-----------

-----------

----------

----------

TableA. Infantmortalityratesby age, color,and sex:UnitedStatea,1962


[DMIIrvfm’only (O deathsoccwrinc., withinthe United SM.~s.
 Excludes fetal deaths. F]gures by-color exclude data for residents of New Jersey because 

thisStatedidnot require reporting oftheiten~ 

Total White ITonwhite


Age


Both Male Female Both Male Female Both Male Female
 sexes sexea sexes


Rates per 100,000livebirthsin specifiedcolor-sex groupa 

Under 1 year- 2,531.1 2>857.7 2.L88.8 2.233.7 2,543.7 1,907.3 4,135.9 4,568.5 3,693.0 

Under 28 days-- 1.832.0 2,086.8 1,565.0 1,935.6 1,423.0 2,605.1 2,893.7 2,309.7


Under 1 day-------- 1,035.9 1.170.7 894.2 959.1 1,084.1 827.6 1,434.1 1,616.9 1,247.0


1,685.9 

Under

1-23houra


1 hour


z

day-------------­


days


days


days


daya


days


7-13days


14-20daya


21-27days


28-59days 

2 months 

3 montha 

4 months 

5 months 

b months 

7 months 

8 mmths 

9 months 

10months


11 months


198.6 209.8 187.0 184.8 192.8 176.4 264.8 290.5 238.5 

837.1 961.0 707.2 774.4 891.4 651.2 1,169.3 1,326.4 1,008.5 

262.0 301.6 220.6 247.4 291.3 201.2 337.8 358.0 317.0 

173$1 206.9 137.7 165.2 200.9 127.6 215.4 242.8 187.4 

77.4 92.1 62.1 73.3 87.7 58.2 100.8 119.2 82.0 

43.6 51.2 35.7 39.3 47.7 30.5 66.1 69.3 62.8 

31.2 35.4 26.8 27.7 31.5 23.6 50.2 57.0 43.2 

22.8 24.7 20.8 19.4 21.2 17.5 41.6 44.1 39.1 

91.5 100.0 82.7 77.4 85.6 68.8 168.8 181.2 156.1 

53.0 58.6 47.2 42.7 47.5 37.7 109.1 116.8 101.3 

41.5 45.8 37.1 34.3 38.0 30.3 81.2 88.4 73.8 

161.5 188.2 133.5 129.3 152.1 105.2 337.6 385.1 289.0 

132.4 149.8 114.3 104.5 120.2 87.9 289.3 317.3 260.6 

96.8 106.0 87.1 74.7 82.9 66.2 219.8 235.7 203.5 

71.4 77.0 65.4 53.7 57.7 49.3 169.3 185.2 153.0 

55.6 57.6 53.6 41.3 42.6 39.9 133.4 140.2 126.5 

44.3 46.1 42.5 34.7 36.8 32.5 93.7 95.2 92.1 

35.7 39.7 31.6 28.2 31.2 25.0 77.5 88.1 66.6 

30.4 33.2 27.4 23.6 25.1 22.1 68.1 79.2 56.8 

26.0 27.6 24.2 21.1 22.7 19.4 52.4 54.5 50.2 

23.1 23.3 22.9 19.1 L8.7 19.6 46.1 49.3 42.0 

21.9 22.3 21.5 17.6 18.1 17.2 43.6 45.0 42.3 I 

Source:AnnualvolumeVitalStatisticsof the UnitedStates,NationalCenterfor HealthStatistics,


PublicHealthService,Washington,U.S. GovernmentPrintingOffice.


thewhiterace,therange among theratesisquite


small. Despitethevariationuneconomic compo­


sition, indegrees ofurbanization, and inmedical


resources, only about 19 percent separatesthe 

geographic division(Mountain)with the highest 

rate (25.7 per 1,000) from the division(West 

North Central)withthelowestrate(21.6per 1,000) 

(infantmortalityrates for 1959-61).Six of the 

ninegeographicdivisionshaveratesthataresepa­


ratedbylessthan lOpercent.Intheotherthreedi­


visions(EastandWest SouthCentralandMountain)


the rates are 10-20 percentabove thefiguresin


the areas with the lowestrates.Only 15 percent


separated the neonatalmortalityrate for white


infantsin the high area from therate inthe low


area. During the postneonatalperiod the rates


diverge, and the margin between low and high


areas increasesto almost 40 percent.


The situationis entirelydifferentamong


nonwhite births.The totalinfantmortalityrate


ranges from 30.4per 1,000inthe Pacificdivision


of Statesto 48.7 per 1,000 intheMountain di-


vision.The composition of thenonwhitepopula­


tionis,however, verydifferentinthesetwoareas.


Over athirdof thenonwhitepersonsinthe Pacific


area are Oriental, and three-fourths in the


Mountain divisionare American Indian.In the


other divisionsall but a small proportionare


Negro. When the comparison isconfinedtothese


divisions,the gap between low and high is still


15

�

larger than that among the white infants. This is 

due to major geographic differentials in the postneonatal rates for nonwhite infants. Rates in the 

South Atlantic and East South Central parts of the 

country (19.2 per 1,000 and 19.8 per 1,000, respectively, in 1959-61) are almost twice the rates 

in the New England and Middle Atlantic areas 

(10.3 per 1,000 and 11.2 per 1,000, respectively). 

The variation among the neonatal rates (excluding 

those for the Mountain and Pacific divisions) is 

negligible by comparison. 

Generally a geographic area with a comparatively low rate among white infants also has a 

comparatively low rate among the nonwhite; this 

is also true for high rates. A more important 

observation is that infant mortality is far greater 

everywhere among the nonwhite children. The 

gap is narrowest in the Pacific division, where 

Oriental persons represent a substantial proportion of the nonwhite population. h But here, too, 

the margin—34 percent—is large. 

Pursuing the issue of geographic variability 

in infant mortality rates on the basis of smaller 

aggregates of population than geographic division 

leads to a number of inferences that are highly 

relevant to the present discussion. Taking the 

State as the unit, it is clear that with only a few 

exceptions the State rates for white births cluster 

very closely around the national average; for nonwhite births the spread is substantial (table 7). 

In every State with sufficient numbers of births to 

make the comparison (except Hawaii), infant 

mortality in the nonwhite group is considerably 

above the rate in the white. These findings are 

consistent with what has already been pointed 

out for the geographic divisions. They support 

the fact that geography does not alter certain 

fundamental properties of the infant mortality 

rate at the present time —i.e., an underlying similarity in the level of the rate for the white population when large areas are the unit of analysis 

and a wide gap between the loss rates for white 

and nonwhite children almost everywhere. 

This is also confirmed when other geographic 

aggregates are examined. Comparison of mor­

‘Infant mortality rates are lower among Oriental persons 

than among white. The higher rate among the nonwhite population in the Pacific division is due entirely to excess mortality among the other nonwhite persons in the area. 

tality rates for metropolitan counties with those 

for nonmetropolitan counties as well as for cities 

classified by size leads to the same conclusion 

(table 8). As a further test infant mortality rates 

in the 51 cities with a population of 250,000 

or more in the 1960 census have been compared. For white infants the lowest rate was 

20.3 per 1,000; the highest, 29.6. Five sixths 

of the cities fell in the narrow range of 20.3-

25.5 (data for 1960-61). In about half of the 

cities the rate among the nonwhite infants was 

at least 50 percent above the figure for the 

white. It should be noted that the cities are 

scattered throughout the country-in the North, 

South, East, and West. 

In the previous discussion variation in the infant mortality rate for white infants has been characterized as relatively small where States, aggregates of States, or individual cities are considered. This should not obscure the fact that 

within each of the areas there are subregions or 

neighborhoods (as in the case of cities) with loss 

rates that deviate widely from overall averages. A 

more detailed approach to the question of geographic variability in infant mortality would lead 

to groupings of areas based on demographic, economic, and medical resource indices and to a 

clearer identification of special problem areas. 

Cause of death. —Despite important limitations cause-of-death data are of some help in 

clarifying the nature of the loss in infancy. With 

the concentration of infant mortality in the first 

few days of birth a large proportion of the deaths 

are not clearly the culmination of a known, specific 

disease process. About two of five of the deaths 

are ascribed to a generalized state such as immaturity, unqualified and postnatal asphyxia. and 

atelectasis or to ill-defined diseases peculiar to 

early infant y. In almost another 10 percent of the 

cases the cause of death is birth injury, which 

combines many different circumstances and often 

does not reflect the underlying cause of death as 

much as the known, immediate mechanism which 

caused the death. Actually almost the entire set 

of conditions included under the general heading 

certain diseases of early infancy is, in a sense, 

vague and probably subject to considerable variation from place to place, from one population 

group to another, and in what the physician records 

as the particular cause of death. This restriction 

16 
-------------------------

------------------

-----------------

---------

--------

------------------

----------------------------

--------------------

---------------------

------

- - - - - - - - ---- - ----- - - - - --

Table B. Average annual infant mortality rates for selected causes of death, by age at 

death: United States, 1959-61 

> 

Cause of death Under Under Unpr 1-6 

7-27 28 days­

(7th Revision—International 1 28 11 

Classification of Diseases) year days day days days months 

Rates per 10,000 live births 

All causes 259.0 187.1 103.1 63.9 20.2 71.9 

Infective and parasitic dis­


eases-.------ (001-138) 3.4 0.5 0.0 0.1 0.3 2.9 

Influenza and pneumonia, including 

pneumonia of newborn-------(48O-493,763) 31.0 8.6 1.1 3.4 4.1 22.4 

All other diseases of respiratory 

system (470-475,500-527) 6.2 0.7 0.2 0.2 0.3 5.5 

Gastritis and duodenitis, 

etc.1--.-.-------------(543,571,572,764) 6.9 1.1 0.0 0.1 1.0 5.8 

All other diseases of digestive


system (530-542,544-570,573-587) 2.4 0.8 0.9 0.6 

Congenital malformations (750-759) 3::: 23.9 8.9 1::2 

Birth injuries (760,761) 23.9 23.9 1;:2 7.4 i:; 0.0 

Intracranial and spinal injury at 

birth (760) 4.0 0.5 0.0 

Other birth injury----------------(76l) 1;:: 1[:: 1;:: 3.4 :.; 0.0 

Postnatal asphyxia and atelectasis-- (762) 45.7 45.0 27.4 16.4 0.7 

Hemolytic disease of newborn--------(77O) ::: 0.0 

Immaturity unqualified--------------(776) 4;:: 4::! 3?:: 1::2 . 0.3 

Neonatal disorders arising from certain 

diseases of mother during pregnancy, etcOS------------------(765-769,771-774) 27.5 25.0 11.8 10.8 2.4 2.5 

Symptoms and ill-defined conditions (780-793,795) 5.8 2.4 0.8 0.6 3.4 

Accidents (E800-E962) 1.4 u 0.5 0.8 ;.:

Resi,dual (140-468,590-749,E963-E985) ::; 2.5 0.7 0.8 1.0 . 

C;;;~~ydiseases of early 

(760-776)~ 157.1 153.5 90.6 51.8 11.1 3.6 

‘Includes gastritis and duodenitis; gastroenteritis and colitis, except ulcerative, 

age,4 weeks and over; chronic enteritis and ulcerative colitis; diarrhea of newborn. 

‘Includes neonatal disorders arising from certain diseases of the mother during 

pregnancy; ill-defined diseases peculiar to early infancy; immaturity with mention of 

other subsidiary condition; and other diseases peculiar to early infancy not already


shown . Ill-defined diseases peculiar to early infancy accounted for 62 percent of


these deaths.


Source: Special tabulations of the Division of Vital Statistics,National Center for


Health Statistics, Public Health Service, U.S. Department of Health,Education, and


Welfare.


is of lesser importance for the other causesof 

death although here, too, uncertainty as to the 

cause of death does occur. Also, how physicians 

resolve the problem may vary geographically and 

by population subgroup. 

Diseases ofthe respiratory systempredominate among the more specific causes of infant 

deaths, Approximately 14 percent of the deaths 

under 1 year in 1959-61 were in this category, 

with influenza and pneumonia accounting for the 

bulk of the deaths (tables B and 9). Closely following the respiratory group as a principal cause 

of death are congenital anomalies; 14 percentof 

all infant deaths were classified as having been 

caused by a malformation. All of the diseases of 

the digestive system accountedforonly 4.lpercent 

17

of the infant deaths, and the infective and parasitic 

disease category was responsible for an even 

smaller proportion of the mortality (1.3 percent). 

The relative importance of the various causes 

of death shifts radically as the infant advances in 

age. In a matter of several days the overwhelming 

concentration among causes that reflect the influence of conditions present before the birth or 

that occur during the birth is attenuated. At ages 

7-27 days certain diseases of early infancy accounts for only about half of the deaths; in the postneonatal period this category is of negligible significance. The infectious diseases, particularly 

pneumonia and influenza, dominate the causes of 

death after the first 4 weeks. With regard to mortality due to congenital malformations the rate remains comparatively high throughout infancy. 

Cause-of-death data give the strong impression that no special group of conditions is responsible for the excess mortality among males 

during infancy. The rate for every major cause 

of death, whether biological or environmental in 

origin, was substantially higher among males than 

females. To be sure, the relative margin varied 

from one cause-group to another; e.g., the difference between rates for congenital malformations was under 20 percent, and the difference 

between rates for birth injuries was especially 

large (40 to 50 percent). But the basic observation 

remains: male infants had a distinctly higher mortality rate than female infants in all important 

cause-of-death categories. Among the comparatively low frequency causes one stands out as an 

exception to the rule. This is hemolytic disease 

of the newborn. Here the difference between the 

rates for males and females is negligible. 

Less consistency is found when cause-ofdeath rates are compared for white and nonwhite 

infants. Although styles of reporting causes of 

death may differ for these two population groups, 

it is clear “that infectious diseases of all types are 

more common causes of death both early in infancy and later on among the nonwhite births than 

the white. Compared with the margin for these 

causes, the rates for birth injuries and other 

digestive diseases are quite similar for the two 

races. In two cause categories, congenital anomalies and hemolytic diseases, the rates are higher 

among white than nonwhite infants. 

Fetal and Perinatal Mortality 

As previously discussed, national data on fet: 1 

mortality are most extensive for fetal deaths c,f 

20 weeks or more gestation. About 85 percent c,f 

the population in the United States lives in areas 

covered by laws that limit fetal death reporting t> 

this gestational age. In most of the other areas, 

reporting is required for all products of concep ­

tion without regard to gestational age. Unless 

otherwise stated, measures of fetal loss discusse i 

below refer to fetal deaths of 20 weeks or mor t 

gestation (plus fetal deaths of unknown gestatio a 

age). 

The fetal death ratio in 1961 was 16.1 per 

1,000 live births (table 4). This almost equals th 2 

neonatal death rate (18 .4). The male-female dif ­

ferential in fetal loss was 12 percent; this is considerably less than the differential found in th: 

neonatal mortality rate (32 percent). On the othe c 

hand, the margin between the white and nonwhite 

races is much greater for fetal loss (91 percent) 

than for neonatal deaths (55 percent). 

Fetal death ratios for geographic division ~ 

have a wider dispersion around their nationa 1 

average than is the case for neonatal death rates 

(tables 5 and 6). Even so, the range from high to 

low is not extraordinary in the white population; 

in the nonwhite the range is 57 percent among the 

divisions whose nonwhite populations are almost 

exclusively Negro. This assessment of the variation among geographic divisions is based on an 

adjustment of the ratios for the Middle Atlantic 

division of States. The white and nonwhite ratio:; 

are higher in this area than anywhere else. Thi:j 

is due to an artifact of reporting. Because of 

special promotional campaigns to obtain reports 

of all fetal deaths, New York City, which is con.. 

tained in the Middle Atlantic division, has an es.. 

pecially high ratio for fetal’ deaths in the categor:~ 

20 weeks or more gestation and gestation not 

stated (28.0 per 1,000 live births in 1959-61), 

Excluding the New York City experience from tht: 

Middle Atlantic division lowers the 1959-61 ratio~i 

to 15.8 for the geographic area. With these ad-. 

justments the areas that emerge as having tht: 

highest fetal death ratios are the South Atlantic: 

and East South Central. These are the two divisiom + 

that also had the highest neonatal death rates, 

18 
No new insights are gained from the perinatal 

mortality rates. This, of course, results from 

the similarity in the direction of differences in 

fetal and early infant loss rates for the variables 

sex, race, and geographic area. Compared with 

mortality rates for early infancy, the perinatal 

mortality rates show a narrower male-female 

rn:lrgin, a larger white-nonwhite differential, and 

~1-LYltL3?” )~~()!~r~phic v~ri~~tion. 

Other Selected parameters of Infant Mortality 

12iYt11 twi,yhl. —-(Jne of the most important 

[hV.?LldS that runs through any consideration of 

infant mortality is the critical role of the maturity 

of the infant at birth. For years the primary measure used in statistical studies to classify the 

newborn infant by developmental maturity has been 

weight at birth. From the beginning the imperfections of this measure have been recognized. 

A major source of dissatisfaction arose from the 

clinical observation that a particular birth weight 

retlects different levels of maturity in various 

population subgroups. In favor of relying on birth 

weight has been the comparative ease of collecting 

on a mass scale reasonably uniform data subject 

to less error than such other measures of maturitY 

as gestation age and heel-to-crown length. There 

is good reason to continue to exert efforts to improve the reporting of gestation age; in fact, moves 

in this direction are increasingly being made by 

offices of vital statistics. Such improvement will 

not mean that birth weight will be replaced by 

gcwt:~tion age but rather that additional classifications will become available for the study of 

high-risk groups of infants. Although the main 

brunt of the analysis that follows is borne by the 

birth weight item, some indication of what maybe 

learned through the joint use of birth weight and 

;:estation age data is also provided. 

It is often desirable to discuss the relationship 

of birth weight to many parameters in terms of all 

children who weighed 2,500 grams or less and the 

remaining children who weighed more than 2,500 

grams. Until recently the terms premature and 

immature were applied to the former group. In 

view of the literal interpretation of these terms 

and the recobmition that birth weight has serious 

shortcomings as a criterion for prematurity, the 

phrase low birth weight has come into favor. AS 

used here, this phrase refers to infants with birth 

wc~iqhts of 2,5(Io grams (S!i pounds) or less. 

Based on data for a recent period (1960), 

7.7 percent of the infants have low ‘birth weights: 

i.e., 2,500 grams or less (table C). Very small 

babies (1,500 grams or less) represent almut 1.1 

percent of all live births. A somewhat higher proportion weigh 1,501-2,000 grams (1.4 percent). 

With increasing weight the proportion rises 

sharply, and 5.1 percent, or two-thirds of all those 

weighing 2,500 grams or less, are in the categor y 

2,001-2,500 grams. The modal weight group 3,001-

3,500 grams contains 38 percent of the live-born 

infants. Above this weight the decrease is rapid, 

and only 1.6 percent are born at the very high 

weights 4,501 grams or more. 

Members of plural sets represent 2.0 percent 

of all live births, but they account for 14 percent 

of the children weighing 2,500 grams or less at 

birth. Over half of the children in multiple deliveries (54 percent), as compared with 6.8 percent among single births, are at these low weights. 

This is by far the largest differential between two 

groupings of births in the proportions that are at 

low birth weights. Nevertheless, differences of 

great significance in assessing the problem of 

early infant mortality are found among many other 

variables. Female babies are more likely than 

male infants to have low birth weights. An interesting feature of this relationship is that the entire 

excess in low birth weights is concentrated in the 

2,000-2,50()-gram weight group. Under 2,001 

grams the proportions are similar for males 

and females. 

Racial differences in birth weight are marked. 

The likelihood of a nonwhite infant being born at 

low birth weights where major problems of obstetric and pediatric care exist is almost twice as 

great as for a white infant. 

The only set of national data available on the 

relationship of birth weight to mortality was compiled by the National Vital Statistics Division 

(NVSD) from a special study of the experience in 

January-March 1950.9 There is reason to believe 

that the associations have not changed materially 

since this study. As previously stated, in making 

comparisons between subgroupings of the population, similar birth weights may often involve 

children with quite dissimilar physical developments. 

Among infants weighting 2,500 grams or less 

at birth, 174 in 1,000 died within 4 weeks after 

birth (table D). This rate is extremely high in 

19 
----------- -------------

-------------

-------------

-------------

-------------

-------------

-----------

----------- -------------

-------------

-------------

-------------

-------------

-------------

-------------

-----------

-----------

Table C. Percent distribution of live births, by birth weight and selected charac­


teristics: United States, 1950 and 1960


Plurality Sex Color


Birth weight Total [ I I 1 I


Single Plural Male Female White Nonwhite


~ Percent distribution 

Total------------------- 100.0 100.0 100.0 100.0 100.0 100.0 100.0 

1,000 grams or less 0.5 

1,001-1,500 grams 0.6 

0.5 

0.5 

4.7 

5.4 

0.6 

0.6 ::2 R 1.0 

1,501-2,000 grams 1.4 1.2 14.0 1.4 1.5 1.3 ;:; 

2,001-2,500 grams 29.5 

2,501-3,000 grams------------- 1::: 1;:: 29.6 1::; 2?:; 1% 2!:; 

3,001-3,500 grams 38.0 38,5 13.9 36.3 39.8 38.1 37.1 

3,501-4,000 grams 26.8 27.3 29.5 23.9 28.2 18.9 

4,001-4,500 grams ;.: 7.6 ;:: 9.2 5.6 8.0 4.6 

4,501 grams or more----------- . 1.6 0.0 2.1 1.0 1.6 1.3 

2,500 grams or less 53.7 12.8


2,501 grams or more----------- 9;:; 9!:; 46.3 9;:: 9::2 9!:: 87.2


Median birth weight----------- 3,310 3,320 2,440 3,370 3>250 3,340 3,150


~


Total------------------- 100.0 100.0 100.0 100.0 100.0 100.0 100.0


1,000 grams


1,001-1,500


1,501-2,000


2,001-2,500


2,501-3,000


3,001-3,500


3.501-4.000


4;001-4;500


4,501 grams


2,500 grams


2,501 grams


or less


grams


grams


grams


grams


grams


grams


grams


or more----------­


or less
 or more-----------


::2 0.4 0.5 

4.0 0.5 

0.6 M 0.4 

0.6 

0.6 

0.9 

1.4 12:? 1.4 1.3 

::: 30.0 H ::: 

1::: 18.1 29.0 1;:: 21.2 1;:: 21.4 

37.9 38.4 13.8 36.2 39.6 38.3 35.3 

26.8 27.3 29.6 23.9 2;.; 2:.; 

7.5 ::; 9.3 5.6 

1.9 ;:; 0.1 2.5 1.3 1:7 3:3 

6.6 54.1 10.4 

9::: 93.4 45.9 9;:: 9::: 9;:: 89.6 

Median birth weight 3,310 3,330 2>440 3,380 3,250 3,320 3,250


Source: Annual volumes Vital Statistics of the United States, National Center fo,~


Health Statistics, Public Health Service, Washington, U.S. Government Printing Office,


comparisonwiththerateforallotherinfants,7.8


per 1,000. Infact,although children
withlowbirth


weightsrepresentonly7.7percentofallthenew-


borninfants,
 deathsamong thesechildrenaccount


for two-thirdsof the totalnumber of neonatal


deaths.


Only averysmall proportion
ofthechildren


under1,001grams (1of8)livedthroughthefirst


28 days.Chances of survivalimproved consid-


erablywithamoderate increaseinweight,buts


little
over halfof thoseweighing1,001-1,500


grams alsodied.Mortalitycontinuedtodecline


steeplywitheachadded500grams ofweight,and


neonataldeathsat 2,001-2,500grams amounted


to 50.4per 1,000infants. Substantial
 decreases


were recordedwellintothehigherweightgroups;


20

----------- -------------

-------------

-------------

-------------

-------------

-------------

-------------

-----------

Table D. Neonatal mortality by birth weight and selected characteristics: United


States, January-March 1950


[Excludes data for Massachusetts] 

Birth weight


Total-------------------


Sex Color


==T== White INonwhite


Rates per 1,000 live births of specified birth weight


20.0 18.3 98.6 22.7 17.1 18.9 26.7 

871.7 871.7 871.5 894.2 848.0 883.3 821.4 

551.3 562.3 503.7 621.8 478.2 562.1 507.0 

211.0 228.9 145.4 265.0 160.5 214.6 195.7 

50.4 52.8 32.9 67.4 36.6 50.6 49.5 

12.6 12.6 11.3 16.6 9.5 12.0 15.4 

6.7 6.7 10.4 8.1 6.2 

5.6 5.6 118.7 6.4 ::2 4.9 1::; 

138.1 12.5 

1;:; J:; 1;:; 1;:; 1!:; 20.2 

173.7 173.4 175.6 213.9 138.9 175.8 164.7 

7.8 7.7 11.8 9.1 6.4 7.1 11.9 

1,000 grams


1,001-1.500


1;501-2;000


2,001-2,500


2,501-3,000


3>001-3>500


3,501-4>000


4,001-4,500


4,501 grams


2,500 grams


2,501 grams


or less


grams


grams


grams


grams


grams


grams


grams


or more----------­


or less
 or more----------­


lRates based on less than 20 deaths.


NOTE: Figures for birth weight not stated are distributed.


Source: Shapiro, S. Influence of birth weight, sex, and plurality on neonatal loss


in the United States. Am. J. Pub. Health 44:1142-ll_53,Sept. 1954.


theoptimum birthweightforthesurvival
ofin-


fantswas3,501-4 ,000grams (5.6deathsperl
 ,000


livebirths). Additional weight,particularly
 when


itbroughtthe weightabove4,500grams,was,on


theaverage,decidedly
disadvantageous.


Becauseoftheheavypreponderanceof
 plural


birthsat the lowweights, theneonatal
mortality


rateforbabiesborninmultiple
sets was five to 

six timestherateforsinglebirths.C)na weight­


specificbasis themortalityriskamong plural


birthswas actually lowerthanamongsingle
births


between1,001and 3,000grams. Almve thispoint


singlebirthshad a major advantage.


Duringtheneonatal periodthemortality
 risk


formales andfemalesdiffered
greatlyatalmost


every weightlevel.The prognosiswas consid­


erablybetterforgirlsthanforboysatmostbirth


weights.Neonatalmortality
ratesforfemalesat


weightsbetween1,001and4,000grams wereone-


halftothree-fourths
 ofthoseforthemales.C)nly


inthehighestweightgroup(4,501
gramsormore)


was the ratelower for males.Thus, despitea


less favorableweight distribution
 girlshad a


lowertotal neonatal mortality
ratethandidboys.


Below 2,001grams thenonwhiteinfants
 hada


betterchanceofsurvival
thandidthewhite.The


mortalityratesfor the twogroupsdiffered
only


slightlyat 2,001-2,500grams. At allhigher


weightsthemortality
riskamong nonwhitebirths


was the greater,withthegap betweentherates


forthetwo racegroupsbecomingrelativelywider


at each successivelevel through3,501-4,000


grams andthennarrowingslightly.


Birth weight and gestation a&fe.-Thecontributionthatcan be made by havingbothbirth


weightand gestation agedataavailable
 has been


demonstratedin a recentreportfrom the Co­


operativeStudyof ChildDevelopment,Oakland,


TULI-1U2 O - G5 - 4 

21

---------

----------

---------

----------

--------------------------

------------------

California. Reference to one of the observations of 

this report will tend to underline the value of joint 

consideration of gestation age and birth weight. 

ln developing the gestation age and birth 

weight data, a five-point classification system has 

been devised by Drs. Yerushalmy and van den 

Berg.1° This separates births of 3!ipounds or less, 

regardless of gestation age, into a very high risk 

category. The remaining births are placed in one 

of four categories through the joint use of two 

classes of birth weight (3 pounds 9 ounces to 5 

pounds 8 ounces and 5 pounds 9 ounces or more) 

and two classes of gestation, age (less than 37 

weeks and 37 weeks or more).1 The effect on neonatal mortality rates of the particular combination 

used is striking (table E). There is a three-fold 

increase in the neonatal mortality rate for those 

satisfying only the gestation age criterion for immaturity; the rate is at least doubled again 

for infants meeting only the birth weight cri­

‘The term immaturity is applied to births of 5 pounds 8 

ounces
orlessandtothoseoflessthan37weeks’gestation.


Table E. Neonatal and postneonatal mortality 

terion; and there is a further three-fold increase 

for infants meeting both criteria, even when 

excluding the very small babies of M pounds or 

less. After the neonatal period the gradient diminishes, but large differences in mortality risk 

among the various classes persist throughout the 

first year of life. These findings suggest once 

again that detailed exploration of correlates of 

pregnancy loss could more profitably be executed 

on the basis of the two variables than by means 

of one or the other. 

Prior pregnancy expedience and age of mother. —No parameters of pregnancy loss have been 

as completely or as repetitively explored as parity 

and age of mother. The reason is quite simple. 

These are items that appear on vital records, and, 

therefore, tabulations based on large numbers of 

births can be obtained to satisfy many of the interests of epidemiologists, clinicians, and program agencies. In the current-period of intensive 

study of pregnancy loss new sources of data are 

being developed through” research projects conducted outside the orbit of repetitive, official 

vital statistics. The consistency of overlapping 

rates according to birth weight and length 

of gestation for white single live births: New York City, 1957-1959 

I 

Birth weight, 

grams (lb. , oz.) 

Total number of deaths 

Group I 1,588 (3,8) or less


Group II 1,617 to 2,500 (3,9 to 5,8)­


Group III l,617to 2,500 (3,9 to 5,8)­


Group IV 2,524 (5,9) or more


Group V 2,524 (5,9) ox more


Total 

Total immature ;I-IV


By gestati.on ;I, II; IV-----------------


By birth weight ;I-111----------------


By birth weight and gestati.on;l,II---


Postneonatal
 Neonatal


Gestati_on deaths per 

deaths per 

(weeks) 1,000 live 1,000 survivors 

bir~hs of neonatal 

period 

All gestations 

<37 

37 or more 

<37 

37 or more 

0.. 

. . . 

. . . 

. . . 

4,922 1,706 

14.1 

I 

79.9 11.4 

100.4 11.4 

135.9 14.9 

260.2 20.6 

Source: Yerushalmy, J.,van den Berg,B. J., Erhardt, C. L.,and Jacobziner, H.: Birth


weight and gestation as indices of ‘limmaturityll-neonatal mortality and congenital


anomalies of the ‘linmrature.”l
 A. M. A. J. Dis. Child. 109: 51; Jan. 1965. 

22


4.9 
findings is so high that the full range of information could be viewed as additive despite its 

diversity in time and place. 

The NOVS study of live births early in 1950 

probed into the association between the birth 

order, age of mother and prior fetal loss, and the 

incidence of low birth weight and neonatal mortality. 11 It was found that the rate of low birth 

weight varied only moderately by birth order (table 

IO). The rate was highest among first births and 

births of fifth and higher order (7.7 per 100). 

‘This was not much greater than the low figure 

found among second order births (6.9). Excluding 

births to mothers at ages 15-19 years where the 

risk was particularly high (9.0 per 100), the variPERCENT 

[6 — 

Fourth birth 14 — $, 

\ 

Third ‘$, 

blrlh 

12 

Second 10 

+,+,,�,.,+, 

8	 First — 

birth 

6 

0-

15-19 20-24 25-29 

ation by age of mother was also modest. The rate 

was at a minimum at ages 25-29 years (6.7) and 

then increased moderately to a high of 7.7 after 

age 35 years. 

Interaction of birth order and age of mother 

results in a far greater variation in the rates of 

low birth weight than is indicated when each of 

these parameters is considered separately (fig. 

8). The rate among first births was at its lowest 

point among women 20-24 years of age. From age 

30-34 on the risk increased sharply and about 1 

of 8 of the first- barn infants to women 40-44 years 

old weighed 2,500 grams or less. Rates for the 

other birth orders followed, in general, an inverted 

J-shaped curve, with the highest rates usually_ 

_,,,,,,,,,,, n*,mm,,..slnm*lnl l1*,,* 

. . 30-34 35-39 4U-44 

AGE OF MOTHER (in years) 

NOTE: FiWrcs for birth weight, birth order, and age of mother not stated are distributed. Total-birth order refers to number of children ever born 

mntht,r, inr ludin~ fetal ,deaths. Excludes data for Ma.ssachusetta. 

Suurcv; N~tiunil Office of Vital Statistics: Weight at birth and survival of newborn, by age of mother and total-birth order, by J. Lo?b. Vital Sta­

\/Irs -S/uriu2 hfm’ts, Vol. 47, No. 2. Public Health Service. Washington, D.C., 1958. 

Figure 8. Percent of 1 ive births at birth weights of 2,500 grams or less, by age of mother and totalb irth order: Uni ted States, January-March “[950. 

23 
----------

----------------

---------------

----------------

----------------------

found atthevery young ages 15-19 years. Uninteresting feature of the birth order rates is that 

their narrowest margin occurred at ages 30-34 

years. 

Intervening variables unquestionably exert an 

important influence on the relationships discussed. Illegitimacy, which is particularly high 

under 20 years of age, may provide part of the 

answer to why the rates for low birth weights 

are so high among these young women. 12 The 

explanation for the sizable increase under age 

30 in the risk of low birth weight that accompanies 

increasing birth order (except for first births) is 

more uncertain. On the surface, the demographic 

parameters that are implicated include socioeconomic status, child spacing, and prior fetal 

loss. However, parity and age may have biological 

significance independent of these variables. 

The importance of prior pregnancy outcome 

in assessing the risk in the current pregnancy is 

unequivocal (table F). The proportion of children 

weighing 2,500 grams or less at birth was more 

than 1!4times as high among births of women who 

had reported at least one prior fetal death as 

among other births (10.0 and 6.2 per 100 single 

live births, respectively). Birth order differentials do not explain these relationships. On the 

contrary, the increase in the risk of low birth 

weight among births preceded by a fetal death 

is more marked when comparisons are made by 

birth order than when birth order is ignored. 

As might be expected, the associations between low birth weight and birth order and age 

of mother are generally paralleled by the neonatal 

mortality rates (table 11 and fig. 9). The loss 

rate among first births was moderately high among 

women 15-19 years of age. It dropped sharply to 

a low point at ages 20-24 and climbed rapidly as 

age increased beyond 30 years. Second order 

births among women aged 25-29 had a particularly favorable loss rate. In fact, the lowest neonatal mortality rate for any age-birth order group 

was in this category (14.3 per 1,000 live births 

as compared with the rate of 20.0 for all birth 

orders and ages combined). 

Although the patterns of neonatal mortality 

rates have some similarity to those of the rates 

for low birth weights, there are several notable 

Table F. Percent of single live births at birth weights of 2,500 grams or less, by 

total-birth order, outcome of previous deliveries, and color: United States, JanuaryMarch 1950 

[Total-birth order
refers to number of children wry born to mother, including fetal deaths. Excludes data for Massachusetts] 

Total White Nonwhite


Birth order Prior fetal Prior fetal 

Total 

II deaths I 

TotaI = Total 

deaths 

None :.;: None :.;: None	 1 or 

more 

Total


First 

Second 

Third 

Fourth 

Fourth--------------Fifth and over 

Percent of current live births at birth weights


2,500 grams or less


6.4 6.2 10.0 6.0. 5.9 10.0 8.6 8.4 

6.8 11.4 

::: 5.; 10.; 5.6 5.; - 9.1 8.; 

10.5 1::; 

n H 10.2 ::; H 10.1 ;:: ::: 

5.9 5.4 9.5 5.7 5.1 9.7 6.6 6.0 

10.1


13. i


10.7


10.8


9.1


NOTE: Figures for birth weight and birth order not stated are distributed. 

Source: National Office of Vital Statistics: Weight at birth and survival of newborn, by age of mother and total-birth order, by J. Loeb. Vital Statistics-Special 

Reports, Vol. 47, No. 2. Public Health Service. Washington, D.C., 1958. 

24

CHILDREN WEIGHING ALL CHILDREN 2,500 GRAMS OR LESS 

430 FIRST BIRTH ‘-” 

SECONO BIRTH I- I-I “t----l THIRD BIRTH —

400 L 

FOURTH BIRTH I,~IIIIIIJI 

FIFTH BIRTH --mm 1

I ANo OVER I 42t_____l 370 -

38 

$ 

1-

K 

‘6 

~ 34 — 

> 

i 

o 

_. 

a \ III 250 —~ a 26 —\ 

(0

u 

+ 

< 

= 22 — <..--- ”-” 

160 

14 130 

1 1 1 

LI_LLLu o~ 15-19 20-2425-2930-3435-39 40.44 15-19 20-2425-2930-34 35-3940-44 

AGE OF MOTHER (in years) AGE OF MOTHER [in yeors) 

CHILDREN WEIGHING 

2,501 GRAMS OR MORE 

15 . 

14 

13 

12 

II 

10 

9 

B 

7 

6 

5 

—
 o T T T T 15-19 20-24 23-2930-3435-3940-44 

AGE OF MOTHER (in years) 

NOTE: Based ondeaths under 28d2ysamong children born Jan. lto Mar. 31, 1950. Rates per 1,000 Iive births in specified group. Total-birth order 

.cfer~ to n~mb~r CIfchildren ww bm.n @ mother, including fetal deaths. Figures for birth weight, birth order, cnd age of mother not stated are disributed. Excludes data for Massachusetts. 

Source: N~tional Office of Vital Statistics Weight at birth and survival of newhorn, by age of mother and total-birth order, by J. Loeb. Vital Staislics-Sfkcial Ifeports, Vol. 47, No. 2. Public Health Service. Washington, D. C., 1958. 

Figure 9. Neonatal mortality rates by birth weigkt,age of motherland total-birth order: 

United stateS, January-March 195G. 

differences. Between ages 20 and 39 the relative 

margins among the neonatal death rates by birth 

order are greater than those among the low birth 

weight rates. Fifth and higher order births with 

their high mortality at every age ofmother contribute greatly tothissituation. Anotherdifference 

is that the shape ofthe curves for neonatal death 

rates more nearly approximate “U” than areversed “J,” as was the case for the prematurity 

rates. In other words, the risk for mortality clefinitely swings up after age 30 regardless of the 

birth order. The reason for this is found inthe 

mortality experience among babies bornweighing 

more than 2,500 grams. Here the mortalitycurve 

is J-shaped for every birth order. The turning 

points occur at different ages, but the pictureis 

the same—exceptionally high mortality after35 

years ofage. Again first births are an exception, 

25 

1 
---------------

-------

---------------

--------------- -------

----------------

---------------

--------------- -------

Table G. Neonatal mortality rates among single live births, by birth weight, color,


total-birth order, and outcome of previous deliveries: United States, January-March


1950


[Based ondeaths under 28daysamong children bom January l-hiarcl, ~l, 1950. Total-birth order refers tn number of children 

ever born tKImother, including fetal deaths. Excludes data for Massachusetts 

Birth weight of current live birth


All birth weights 2,500 grams or less 2,501 grams or more


Color and birth ordex


Prior fetal


deaths


Total Total


E 

None ~o~ ‘Tot”I=i5i

Total Rates per 1,000 live births in specified group


Total---------- 18.3 17.6 35.8 173.4 168.8 7.5 13.3 

First---------------- 18.4 17.2 27.6 

Second 16.2 15.; 34.; 173.4 171.; 223.3 6.3 6.; 12.; 

Third---------------- 17.8 16.9 33.0 185.9 180.6 233.0 

Fourth--------------- 19.1 17.2 38.9 183.6 170.9 259.4 ::: ::: 1;:: 

Fifth and over 23.4 21.3 36.5 212.6 205.5 236.9 11.4 10.8 15.5 

White


Total---------- 17.3 16.6 36.1 176.7 172.0 6.9 12.4
 —


First---------------- 17.2 156.1 

Second 15,4 15.; 32.~ 175.6 173.i 228.; ;:: 

Third---------------- 17.4 16.6 32.6 192.1 186.5 242.3 7.0 in 10.; 

Fourth 18.1 16.3 39.5 182.6 168.6 270.4 

Fifth and over 22.7 20.4 38.9 226.2 217.9 256.9 1::: ;:; g::. 

Nonwhite


Total---------- 24.4 23.5 34.9 159.5 154.9 204.0 11.7 11.3 15.9 

First 27.6 136.6 13.6 

Second 23.3 22.; 47.; 161.6 159.; 206,1 22.; 

Third---------------- 20.4 19.2 34.7 157.6 153.8 190.8 ::; ::: 15.8 

Fourth 23.4 21.8 36.8 187.3 179.8 224.5 11.1 10.7 14.0 

Fifth and over 25.1 23.4 32.4 184.1 178.2 201.6 13.8 13.5 15.3 t I 

NOTE: FQures for birth weight and birth order not stated are distributed.


Source: National Office of Vital Statistics:Weight at birth and survival of new­
 born, by age of mother and total-birth order, by J. Loeb. Vital Statistics-Special


Reports, Vol. 47, No. 2. Public Health Service. Washington, D.C., 1958.


with the sharp increasein mortalityoccurring


intheearly30’s.


Among thelowbirth weightinfants
 thepattern


isnotnearlyasclearanddefinite
 asamongchil-


drenwithbirthweightsover2,500grams.Whatis


apparentisthatforsecond, third,
andfourthorder


births, thereislittle variation
 intheneonatalmor­


tality ratesatmost ages.Also,exceptatthe
 more


26


advancedages fifth
andhigherorderbirthshave


thehighestmortality
rate.


Childrenborntomotherswho had aprevious


pregnancyendinginafetaldeathhadintheneo-


natalperiodtwicethemortality
rateoftheother


children(table G).Thisincreasedmortality
risk


was presentat allbirthorders.Onlypartofthe


increasedriskswas due toa higherrateofpre-

--

Q. 

~ ro 

u 

a 

Q 

u 

ii 

~ 60 

u 

n. u) 

~ 

In 50 

: 

w
c1
 First birth 

$ 40 

u

IL 

w

2 

d 30 w 

z

1-

m Sixth birth and over Fourth 

*++ G - 1-, -,-,-,-,- ,-a-8- birth � ~ 20 

Third z birth 

~ Second 10 ‘ birth — $ 

n 

m 

u

l-o


<
E 15-19 20-24 25-29 30-34 35-39 40-44 

AGE OF MOTHER (inyeors) 

NOTE; Data for Massachusetts are not included because tbis State dld not require the repm’ting of birtb order. Figmres for birth order not stated and 

ur agc of mother not stated are distributed. Includes only fetal deatbs forwhich the period of gestation was given as 20 weeks, or 5 months, ormor? 

ru usnot stated, Total-birth order refers to number of children ever born to mother, including fetal deatbs. 

Source: Annual volumes Vital .$frttistics o~tke lJnited Sfates, National Center for Healtb Statistics, Public Healtb Service, Washington, U.S. Governnwrt Printing OffIce. 

Figure 10. Average fetal death rates by age of mother and total-birth order: United States, 1960-61.


maturity. In general, neonatal mortality among 

both the prematurely born and the mature infants 

was greater among children born to mothers who 

. had a previous fetal loss. 

Asinthe caseof neonatal deaths ,fetalmortality (at 20 weeks gestation or later) isstrongly 

relatedto age of mother and birth order(table 12 

and fig. 10). The most favorable loss rates are 

found among gravida 2and3 womenin their 20’s, 

who accounted for 30 percent ofallpregnancies of 

20 weeks or more gestation. More generaHy the 

low fetal mortality rate for women of a specified 

gravidity was at about the same age as occurred 

in the case of neonatal mortality. 

The extent towhich the number ofprior fetal 

deaths is afactor in subsequentreproductive loss 

has been explored on the basis ofvital statistics 

for white single births in upstateNew Yorkduring 

1959 and 1960 (table H).13 Both neonatal and fetal 

mortality (20 weeks or more gestation) rose 

steeply as the number of prior fetal deaths increased. The neonatal mortality rate went from 

14.4 per 1,000 live births where there was no 

prior fetal death to 129.3 per 1,000 live births 

where 3 or more fetal deaths preceded the current pregnancies. The corresponding fetal death 

rates showed a much bigger spread: 11.8to221.4. 

Perinatal mortality rates provide even clearer evidence of the high risk associated with prior 

fetal loss. Almost a third of the women who had 

3 or more previous fetal deaths had their pregnancies terminate with a perinatal death. This 

27

------------------------

------------------------------

------------------------------

------------------------------

------------------------------

------------------------------

------------------------------

------------------------

------------------------------

------------------------------

------------------------------

------------------------------

Table H. Neonatal, fetal, and perinatal mortality rates for white single births, by total-birth


order and prior fetal deaths: upstate New york, 1950-52 and 195g-60


Prior fetal deaths


Birth orderl


Deaths under 28 days2


Total


First


Second-----------------------------


Third


Fourth and over--------------------


Fetal deaths, 20 weeks or mores


Total------------------------


First


Second-----------------------------


Third


Fourth and over--------------------


Perinatal deatha~


Total------------------------


First


Second-----------------------------


Third


Fourth and over--------------------


Deatha under 28 days2


Total


First


Second-----------------------------


Third


Fourth and over--------------------


Fetal deatha, 20 weeks or mores


Total------------------------


First


Second-----------------------------


Third------------------------------


Fourth and over--------------------


Perinatal deaths4


Total------------------------


First


Second-----------------------------


Third------------------------------


Fourth and over--------------------


Total None 1 or more 1 2 3 ormore


1959-60


15.1 14.4 36.8 33.1 49.0 129.3 

14.5 14.5 

14.4 14.1 38.6 38.6 

14.3 13.7 36.4 32.8 5132.3 

16.8 15.3 37.1 32.4 42.0 129.; 

13.4 11.8 61.9 48.2 141.0 221.4 

12.9 12.9 

46.; 46.; 

1::: 1%; 51.0 48.3 5116.; 

18.6 14.8 67.1 48.6 143.0 221.4 

28.3 26.1 96.4 79.8 183.1 322.1 

27.2 27.2 

23.6 22.9 82.; 82.3 

25.8 24.2 85.5 79.6 5233.7 

35.0 29.8 101.3 79.4 179.0 322.i 

1950-52


16.3 15.6 40.3 35.9 73.4 91.3 

15.8 15.8 

15.0 L4.7 34.6 34.6 

16.2 15.3 37.6 35.1 597.; 19.9 17.5 43.8 37.2 69.8 91.; 

15.8 14.3 64.6 55.3 109.8 226.5 

16.6 16.6 

11.3 10.4 64.ii 64.; 

15.4 13.8 51.1 46.4 151.9 

23.0 18.1 71.2 56.5 103.0 226.; 

31.8 29.7 102.3 89.3 175.1 297.0 ; 

32.1 32.1 

26.1 24.9 96.: 96.; 

31.3 28.9 86.8 79.9 234.i 

42.5 35.3 111.8 91.6 165.7 297.0 

lBirth order refers to number of births the mother has had, including fetal deaths.


‘Rates per 1,000 live births in specified group.


3Rates per l,O(ICI
live births plus fetal deaths in specified grouP. 

~Fetal deaths of 20 weeks ormore gestation (and not stated) PIUS infant deaths under 28 days 

per51,000 fetal deatha plus live births in specified group.


Rate based on less than 20 deaths.


Source: Special tabulations of New York State Health Department data.


28

is an extreme situation, but women with 2 prior 

fetal deaths also had an especially high risk with 

1 of 6 of their current pregnancies ending ina 

perinatal death. The full significance of these figures can be appreciated when it is realized that 

all fetal deaths under 20 weeks gestation are excluded. 

Total Suboptimal Pregnancy Outc,ome 

Infant and perinatal mortality rates provide 

only a partial view of the total loss and disability associated with pregnancy. They are the best documented measures of loss and historically have attracted most attention. However, as the attack 

against mortality centers increasingly around 

conditions that affect the development of the fetus, 

the desirability of including the total spectrum of 

loss and congenital defects among children becomes apparent. It is this perspective that has 

led some investigators to postulate a continuum 

of pregnancy wastage involving different types of 

loss that have similar etiologies.14 

Special studies now in progress are beginning 

to produce data designed to measure the components of this 10Ss and disability and to uncover 

clues to their etiology. Selected for presentation 

here are several observations drawn from research with which one of the authors (S.S.) is associated. The data represent a small trickle in the 

flow of information that can be expected from the 

intensive investigations of the National Institute 

of Neurological Diseases and Blindness, the Cooperative Study of Child Development in Oakland, 

California, the Fetal Life Study at Babies Hospital (New York City), Preg~ancy Outcome Study 

(H.I.P.), and other research projects. 

Fetal 10SS. —It is well-known that fetal loss 

of 20 weeks or more gestation is only a small 

fraction of the total volume of fetal deaths at all 

gestational ages. Precisely how many women become pregnant each year and how many of these 

pregnancies end with a dead conceptus is unknown. 

Even in an area such as New York City, where 

determined efforts have been made to obtain complete reporting, it is clear that many fetal deaths 

remain unreported. There are many reasons for 

this, including the possibilities that the woman 

herself may not have been aware that she was 

pregnant or that the pregnancy may have ter7i111-022 O -65-5 

minated so early and with so little discomfort that 

a physician was not seen. 

By applying life-table techniques in local area 

studies ,j Erhardt *5 and French and Bierman16 

have independently estimated the magnitude of the 

fetal loss problem as being more than 20 percent 

of the pregnancies. No study has produced this 

high a figure directly from reported events. However, in a recent investigation of a population insured for comprehensive medical care (H.I.P. in 

the New York City area), it was found that about 

14 percent of the pregnancies known to the physicians terminated in a fetal death. 1718 Because 

of the methodology it was concluded that this was 

close to the limit of reporting accurac y that might 

be reached in a large-scale study. A restriction 

on the generalizability of rates obtained from this 

study is that it is known that women under the care 

of H.I.P. obstetricians have lower prematurity and 

perinatal mortality rates than do other patients 

of private physicians in New York City. Nevertheless, distributions and relationships coming 

from the study clarify a number of the issues in 

fetal and infant mortality which cannot readily be 

dealt with through official vital statistics. 

Almost half of the fetal deaths in the H.I.P. 

study were at gestation ages under 12 weeks, another 32 percent were at ages 12-19 weeks, and 

12 percent were at 20 weeks or more gestation. 

The probability that a “medically known” pregnancy will terminate in a fetal death at a particular gestation age appears to follow a bimodal 

distribution. The first peak is at about 10 weeks; 

the other, after 39 weeks (fig. 11). There is probably little reason to question the general form 

of the curve except for the early gestation ages. 

Prior to 10 weeks the rates are of value for medical care programs only as a reflection of what 

the physician is seeing, and this, of course, is of 

considerable importance. As mentioned earlier, 

estimates of the true state of affairs suggest that 

the risk of a fetal death is greatest prior to 10 

weeks gestation. 

New insights into the relevance of age of rrrother and birth order to the risk of fetal loss at all 

jErhardt’s study was based on a special inquiry among 

physicians and clinics in New York City; French and Bierman’s investigation was located in Kauai, Hawaii. 

29 
A. TOTAL PREGNANCIES 

25 – 

m 

w 

G 

~ 20 — 

z

# 

a

n 

-1 

g 15 -

P 

L 

0 

s 10 — w 

2 

u 

n. 

5 – 

o 

B. PREGNANCIES TERMINATING 

IN FETAL DEATHS 

2.5 I 

I 5 101520253035 40 

GESTATION AGE (weeks) AT TERMINATION 

Source: Shapiro, S., Jones, E. W., and Densen, P. M.: Afifetable ofpre@ancy termbations ndcorrektes of fekl loss. MilbmakM em. FundQfmrt. 

40:7 -45, Jen. 1962. 

Figure Il. Distribution of pregnancies by gestation age at termination: Health Insurance Plan, 

1958-59. 

gestational ages areprovidedby thisstudy’smaterial. Elevated risks at ages over 30 and at the 

higher birth orders were found in the H.I.I?. 

study among fetal deaths under 12 weeks and at 

12-19 weeks’ gestation aswell asat 20 weeksor 

more. The overall impression is that with only 

minor exceptions the pattern of risk shown by 

national vital statistics for occurrences at 20 

weeks gestation or later is a continuation of similar patterns of risk at earlier gestation ages. One 

possible exception concerns gravida 1 women who 

appear to have a lower risk than gravida 2 women 

early in pregnancy (under 12 weeks: gestation) 

(table I). 

Congenital anomalies. —Information is beginning to accumulate about congenital malformations. Until recently there was considerable 

underestimation of the magnitude of the problem. 

Vital statistics could not be expected to do anything more than provide information on those 

severe anomalies that were detectable at time of 

birth or reported on-the death certificate. With the 

appearance of a report on congenital anomalies 

by McIntosh and associates in 1954 it became 

clear that the problem was of similar magnitude 

to low birth weight. 19 In their study of a clinic 

population (Babies Hospital, Sloan Hospital in New 

York City) about 8 anomalies were diagnosed per 

100 children. The H.I.P. study had a very similar 

finding, 7 anomalies per 100 children. Both of 

these figures refer to definite anomalies diag- ( 

nosed by the time the child reached 2 years of age. 

They omit conditions, principally orthopedic defects, abut which there might be some question 

as to whether they are malformations. 

An index of suboptimal pregnancy tewlinations.—A loss-disability index which covers the 

total range of mortality and defects related to 

30 
---------------------

----------------------

----------------------

----------------------

------- ------- ------- ------- ----

--------------

prenatalcircumstanceshas been derivedfrom 

the experience intheH.I. P. investigation.20 Althoughitmust be interpretedas an understatement of the situationin thegeneralcommunity, 

itishighindeed.kTheindexshowsthataboutonefourth(24percent) ofallpregnanciesthatcome to 

medicalattention end in eithera fetal death(14

percent)or ina live-bornchildwho either(a) 

diesduringtheneonatal period(0.8percent), (b)

‘The understatement is due to the type of population studied nnd the fnct that the measure refers to single births among 

womon 19-40 years of age. Also, no adjustment is made for 

tha understatement of very early fetal deaths. 

lThe study was restricted tn conditions diagnosed in the 

normal course of providing medical care during the first 2 years 

of the child’s life. Neurological damage that becomes manifest later is, therefore, not included. 

has a significantanomaly1thatrequiresmedical 

care or will interferewithnormal functioning 

(4.5percent),or (c)has a low birthweight(4.0 

percent).In the lastthreepercentagesshown, 

childrenare countedonlyonce even if,forexample,theydiedandhad acongenitalanomalyand 

a low birthweight. 

The magnitudeofspecialrisksofalltypesin 

the currentpregnancythatmight be associated 

withhow the lastpriorpregnancyterminatedis 

now becomingclearer.The H.I.P.studyindicated 

thatthroughoutthe pregnancy,from theearliest 

weeks on, women whose previouspregnancyhad 

ended in a fetal death were twice or three times 

as likelytohavetheircurrentpregnancyendina 

fetaldeathas theotherwomen. The influenceof 

priorpregnancyexperiencewas aboutthesame 

Table I. Fetal death rates by period of gestation, age of mother, and gravidity:

He<fiInsurance Plan,1958-59 

[Single and plural deliveries included] 

Period of gestation 

Age of mother at LMP and Total 

preg- ~ gravidity nancies Under 12-19 20 weeks Total 12 weeks weeks or more 

Rates per 1,000 pregna~cies in specified 

group z 

Totali 6,844 141.7 67.9 48.9 19.4 

AEe of mother 

Under 20 years------------------- 161 124.2 

20-24 years 1,385 96.8 40!4 40!6 14:9 

25-29 years 2,222 115.2 52.2 39.9 16.3 

30-34 years 1,812 156.2 71.7 57.7 20.2 

35 years or more----------------- 1,190 219.3 120.2 T 64.9 29.6

Gravidity 

1,504 97.1 41.9 36.1 17.3 L-------------------------------1>869 107.0 55.1 35.7 14.1 

3------------------ 1,499 138.1 63.4 56.3 18.9 

4 or more------------------------ 1,898 186.5 93.3 62.8 27.3 

*Totals include pregnancies with age of mother, gravidity, and/or gestation age not 

stated. 

?Rates specific for gestation age are based on total number of pregnancies less 

the number terminating prior to specified age.

aRate not computed, less than 15 deaths. 

Source: Shapiro, S., Jones, E. W., and Densen, P. M.: A life table of pregnancy 

terminations and correlates of fetal loss. Milbank Mere.Fund Quart. 40:7-45, Jan. 

1962. 

31 
-------------------------------------

-------------------------------------

-------------------------------------

------------------------------------- --------------------------------

- - ---- --- -------- - - - - - - ----- - - - - - - --- -- - - -- - - - --- - - -- - ---

---------------------------------------

whether one examined the situation by age of 

mother or birth order (table J). 

One other observation from this study is of 

interest to the present discussion (table K). It was 

found that women whose last prior pregnancy 

ended in either a fetal death or low birth weight 

infant had relatively high reproductive loss or 

damage in the current pregnancy (i.e., fetal mortality plus neonatal death, low birth weight, and 

congenital anomalies). Furthermore, there was 

a tendency for successive pregnancies to repeat 

themselves with regard to the type of loss or disability incurred. If the last pregnant y ended in a 

low birth weight infant, the excess in loss-disability in the current pregnancy was heavily 

weighted with low birth weights; if the prior outcome was a fetal death, the loss-disability excess 

was heavily weighted with fetal deaths. This finding is consistent with results from other investigations.21 

The high-risk group just discussed has an 

appreciable impact on the overall rate of pregnancy loss and disability. Women in this category 

accounted for 1 of 6 of the pregnancies in the 

H.I.P. study. If their experience had paralleled 

that of the other women, the total loss-disability 

rate would have been 19.4 percent instead of 23,7 

percent. 

THE 1950 DECADE 

Previous sections of this report have dealt 

with the trend and current status of the infant, 

fetal, and perinatal mortality rates. The discussion that follows is concerned with the 1950 

decade, when the trend in infant mortality assumed 

Table J. Fetal death rates, by outcome of last prior prewancy~ age ‘f ‘other’ and 

gravidity: Health Insurance Plan, 1958-59 

[M”lt,igmvidae OIIIY. %gle andplural deliveries
 included]

Age of mother at LMP and gravidity 

Age of mother 

Total 

20-24 years 

25-29 years 

30-34 years 

Outcome of last prior pregnancy


J


Totall Live birth Fetal death 

Rates per 1,000 pregnancies in 

specified group 

127.9 110,2 222.2 

35 years or more 

Graviditv 

Total-2 and 3-----------------------------------

2------ - - - . - ------- . ----

3---- . - - - --

4 or more 

105.5 83.9 157.9 

115.7 93.1 151.4 

153.3 111.2 284.5 

199.3 155.0 257.6 

120.8 100.3 186.5 

107.0 91.6 156.3 

138.1 111.6 216.5 1. 

186.5 131.2 255.4 

I“Not stated” are included in totals but are not shown separately. 

Source: Shapiro, S., Jones, E. W., and Densen, P. M.: A life table of pregnancy

terminations and correlates of fetal loss. Milbank Mere. Fund Quart. 40:7-45, Jan. 

1962. 

32


i 
------

--------

-----

------

--------

-----

Table K. Pregnancy loss disability for single deliveries, by outcome of last prior


pregnancy: Health Insurance Plan, 1958-60


Outcome of current pregnancy


Outcome of last


prior pregnancy Total


preg­


nancies


ToCa14----


Gravida 1


Tota14----


Gravida 2 and 3


Tota14----


Live birth


Premature5----


Mature


Fetal death


Gravida 4 or more


T.ota14----


Live birth


Premature5----


Mature


Fetal death


.,


5,984


1,193


3,025


2,671


183


2,371


338


1,700 

1,256


68


1,108


388


Fetal deaths


12 weeks


Total or more


gestation


Rate per 100 preg­


nancies


T


-d--

12.41
 6.1

I


11.3


:::
 1::: 5.2


19.5 11.3


+ 

Live births


Total


live


births


m


Rate per 100 live births


5,123 0.98 5.9 5.5 23.7


1,077 0.56 7.4 4.4 19.9


2,651 0.87 5.4 5.3 21.4 

2,368 

167 

0.93 1::: 5.2 

9.0 

20.0 

30.0 

2,132 0.$4 4.0 5.0 18.0 

272 a 8.8 5.5 30.5 

1,386 1.52 5.7 6.7 28.2
 —


1,071 1.49 5.8 6.7 24.9


58 ‘a 24.1 41.2


970 1.34 4.9 6:8 22.2
 -ul__E 285 a“ 5.6 5.6 34.8 

lLive-born children with one or more severe or significant congenital anomalies


diagnosed before 2 years of age. Anomalies included ar~ those that tiill probably make
 a difference in the child’s life by affecting his survival or by necessitating paren­


tal,medica~, surgical, educational, and/or public attention not required by a majority


of ~he individuals at the same age.


Loss-disability index is the total number of pregnancies that terminated in either


a fetal death (of any gestational age) , a low birth weight child, a child who died in


the neonatal period, or a child who has an “S” anomaly per 100 pregnancies. 

b ‘~Ratesrelate to pregnancies at risk in specified gestation age range. 

“tNotstated are included in totals but are not shown separately. 

5Determined primarily from obstetrical notes recorded at first prenatal visit. Entries were, for the most part, in terms of birth weight. 

I aRates not computed, 5 or fewer deaths. 

Source: Shapiro, S., Ross, L. J., and Levine, H. S.: Relationship of selected pre-


natal factors to pregnancy outcome and congenital anomalies. Am. J. Pub. Health 55:268-


282, Feb. 1965.


33

--

the slowest rate of decline on record in the United 

States. Two questions are explored: first, to what 

extent does the lack of progress in reducing the 

total infant mortality rate reflect changes that 

occurred during the 1950-60 decennium in parameters of infant loss? and second, how did the 

high-risk groups fare; did any of them deviate 

from the general pattern of small decreases in this 

period? But first a brief review of the demographic and economic changes that took place in 

the 1950’s is presented in the following paragraphs. 

Most indicators of socioeconomic status 

point toward a major improvement during the 

1950’s in the living standards of the population as 

a whole. These changes followed impressive gains 

in the 1940’s. Educational attainment increased, 

and family income rose (even after taking into ac -

count the rise in the cost of living) (Appendix table 

I). The only countertrend for the country as a whole 

was in the illegitimate birth rate, which rose appreciably in this period (Appendix table 11). 

The birth rate increased during World War 

11 and rose sharply in the immediate postwar 

period; it is only in the past few years that a decrease has begun (Appendix table III). To a great 

extent, the maintenance of a high birth rate was 

due to the rate at which families were increasing 

in size with the birth of four, five, and additional 

children (Appendix table IV). Also, age at marriage continued to decrease. Despite these changes 

more of the women aged 14-44, including those 

with preschool children, were in the labor force 

in 1960 than previously (Appendix table V). 

Large-scale shifts in the geographic distribution of the population, thereby rivaling the massive movement in the previous decade, occurred 

during the 1950’s. Half of the population in 1960 

were living in a house different from the one they 

occupied 5 years earlier. Nine percent moved to 

another county in the same State, and 9 percent 

moved to another State (Appendix table VI). The 

movement was out of rural areas and into 

urban centers in every section of the country. 

By 1960 about 70 percent of the population was 

living in a city or the urbanized area around a 

city (Appendix table VII). Increasing proportions 

of the population took up residence in the West, 

and in 1960 almost one in six persons lived in 

this region (Appendix table VIII). 

Changes in Parameters of Infant Loss 

and Their Effect on Trend , 

Sufficient information is available to examine 

this issue, although not as intensively as would 

be desired, for several of the parameters previously considered. Other parameters, such as 

child spacing and socioeconomic status, would unquestionably add greatly to the understanding of 

events during the 1950’s, but there is no direct 

evidence of these variables through mortality 

rates. Although all of the indicators of socioeconomic status point toward improvement, what 

is not known is whether the distribution of live 

births has also shifted toward greater proportions in the higher status groups or whether the 

differentials in infant mortality among the various 

socioeconomic classes have chagged.m 

The variables that can be studied include race, 

birth-order—age-of-mother, geography, and birth 

weight. With regard to race nonwhite persons have 

consistently had higher birth rates than have white 

persons for as long as vital statistics have been 

available. As compared with the previous decade, 

racial differentials in the birth rate increased 

during the 1950’s. But since white births still represented a large majority of all births, the effect 

of the increased birth rate differentials on changes 

in the infant mortality rate was negligible. If the 

racial composition of the live births had not altered, the infant mortality rate would have decreased between 1949-51 and 1959-61 by about 14 

percent, which is almost the same as the decrease 

based on the observed rates (13 percent). 

The influence of changes in birth-order—ageof-mother distributions among live births has also 

been examined. Two circumstances of potential 

importance for the infant mortality rate were 

operating during the 1950’s. As mentioned, age at 

marriage continued to go down, and there was a 

persistent trend toward higher birth orders. The 

‘No studies have been conducted in the United States, 

either locally or nationally, on the trend in infant mortality 

by socioeconomic status. Also, data are not available for 

differentials in infant mortality among the various socioeconomic groups for a recent time period. However, in a study 

of fetal deaths and infant mortality during 19 M)-52 in upstato 

New York, Chase demonstrated that fetal, neonatal, and postne:,noatal death rates varied inversely writh socioeconomic c leveL occupation of the child’s father was used as the socioeconomic indicator. 

!

34 
net result was that the age-of-mother—birthorder distribution of births has been more unfavorable for survival of the newborn infant in 

recent years than in 1950; a small part of the 

slowdown in the rate of decline of the neonatal 

death raten could be attributed to this factor. If 

all other conditions had remained stationary except the distribution of births by birth-order— 

age-of-mother, the neonatal “mortality rate for 

the United States would have increased by 6 percent between 1950-51 and 1960-61 instead of de. 

creasing by the observed 8 percent. Thus, if ageof-mother—birth-order had not changed, a decrease of about 13 percent in the neonatal rate 

might have been expected. This is still far below 

the decrease that occurred during the 1940 decade 

(28 percent). 

Taking this approach to evaluating how 

changes in age-of-mother—birth-order distributions affected the neonatal mortality rate for 

white infants indicates that the overall decrease 

hmween 1950-51 and 1960-61 would have been 16 

percent, instead of the 11 percent actually observed, if it had not been for the more adverse 

distributions. The decrease in the previous decade 

was 27 percent. Among nonwhite infants the 

changes in distribution of these two variables resulted in only a 1-percent reduction in the decline 

of the neonatal rate. In summary, the shift toward 

a greater proportion of births being in relatively 

poor-risk age-of-mother—birth-order categories 

exerted a small but noticeable deterring effect on 

the downward trend in the neonatal mortality rate 

for the United States. 

The basic figures in the above analysis 

follow:” 

Neonatal mortality rates 

per 1,000 live births 

—— 

Total White Nonwhite

Adjusted 1950-51- 19.9 18.8 26.4 

Expected 1960-61- 21.0 20.0 26.7 

observed 1950-51- ~~.: 19.2 27.4 

Observed 19b0-bl- . 17.1 26.6 

Geographic changes in the distribution of the 

population might be expected to have an important 

eff~’ct {m infant mortality rates, particularly since 

at the beginning of the 1950 decennium there was 

considerable variability in the rate among geographic areas and since a high degree of population mobility characterized the 1950’s. Nevertheless, as shown below, when the average rates 

for 1949-51 are applied to the 1959-61 births 

classified by groupings of geographic areas, the 

resulting figures are in almost all cases below 

the observed rates for 1949-51. 

Infant morta lit y rates 

per 1,000 live births 

Total White Nonwhite 

Observed 1949 -51----------- 29.6 27.1 45.5 

Observed 1959 -61----------- 25.9 22.8 42.5 

ExDected 1959-61 

‘la) Baaed on 9 msj or geo- graphic diviaiona---- 29.4 27.1 44.6 

(b) Baaed on m$+ropolitannoranetropolltan 

groupings of counties- 28.3 25.9 43.3 

These data lead to the conclusion that without 

the geographic shifts the decline in the white and 

nonwhite rates might have been slightly less than 

did occur. It could be argued that for the nonwhite 

infants in particular the altered distribution of 

births by geographic area was accompanied by 

improvement in registration completeness and 

possibly by an increased likelihood that a death 

in early infancy would be reported as both a live 

birth and death instead of as a fetal death. 

Other questions can be raised about the effect 

of mobility on trends. To what extent and how 

n’rhis issue could be tested only in relation to the neonatal mortality rate, since mortality rates by age-of-mother–birthorder were available on a national scale only for the neonatal 

period. 

“’Expected” rates were obtain ed by applying the neonatal mortality rates hy birth-order–age-of-mother from the speoi al study of January-hiarch 1950 to the appropti ate subgroups 

in 1960-61. “Adjusted” rates for 1950-51 were obtained in a 

similar manner. The adjustment was required since the birthorder–age-o f-mother rates were for January-March 1950. Rates 

exclude hiassachusetts, where birth order data are not collected. “Observed” rates also exclude Massachusetts. 

35 
-- -----

-----

------- -----

quickly does an in-migrant group adopt the medical 

care practices of persons of like economic and 

social circumstances who are already in the community? Also, is the migrant group sufficiently 

selected economically and socially to modify the 

composition of the areas from which they come and 

the composition of the areas to which they migrate? 

Available data provide evidence that these questions are highly pertinent. 

The change in infant mortality rates among 

the nonwhite infants has been examined for cities 

of 500,000 or more persons in 1960. The average 

rates for 1950-51 and 1960-61 were compared in 

each of the 19 cities which had more than a third 

increase in their nonwhite population during the 

1950’s. In 10 of these cities the rate increased. 

Rates for white infants do not lend themselves as 

easily to this type of analysis, but some cities 

have had an increase in the infant mortality rate 

among white children. The role of changing composition of the populations of the cities is certainly 

worthy of further study. 

By far the strongest discriminating variable 

in neonatal mortality is weight at birth. Changes 

in birth weight distributions which result in even 

moderate increases or decreases in low birth 

weight groups could have an important effect on 

neonatal mortality. Between 1950 and 1960 there 

was no change in any respect in the birth weight 

distribution for white and nonwhite births combined. When the two race groups are considered 

separately, changes in opposite directions are 

found. The distribution for white infants showed a 

small decrease in the proportion of low birth 

weight babies, while the distribution for nonwhite 

infants showed a marked increase. Application of 

neonatal mortality rates for January-March 1950 

to 1950 and 1960 detailed distributions of live 

births by birth weigh~” results in the following 

neonatal rates: 0 

Neonatal mortality rates 

per 1,000 live births 

—Total — 

White Nonwhite

Adjusted- 1950-- 19.8 18.6 27.2 

Expected- 1960-- 20.9 18.6 32,8 

From these figures it is clear that the changes 

in birth weight among white children were too 

small to have an effect on the trend in the neonatal mortality rates for white infants. The increasing number of low birth weight infants among 

the nonwhite births, however, exerted a strong 

brake during the 1950’s on the rate of decline in 

the neonatal mortality rate in this group. 

Changes in High Mortality Risk Groups 

The slower rate of decline in the nonwhite 

infant mortality rate has already been considered, 

but it is worth returning to this point and drawing 

it to a conclusion within the context of the current 

discussion. In a real sense the nonwhite infants 

have represented a high mortality risk group. 

Events during the 1950’s widened the margin between the mortality rates for white and nonwhite 

children both in early infancy and later on. This 

is clearly seen in the following figures: 

Percent decrease 

in races from 

1949-51 to 1959-61 

White Nonwhite 

Infant mortality 

Neonatal mortali_ty ;; : 

Postneonata 1 morta Iity - 26 11 

Percent excess of 

nonwhi,te over 

white ratea 

1959-61 1949-51 

Infant mortality 86 68 

Neonatal mortality 

Postneonata 1 morta lit y- 1% 1;: 

Perhaps the most impressive departure from 

the general pattern of small decreases in infant 

mortality during the 1950 decade was the substantial decrease in mortality among white infants 

in areas that had comparatively high rates. The 

East and West South Central and Mountain geographic divisions had the highest infant mortality 

rates in the country in the period 1949-51. During 

the next 10 years their rates for white infants decreased by about 25 percent in contrast with reductions ranging from 8-17 percent in the other 

areas. The only geographic division that experi36 
enced a sizable decrease in the nonwhite rate 

was the Mountain area. Here the nonwhite group, 

a majority of which was Indian, had the exceptionally high rate of 94.4 per 1,000 live births in 1949-

51; in 1959-61 the rate was 48.7. 

The closing of the geographic gap in infant 

mortality among white births resulted almost 

entirely from major strides in reducing postneonatal mortality in geographic divisions where 

these rates were exceptionally high in 1949-51. 

Postneonatal rates in the East South Central, 

West South Central, and Mountain divisions were 

reduced by 40-50 percent during the 1950’s and 

are now much closer than they have ever been 

to the rates in the other divisions. Among nonwhite births the situation differed greatly. Omitting the Mountain division, the geographic variability was not reduced for either the neonatal 

or postneonatal rates. Actually the range between 

high and low areas increased for the postneonatal rates. 

The sizable reduction in infant mortality differentials among white births just discussed was 

not simply a continuation of events in the 1940’s. 

During this earlier period neonatal and posmeonatal mortality rates decreased by about the same 

relative amounts in all areas. As a result, the 

gaps between high and low geographic divisions 

changed little between 1939-41 and 1949-51. 

Among nonwhite births the outstanding characteristic of the 1940 decade was the sizable reductions that occurred in both the neonatal and 

postneonatal mortality rates in all geographic 

areas. As indicated above, except for the Mountain area the changes in the 1950 decade were 

negligible by comparison. 

Other aggregates of geographic areas support the view that there has been a general reduction in geographic variation in the infant mortality rates among white births (tabIe 8). At the 

beginning of the 1950’s the rates among white 

children were about a fifth higher in nonmetropolitan counties than in metropolitan counties. 

During the next 10 years the mortality rate in 

nonmetropolitan counties was reduced by 20 percent as compared with only 9 percent in metropolitan counties, and the gap between the rates 

for white infants in the two areas was more than 

cut in half. Among nonwhite infants there was 

little change in mortality in either sets of areas, 

and the rate in nonmetropolitan counties remained 

substantially above the rate in metropolitan 

counties. 

One of the more critical variables to consider in a discussion of high-risk groups is birth 

weight. In the absence of national data on changes 

that have occurred during the 1950’s in the mortality by birth weight, it is necessary to utilize 

the experience of upstate New York. While the 

observations based on data for this area cannot 

be generalized for the country as a whole, they 

are indicative of what can and does happen in a 

large area where the rate of decline in infant 

mortality slowed down during the 1950’s. Upstate 

New York is also interesting because of its major 

programs in maternal and child health and the 

improvement in mortality among low birth weight 

infants that occurred between 1945 (when the neonatal death rate in this birth weight group was 

228 per 1,000 live births) and 1950 (when the rate 

was 183 per 1,000).13 

Assessment of changes in the 1950 decade is 

based on mortality rates in the two time periods 

1950-5224 and 1959-6023 (table L). With regard to 

the highly vulnerable group of low birth weight 

infants it is clear that mortality risks shortly 

after birth were not lowered. This was true for 

the white and nonwhite races. In fact, among the 

nonwhite races the neonatal mortality rate for 

the birth weight group 2,500 grams or less 

was appreciably higher in the more recent period 

than at the beginning of the 1950 decade. This 

excess is primarily due to an increase in the 

proportion of infants WHOwere born at very low 

birth weights where the mortality rates are extremely high. To a lesser extent, the same situation was found among white children. Despite 

these circumstances the main conclusion holds: 

during the 1950’s there was apparently no decrease in neonatal mortality among infants at 

low birth weights (see adjusted mortality rates 

in table L). 

Once the neonatal period was passed, babies 

weighing under 2,501 grams at birth had a better chance of surviving to the end of the first 

year of life in the more recent period 1959-60 

than previously. The reduction in mortality was 

substantial and was shared by white and nonwhite 

71{U-CLV O - 85 -6 

37 
-------- -------- ------

-----------------

-----------------

-----------------

-----------------

-----------------

---------------

---------------

---------------

---------------

Table L. Infant mortality rates for single births, by birth weight, color, and age at


death: Upstate New York, 1950-52 and 1959-60


Birth weight and color


White


Tota14


1,000 grams or less---------------


1,001-1,500 grams


1,501-2,000 grams


2,001-2,500 grams


2,501-3,000 grams


3,001-3,500 grams


3,501 grams or more


2,500 grams or less


2,501 grams or more


Nonwhite


Tota14----------------------


2,500 grams or less---------------


2,501 grams or more


1959-601 1950-52


Under 28 days- Under 28 daysTota12 28 11 Tota12 28 11


days2 months3 days2 monthss


19.0 15.1 4.0 21.6 16.3 5.4 

954.2 950.9 944.8 941.2 

:;:.; 549.3 35?8 566.5 544.2 48:8 

203.3 16.7 228.5 207.3 26.6 

54:1 43.4 11.2 55.0 43.0 12.6 

14.9 9.5 5.5 16.8 1;.; 

7.0 3.7, 3.3 9.6 ::; 

6.2 3.5 2.7 8.0 4:4 3.7 

183.7 172.7 13.4 178.0 164.2 16.5 

8.3 4.8 3.3 10.4 5.8 4.7 

37.4 27.7 9.9 35.8 23.9 12.2 

I 

194.6 173.4 25.7 179.7 150.7 34.2 

15.0 7.0 8.1 17.5 7.6 10.0 

lMortality rates for 1959-60 adjusted to birth weight distributions in 1950-52 fol­


low (adjustment is made by applying mortality rates by 500-gram intervals for 1959.60


to the distributions in the earlier period):
 . ,- Under 28 daysTotal 28 11 

days months 

White: 2,500 grams or less 175.8 164.7 13.3 

2,501 grams or more 8.3 4.8 3.5 

Nonwhite: 2,500 grams or less 175.0 153.0 25.8 

2,501 grams or more 15.0 7.0 8.0 

‘Rates per 1,000 live births in specified group.


3Rates per 1,000 survivors of neonatal period.


4Not stated birth weights are included in totals but not distributed in 1950-52.


Three percent of infant deaths had birth weight not stated; in 1959-60 the figure was
 1 percent.


aRates not computed, less than 20 deaths.


Source: Unpublished data for 1959-60 received from Dr. A. Gittlesohn,New York State


Department of Health; unpublished data for 1950-52 received from Dr. J. Yerushalmy,


University of California, School of Public Health.


38 
infants. Among the children born weighing over 

2,500 grams, decreases in mortality occurred 

during both the neonatal and postneonatal periods. 

The gains were much greater in the white group 

than the nonwhite. Among white infants it appears 

that the improvement was more marked above 

3,000 grams than in the weight class 2,501-3,000 

grtims. This is of interest since it further supports the impression that the most impressive 

gains occurred in those weight groups that already had the most favorable chances of surviving. 

The upstate New York data also provide an 

opportunity to look at another variable that distinguishes between comparatively high- and lowrisk pregnancies, This is “prior fetal loss.” 

The time periods involved are the same as mentioned above. Whether one examines neonatal or 

fetal mortality in the current pregnancy, the impression is that the gap between the poor-risk 

groups (i.e., pregnancies preceded by at least 

one fetal death) and the others did not close (table 

H). 

SUMMARY-MORTALITY RATES 

The persistence of a slow rate of decrease 

in infant mortality over what is now more than 

a decade has led to the current examination of 

trends and present status of infant and perinatal 

mortality. Many of the parameters of loss in 

pre~mancy are studied with a twofold objective: 

first, to clarify events in the 1950’s when the 

infant mortality rates leveled off and second, 

to define once more the high-risk groups in the 

population. A summary of available data on these 

issues follows: 

1.	 Until about 1950 there were large reductions in infant mortality. The decreases were greater after the first few 

weeks of life than shortly after birth, 

but the improvement in mortality at all 

ages was significant. Every area of the 

country and both the white and nonwhite 

populations shared in the sizable reductions in the loss rate. A major contributory factor to the sharp decline in 

the death rate was the lowering of mortality from infectious diseases of all types. 

2.	 During the 1950’s and the early 1960’s 

the decline in the infant mortality rate 

slowed down appreciably. The specific 

year when this change occurred differed 

by age at death, but the general conclusion 

is the same—the major declines that 

formerly characterized the mortality 

rates are no longer being experienced at 

any stage during infancy, including the 

postneonatal period. This reflects lack of 

change in the rates for most of the important causes of death. There were, 

however, continued declines in the rates 

for infective diseases and for infections 

of the digestive system. Increases occurred in the rate for respiratory diseases other than influenza and pneumonia. 

The rates for both white and nonwhite 

infants have leveled off, but the slowdown in the rate of decline has been more 

marked among the nonwhite infants. 

Decreases in the infant mortality rate 

during the 1950’s were small in all geographic areas. Nevertheless, areas that 

were comparatively high in their rates 

at the beginning of the decade showed a 

larger decrease in their infant death 

rates. The gap between rates in the metropolitan and nonmetropolitan areas narrowed, and the rates in geographic divisions (representing aggregates of States) 

varied less at the end of the 1950 decade 

than formerly. 

Infant mortality increased in many large 

cities. Nonwhite infants especially were 

affected by this increase, but in some 

cities white infants also had a higher rate 

in 1960-61 than 10 years earlier. The 

widespread increase in infant mortality 

among nonwhite births in cities appears 

to be related to the movement of many 

nonwhite persons to major cities during 

the 1950’s. Large-scale migration was 

common in all population groups, but 

among white persons the movement frequently was from the central city to the 

suburban areas. 

3.	 Changes in racial or geographic composition of births do not explain the slow 

decline in the infant mortality rate. More 

important is the increase in the propor39 
tions of births in the comparatively h~ghrisk groups of very young mothers and 

women with many pregnancies. However, 

if this factor were eliminated, the decrease in the mortality rate during the 

1950’s still would lag far behind the decrease in the 1940’s. 

The distribution of births by birth weight 

hardly changed for the country as a whole. 

Changes were in opposite directions in the 

two race groups. Among white babies the 

proportion that were 2,500 grams (5% 

pounds) or less decreased slightly; among 

nonwhite babies the proportion increased 

markedly. The latter exerted a strong 

brake on the rate of decline in the neonatal mortality rate among nonwhite infants. 

4.	 High-risk groups identifiable through vital 

statistics all showed little improvement 

in the 1950’s in the infant mortality rates. 

This held for low birth weight groups, 

children born to mothers who previously 

had a fetal death, and nonwhite infants. 

The situation in high-risk groups as compared with more favored groups follows: 

Il. MEDICAL RESOURCES AND 

PERSONNEL, FACILITIES AND SERVICES, 

a.	 Nonwhite infants have almost twice as 

high a death rate as white infants. The 

differential is relatively small shortly 

after birth, but it rapidly increases 

as postnatal environmental conditions 

become the dominant factors. The loss 

rate in every part of the country is 

greater among nonwhite than white 

infants. 

b.	 Infants weighing 2,500 grams or 

less at birth have a neonatal death 

rate that is about 22 times the rate 

for the other babies, and they account 

for two-thirds of all the neonatal deaths. 

Chances of survival improve with increasing weight to reach an optimum in 

the birth weight class 3,501-4,000 

grams. 

c.	 Pregnancies among women who previously had a pregnancy which terminated in .2 fetal death are at least twice 

as likely to end in a neonatal or fetal 

death as are pregnancies among other 

women. Very young mothers and women 

with many prior pregnancies also represent high risks with respect to neonatal and fetal mortality. 

HEALTH PROGRAMS 

AND FINANCING OF CARE 

Physicians 

Obstetrical and infant care in the United 

States is characteristically rendered through arrangements between the individual practicing physician and the pregnant woman with all but 3 

percent of the deliveries performed by physicians 

in hospitals. Outside the larger cities, where 

hospital clinics are available for outpatient prenatal and postnatal care, even indigent and medically indigent patients receive their care through 

individual arrangements under the sponsorship 

of a public welfare or other official agency. Other 

types of arrangements for obstetrical and infant 

services cover only a small proportion of the 

population. 

Whatever the pattern of obstetrical and 

pediatric services, any assessment of the trends 

in these services must first consider the quantity 

and training of medical manpower available for 

all types of medical care. The overall ratio of 

physicians to total population—about 138 per 

100,000 population-has remained essentially unchanged between 1949 and 1962 (table M).26 

However, the ratio of physicians in private practice to population has declined from 101 to 90 

per 100,000. About half of this decline is balanced 

by an increase in the ratio of physicians in 

other full-time practice from 15.2 to 20.6 per 

100,000 population; the other half is related to 

an almost identical increase in the number of 

graduate physicians still in training. 

40 
----------------------------------------

------------------------------------------- ------------------------------------

------------------------------------

------------------------------------

-----------------------------------

------------------------------------------- ------------------------------------

------------------------------------

------------------------------------

-----------------------------------

Table M. Ratio of physicians to total population and percent distribution,by type of


practice: United States 1949 and 1962


Type of practice


Total--------


Private practice


Full-time specialists


Part-time specialists


General practitioners


Other full-time practice3----------------------------------


Training programs3-----------------------------------------


Retired, not in practice


Total------------------------------------------------


Private practice


Full-time specialists


Part-time specialists


General practitioners


Other full-time practice3----------------------------------


Training programs3-----------------------------------------


Retired, not im practice


19621 I 19492 

Ratios per 100,000


population


136.9[ 138.3


89.8 100.9 

52.6 36.8 

15.4 

3::; 48.7


20.6 15.2


20.0 15.7 

6.5 6.5 

Percent distribution


100.OI 100.0 

65.6 72.9 

3;.; 26.6 

11.1 

22:3 35.2 

15.1 11.0 

14.6 11.4 

4.71 4.7 

lIncludes 50 States, District of Columbia, and Puerto Rico and outlying areas. ~Includes the 48 States and the District of Columbia. 

31ncludesFederal and non-Federal physicians and all interns and residents.


NOTE: Population includes Armed Forces overseas.


Source: Adapted from DivLsion of Public Health Methods: Medical specialists, by 

P. Q. Peterson and M. Y. Pennell. Health Manpower Source Book, Section 14. PHS Pub. No. 263. Public Health Service. Washington. U.S. Government Printing Office, 1962. 

These changesarereflectedinthepercentageand 1962thenumberofobstetrician-gynecologists


distribution
 of physiciansby the natureoftheir


practice. lnthe interval
between1949 and1962


thepercentageof physiciansinprivatepractice


declinedfrom 72.9to 65.6.The decreaseinthe


percentageofgeneralpractitionersand
 part-time


specialists
 faroutweighedeven the sharplyin­


) creased proportionof full-timespecialists
 in


privatepractice.


Ofmore directpertinence toobstetrical
 and


pediatriccare are theratiosof generalprac­


titioners and of specialists
 in obstetrics-gyne­


cology and pediatrics to the specific
segments


of the population served(table
N).Between1949


per 100,000 deliveriesalmost doubled,going


from 140 to 271. This figurewould be more


meaningfulifitcouldbe relatedtothetrendin


the proportionof specialists
 in academicwork


and trainingprograms,but information
of this


kindis not available.
 In any event,theincrease


intheavailability ofspecialistmanpowerhas
 been


almostcompletely offset
by thestrikingdecrease


from 1,999to 1,340in thenumber of general


practitioners
 per 100,000deliveries.


Definitive assessmentoftheactualamount
of


physicians‘ time available for obstetrical
 care


wouldrequireinformation
 notcurrentlyavailable


41 
-------------------------------------------

------------------------------------------- ------------------------------

------------------------------------------- ------------------------------------

Table N. Ratio of general practitioners and full-time specialists in obstetrics-gyne-


cology and in pediatrics to specified population and birth groups: United States,


1949 and 1962


Population group 19621	 I 19492 I 

Ratios per 100,000 in


specified population


General Practitioners group


Total population

Fetal deathss and live births------------------------------ 30.5 

1,340.0 

48.7 

1,998.6 

Children under 15 years------------------------------------ 97.7 179.5 

Specialists in obstetrics-gynecology 

Total population 6.2 

Fetal deathss and live births 270.8 

Specialists in pediatrics


Total population 5.6


Children under 15 years 17.8


lIncludes50 States, District of Columbia, and Puerto Rico and outlvinsz .­
 areas.
 ‘Includesthe 48 States and the District of”Columbia.


3Fetal deaths of 20 weeks or more gestation or gestation not stated.


NOTE: Data for specialists include those in private practice, hospital service


(other than interns and residents), teaching, administration,research, and preventive


medicine; data for general practitioners refer to those in private practice. Popula­


tion includes Armed Forces overseas.


Source: Adapted from Division of Public Health Methods: Medical specialists,by


P. Q. Peterson and M. Y. Pennell. Health Manpower Source Book, Section 14, PHS Pub.


No. 263. Public Health Service. Washington. U.S. Government Printing Office, 1962.


on theproportionof time generalpractitioners


devoteto obstetrics
and similarlythepropor­


tionof timethatobstetrician-gynecologists
 de­


votetotheobstetrical
 aspectsoftheirspecialty.


Broad assumptionscan be made on thesepoints:


generalpractitioners
 devoteabout10percentof


theirtime to obstetrical
 care,andobstetrician­


gynecologists
 devote60 percentoftheirtimeto 

obstetrics.On thebasisofthesetwoassumptions


the ratioof physiciantimetothenumberof de­


Iiveries has increasedonlyslightly
 between1949


and 1962.


Otherfactorsmust alsoreconsideredinat­


temptingtoquantitate trendsinmedical
 manpower


in relationto changingobstetrical
 needs.The


declineinthepercentageofdeliveriesperformed


by untrainedmidwives from 4.5percentof the


totalin1950to 1.8percentin 1962(table
O) points


to a correspondingincreaseintheproportionof


deliveriesby physicians.
Itis alsolikelythat


physiciansin generalpracticehavereducedthe


proportionof theirtime devotedto obstetrical


care, particularly in those localities
 in which


the concentration of specialists
 has increased


most rapidly.
Partoftheimpactofthesefactors


tendingto reducethe ratioof manpower tode­


liverieswould be offsetby the increasein the


proportion of physicianstill ingraining,
 butthe


caregivenbyinternsandresidentstill
requires


supervisionby otherphysicians
 .Furthermore,the


broadenedconceptof obstetrical
 care thatis


attracting attention, especially withrespect
tothe


meticulousand time-consumingdiagnostic
and


therapeuticservicesrequiredby women with ‘


a historyof relativeinfertility
 or previously


complicated
eliveries,makesincreaseddemands


on the time of specialists
 in obstetrics-gyne­


cology.


About 20 years ago the goalwas suggested


that“intheUnitedStatesallmaternitypatients


42

-------------------------------------

Table O. Percent distribution of live births,by person in attendance and color:United 

States, 1940, 1950, 1960, 1962 

Year and color 

Total 

1962--------------------------------------

1960--------------------------------------

1950--------------------------------------

1940--------------------------------------

White 

1962s 

1960--------------------------------------

1950--------------------------------------

1940--------------------------------------

Nonwhite 

1962:~-------------------------------------

1960--------------------------------------

1950--------------------------------------

1940-------------------------------------­

~‘eta” 

Percent distribution 

100.0 

100.0 

97.2 

96.6 M 

100.0 88.0 4.5 

100.0 55.8 8.7 

100.0 99.0


100.0 98.8 :::


100.0 92.8


100.0 59.9 M


100.0 86.9 9.9


100.0 85.0 11.0


100.0 57.9 26.1


100.0 26.7 48.0


llncludes other and not stated, not shown separately. 

21t is assumed that all births in hospitals are attended by physicians. 

~Figures by color im 1962 exclude data for residents of New Jersey . because that 

State did not %equire reporting of the item in that year. 

Source: Annual volumes Vital Statistics of the United States, National Center for 

Health Statistics, Public Health Service, Washington, U.S. Government Printing Office, 

and special reports. 

should have advice and treatment throughout the 

maternity cycle by or undertheimmediate supervision of a doctor of me~6cine recognized as a 

specialist in obstetrics. ” Recent estimatesby 

Hellman27 throw some light ontheextentto which 

this goalis being achieved. Using a conservative 

figure of an annual average of 200 deliveries for 

all diplomats of the American BoardofObstetrics and Gynecology, whether in privatepractice, 

academic life, or administration, he estimated 

that 17.2 percent of the births duringthe1950-

)	 54 period were attended by diplomats and that 

this would rise to 27.1 percent of the births in 

the 1960-64 period, He envisioned only aslight 

further increase in this percentage toa peakof 

29.2 percent in 1970-74 and adecline in the percentage thereafter. At the same time a continued 

decrease inthe proportionofgeneral practitioners 

in attendance atdeliveries would, accordingtothis 

forecast, be accompanied by a corresponding increase in the proportion of deliveries in ward 

services ofhospitals. 

The number of pediatricians per 100,000 

children under 15 years of age has increased 

from 10.7 in 1949 to 17.8 in1962 (table N).However, medical care of children is still largely 

relatedto theavailabilityofgeneralpractitioners. 

If it is estimated thatgeneralpractitioners devote 

about 20 percent of their time to the careof 

children under 15 years of age, then the availability of medical manpower for thecare ofthis 

segment of the population will have declinedfrom 

46.6 t037.3 physicians per 100,0OOchildrenunder 

15 years during the 13-yearinterval priorto1962. 

The actual decline wouldprobably beevengreater, 

as in the case of obstetrical care, since general 

43 

1 
---------------------------

--------------------------------------

practitioners in areas having a high proportion 

of pediatricians would tend to devote a smaller 

fraction of their time to the care of children 

than would general practitioners in other areas. 

One index of the quality of medical care 

available is the proportion of physicians in a 

specialty who are diplomats of their respective 

specialty boards. Of the full-time specialists in 

obstetrics-gynecology in clinical practice about 

half (48.8 percent) are diplomats of the American 

Board of Obstetrics and Gynecology (table P). 25 

Among obstetricians in other full-time practice 

only 36.7 percent were Board diplomats in 1961. 

Full-time pediatricians as a group have a higher 

proportion of diplomats (licentiates) of the 

American Board of Pediatrics. Among those in 

clinical practice fully 62.8 percent fall in this 

group, and those in full-time practice rank only 

a fraction of a percentage lower. 

The distribution of obstetricians is highly 

variable in different regions of the United States. 

The number of specialists in obstetrics-gynecology per 100,000 deliveries ranges from a 

high of 398 in the Northeast to a low of 234 in 

the South (table Q).zs The North Central region 

had only a slightly higher proportion of specialists 

in obstetrics-gynecology than the South, with the 

West in an intermediate position. Specialists in 

pediatrics showed a similar type of distribution. 

Again the Northeast had the highest level with 26.0 

.-

pediatric specialists per 100,000 children under 

15 years of age. However, the North Central region, with 14.6 pediatricians per 100,000 child population, had a definitely smaller concentration 

than the South, with 15.6. 

Physicians in private practice are overwhelmingly solo practitioners. While the number 

of medical groups in the United States increased 

by 214 percent between 1946 and 1959 (368 to 

1,154), the number of physicians in group practice 

still constituted only 7 percent of the active, 

practicing physicians in the countxy. 28 Thehighest proportion of physicians in group practice 

is found west of the Mississippi River. 

The supply of physicians for maternal and 

child health programs does not appear to be keeping pace with the increasing needs in this field. 

An annual average of about 14 physicians were 

majoring in maternal and child health in schools 

of public health in the decade starting with the 

1951-52 academic year. 29 There were 76majors 

during the second half of this period and 68 

during the first half, but the number during the 

1960-61 academic year (11) was considerably 

lower than in the preceding 3 years. 

As of January 196217 percent of the positions 

of directors of State maternal and child health 

programs were unfilled. 29 Of those filled, 27 percent were certified by the American Board of 

Preventive Medicine, 9 percent by the Board of 

Pediatrics, and 5 percent by the Board of Obstetrics and Gynecology. 

Table P. Diplomate status of full-time specialists in obstetr~cs-gynecology and in 

pediatrics, exclusive of those in training: United States, 1961 

Percent diplomats 

Type of specialist Among those 1 

Total Among those in other 

in clinical full-time 

practice practice 

i 

Obstetrics-gynecology 48.1 48.8 36.7 

Pediatrics 62,7 62.8 62.3 

Source: Adapt ed from Division of Public Health Methods: Medical special~;;s$u~y 

P. Q. Peterson and M. Y. Pennell. Health Manpower Source Book, Section 14. 

No. 263. Public Health Service. Washington. U.S. Government Printing Office, 1962: 

44 
------------------------

----------------- ------------------------

------- ----------

-----

-. 

Table Q. Ratio of full-ti,mespecialists in obstetrics-gynecologyand in pediatrics to


specified population and birth groups: United States and geographic regions, 1961


United IINorth- 1

North Population group States east Central SOU th I West 

Specialists in obstetrics-mmecolom Ratios	per 100,000 im specified


~opulat~on grc


Total population


Fetal deathsl and live births-----------


Specialists in pediatrics


Total Pomlation


Childr%-under 15 years
 I 

‘Fetal deaths of 20 weeks or more gestation or gestation not stated.


NOTE: Data for specialists include non-Federal physicians and interns and resi­


dents. Population is 1961 estimated population exclusive of ‘ArmedForces abroad.


Data from the 1960 census used for the population under 15 years of age.


Source: Adapted from Division of Public Health Methods: Medical specialists, by


P. Q. Peterson and M. Y. Pennell. Health Manpower Source Book, Section 14. PHS Pub.
 No. 263. Public Health Service. Washington. U.S. Government Printing Office, 1962.


Nurses in nursingpositions,may, inlargemeasure,be


Itis generallyagreedthatthereis a con- tracedto a decreaseintheproportion
ofwomen


tinuing shortageinnursingpersonnelatalllevels enteringthe nursingfield, an increasing
demand


of training
even thoughtheratioofnursingper­


sonnelto totalpopulation
has increasedduring


thepastdecade(table R).The shortage
ofnurses,


as evidencedby a highproportionof vacancies


Table R. Ratio 05 nursing personnel to


population, by type of nurse: United


States, 1950 and 1962


Type of nurse 1962 1950


Ratios per 100,000


total population


Total-------- 642 487 

Professional 298 249 

Practical 122 91 

Aides, orderlies, 

and attendants m 222 147 

Source: Adapted from Division of Pub­


lic Health Methods:Man~ower in the 1960b.


Health Manpower Source-Book. Section 18.


PHS Pub. No. 263. Public Health Service, 

Washington. U.S. Government Printing Of; 

fice, 1964. 

fornursingservices,and a declineinthework


week of nursingpersonneltoward a national


standardof 40 hours.Professional
 nurses,i.e.=


registerednurses or nurseswitha bachelors


degreeor higher,haveincreasedfrom 249t0298


perlOO,OOOpopulation,
 anincreaseof20percent,


between1950 and 1962.
30 Duringthisperiodthe


ratioof practical
nurseshas increasedby one­


third,from 91 to 122 per 100,000population;


the proportionate
increase in nurses*aides,


orderlies,
and otherattendants—147to 222per


100,000population-hasbeen even greaterthan


thatof practical
nurses.


Marked regionalvariations
arefoundinthe


ratiosof professional and practical
nursesto


population(tableS).The ratioof professional


nurses to populationwas twiceas highin the


Northeastas intheSouth,withtheotherregions


of the countryat a levelabouthalfwaybetween


thesetwo extremes.The distribution
 ofpractical


nurses, however, was practically
the same


throughouthecountry, thevariation
 beingwithin


theverynarrow limitsofalowoflll per 100,000


population
in theNorth CentralStatestoa high


of122 per 100,000intheWest.3031


45

------

----------

Table S. Ratio of professional and prac­


tical nurses in practice to population:


United States and geographic regions,


1960 and 1962


I Professional Practical


Region nurse nurse
 I 1962 I 1960 

Ratios per 100,000


population


Total---- 298I 114 

I 

Northeast 396 115 

North Central-- 290 111 

South 209 113 

West----------- 321 122 

Sources: Division of Public Health 

Methods: Manpower in the 1960’s. Health 

,Manpower Source Book, Section 18. PHS 

Pub. No. (1964). and Surgeon General’s 

Consultant Group on-Nursing: Toward Quality in Nursing, Needs and Goals. PHS 

Pub. No. (1963): Public Health Service; Washingt&. U~S. Government Printing 

Office. 

The number ofpublic
healthnurses,including


nurses employedby boardsofeducation,
 has ex­


ceededthe growthofthepopulation.
 The number 

increasedfrom 25,800 to 34,700 between1954 

and 1962, representing an increase from about 

16 to 19 in the number of nurses employed for 

such public health work per 100,000population.30 

A major part of this increase appears to have 

resulted from the increased number of nurses 

employed by boards ofeducation.32 Therearealso 

indications that referrals to public health nurses 

for routine services in the area of maternal and 

child health care are decreasing. 

Midwives 

As previously indicated, the untrained midwife is rapidly disappearing from the American 

scene. In contrast to 8.7 percent in 1940 and 

4.5 percent in 1950, in 1962 midwives werein attendance at only 1,8 percent of live births in 

the UnitedStates(tableO).In1962 midwife deIiveries constituted 9.9 percent of the totalamong 

nonwhite and only 0.3 percent among white 

persons. Actually a large majority of all midwife deliveries (84 percent) were in the nonwhite population. Furthermore, it is the rural 

nonwhite population, mainly in the South, that accounts for most of the midwife deliveries. 

At the present time the use of the wellqualified nurse-midwife in the actual conduct 

of deliveries is still largely experimental in 

the United Stateso 0nly86 nurse-midwives corn- , 

pleted the training program inthe 5-year period 

through 1963, and only 130fthese took positions 

in this country in which they actually performed 

deliveries.27 The nature and extent of the role 

of the well-qualified nurse-midwife in helping to 

meet anticipated needs in the field of obstetrics 

must await future developments. 

Hospitals 

Since the launching of the Hill-Burton programin 1946 the expansion of hospital facilities 

has proceeded at a pace more rapid than any 

earlier period in the Nation’s history. The rate 

of increase in general hospital beds has exceeded 

even the rapid rate of growth of the population. 

Between 1948 and 1962 the number of hospital 

beds has increased from 3.2 to 3.6 per 1,000 

population (table T).33 This was the result ofa 

net annual increase of about 7,000 beds over 

theneeds from the increase inpopulation.:{~ 

The increase intheratio of general hospital 

beds to population hasdiffered ineach region of 

the country. The ratio in the South, starting from 

the lowest level ofanyregion in1948, increased 

by 27 percentto 3.3beds per 1,000population 

in1962, equal to the ratio inthe West in the same 

year. The number of beds in the Northeast and 

the West barely kept pace with the increase in 

population,
while theNorth Centralregion in­


creased by 18 percent in the ratio of beds to 

population. i. 

The quality of hospital facilities has also 

improved. Whereas only 59.4 percent of the general hospital beds were considered acceptable 

under Hill-Burton planning in 1948, fully 80.3 

percent fell into theacceptable category in 1962. 

46 
--------------------------

---------------------------- ------------------------ --------------------------------

I


Table T. Ratio of general hospital beds to total population and ratio of bassinets to 

I live births: United States and geographic regions, 1948 and 1962 

General hospital beds Bassinets per 1,000 

per 1,000 population live birthsl 

Region 

1962 1948 1962 1948 

Total 

Northeast


North Central


South


West --------------------------------­


lShort-term general and special hospitals 

and psychiatric hospitals. 

Source: Ameri,can Hospital Association, 

1949 andAug. 1963. 

However, even today there are areas without 

acceptable general hospital beds. 34 

Emphasis in the Hill-Burton program for 

general hospital beds has been on the needs of 

the smaller communities and the rural areas 

ofthe country whichhad been morepoorlyserved 

by hospitals than had been the cities. Theobsolescence ofhospital facilities inthe majormetropolitan areas, coupled with the influx of lower 

socioeconomic groups into the core cities and 

the flight of middle- and upper-income groups 

to the suburbs and beyond, has recently resulted 

in a shift in emphasis toward the large centers 

of population. 

Information on the absolute number ofobstetrical beds oronthe ratio of obstetrical beds 

to deliveries is not currently available. The 

nearest approximationis the information onhospital bassinets which ispublished annually in the 

Journal of the American Hospital Association. 

The number of bassinets per 1,000 live births 

increased slightly from 23.5 t023.9 between1948 

and 1962 (table T). Actually the South was the 

only region to show an increase during thispe3.6 I 3.21 23.9 I 23.5 

I I I 

4.0 3.8 26.3 29.9 

3.9 3.3 25.3 26.1 

22.3 17.6 

::: $:: 21.1 22.1 

exclusive of short-term Federal hospitals 

Journal of the: Hospitals,Guide Issues,Aug. 

riod. Even withits increase inbassinetstheSouth 

in 1962 still ranked ahead of only one other retion, the West, in the ratio ofbassinetts to live 

births. 

Inthe past few years the decline inthe crude 

birth rate and the leveling off in the absolute 

number of births, accompaniedbyashorterlength 

ofhospital stay after delivery, have at times resulted in underutilization of obstetrical beds in 

some areas. Even though the outlook during the 

next decadeis for anew increase of sizable proportions in the number of births. and, as aresult, pressure on obstetrical facilities, the current lull has reactivated interest in admitting 

selected gynecological patients to the obstetrical 

service when it is not possible to use flexible 

partitioning of the hospital corridor to permit 

proper contraction or expansionof theobstetrical 

service. 

A greater problem is the heavy pressure on 

obstetrical ward services in large cities. 

Lesser35 has cited instances in which municipal 

hospitals in large cities have been forced to 

discharge patients 24 to 72 hours after delivery 

47 
--------------------------------------

-------------------------------------------

-------------------------------------------

-------------------------------------------- ----------------------------------- -------------------------------------------

------------------------------ ---------------------------------- ------------------------------------------------------- ---------------------------------------------- ----------------------------- --------------------------- ----------------------------------------------

------------------------------

-------------------------------

------------------------------

because of overcrowdingof theirfacilities.
 In­


adequacyoffacilities
 has beena longtimechar­


acteristic
 of ruralareas,butthe growthofthe


problem in largecitiesisa relatively
 new phe­


nomenon.


Financing of Care 

Expendituresfor healthand medicalcare


in the UnitedStatesmore thandoubledin the


decade from 1950 to 1960:theyrosefrom about


12.4billion
 dollarsinthe1949-50Federalfiscal


yeartoabout26.5billion in1959-60 (table U).36


This representedan increasefrom 4.7 to 5.4 

percentin theproportionof the gross national 

productdevotedto healthand medicalcareexpenditures. 

AS might be anticipated
from the rising


standardof livingforbroadersegments of the I


population, the risein privateexpenditures
 was


at a more rapid rate than thatof publicex­


penditures. Theproportion ofprivate
xpenditures


increasedfrom 73.1to 76.5percentofthetotal 

duringthe decadeeventhoughgovernmentalexpendituresincreasedfrom $3.3to $6.2billion, 

an increaseof 87 percent.Stateand localexpenditureshave increasedmore rapidlythan 

haveFederalGovernmentexpenditures. 

The proportionof expenditures
for identi- ‘


fiablematernaland childhealthservicesatall


levelsof government fared betterthan most


other publicexpenditures.
The increasefrom


$29.8to $139.4millionin thedecadefrom 1950


Table U. Percent distribution of private and governmental expenditures for health and


medical care by type of expenditure:United States, fiscal years 1949-50 and 1959-60


Type of expenditure 1959-60 1949-50 

Total (in millions) $26,503 $12,365 

Total (percent) 100,0 100.0 

Private expenditures 76.5 73.1 

Public expenditures 23.5 26.9 

State and local government 13.9 15:4 

Federal Goverment 9.6 11.5 

Public expenditures (percent)---------------------------- 100.0 100.0 

General medical and hospital care 34.9 35.3 

Defense Department facilities 10.0 

Medicare ::; 

Public assistance 

Maternal and child health services 2:2 0.9 

School health (educationalagencies) 0.9 

Medical research~ ::: 

Other health and medical services 27.9 

Medical facilities’ construction 8.9 

Percent of gross national product 5.4 4.7 

lIncludesmedical research carried on by Veterans Administration.


Source: Division of Community Health Services: Medical care financing and uti­


lization. Health Economics Series, No. 1. PHS Pub. No. 947. Public Health Service.


Washington. U.S. Government Printing Office, 1962.


48 
------------------------------

---------------------------

----------------------------

----------------------------

----------------------------

to 1Q60 raised the proportion of all public expenditures devotedto identifiable
 maternaland


childhealthservicesfrom 0.9 to 2.2percent


ofthetotal. These areonlya fraction
ofthetotal


publicexpenditures
 formaternalandchildhealk


purposes,sincethey do not includethe costs


ofhospital inpatient andoutpatient
 careandother


serviceswhich cannotreadilybe extracted
from


thecostsofgeneralhospital
careinvariousgov­


ernment programs. Despitethe greateravail­


ability of governmental
 fundsinsupportofpublic


healthservices,the economicburdenof these


servicesis especially
heavy in familieswith


lowerincomes(table V). Whilethefamilies
with


annualincomes of lessthan$2,000spent$165


forhealthservicesin 1957-58incomparisonto


an averageexpenditure
of $411 in the families 

with incomes of $7,500and over, the former 

represented13 percentoffamilyincomeincontrastto only3.9percentin the higher income 

level. In fact,an inverserelationship
 between


familyincome and thepercentageofincomede­


votedtopersonal health services exists
throughout


the income scale.Five years earlier —
1952-


53—the situationwas similar.An important


changedidoccur,however,inthepercentageof


income devotedto healthpurposes.At eachin­


come level, particularly above$2,000,
thisfigure


increasedappreciably
 .37


Healthinsuranceis graduallycoveringan


increasing
proportionof the costsof personal


healthservices.In 1952-53insurancebenefits


formaternitycare were receivedby 45 percent


of the familiesin which a deliveryoccurred,


and by 1957-58thisproportion
had risento 55 

percent. 38As a consequence,theextenttowhich


voluntaryhealthinsurancemet physicians’
 fees


forobstetrical
 servicesreceivedinthecountry


as a wholerosemoderatelyfrom 25percentto30


percentin thisperiod.Takingintoaccountex­


penditures forallpersonal health services
related


to maternitycare (i.e., physicians,
hospitals,


drugs,and otheritems),therewas an increase


from 30 to 38 percentintheproportion
ofcosts


met by healthinsurance. These percentages
are


twicethecomparablefiguresforbenefits
 tocover


allprivateexpenditures
on health(15percentin


1952-53 and 19 percentin 1957-58).In view


Table V. Annual mean gross charges incurred for personal health services and charges
 as percent of family income, by family income group: United States,1952-53 and 1957-58


Annual mean gross


charges per Percent of income


Family income family


1957-58 1952-53 1957-58 1952-53


Total $294 $207 5.5 4.8


$2,000 or less 165 130 13.0 11.8 

$2,000 -$3,499 226 152 8.4 6.1 

3,500 -$4,999 287 207 6.4 

ii 5,000-$7,499 

+7)500 or more--------------------------- 336 

411 

259 

353 

5.4 

3.9 

::; 

3.0 

NOTE: Data based on national sample surveys conducted by National Opinion Research


Center, University of Chicago. Health insurance premiums excluded from data.


Source: Anderson, O. W., Collette, P., and Feldman, J. J.: Family expenditure pat­


terns for personal health service, 1953 and 1958: nationwide surveys. HIF Research


Series, No. 1.4.New York. Health InformationFoundation, 1960.


49

of the spread of health insurance with varying 1

degrees of coverage to about three-fourths of the 

population, by now (1964) the proportions given 

for 1957-58 may have been exceeded by a considerable margin. 

Some idea of the costs of hospital obstetrical 

care is obtainable from the experience under the 

Federal Medicare Program for dependents of 

personnel in the Armed Forces. The average 

length of hospital stay in 1959 was 4.9 days.ss 

At an average per diem charge of $30.92 the 

average hospital cost per case was $151.52, 

exclusive of Medicare administration costs. The 

costs of physicians’ fees for care during the maternity cycle must be added to this to obtain 

the total charge per case. 

MATERNAL AND CHILD HEALTH 

PROGRAMS AND SERVICES 

The many hazards to which the fetus and 

infant may be vulnerable—genetic disorders, 

environmental deprivation, oxygen deficiencies, 

hormonal and enzyme imbalances, infections, and 

metabolic disorders, to mention a few—call for 

a multidisciplinary approach to the problem of 

perinatal and later infant wastage. The acquisition 

and dissemination of knowledge about the classic 

art of obstetrics, of knowing when and how to 

intervene and when it is best to support the 

patient without intervention, is only one important aspect of the total attack on the problem; 

the solution to this problem must consist of 

a broad program in maternal and child health. 

The application of the rapid scientific and 

technical advances of recent years has been uneven, In some instances, as in the screening of 

newborn infants for phenylketonuria, testing and 

application of a significant, new development proceeded simultaneously. In contrast, some of the 

highly sophisticated techniques for the evaluation 

of women with certain suspected metabolic or 

e~ljocrinologic disorders can be developed initiall y in only a few medical centers. As matters 

now stand, the application of some of these services to broad population groups may be deferred 

indefinitely. For the most part, new research developments are probably applied more rapidly 

today than at any time in the past. 

Changes in patterns of living, particularly in 

transportation, have introduced an apparent contradiction in the provision of health services. 

On the one hand, the improvement in roads and 

the ease of movement in most rural areas have 

obviated the need for a physician in every hamlet. This makes possible the development of hospitals large enough to provide more complex services for broad geographic areas. At the same 

time, planning over these wider areas to avoid 

duplication of expensive facilities and services 

becomes an urgent need. 

On the other hand, many of the underprivileged 

groups, even in the large cities, cannot or will 

not take advantage of medical services not in the 

immediate vicinity of their homes. This is often 

due to a variety of highly involved circumstances 

wilich may be generally characterized as economic, educational, or cultural, or to specific 

conditions such as lack of care for other children 

in the absence of the mother. These problems 

are increased when the services are overcrowded 

OK impersonal. One approach to help overcome 

this problem is to bring the less complicated 

services close to their intended recipients. 

General Health Services 

The level of the community’s general health 

services, the foundation on which specialized 

maternal and child health services must be built, 

directly affects the health of mothers and children. 

Environmental health services. —Over the 

past several decades the provision of safe milk and 

water supplies has been the major factor in the 

marked reduction in mortality from diarrheal 

diseases in infancy. This hazard has been reduced 

to such a low point in many communities that 

som,e pediatricians are advocating the preparation 

of infant feedings with unboiled tap water for use 

in the home. Pasteurization of milk and control 

of bovine tuberculosis have made human tuberculosis of the Ixmes and joints a rarity; this 

contrasts with the situation after the turn of the 

century when entire institutions were devoted tCJ 

the care of children with this condition. New proh50

lems, stmhas those of water supply and sewage 

disposal insuburban housing developments, continue to arise. Air pollution, while far from a 

new problem, has recently been linked as a possibly significant factor in the health of infants as 

well as elderly persons. 

The potential damage from medical uses of 

radiation to present and future generations of infants and children has provided the chief impetus 

to the development of radiation control programs 

at the national, State, and city levels. Stricter 

controls are being applied to prevent radiation 

scatter and to protect the gonads. Major areas 

of the country, however, still lack effective radiologic health programs. 

Comnumity nursing services. —This public 

health responsibility has traditionally been divided 

between voluntary visiting nurse services and the 

official nursing services of health departments. 

The former, found mainly in the metropolitan 

areas, have concentrated on bedside nursing. The 

trend toward consolidation of the two types of 

agencies has been slow and spotty. 

The slight increase in the number of public 

nurses, other than those employed by boards of 

education, was not sufficient between 1950 and 

1960 to maintain the earlier ratio of public health 

nurses to total population. The discrepancy would 

have been even greater if the ratio were calculated on the basis of public health nurses to 

number of deliveries. 

The public health nurse is the vital link 

in reaching the high-risk groups early in pregnancy and in maintaining and insuring care for 

women who have had an unfavorable outcome of 

a previous pre~mancy. The need to concentrate 

limited public health nursing manpower on those 

health problems which are most acute has resulted in decreased attention on home visiting for 

routine prenatal and newborn care. Furthermore, 

the rising demands for bedside nursing care may 

distract attention from the needs of even the 

high-risk groups of pregnant women unless special 

emphasis is placed on the latter. 

Nutrition #roWams.-Nutrition programs directed mainly toward pregnant women may be relatively ineffective because they may not reach 

the most vulnerable groups. For example, women 

who have late or no prenatal care remain outside 

the scope of the programs. Also, the early age 

at which the first pregnancies now occur suggests that any nutritional inadequacies during 

adolescence would carry over into pregnancy, 

and limited, unbalanced diets and food fads are 

frequent among adolescent girls at all social 

levels in this country. 

Health pyo~am”s fo~ migrant- wovkey families. —The migrant farm worker and his family 

suffer the general disadvantages of being on one 

of the lowest rungs of the economic ladder. In 

addition, their constant transiency interferes with 

their ability to make use of local health services. 

For these reasons special grants of Federal 

funds have been made available to the States for 

special health programs for migrants and their 

families. Maintaining the continuity of health 

care as the migrant laborer and his family 

follow the crops still presents a major problem. 

Specialized Health Programs 

for Mothers and Infants 

Pyenatal and postpavtal health supervision. —€

It has been estimated that a great majority of 

the wom’en delivered by private obstetricians have 

had regular prenatal care from the first trimester of pregnancy. 35 The prenatal visits, which 

are spaced more closely together as term approaches, include routine medical examinations 

and laboratory tests. This highly personalized 

type of routine care has probably been the major 

factor in the decline in toxemias and other serious 

complications of pregnancy. 

Maternal health programs of the past, often 

utilizing itinerant clinics, concentrated on promoting regular prenatal care through health education and the provision of demonstration prenatal care services. The Federal Emergency 

Maternity and Infant Care Program of World War 

H attempted to meet needs in a wartime period. 

The problem today appears to be focused 

among the indigent and medically indigent groups 

in major metropolitan centers and some rural 

areas. In most of the large cities and in many 

of moderate size prenatal and postpartal care 

for these groups is provided mainly through outpatient clinics housed in either municipal or voluntar y hospitals. The same population shifts that 

51 
have increased the pressure on inpatient facilities 

have operated on outpatient clinics as well. In 

some areas the pressure has become so great 

that clinic patients may have to spend an entire 

day for a single prenatal visit. While there are 

many factors that interfere with the provision 

of adequate prenatal care to women in the lower 

socioeconomic groups, gross inadequacy in the 

volume of clinic services is undoubtedly an important element in discouraging prenatal care 

among groups which may not be highly motivated 

to seek care in the first instance. In major municipal hospitals in widely scattered areas of the 

country, between 20 and 45 percent of the women 

had no prenatal care at all and first came to the 

hospital after labor had started.zs 

Increased Federal funds for maternity and infant care have been one response to these growing 

urban problems. Under the Social Security Act 

the Children’s Bureau had $25 million available 

in Federal fiscal year 1962-63 for grants to the 

states for maternal and child health services. In 

recognition of the need for expanded and improved obstetrical services for deprived segments 

of the population and with particular emphasis on 

the bearing these services have on the prevention 

of mental retardation, Congress provided for a 

gradual increase in the annual appropriation to 

a level of $50 million over a period of 7 years. 

It also established anew 5-year program of grants 

for obstetrical and pediatric care for high-risk 

~roupS, starting with $S million in fiscal year 1964 

and rising to an annual level of $30 million during 

1966 through 1968. An additional amount was appropriated for program-oriented research in the 

maternal and child health field. 

Special projects are being developed for the 

provision of obstetrical care through the expansion 

of basic hospital facilities and in special circumstances the development of new clinics in depressed neighborhoods. The latter, so-called 

satellite clinics staffed by personnel from the 

parent hospital in which delivery is to take place, 

help insure continuity of care throughout the maternity cycle. In these special projects the hospital and clinic services are closely coordinated 

w~th available public health nursing and other 

public health services. 

In those States with a large proportion of 

rural-midwife deliveries State and local health 

departments have conducted programs in which 

nurse-midwives provide supervision and limited 

training of the essentially untrained midwives. 

Medically reamed clinics have also been provided 

for midwives’ patients who present suspected 

complications of pregnancy. 

In many centers throughout the country specially organized facilities are available for the 

study of problems of infertility regardless of the 

specific cause. Usually multidisciplinary in character these clinics utilize the services of a variety 

of paramedical personnel and provide the opportunity to conduct sophisticated laboratory 

studies; their staff often serves in a consultative 

capacity to the primary physician. 

For women who have suffered unfortunate 

outcomes in previous pregnancies, organized preconceptional clinics are available in a few medical 

centers. These services are also usually provided 

on a selective, consultative basis for the more 

difficult clinical problems, since many conditions 

inimical to fetal welfare can be handled through 

the diagnostic and therapeutic armamentarium in 

the office of the physician or in conventional out -

patient clinics. The extent to which the elaborate 

biochemical, endocrinologic, and other laboratory 

studies are available throughout the country is 

not known, but the full range of needed laboratory 

procedures is probably to be found almost exclusively in medical centers having a research 

interest in these problems. 

New approaches are being taken to the related 

question of family planning for medical and socioeconomic reasons. For the most part, voluntary 

efforts still provide the major support for family 

planning, but the health or welfare departments 

in an increasing number of States and localities 

are supporting services which offer a choice of 

methods in accordance with the wishes and 

conscience of the recipients. 

Hospital cave. —Many of the problems relating to delivery care have been discussed under 

hospital facilities. Most organized community ma- , 

ternal health programs for individual patients 

stop at the hospital entrance. Since the termination of the Federal Maternity and Infant 

Care Program shortly after World War II only 

a few, relatively limited State and local programs 

have covered hospitalization of women presenting 

complications of pregnancy. This situation prom52 
iscs to change sharply with the spread of the 

new projects under the Maternity and Infant Care 

Grants. 

Most State maternal and child health pro1 grams include some type of supervision of hospital obstetrical services (including newborn 

nurseries) or of the newborn nurseries alone. 

While originally motivated by the desire to control puerperal infections and epidemic diarrhea 

of the newborn infant, these supervisory services have been broadened to cover the total 

management of the hospital maternity and newborn units. Prepackaged infant formulas have been 

a recent innovation for the newborn nursery. The 

introduction of screening for phenylketonuria on a 

routine basis promises to be the prototype of 

a battery of screening tests for genetically determined disorders of metabolism which in the absence of early and adequate treatment could 

lead to death, mental retardation, or a permanent 

physical disability. At least two States have mandated testing the newborn for phenylketonuria. 

For nearly three decades maternity mortality 

conferences have been conducted in individual 

hospitals or on a community-wide basis to” review the factors involved in maternal deaths. 

These conferences are a first step in preventing 

a repetition of the circumstances surrounding 

maternal deaths. This technique has been extended 

in the past few years to the study of perinatal 

deaths. 

Cart? of infants of low birth weights. —In 

the past 20 years many hospitals have developed 

specially equipped and staffed newborn nurseries 

for infants of low birth weight. When these 

nurseries have been set up to care for infants 

brought in from other hospitals in the surrounding area, they have often been referred to as 

premature centers. Programs for transporting 

infants to the premature centers, often with payment for care provided at the centers, are conducted by State health departments and some 

6 health departments in large cities. 

As discussed previously, the impact of such 

care on the birth weight-specific death rates of 

these infants appears to have leveled off. Further major declines in the birth weight-specific 

fatality rates do not appear likely in the near 

future unless there is a new breakthrough in 

infant care. In any event, the high incidence of 

low birth weight infants among certain segments 

of the population suggests that there are controllable factors leading to premature delivery 

and low birth weight which, if regulated, offer the 

greatest promise of long-term results in the prevention of death and disability. 

Surveillance of records. —The recent thalidomide tragedy has projected dramatically the need 

for a continuing mechanism for the prompt detection of unusual events affecting infants. A 

system of surveillance of the incidence of congenital malformations reported on live-birth certificates and other vital records 39 has been considered a first step toward a more inclusive approach to an ongoing review of fetal and neonatal 

deaths by hospital and geographic area. 

Patterns of Care 

Diversity, complexity, and change are the 

outstanding characteristics in the patterns of 

health care in this country today. The basic relationship of the individual to a physician for 

services financed directly by the individual is 

strongly affected by the growing trend toward 

medical specialization. The rapidly expanding fund 

of medical knowledge enables each specialty to offer service of greater depth within its special area 

of competence. The public is generally eager to 

take advantage of these services and often directly 

seeks out a specialist for a particular medical 

problem. Greater understanding of what modern 

medical care has to offer has led to the development of new methods and arrangements for 

meeting the costs of medical care. In these situations the primary physician may, on occasion, 

not be readily identifiable. 

The services provided or financed by government proceed simultaneously under Federal, 

State, and local auspices. To describe these as 

levels of services would not present a fair picture of the interrelationships involved, since 

both Federal and State programs in many cases 

cover services to individuals in their home communities without involvement of any local governmental jurisdiction. In other instances Federal 

or State funds, or both, may be made available to 

local jurisdictions as outright grants or to supplement local funds. 

To complicate the picture further, voluntary 

agencies and private foundations have been prom53 
inent in almost every field of health, and each 

agency and foundation has its own policies. Some 

limit their activities to health education; others, 

to the support of research. Still others promote 

and support special clinical facilities and services 

or finance individual patient care. Coordination 

of these services is needed if continuity of care 

is to be attained in the best interest of the patient. 

SUMMARY—MEDICAL RESOURCES 

AND HEALTH PROGRAMS 

Changes in the availability and use of medical personnel, facilities and services, and the financing of medical care as relate~ to obstetrics 

and pediatrics are reviewed briefly in this 

section. Maternal and child health programs 

and services are discussed primarily in terms 

of the current situation. Highlights follow: 

Medical Manpower and Facilities 

1.	 Large increases have occurred during the 

past 10-15 years in the availability of 

specialists in the fields of maternal and 

child health. The ratio of the number of 

obstetricians -gynecologists to the number 

of deliveries has doubled since 1949, and 

the ratio of pediatricians to children under 

15 years of age rose sharply. Offsetting 

these increases is the marked reduction in 

the corresponding ratios for general practitioners. Accordingly the ratio of medical 

manpower (specialist and general practitioner) to the number of deliveries increased only slightly since 1949; the ratio 

in the case of children decreased. 

2.	 The distribution of specialists in obstetrics-gynecology and pediatrics varies 

greatly with geographic region. The highest ratios of these specialists to the number of deliveries and the number of children under 15 years of age, respectively, 

are in the Northeast. The South has the 

lowest ratio in obstetrics, and the North 

Central region has the lowest ratio in 

pediatrics. 

3.	 Nursing personnel are still in short 

supply although there have been increases 

in recent years in both professional 

nurses and practical nurses. The supply 

of public health nurses per 100,000 population has risen, mainly due to increases 

in nurses employed by boards of education. 

4. The long-term trend toward increased use 

of hospitals at time of confinement has 

continued to the present. All but 3 percent 

of the deliveries are now performed by 

physicians in the hospital. Deliveries by 

untrained midwives are almost entirely 

confined to nonwhite women, but even in 

this group they account for only 1 of 

10 deliveries. 

5.	 Major expansion has taken place in hospital facilities since World War II. This 

has affected all parts of the country. 

Initially the emphasis in hospital construction was on the needs of smaller 

communities and rural areas; recently 

attention has shifted to large centers of 

population. Hospitals in many large cities 

face an acute problem related to population changes. Migration has resulted 

in greater concentration of low socioeconomic groups in some of the large 

cities. This has increased pressures on 

prenatal clinics and obstetrical ward services. 

Financing of Medical Care 

1.	 Expenditures for health and medical care 

more than doubled in the 1950 decade. The 

proportion of the gross national product 

devoted to health and medical care expenditures rose from 4.7 percent (1950) 

to 5.4 percent (1960). About three-quarters of the expenditures for health and 

medical care are met from the private 

sector of the economy. In 1957-58, the 

most recent period for which national data 

are available, the economic burden of personal health services was heaviest in 

families with low incomes. 

2.	 Health insurance coverage has become ~ 

widespread. Three of four persons 

today have basic insurance which provides 

coverage in varying degrees of in-hospital, surgical, and obstetrical costs. No 

recent data are available concerning the 

54 
extent to which health insurance is meeting costs of maternity care. In 1957-58 

38 percent of the total expenditures for 

medical, hospital, and other health se”i._vices related to maternity were met by 

insurance (i.e ., for insured and uninsured 

persons combined). About 30 percent of 

the physician charges for obstetrical services were covered by health insurance. 

Maternal and Child Health Programs 

1.	 Chan!:es in scope of emphasis of many 

general health services at the community 

level have an impact on the health, of 

mothers and children. Included among 

these services are radiation control programs, efforts to deal with air pollution 

and other environmental health problems, 

and special programs for migrant-worker 

families. Limited public health nursing 

manpower has resulted in decreased attention on home visiting for prenatal and 

newborn care. 

2.	 A large majority of the patients of private physicians receive regular prenatal 

care from the first trimester of pregnant y. Substantial segments of women who 

are delivered in general service wards of 

municipal and voluntary hospitals obtain 

little or no prenatal care prior to the delivery. Programs are being focused on 

the indigent and medically indigent groups 

in the major metropolitan centers and in 

some rural areas. Special projects supported by Federal funds are concentrating 

on the expansion of facilities and on new 

means of providing medical care in lowincome areas. 

3.	 Special facilities are becoming more 

numerous for the study of problems of 

infertility and for dealing with problems 

of repeated pregnancy loss. Also, new 

approaches to the question of family planning are being adopted. 

4.	 Hospitals and health agencies are engaged 

in programs concerned with prematurely 

born infants and the adoption of new advances in medicine. No information is 

available on how widespread the implementation of these programs has been. 

Ill. PERSPECTIVE ON FUTURE COURSE


OF INFANT 

The outstanding characteristic of the trend 

in the infant mortality rate in the United States 

since 1950 has been the lack of large-scale reductions in the rate for any segment of the population. This is true whether one considers geography, race, or such parameters of infant mortality”as prior pregnancy history and birth weight. 

I Iigh-risk groups have fared worse in this regard 

than the better advantaged groups. But even if 

all groups had experienced similar reductions 

in their death rates, the decrease in the total infnnt mortality rate would have lagged far behind 

the improvement during the 1940’s. This situation 

raises a number of provocative questions about 

the immediate past and the potentials for the 

future. 

Why is it that during a period of great economic advancement and expanding allocation of 

economic resources to medical care (i.e., from 

1~50 to date) the infant mortality rate has underMORTALITY 

gone only minor reductions? Given the present 

state of medical knowledge and practice, is the 

irreducible minimum in infant mortality being 

approached, or are there prospects for further 

reductions in the mortality rate? Are new orientations for dealing with the problem of infant 

mortality indicated? 

There seems to be no question that we are 

dealing with a difficult” paradox when economic 

and medical care advances in the 1950’s are contrasted with what happened to the infant mortality 

rate. Reductions in the proportion of the population in the low socioeconomic classes and migration of population groups from rural areas 

with high mortality rates and relatively poor 

medical facilities to large urban centers where 

highly trained physicians and large medical institutions are located could logically have been 

expected to result in major decreases in infant 

mortality. In the 1940’s, when similar conditions 

55 
prevailed, infant mortality did decline markedly. 

There were a number of differences, however, 

between these two periods. 

During the 1940’s maternal and child health 

programs at the State and local levels were 

greatly strengthened, and infant mortality was a 

prime target of health department activities. The 

Federal Emergency Maternity and Infant Care 

Program,. designed to meet the urgent needs of 

wives and infants of men in the Armed Forces 

during World War II, helped bring regular prenatal and infant health supervision to broad segments of the population. This program ended 

after World War II. A large part of the reduction 

in infant loss was concentrated in the control of 

infectious diseases whose toll was still substantial 

at the beginning of the 1940’s. In some areas the 

introduction of special programs for the care of 

prematurely born infants also had an impact on 

the mortality rate. 

In the 1950’s a general attitude that significant 

progress in reducing infant mortality required, 

above all, new insights to basic biological processes tended to dampen the fervor for action 

programs. The 1950’s might also be characterized 

as a decade in which earlier medical and program 

advances continued without significant innovations. This occurred in the absence of major 

scientific breakthroughs that could have been expected to produce broad effects through immediate 

application. 

Finally, some of the very conditions which, 

on the surface, might be taken as harbingers of 

improvement had the reverse result. An outstanding example is the migration of nonwhite 

persons to large metropolitan areas; in these 

areas, then, infant mortality increased. The explanation is complex, encompassing many social, 

economic, and program issues. High on the list 

rn~ght well be a lag in community facilities in accommodating themselves to the change and a delay 

in the adaptation of the in-migrant group to their 

new medical care and social environment. 

Speculation about the possibility that an irreducible minimum in infant mortality is near 

generally focuses on the following conclusions: (1) 

most of the losses occur in early infancy, (2) 

many of the underlying mechanisms are poorly 

understood, and (3) reduction in the incidence 

of low birth weight is central to the problem. 

These are truisms; but to accept the irreducible 

minimum theory, one must also embrace another 

proposition: biological processes are involved 

which are not susceptible to modification through 

an alternation of environmental conditions. It 

is difficult to accept this hypothesis if environmental conditions are broadly defined to include 

not only general socioeconomic circumstances but 

also family planning, organization and availability 

of high quality medical care, and personal health 

practices of the population. 

Actually the question that needs to be posed 

is not whether there will be further reductions 

in infant mortality but whether the rate of decline 

in the mortality rate will accelerate. Reduct ions 

in infant mortality, although small, are occurring, 

and the prospects are for these to continue. Close 

to 30 percent of the infant deaths are still attributed to factors related to identifiable environmental conditions and to conditions that may 

reflect quality of medical and hospital care. 

Decreases in the frequency of deaths from these 

causes alone would have a significant effect on 

the level of the infant mortality rate. If mortality 

from infectious diseases of all types (respiratory, 

digestive, etc.), accidents and such conditions as 

hemolytic disease of the newborn and neonatal 

disorders arising from maternal disorders (diabetes, toxemia, etc.), and ill-defined diseases of 

the newborn were cut in half, the infant mortality 

rate would decline from 25.3 per 1,000 (in 1962) 

to about 22.5. 

Additional reductions would have to be sought 

primarily through decreases in the frequency of 

prematurity and in mortality attributed directly 

or indirectly to immaturity. The potential for 

such reductions is, of course, uncertain. But 

it should be recognized that only slight improvements in the rates among low-risk groups, if 

accompanied by a moderate closing of the gap 

between high- and low-risk groups, would result 

in lowering the overall mortality rate projected 

above (22 .5) to abut 20 per 1,000. 

Attainment of an infant mortality rate of 20 

per 1,000 in the United States would appear to be 

a realistic goal. General conditions that are expected to contribute to the movement toward this 

goal are continued improvements in standard of 

living, strengthening of medical and hospital resources, and the likely shift over the next few 

56 
--------

Table 1.


2.


3. 

4. 

5. 

6. 

7. 

8. 

9. 

10, 

11. 

12. 

DETAILED TABLES 

Infant mortality ratea by age at death: United States, 1935-62------------------


Infant mortality rates by age at death and sex: United States, 1935-62----------


Infant mortality rates by age at death and color: United States, 1935-62--------


Fetal death ratioa by gestation, sex, and color: United States, 1942-62---------


Perinatal mortality rates by sex and color: United States, 1942-62--------------


Average annual infant mortality rates by age at death, color, and geographic di­


vision; average annual fetal mortality ratioa and perinatal mortality rates by


color and geographic division: United States, selected decennium periods


Average annual infant mortality rates. by age at death and color: United States, 

each geographic division and State, 1959-61-------------------------------------

Average annual infant mortality rates by age at death, and color: United States,


metropolitan and nonmetropolitan counties, and cities over 250,000 population,


1950-51 and 1960-61-------------------------------------------------------------


Average annual infant mortality rates for selected cauaes of death, by age at


death, sex, and color: United States, 1959-61-----------------------------------


Percent of live birtha at birth weights of 2,500 grama or less,by age of mother,


color, and total-birth order: United Statea, January-March 1950-----------------


Neonatal mortality rates by total-birth order, color, and age of mother: United


Statea, January-March 1950------------------------------------------------------


Average fetal death rates by age of mother, color, and total-birth order: United


States, 1960-61-----------------------------------------------------------------


Page


61


62


64


66


67


68


70 

72


75


77


78


79


60

-----------------------------

Table 1. Infant mortality rates by age at death: United States, 1935-62


— 

Under Under Under


Year 1 28 1 1-6 7-27 1-5 6-11


year daysl day days days 1 months months


II II I I I I 

Rates per 1,000 live births


19622--------------------------- 25.3 18.3 10.4 6.1 5.2 1.8


1961:--------------------------- 25.3 18.4 10.3 5.2 1.8


1960---------------------------- 26.0 18.7 10.3 ;:: 5.4 1.9


19599--------------------------- 26.4 19.0 5.4 

1958---------------------------- 27.1 19.5 ;:$ 5.6 ;:: 

;;’9;---------------------------- 26.3 19.1 6.8 5.3 2.0 

26.0 18.9 6.7 

1955---------------------------- 26.4 19.1 7.0 ;:; %: 

1954---------------------------- 26.6 19.1 7.1 5.3 2.2


1953---------------------------- 27.8 19.6 7.5 2.4


1952---------------------------- 28.4 19.8 7,5 ::: 2.6


1951---------------------------- 28.4 20.0 7.7 2.5


1950---------------------------- 29.2 20.5 7.7 ?; 2.7


1949---------------------------- 31.3 21.4 10.5 2.9 

1948---------------------------- 32.0 22.2 1o.7 ;:; ;:: 3.0 

L947---------------------------- 32.2 22.8 10.7 

1946---------------------------- 33.8 24.0 11.4 ::2 ::: ;:; 

1945---------------------------- 38.3 24.3 11.2 8.5 9.6 4.4 

1944---------------------------- 39.8 24.7 11.5 8.5 10.1 4.9 

1943---------------------------- 40.4 24.7 11.6 8.4 10.5 

1942---------------------------- 40.4 25.7 12.3 8.5 2:; 

1941---------------------------- 45.3 27.7 13.2 9.0 1!:: 5.9 

1940---------------------------- 47.0 28.8 13.9 9.4 12.2 6.0 

1939---------------------------- 48.0 29.3 14.1 9.6 12.2 6.6


1938---------------------------- 51.0 29.6 14.1 13.8


1937---------------------------- 54.4 31.3 14.7 1%; 15.0 ;:;


1936---------------------------- 57.1 32.6 15.1 10.7 15.8 8.7


1935---------------------------- 55.7 32.4 15.0 10.5 15.0 8.3


~FrOQ 1935 to 1948 these categories refer to deaths at ages “7-29 days” and “under 1 month,”


res~ectively.


-Includes Alaska and Hawaii.


Source: Annual volumes Vital Statistic of the United States, National Center for Health Sta­


tistics, Public Health Service, Washington, U.S. Government Printing Office, and special tabu­


lations.


61

--------------------------

Table 2. Infant mortalityrates by age at death and sex: United States, 1935-62


Under Under Under 1-6 7-27 1-5 6-11
 Year 1 28 1


year days1 day days daya1 months months


~ Rates per 1,000 live births 

19622--------------------------- 28.6 20.9 11.7 7.L 2.0 5.8 1.9 

19612--------------------------- 28.4 20.8 11.5 7.2 2.1 5.7 1.9 

19602--------------------------- 29.3 21.2 11.6 7.4 2.2 6.0 2.1 

19592 29.6 21.6 11.6 7.7 2.3 6.0 2.0 

1958---------------------------- 30.2 21.9 11.4 7.9 2.6 6.2 2.1 

1957---------------------------- 29.5 21.6 11.1 7.8 2.6 5.9 2,1 

1956---------------------------- 29.2 21.5 11.3 7.8 2.5 5.7 2.1 

1955---------------------------- 29.6 21.7 11.2 8.1 2.4 5.7 2.2 

1954---------------------------- 29.8 21.7 10.8 8.3 2.6 5.8 2.3 

1953---------------------------- 31.2 22.3 10.9 8.7 2.7 6.3 2.6 

1952---------------------------- 31.8 22.5 11.0 8.8 2.8 6.5 2.8 

1951---------------------------- 32.0 22.9 11.1 9.0 2.8 6.4 2.7 

1950---------------------------- 32.8 23.3 L1.5 8.9 2.9 6.6 2.8 

1949---------------------------- 35.1 24.5 11.9 9.1 3.5 7.6 3.0 

1948---------------------------- 35.9 25.2 12.1 9.5 3.6 7.6 3.1 

1947---------------------------- 36.1 25.9 12.1 9.9 3.9 7.4 2.9 

1946---------------------------- 37.8 27.2 12.9 10.0 ‘4.3 7.5 3.0 

1945---------------------------- 42.7 27.6 12.6 9.9 5.1 10.5 4.6 

1944---------------------------- 44.1 27.7 12.8 9.8 5.2 11.2 5.2 

1943---------------------------- 45.1 28.1 13.1 9.7 5.2 11.5 5.5 

1942---------------------------- 44.9 29.1 13.9 9.9 5.3 10.8 5.1 

1941---------------------------- 50.4 31.2 14.9 10.4 5.9 12.9 6.3 

1940---------------------------- 52.5 32.6 15.7 10.9 6.0 13.4 6.5 

1939---------------------------- 53.3 32.9 15.8 11.0 6.1 1.3.3 7.1 

1938---------------------------- 56.7 33.4 16.0 11.0 6.4 15,1 8.2 

1937---------------------------- 60.3 35.1 16.5 11.5 7.1 16,4 8.8 

1936---------------------------- 63.4 36.8 17.1 12.3 7.4 17.4 9.3 

1935---------------------------- 62.2 36.7 17.0 12.1 7.6 16,6 9,0 

62

Table 2. Infantmortalityrates by age at death and sex: United States, 1935-62—Con.


Under Under Under 1-6 7-27 1-5 6-11
 Year 1 28 1


year days1 day days days1 months months


Female


1962:---------------------------


19612---------------------------


19602---------------------------


19592---------------------------


1958----------------------------


1957----------------------------


1956----------------------------


1955----------------------------


1954----------------------------


1953----------------------------


1952----------------------------


1951----------------------------


1950----------------------------


1949----------------------------


1948----------------------------


L947----------------------------


1946----------------------------


L945----------------------------


1944----------------------------


1943----------------------------


1942----------------------------


1941----------------------------


1940----------------------------


1939----------------------------


1938----------------------------


1937----------------------------


1936----------------------------


1935----------------------------


Rates per 1,000 live births


21,9 15.7 8.9 5.0 L.7 4.5 1.7 

22.0 15.8 9.0 5.1 1.7 4.6 1.6 

22.6 16.1 9.0 5.3 1.8 4.7 1.8 

23.0 16.3 9.0 5.5 1.9 4.9 1.8 

23.7 16.8 9.0 5.9 2.0 5.0 1.9 

23.0 16.4 8.7 5.6 2.1 4.7 1.9 

22.6 16.2 8.5 5.6 2.0 4.5 1.9 

23.0 16.4 8.8 5.8 1.9 4.7 2.0 

23.2 16.3 8.4 5.9 2.1 4.8 2.1 

24.2 16.7 8.3 6.2 2.2 5.2 2.3 

24.9 17.0 8.4 6.2 2.3 5.4 2.5 

24.7 17.1 8.4 6.4 2.3 5.2 2.4 

25.5 17.5 8.8 6.4 2.4 5.4 2.6 

27.3 18.3 9.0 6.5 2.8 6.3 2.7 

27.9 19.0 9.1 6.9 3.0 6.1 2.8 

28.1 19.5 9.3 7.1 3.2 6.0 2.6 

29.5 20.7 9.9 7.2 3.6 6.1 2.8 

33.6 20.9 9.7 7.1 4.1 8.6 4.1 

35.2 21.5 10.1 7.1 4.3 9.0 4.7 

35.4 21.2 9.9 7.0 4.3 9.3 4.8 

35.7 22.1 10.6 7.1 4,3 9.1 4.5 

40.0 23.9 11.4 7.6 4.9 10.7 5.4 

41.3 24.7 12.1 7.7 4.9 11.0 5.5 

42.5 25.5 12.4 8.2 4.9 10.9 6.1 

45.1 25.6 12.2 8.1 5.4 12.4 7.1 

48.3 27.3 12.8 8.5 5.9 13.4 7.5 

50,5 28.2 13.0 9.0 6.2 14,2 8.1 

48.9 27.9 12.8 8.8 6.3 13.4 7.6 

‘From L935 to 1948 these categcmiesrefer to deaths at ages “7-29 days” and “under 1 month,”


res~ecEively.


-IncludesAlaska and Hawaii.


Source:Annual volumes Vital Statisticsof the.UnitedStates,National Center for Health Sta­


tistic, Public Health Service,Washington, U.S. GovernmentPrinting Office, and special tabu­


lations.


63

Table 3. Infant mortality ratea by age at death and color: United States, 1935-62 

Under Under Under 1-6 7-27 1-5 6-lL Year 1 28 1

year days1 day days days1 months months 

White 

19622---------------------------

19612---------------------------

19602---------------------------

19599---------------------------

1958----------------------------

1957----------------------------

1956----------------------------

1955----------------------------

1954----------------------------

1953----------------------------

1952----------------------------

1951----------------------------

1950----------------------------

1949----------------------------

1948----------------------------

1947----------------------------

1946----------------------------

1945----------------------------

1944----------------------------

1943----------------------------

L942----------------------------

1941----------------------------

1940----------------------------

1939----------------------------

1938----------------------------

1937----------------------------

1936----------------------------

1935----------------------------

Rates per 1,000 live births 

22.3 16.9 9.6’ 5.7 1.5 4.0 1.4 

22.4 16.9 9.5 5.8 1.6 4.1 1.4 

22.9 17.2 9.6 6.0 1.7 4.2 1.5 I 

23.2 17.5 9.5 6.2 1.7 4.2 1.5 

23.8 17.8 9.5 6.4 1.9 4.4 1.6 

23.3 17,5 9.3 6.3 2.0 4.2 1.6 

23.2 17.5 9.3 6.3 1.9 4.1 1.6 

23.6 17.7 9.3 6.6 1.8 4.2 1.7 

23,9 17.8 9.0 6.8 2.0 4.3 1.8 

25.0 18.3 9.1 7.1 2.1 4.7 2.0 

25.5 18.5 9.2 7.1 2.2 4.8 2.I. 

25.8 18.9 9.3 7.3 2.3 4.8 2.1 

26.8 19.4 9.7 7.4 2.3 5.1 2.3 

28.9 20.3 10.1 7.5 2.7 6.0 2.5 

29.9 21.2 10.3 7.9 2.9 6,1 2.7 

30.1 21,7 10.4 8.2 3.2 5.9 2,4 

31.8 23.1 11.2 8.4 3.6 6.1 2.6 

35.6 23.3 11.0 8.1 4.1 8.5 3.9 

36.9 23.6 11.2 8.1 4.3 9.0 4.3 

37.5 23.7 11.4 7.9 4.4 9.3 4.5 

37.3 24,5 12.1 8.1 4.4 8.7 4.1 

41.2 26.1 12.9 8.4 4.8 10.2 4.9 

43.2 27.2 13.6 8.8 4.8 10.8 5.2 

44.3 27.8 13.8 9.1 4.9 10.7 5.7 

47.1 28.3 13.9 9.0 5.3 12,2 6.6 

50.3 29.7 14.5 9.4 5.9 13.4 7.2 

52.9 31.0 14.9 10.0 6.1 14.1 7.7 

51.9 31.0 14.8 9.9 6.3 13.5 7.4 

64 
Table 3. Infant mortality rates by age at death and color: United Statea, 1935-62--Con.


Under Under Under 

Year 1 28 1 1-6 7-27 1-5 6-11 

year days 1 day days days 1 months months 

Nonwhite Rates per 1,000 live births 

19622--------------------------- 41.4 26.1 14.3 8.1 3.6 11.5 3.8 

196i2--------------------------- 40.7 26.2 14.2 8.3 3.8 11.0 3.5 

19602--------------------------- 43.2 26.9 14.4 8.5 4.0 12.1 4.2 

1959U--------------------------- 43.7 27.5 14.5 8.8 4.2 12.1 4.1


1958---------------------------- 45.7 29.0 14.3 10.0 4.7 12.4 4.3


1957---------------------------- 43.7 27.8 13.9 9.3 4.6 11.6 4.3


1956---------------------------- 42.1 27.0 13.7 8.9 4.4 10.9 4.1


1955---------------------------- 42.8 27.2 13.9 9.1 4.2 11.3 4.3


1954---------------------------- 42.9 27.0 13.3 9,4 4.4 11.3 4.6


1953---------------------------- 44.7 27.4 12.9 9.8 4.7 12.3 5.0


1952---------------------------- 47.0 28.0 12.8 10.2 5.0 13.3 5.7


1951---------------------------- 44.8 27.3 12.7 10.0 4.6 12.2 5.3


1950---------------------------- 44.5 27.5 13.0 9.8 4.8 11.7 5.2


1949---------------------------- 47.3 28.6 12.8 10.1 5.7 13.5 5.3


1948---------------------------- 46.5 29.1 12.9’ 10.4 5.7 12.3 5.0


1947---------------------------- 48.5 31.0 13.5 11.2 6.2 12.4 5.1


1946---------------------------- 49.5 31.5 13.4 11.0 7.2 12,5 5.4


1945---------------------------- 57.0 32.0 12.7 11.3 8.0 17,3 7.8


1944---------------------------- 60.3 32.5 i3.2 11.3 8.0 18.4 9.4 

1943---------------:------------ 62.5 32.9 13.2 11.7 8.0 19.2 10.3 

1942---------------------------- 64.6 34.6 14.4 12.0 8.3 19.7 10.2 

1941---------------------------- 74.8 39.0 15.7 13.5 9.8 23.0 12.8 

1940---------------------------- 73.8 39.7 16.0 13.7 10.0 22.5 11.5 

1939---------------------------- 74.2 39.6 16.2 13.5 9.8 22.2 12.5 

1938---------------------------- 79.1 39.1 15.8 13.4 9.9 24.9 15.1 

1937---------------------------- 83.2 42.1 16.1 14.7 11.3 26.0 15.1 

1936---------------------------- 87,6 43.9 16.4 15.6 11.9 27.9 15.9 

1935---------------------------- 83.2 42.7 16.2 14.8 11.6 25.8 14.7 

lFr~m L935 to 1948 these categories refer to deaths at ages “7-29 days” and “under 1 month,” 

res~ectively. 

-Includes Alaska and Hawaii. New Jersey excluded from data for 1962; color not reported on


vital record.


Source: Annual volumes Vital Statistics of the United States, National Center for Health Statistics, Public Health Service, Washington, U.S. Government Printing Office, and special tabulations. 

65 
---

---

---

---

---

---

---

---

---

---

---

---

---

----

---

---

---

---

---

---

---

---

---

---

Table 4. Fetal death ratios by gestation, sex, and color: United States, 1942-62


Fetal death ratio 112 

Fetal 

Year death ~ Total White Nonwhite 

:atio I 

Total Male Female Total Male Female Total Male Female


19623--------------- 11.5 15.9 16.8 15.0 13.9 14.6 13.3 26.7 28.9 24.5


19613--------------- 11.6 16.1 17.0 15.2 14.1 14.7 13.5 27.0 29.4 24.6


19603--------------- 11.6 16.1 16.9 15.2 14.1 14.7 13.5 26.8 29.1 24.4


19593--------------- 11.7 16.2 17.0 15.3 14.2 14.8 13.5 27.3 29.6 25.0 

1958---------------- 11.9 16.5 17.4 15.6 14.5 15.1 13.9 27.5 30.1 24.9 

1957---------------- 12.0 16.3 17.3 15.4 14.5 15.2 13.8 26.8 29.2 24.4 

1956---------------- 12.1 16.5 17.4 15.5 14.6 15.3 13.9 27.2 29.4 24.9 

1955---------------- 12.6 17.1 18.0 16.2 15.2 15.8 14.5 28.4 31.0 25.8 

1954---------------- 12.9 17.5 18.4 16.4 15.5 16.3 14.7 28.9 31.2 26.5 

1953---------------- 13.4 17.8 18.7 16.8 15.9 16.6 15.1 29.6 32.2 27.0 

1952---------------- 13.8 18.3 19.4 17.2 16.1 16.8 15.3 32.2 35.6 28.9 

1951---------------- 14.3 18.8 20.0 17.6 16.7 17.6 15.8 32.1 35.4 28.7 

1950---------------- 14.6 19.2 20.5 17.9 17.1 18.0 16.1 32.5 36.0 28.9 

1949---------------- 15.1 19.8 21.1 18.5 17.5 18.5 16.6 34.6 38.0 31.2


1948---------------- 15.5 20.6 21.8 19.4 18.3 19.3 17.2 36.5 39.6 33.3


1947---------------- 16.1 21.1 22.5 19.6 18.7 19.8 17.4 39.6 43.1 36.0


1946---------------- 17.2 22.8 24.3 21,2 20.4 21.7 19.1 40.9 44.6 37.2


1945---------------- 18.5 23.9 25.5 22.3 21.4 22.6 20.1 42.0 46.3 37.6


19444--------------- 19.0 24.5


19434--------------- 19.3 24.5


19424----------.---- 20.1 25.6


lFetal death ratio I is defined as fetal deaths of 28 weeks or more gestation and a .Propor­
 .
 tionate number of fetal deaths of unknown gestation per 1,000 live births:


2Fetal death ratio II differs from fetal death ratio I in that it includes fetal deaths of 20


weeks or more gestation plus all not stated gestation age.


3Hawaii not available by sex for 1959. Therefore, 1959 does not include Hawaii but includes


Alaska. Alaska and Hawaii included beginning 1960. New Jersey excluded from data by color for


1962; color not reported.


qFor 1942-44,data not available by color or sex.


NOTE: Fetal deaths with sex not stated distributed proportionately.


Source: Annual volumes Vital Statistics of the United States, National Center for Health Sta­


tistics, Public Health Service, Washington, U.S. Government Printing Office, and special tabu­


lations.


66

---------------

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

1 

Table 5. Perinatal mortality rates by sex and color: United States, 1942-62
 I 

Perinatal mortality rate 112


Perinatal


Year uortality Total White Nonwhite


rate 11


1962:{---------------


1961:’


1960:]---------------


19593-..-----------.


1958----------------


1957----------------


1956----------------


1955----------------


1954----------------


1953----------------


1952----------------


1951----------------


1950----------------


1949----------------

1948----------------


1947----------------


1946----------------


1945----------------


19444---------------


19434---------------


19424---------------


Total Male Female Total Male Female Total Male Female


27.7 33.7 37.0 30.2 30.4 33.4 27.2 51.4 56.2 46.4 

28.0 34.C 37.0 30.6 30.6 33.5 27.5 51.8 56.9 46.7 

28.2 34.: 37.5 30.’8 30.9 33.9 27.8 52.2 57.5 46.9 

28.4 34.6 38.0 31.1 31.2 34.3 27.9 53.5 58.5 48.4 

28.9 3.5.4 38.6 32.0 31.9 34.8 28.7 55.0 60.3 49.6 

28.5 34.8 38.2 31.3 31.6 34.7 28.3 53.2 58.2 47.9 

28.6 34.8 38.2 31.2 31.6 34.8 28.3 52.8 58.1 47.3 

29.3 35.6 39.0 32.1 32.4 35.5 29.1 54.1 59.4 48.7 

29.5 35.9 39.4 32.2 32.8 36.1 29.4 54.3 59.5 48.9 

30.3 36.7 40.2 33.0 33.6 37.0 30.1 55.3 60.3 50.2 

30.8 37.4 41.1 33.6 34.1 37.4 30.6 58.4 64.8 51.8 

31.5 38.1 42.0 34.1 35.0 38.5 31.3 57.6 64.2 50.8 

32.2 39.0 42.9 34.8 35.8 39.5 32.0 58.1 64.4 51.7 

33.1 40.5 44.6 36.1 37.2 41.0 33.2 61.1 67.5 54.4 

34.1 41.9 46.1 37.5 38.7 42.6 34.6 63.3 69.3 57.2 

35.1 42.9 47.3 38.4 39.6 43.7 35.3 67.9 74.4 61.2 

36.9 45.8 50.3 41.0 42.6 46.9 38.0 69.6 76.2 62.9 

37.8 47.2 51.8 42.3 43.7 48.0 39.2 71.0 78.6 63.2 

38.6 44.5 

38.8 48.1 

40.5 50.0 

‘Perinatal mortality rate I is defined as infant deaths under 1 week plus fetal deaths of


28 weeks or more gestation and a proportionate number of fetal deatha of unknown gestation per


1,0~0 live births plus specified fetal deaths.


‘Perinatal mortalitv rate II differs from Derinatal :mortalitv rate I in that it includes


infant deaths under 28-days plus fetal deaths o? 20 weeks or more ~estation plus all not stated


gestation age.


‘~Hawaiinot available by sex for 1959. Therefore, 1959 does not include Hawaii but includes


Alaska. Alaska and Hawaii included beginning 1960. New Jersey excluded from data by color for


1962; color not reported.


‘For 1942-44,data not available by color or sex.


NOTE: Fetal deatha with sex not stated distributed proportionately.


Source: Derived from annual volumes Vital Statistics of the United States, National Center for


Health Statistics,Public Health Service, Washington, U.S. Government Printing Office, and special


tabulations.


67

1

Table 6. Average annual infant mortality rates by age at death, color, and geographic division; average annual fetal mor­ tality ratios and perinatal mortality rates by color and geographic division: United States, selected decennium periods 

Geographic division


Infant, feta1,and perinatal


mortality; color; and
 decennium


INFANT MORTALITY


Under 1 year


Total


1959-611------------------


1949-51-------------------


1939-41-------------------


White


1959-611------------------


1949-51-------------------


1939-41-------------------


Nonwhite


1959-611------------------


1949-51-------------------


1939-41-------------------


Under 28 daysz


Total


1959-611------------------


1949-51-------------------


1939-41-------------------


White


1959-611------------------


1949-51-------------------


1939-41-------------------


Nonwhite


1959-611------------------


1949-51-------------------


1939-41-------------------


28 days-11 months2


Total


1959-611------------------


1949-51-------------------


1939-41-------------------


White


1559-611------------------


1949-51-------------------


1939-41-------------------


Nonwhite


1959-611------------------


1949-51-------------------


1939-41-------------------


68 

Jnited New Middle East West South East West North North South South Mountain ?acific
 States England ~tlantic Central Centra1 Atlantic Central Central


25,9 22.5 24.2 24.1 22.8 30.4 31.; 2s.2 27.4 23.6


29.6 24.3 25.8 26.6 26.1 34.0 37.t 36.2 37.1 25.3


46.8 38.6 39.3 39.1 39.5 58.6 56.1 58.? 60.6 37.8


22.8 21.9 21.8 22.3 21.6 23.7 25.: 24.2 25.7 22.7


27.1 24.0 24.3 25.6 25.2 28.4 33.4 33.7 33.9 24.7


42.9 38.3 37.8 38.2 38.1 49.4 50. $
 54.1 56.7 37.1


42.5 37.5 41.9 38.2 41.4 46.5 46.9 43.5 48.7 30.4


45.5 41.2 42.2 39.4 47.6 46.9 46.8 46.3 94.4 34.5


74.3 59.2 62.8 58.3 80.5 79.7 69.7 76.1 160.1 55.1


18.7 17.1 18.5 18.0 17.1 20.7 21.2 19.5 19.2 17.4


20.7 18.6 19.6 19.4 19.3 22.4 24.1 22.6 23.3 18.7


28.5 26.0 26.2 25.7 25.9 33.5 32.2 32.0 31.5 24.9


17.2 16.7 16.8 16.9 16.5 L7.9 18.7 17.6 1s.9 16.8


19.5 18.4 18.5 18.7 19.0 20.2 22.5 21.4 22.7 18.3


27.0 25.8 25.5 25.2 25.5 30.0 30.4 29.S 30.7 24.S


26.9 27.2 30.7 26.8 26.5 27.3 27.1 26.4 23.5 21.2


27.8 31.0 30.5 26.8 27.7 27.6 27.9 27.4 34.2 23.2


39.4 37.0 37.6 34.8 39.2 41.6 36.9 41.0 52.4 28.1


7.2 5.4 5.7 6.0 5.7 9.7 10.6 8.S S.2 6.3


9.0 5.7 6.3 7.3 6.8 11.6 13.3 13.6 13.8 6.7


18.2 12.6 13.1 13.4 13.6 25.1 23.9 26.4 29.1 12.9


5.6 5.2 5.0 5.4 5.1 5.7 6.7 6,6 6.S 5.9


7.6 5.6 5.7 6.8 6.2 8.2 10.9 12.3 11.2 6.3


15.8 12.5 12.3 13.0 12.6 19.4 20.5 24.3 26.0 12.3


15.7 10.3 11.2 11.4 L4.9 19.2 19.8 17.1 25.3 9.2


17.7 10.2 11.7 12.6 19.8 19.21 18.9 18.8 60.2 11.3


34.9 22.3 25.3 23.5 41.3 38.1 32.8 35.0 107.7 27.0

------------------

Table 6. Average annua1 infant mortality rates by age at death, color, and geographic division; average amual fetal mor­


tality ratios and perinatal mortality rates by color and geographic division:United States,selected decsnnium periods-Con.


Geographic division


Infant, feta1,and perinatal


mortality; color; and East West East West
 South decennium ‘nited New iiddle North North South South [ountain tates England tlantic entra1 entra1 ,tlantic entra1 entral 

FET~ MORTALITY


Tata1


1959-611------------------


1949-51-------------------


white


1959-bll


1949-51-------------------


Nonwhite


1959-611------------------


1949-51-------------------


PERINATAL MORTALITY


Total


1959-611------------------


19/+9
-51-------------------


White


1959-611------------------


1949-51-------------------


Nonwhite


1959-611------------------


!.949-51-------------------
 ———


!,IncludeAlaska and Hawaii.


16.1 13.6 319.6 14.4 13.2 19.0 19.8 15.7 13.4 13.0


19.3 16.5 321.0 17.4 16.4 23.3 23.4 20.1 15.s 14.9


14.1 13.4 3L7.4 13.3 12.5 15.0 14.9 13.2 13.2 12.4


17.1 16.4 819.5 16.5 15.7 18.1 18.4 17.1 15.4 14.5


27.0 20.1 335.8 23.2 23.1 28.5 31.5 24.8 16.6 16.9


33.0 23.4 336.9 2S.4 32.6 35.2 35.2 32.0 22.9 20.4


34.3 30.3 437.4 31.9 29.9 3s.9 40.1 34.6 32.2 29.9


39.2 34.6 439.8 36.2 35.2 44.7 46.4 41.9 38.4 33.0


30.9 29.7 433.6 29.8 28.t 32.5 33.0 30.4 31.6 28.9


36.0 34.2 437.3 34.7 34.2 37.7 40.1 37.9 37.5 32.3


52.4 46.4 464.2 48.9 48.5 54.2 56.8 49.9 39,4 37.5


58.9 53.1 465.0 53.7 5s.5 60.7 61.0 57.6 55.8 42.8


~1939-41 age categories are under 1 month and 1-11 months, respectively.
 By excluding New York City, the following feta1 death ratios result for the Middle Atlantic division:


ml my% 

1959-61------------------- 15.8 14.8


1950-51------------------- 18,7 17.9


‘4By~xc~uding New york City, the following perinatal ~o~tality 

~ W*


1959-61------------------- 33.5 31.2


1950-51------------------- 37.3 35.7


Nonwhite


25.6


30.0


rate.=, result for the Middle Atlantic division: 

Nonwhite


54.9


59.3


NOTE: Infant mortality rates are per 1 000 live births. Fetal death ratios are all reported fetal deatha of 20 weeka or 

more gestation (plus not stated)per 1,000 !livebirths. Perinatal mortality rates are reported fetal deaths (ZO weeks or ~ore 

gestation plus not stated) plus neonatal deaths per 1,000 live births plus fetal deaths. 

SOUrCe: Annua1 volumes Vita1 Statistics of the United states, National Center for Health Statistics, public Health


Service, Washington, U.S. Government printing oftme; annual vital statistics summary of the New York City Department of


Health,


69 
-------

----------

--------------

------

------------

------

-------

--------

------

-----------

---------

-------

---------------

------------

-----------

-----------

----------

----------

---------------

-----------

-------

-------

-----------

-------------

-------

-----------

-----------

Table 7. Average annual infantmortality rates by age at death and


Under 1 year Under 28 days 28 days-n months


Area


Total White Nonwhite Total White Nonwhite Total White Nonwhite


Rates per 1,000 live births


United Statesl 25.9 22.8 42.5 18.7 17.2! 26.9 7.2 5.6 15.7
 — — _ —


New England 22.5 21.9 37.5 17.1 16.7 27.2 5.4 5.2 10.3 

Maine 25.6 25.7 a 18.8 18.9 a 6.8 6.8 a 

New Hampshire 23.4 23.4 a 17.6 17.6 a 5.8 5.8 a 

Vermont 25.0 25.0 18.6 18.7 6.4 6.4 

Massachusetts 21.8 21.3 34.3 16.6 16.3 24.0 5.2 5.0 10.3 

Rhode Island 23.3 22.8 34.2 17.1 16.9 22.3 6.1 5.9 11.8 

Connecticut 21.9 20.4 43.9 17.1 16.0 33.5 4.8 4.4 10.4 

Middle Atlantic 24.2 21.8 41.9 18.5 16.8 30.7 5.7 5.0 11.2 

New York 24.2 21.6 41.5 18.4 16.5 30.6 5.8 5.1 10.9 

New Jersey 24.2 21.4 42.3 18.5 16.6 30.4 5.7 4.8 12.0 

Pennsylvania 24.3 22.2 42.3 18.7 17.3 31.1 5.6 4.9 11.2 

East North Central--- 24.1 22.3 38.2 18.0 16.9 26.8 6.0 5.4 11.4 

Ohio 24.1 22.3 38.7 18.5 17.2 29.4 5.5 5.1 9.3 

Indiana 23.7 22.4 38.8 17.4 16.6 26.6 6.4 5.8 12.2 

Illinois 24.8 22.1 38.5 18.0 16.6 25.1 6.8 5.5 13.4 

Michigan 24.1 22.5 36.9 18.3 17.2 27.2 5.8 5.4 9.7 

Wisconsin 22.6 22.0 37.4 17.1 16.8 25.6 5.5 5.3 11.8 

West North Central--- 22.8 21.6 41.4 17.1 16.5 26.5 5.7 5.1 14.9 

Minnesota 21.6 21.4 30.4 16.1 16.1 17.6 5.5 5.3 12.8 

Iowa 21.3 21.1 35.9 16.3 16.2 23.7 5.0 4.9 12.2 

Missouri 24.6 21.6 43.5 18.1 16.3 29.2 6.5 5.3 14.3 

North Dakota 23.9 23.1 43.8 18.3 18.1 23.5 5.6 5.0 20.3 

South Dakota 25.4 22.3 63.5 17.7 17.0 27.3 7.6 5.4 36.2 

Nebraska 22.7 22.0 36.7 17.5 17.2 24.2 5.2 4,9 12,5 

Kansas 22.3 21.5 33.1 17.0 16.6 22.5 5.3 4.9 10.6 

South Atlantic 30.4 23.7 46.5 20.7 17.9 27.3 9.7 5.7 19.2 

Delaware 24.9 19.8 47.0 18.2 15.5 29.7 6.8 4.3 17,3 

Maryland 27.2 22.1 44.4 20.0 17.2 29.7 7.1 5.0 14.6 

Dist. of Columbia-- 36.2 29.4 39.4 27.4 23.4 29.3 8.8 6,0 10.1 

70

-----------

------

-----

-----

------------

------------

----------

------------

--------

-----------

----------

-------------

------------

------------

-----------

---------

------------

---------------

-------------

---------

-------------

---------

-------------

-------------

color: United States, each geographic division and State, 1959-61


Under 1 year Under 28 days 28 days-n months


Area


Total White Nonwhite Total White Nonwhite Total White Nonwhite


Rates per 1,000 live births 

Soubh Atlantic—Con. 

Virginia 29.6 24.2 45.9 20.9 18.2 29.0 8.7 6.0 17.0 

West Virginia 26.5 26.0 34.6 18.7 18.7 19.6 7.7 7.3 15.0 

North Carolina 31.7 23.1 50.3 20.6 17.4 27.5 11.1 5.7 22.8 

South Carolina 33.9 23.4 48.1 20.0 17.0 24.2 13.8 6.5 23.9 

Georgia 31.6 23.5 46.3 20.8 17.9 26.0 10.8 5.6 20.3 

Florida 30.1 24.0 46.5 21.1 18.6 27.7 9.0 5.4 18.8 

East South Central--- 31.7 25.3 46.9 21.2 18.7 27.1 10.6 6.7 19.8 

Kentucky----------- 27.7 26.1 44.0 19.7 18.8 28.6 8.0 7.3 15.4 

Tennessee 29,6 25.7 43.1 20,6 19.0 26.1 9.1 6.8 17.0 

Alabama 31.7 24.0 44.6 20.8 17.9 25.8 10.9 6.2 18.9 

Mississippi 39.4 24.9 51.8 24.3 19.2 28.6 15.2 .5.7 23.2 

West South Central--- 28.3 24.2 43.5 19.5 17.6 26.4 8.E 6.6 17.1 

Arkansas 27.1 22.2 38.6 17.4 16.2 20.1 9.7 6.0 18.5 

Louisiana 31.8 22,0 46.9 22.C 17.2 29.5 9.7 4.8 17.4 

Oklahoma----------- 24.5 22.1 39.6 17.6 16.6 23.8 6.5 5.4 15.8 

Texas-------------- 28.0 25.5 42.6 19.: 18.1 26.0 8.[ 7.4 16.6 

Mountain 27.4 25.7 48.7 19.2 18.9 23,5 8.2 6.8 25.3 

Montana 25.0 23.5 44.1 17.4 17.1 21.3 7.6 6.4 22.9 

Idaho-------------- 22.7 22.5 35.2 17.1 17.1 a 5.6 5.4 a 

Wyoming 27.4 26.6 50.9 20,8 20.5 29.6 6.6 6.1 a 

Colorado 27.5 27.0 40.9 20.9 20.6 29.3 6.6 6.4 11.6 

New Mexico 31.9 30.1 46.8 20.6 20.4 21.8 11.3 9.7 24.9 

Arizona 31.9 27.5 55.3 20.1 19.5 23.6 11.7 8.0 31.7 

Utah 20.0 19.4 43.1 15.0 14.9 20.5 5.0 4.6 22.7 

Nevada 30.2 28.3 43.6 21.5 21.3 22.9 8.7 6.9 20.7 

PacificI------------- 23.6 22.7 30.4 17.4 16.8 21.2 6.3 5.9 9.2 

Washington 23.4 22.5 37.8 17.0 16.7 22.6 6.3 5.8 15.2 

Oregon 23.7 23.4 32.0 16.8 16.8 17.6 6.9 6.6 14.4 

California 23.4 22.6 29.7 17.3 16.8 21.6 6.1 5.8 8.1 

Alaska 40.0 26,8 66.9 23.3 20.0 30.0 16.7 6.8 36.8 

Hawaii 22.9 22.1 23.3 18.0 17.6 18.2 4.9 4.5 5.1 

l~ncludes Alaska and Hawaii. 

aRates not computed, based on less than 20 deaths. 

Source: Annual volumes Vital Statistics of the United States, National Center for Health Sta­


tistics, Public Health Service, Washington, U.S. Government Printing OffIce; special tabulations


of OffLce of Health Statistics Analysis.


71

--------------

-----------

--------

----------------

----------------

-------------------

------------------

--------------------

----------------

----------------

-------------------

-------------------

Table 8. Average annual infant mortality rates by age at death and color: United Statea, metroTotal


Area 

United States


Metropolitan countieal


Nonmetropolitan countiesl


Cities by sizez


1,000,000 or more 

250,000-1,000,000 

100,000-250,000------------------

Individual cities by size3
 1.000,000 or more


New York, N.Y.4------------------

Chicago, 111.4-------------------

Loa Angeles, Calif.4-------------

Philadelphia, Pa.4---------------

Detroit, Mich.4------------------

500,000-1,000,000


Baltimore, Md.4------------------
 Houston, Tex.4-------------------


Cleveland, 0hio4-----------------


Washington, D.c.4----------------
 st. LOUiS, MO.4------------------


Milwaukee, Wia.4-----------------


San Franciaco, Calif.4-----------
 Boston, Mass.4
 Dallas, Tex.4--------------------


New Orleans, La------------------


Pittsburgh, Pa-------------------


San Antonio, Tex.4---------------


San Diego, Calif.4---------------


Seattle, Wash.4


Buffalo, N.Y.4-------------------
 Cincinnati, 0hio4----------------


250,000-500,000 

Memphis, Term


Denver, Col----------------------


Atlanta, Ga----------------------
 Minneapolis, Mien


Indianapolia,Mr$


%Zu::ziio-:.::::::::::::::::


Phoenix, Aria--------------------
 Newark, N.J----------------------
 Louisville, Ky


Portland, Oreg-------------------


Oakland, Calif-------------------


Fort Worth, Tax------------------


Long Beach, Calif----------------


Birmingham, Ala------------------
 Oklahoma City, Okla--------------


Rochester, N.Y-------------------


Toledo, Ohio---------------------
 St. Paul, Mien


Norfolk, Va----------------------


Omaha, Near----------------------


Honolulu, Hawaii8----------------
 Miami, Fla-----------------------
 Akron, Ohio----------------------


El Paso, Tax---------------------


Jersey City, N.J-----------------


Tampa, Fla-----------------------
 Dayton, Ohio---------------------


Tulsa, Okra----------------------


Witchita, Kens-------------------


Under 1 year I Under 28 days 28 days-11 months 

1960-61 1950-51 1960-61 1950-51 1960-61 1950-51 

Rates per 1,000 live birtha 

25.7 20.3 7.1 8.6 

24.7 26.> 18.4 19.6 6.2
 27.5 32.: 18.8 21.2 8.7 1!::


27.1 26.( 20.1 19.9 6.1
 27.9 27.1 20.9 21.1 6.3
 26.5 27.! 19.8 20.7 6.8


29.4 

26.0 24.< 19.2 6.5 28.4 25.1 18.9 8.6 24.1 24.t 20.1 5.8 30.7 31.1 23.5 26.< 20.2 z:?


32.6
 ::2 

6.0


8.6


8.3


:::


6.0


6.5


8.7


5.8


:::


6.5


5.9


5.9


22.7 

21.7 24.1 

22.8 R 24.3 23.7 9.7 18.9 20.1 5.7 20.4 18.9 7.4 18.8 24.2 18.4 18.6 ;:$ 19.1 31.2 25.9 24.5 1;:: 21.8 23.4 6.1 18.3 16.7 6.6 20.3 19.2 6.6 18.8 25,0 8.6 

19.0 18.5 6.6 

21.4 23.5 8.2 

20.0 1.9.4 6.2 

18.0 21.5 4.9 

17.9 19.6 18.0 18.1 ;:; 

23.3 26.2 

20.3 21.5 U 

17.8 4.0 

21.7 ;:.: 6.6 

19.5 5.4 

18.9 23:5 6.1 

21.4 21.6 7.5 

25.6 25.6 

22.9 23.1 2:? 

19.5 22,1 6.4 

19.1 21.0 6.5 

72 
---

---

---

---

---

---

---

---

--

--

DO1itan and nonmetropolitan counties, and cities over 250,000 population, 1950-51 and 1960-61


. Nhite Nonwhite 

Under 1 year Under 28 days 28 days-11 months Under 1 year I Under 28 days 28 days-11 months 

1960-61 1950-51 1960-61 1950-51 1960-61 1950-51 960-61 1950-51 I 1960-61 1950-51 1960-61 1950-51 1 

Rstes per 1,000 live births Rates per 1,000 live births


22.7 26.3 17.1 19.1 5.6 7.2 42.0 44.6 26.5 27.4 15.4 17.2
 — — —


22.0 24,2 16.9 18.4 5.8 38.6 40.0 26.8 27.8 11.8 12.2


23.8 29.1 17.5 20.1 ::: 8.9 48.4 49.6 26.1 27.1 22.3 22.5


22.5 23.3 17.0 18.0 5.5 5.3 38.4 38.3 27.7 28.6 10.7


24.2 25.2 18.6 19.8 5.6 5.4 37.7 37.4 26.9 27.1 10.7 1;:2


23.3 25.5 18.0 19.7 5.3 5.8 39.8 43.7 27.5 30.2 12.3 13.5


21.5 22.4 16.2 17.2 5.2 41.3 39.1 30.5 30.4 10.8 ;.; 

23.1 23.0 16.9 17.4 ::; 37.9 34.8 25.2 25.0 12.7 

;;.; :;.; ~ 16.9 

19.5’ 

18.9 

20.1 5.2 

5.3 ;:: 29.9 

41.2 34.9 

46.9 

22.4 

30.3 27.6 

33.4 1::: 7:3 

13.5 

24:7 24:9 19.3’ 18.8 5.5 6:1 37.0 34.6 28.1 25.8 8.8 8.9 

22.9 25.6 17.8 21.2 5.1 ::: 36.9 38.5 21.6 31.1 15.2 

24.8 23.1 19.5 17.9 5.3 38.0 34.9 30.6 25.6 ;:: 

28.3 30.5 22.4 26.0 5.9 ::: 39.4 30.3 29.5 22.6 ;:$ 7.7 

24.5 21.2 18.6 16.2 5.0 43.9 40.9 31.8 29.3 12.0 

23.2 24.9 18.4 19.8 H 34.0 33.2 25.2 22.9 8.9 5:$: 

22.8 21.2 17.0 17.1 5.8 ::: 26.3 24.1 19.6 17.9 6.7 56.2 

22.5 24.4 17.2 19.7 5.3 4.7 35.4 34.7 25.5 25.6 57.4 

23.9 24.0 19.4 18.9 4.4 5.0 36.9 44.8 25.3 35.4 1?:: 59.3 

23.4 

26.2 

27.0 

24.1 19.0 

21.7 

21.6 

20.6 4.5 

4.5 

5.3 

3.5 41.9 

39.2 

34.5 

43.6 

28.7 

29.0 25.7 

36.3 

13.2 

10.2 58.8 

57.3 

29.6 38.2 20.3 22.1 9.2 16.1 39.5 34.2 29.1 10.4 57.3 

24.3 28.0 18.4 20.6 35.2 44.9 25.5 5%:; 9.7 518.0 

23.0 24.0 16.8 18.9 ::; H 27.9 42.6 19.7 31.4 8.2 511.2 

25,3 23.8 19.3’ 18.1 6.0 40.3 33.8 29.6 523.1 10.8 510.8


23.3 25.5 18.1 20.5 5.2 5.0 35.8 26.5 27.5 15.1 ;.; 1:.:


20.3 23,9 15.0 16.8 5.3 7.0 35.7 38.3 28.1 28.7


23.7 

26.0 

29.2 

24.2 

;8.8 

;3.9 

-.. 

19.6 

20.8 

22.8 

18.7 

22.3 

8---

19.5 

6---

4.1 

5.1 

6.4 

5.5 

6.5 

6---

4.3 

6---

37.4 

38.3 

39.0 

31.2 

39.4 

6---

42.7 

26.1 

29.7 

25.8 

23.0 

26.4 

6---

30.2 

6---

11.3 

$! 

.11.1 

12.5 

24.3 25.3 1.7.8 18.0 6.5 7.3 38.5 :Gl 28.2 24.1 10:2 E; 

22.4 28.3 16.3 23.4 6.1 37.4 44.9 26.3 29.0 11.1 15.9 

22.1 

26.0 

~3.8 

,--- 17.2 

18.7 

18.1 

6--- 5.0 e::: 33.5 

36.7 

:4.: 23.7 

23.7 

21.8 

6--- 1;:: 

512.9 

6---

21,9 25.0 18.8 19.5 ;:: 5.5 46.7 4;:5 32.8 38.7 13.9 9.8 

25.2 29.3 20.2 23.4 5.8 37.1 27.2 22.9 12.6 

24.5 L9.4 18,4 16.1 :;? 29.0 %:; 18.1 528.8 51::: 54.8 

22.4 21.9 17.6 17.7 4.8 ::: 34.2 33.9 24.6 24.9 9.6 59.0 

21.8 

25.0 

23,4 

22.9 

21.6 

~8,5 

..-

26.1 

~4.5 

16.1 

18.8 

18.6 

17.9 

17.8 

~2.9 

21.1 

;8.5 

::; 

4.8 

4.9 

5.6 

6---

5.0 

5.9 

6---

48.4 

31.1 

36.6 

41.3 

30.0 

:::: 

37.2 

:2.7 

29.0 

21.0 

24.5 

29.4 

18.9 

:::: 

26.2 

26.1 

6---

M:? 

:;.; 

11:1 

51”.1 

6---

11.0 

56.5 

6---

22,0

II 24.3 

8--- 16.6 

0--- 17.9 

6--- ::: 

6--- 6!:2 & $~:: 24.4 

6--- 35.0 

6--- 56.9 

6--- 510.0 

6---

23.7 25.1 18.4 20.0 5.3 55.1 49.2 52.0 35.0 ;;.; 

24.5 25.0 19.8 21.2 3.9 30.8 36.4 24.1 5;;:: %:;


21.9 18.5 Ai 21.9 17.6


23.9 22,1 19,8 19.0 53.1 34.7 38.7 24.6 32.5 1::;


6--- 6--- 6--- 6--- 6--- 6---

25.3 22,3 19.1 18.C 40.1 60.6 28.6 49.6 11.5 5!iG 

26.5 27.3 21.7 24.1 ::: 5::2 53.8 :;.: 38.3 31.9 15.5 %1.1 

24.6 27.7 19.2 22.8 5.5 4.8 42.0 32.3 24.8 512.8 

23,3 

25.0 

;5,4 18.4 

19.7 

;:.2 -. 4.9 

5.4 6?;! 40.7 

30.0 

:5:: 25.9 

15.6 :6:6 1::; 

14.4 523.8 

6---

~::g 22.8 17.8 19.4 e!:: 3.4 @ 48.6 :::! :::? 11.9 %::


See fOOtnOtes on next psge.


73 
Footnotes for table 8.


lCounties are classified by their Standard Metropolitan Area status as of the particular de­


cennial census period for which the rates have been computed. The division between metropolitan


and nonmetropolitan counties is based on the “Standard Metropolitan Area” definition established


by the Federal Committee on Standard Metropolitan Areas (SMA). In 1950-51, except in New England,
 an SMA was a county or group of counties which contained at least one city of 50,000 inhabitants


or more. Contiguous counties were included in the SMA if they met certain criteria of metropoli­


tan character and social and economic interzration. [In New En!zlandasDecial definition wasaDvlied.)


In 1960-61 the definition changed mainl~ in that’under ce;tain circumstances an area co;tainin~


two contiguous cities with a combined population of at least 50,000 qualified the area as an SNA.


‘Cities are classified by their size as of the particular decennial census period for which


the rates have been computed.


31ndividual cicies classified bysize according to 1960 census. Data in 1950-51 column refer to


1950 only.


4Number of nonwhite inhabitants increased by at least one-third between 1950 and 1960. (Only


those cities with a population of 500,000 or more are so identified.)


5Rate based on less than 20 deaths.


6

Data not available by color.


7


Based on 1960 data only.


8


For 1950, data not available for Honolulu by place of residence.


Sources: Annual volumes V~ National Center for Health Sta­


tistics, Public Health Service, Washington, U.S. Government Printing Office; 1960 Census of Pop­


ulation, Bureau of the Census, U.S. Department of Commerce.


74

------------------------------------

------------------

--------------------

-----------------------------

--------------------------------

-----------------

------------------------------------

--------------------

--------------------------------

-----------------

Table 9. Average annual infantmortality rates for selected causes of death, by age at death,


sex, and color: United States, 1959-61


Cause of death


(7’chRevision—International


Classificationof Diseases)


Rates per 10,000 live births of


Male specifiedsex


All causes 291.0 212.2 115.7 74.2 78.8


Infectiveand parasiticdiseases-----------(OOl-l38) 3.8 0.6 0.0 0.1 0.4 3.2 

Influenzaand pneumonia,including 

pneumoniaof newborn (480-493,763) 34.6 9.9 1.2 4.0 4.7 24.7 

All other diseasesof respiratory 

system-----------------------i---­ (470-475,500-527) 7.1 0.8 0.2 0.3 0.4 6.3


Gastritisand duodenitis,etc. ----(543,571,572,764) 7.5 1.2 0.0 0.1 1.1 6.3


All other diseasesof digestive


system (530-542,544-570,573-587) 0.9 0.7 

Congenitalmalformations-------------------(75O-759) 2;:; 9.8 1;:: 6.0 1;:; 

Birth injuries (760,761) 28.1 28.0 18.4 8.9 0.7 0.1 

Intracranialand spinal injury at birth------(76O) 3.8 0.5 0.0


Other birth injury---------------------------(76l)1;:; 1::; 14.7 ::: 0.2 0.1 

Postnatalasphyxiaand atelectasis-------------(762) 53.0 52.2 31.6 19.4 0.7 

Hemol.yticdisease of newborn-------------------(77O) 5.2 3.1 ::: 0.1 

Immaturityunqualified-------------------------(776)50.0 42:; 35.0 1::: 1.6 0.3 

Neonatal disordersarising from certain 

diseasesof mother during pregnancy,


etclL-----------------------------(765-769 ,771-774) 32.0 29.1 13.6 12.9


Symptomsand ill-definedconditions----(7793,795)95) 2.6 1.0 ::; H 

Accidents (E800-E962) $:; 1.5 ::! 0.6 0.8 8.1 

Residual (140-468,590-749,E963-E985) 10.3 2.9 0.8 1.0 1.1 7.4 

Certain diseasesof early infancy----------(76O-776)179.2 “175.1 102.8 60.1 L2.2 4.0


Female


All causes 225.4 160.8 89.7 53.0 ‘,8.0 64.6


Infectiveand parasiticdiseases-----------(OOl-l38) 3.0 0.4 0.0 0.1 0.3 2.6 

Influenzaand pneumonia,including 

pneumoniaof newborn------------------(48O-493,763)27.3 7.3 0.9 2.8 3.6 20.0 

All other diseasesof respiratory 

(470-475,500-527) 5.2 0.6 0.2 0.2 0.3 4.6 

Gastritisand duodenitis,etc. ----(543,571,572,764) 6.3 1.0 0.0 0.1 0.9 5.3 

All other diseasesof digestive 

system (530-542,544-570,573-587) 0.8 0.8 ;.; 1.1 

Congenitalmalformations-------------------(75O-759) 2;:; 9.2 7.4 12.0 

19.6 19.5 1;.; 5.8 0:5 0.0 

Other birth injury---------------------------(76U 14.0 13.9 10:9 2.9 0.1 0.0 

Postnatalasphyxiaand atelectasis-------------(762) 38.0 3;.$ 23.0 13.3 0.6 

Hemolytic disease of newborn-------------------(77O) 4.9 ;:: 0.0 

Immaturityunqualified-------------------------(776)40.5 40:2 2;:: J:: . 0.3 

)’ Neonatal disordersarising from certain 

diseasesof mother during pregnancy,

etc;~-----------------------------(765-769,77l-774) 

system-----------------------i----

Birth injuries-----------------------------(76O,76l)


Intracranialand spinal injury at birth------(76O) 5.6 5.6 2.9 0.4 0.0 

22.9 20.6 

Symptomsand ill-definedconditions----(7793,795)95) 5.2 2.1 %; ::; ::; ::: Accidents (E800-E962 7.9 1.3 0.2 0.4 0.8 6.6


Residual (140-468,590-749,E963-E985 1
 8.0 2.1 0.6 0.7 0.8 5.9


I 

Certain diseasesof early infancy----------(76O-776)134.0 130.8 77.9 43.0 9.9 3.2


75

--------------------------------

--------------------------------

-----------------

Table 9. Average annual	 infant mortality rates for selected causes of death, by age at death, sex, and color:-United States, 1959-61—Con. 

Cause of death


(7th Revision—International


Classification of Diseases)


White


All causes------------------------------------


Infective and parasitic diseases-----------(OOl-l38)


Influenza and pneumonia, including


pneumonia of newborn------------------(48O-493,763)


All other diseases of respiratory


system---------------------------- (470-475,500-527)


Gastritis and duodenitis, etc.l----(543,571,572,764)


All other diseases of digestive


system-------------------- (530-542,544-570,573-587)


Congenital malformations-------------------(75O-759)


Birth injuries-----------------------------(76O,76l)


Intracranial and spinal injury at birth------(76O)


Other birth injury---------------------------(76l)


Postnatal asphyxia and atelectasis-------------(762)


Hemolytic disease of newborn-------------------(77O)


Immaturity unqualified-------------------------(776)


Neonatal disorders arising from certain diseases


of mother during pregnancy, etc.~-(765-769,771-774)


Symptoms and ill-defined conditions----(7793,795)95)


Accidents (E800-E962)


Residual----------------- (140-468,590-749,E963-E985)


Certain diseases of early inTancy----------(76O-776)


Nonwhite


All causes------------------------------------


Infective and parasitic diseases-----------(OOl-l38)


Influenza and pneumonia, including


pneumonia of newborn------------------(48O-493,763)


All other diseases of respiratory


system---------------------------- (470-475,500-527)


Gastritis and duodenitis, etc.l----(543,571,572,764)


All other diseases of digestive


system-------------------- (530-542,544-570,573-587)


Congenital malformations-------------------(75O-759)


Birth injuries-----------------------------(76O,76l)


Intracranial and spinal injury at birth------(76O)


Other birth injury---------------------------(76l)


Postnatal asphyxia and atelectasis-------------(762)


Hemolytic disease of newborn-------------------(77O)


Immaturity unqualified-------------------------(776)


Neonatal disorders arising from certain diseases


of mother during pregnancy, etc.2-(765-769,771-774]


Symptoms and ill-defined conditions----(7793,795]95]


Accidents (E800-E962)


Residual (140-468,590-749,E963-E985)


Certain diseases of early infancy----------(76O-776)


I I
 Under Under Under 1-6 7-27 28 days­
 . 28 1 11


yeir days day days days months


Rates Der 10.000 live births in


s~ecifi;d color group


228.5 172.2 95.6 60.0 16.6 56.3 

2.6 0.3 0.0 0.1 0.2 2.3 

22.9 6.6 0.8 2.8 3.0 16.3 

0.2 0.2 4.6 ::; M 0.0 0.1 ::; 3.4 

0.9 0.6 

3;:; 2;:; 1::? 1::; 

23.4 23.3 15.7 ;:; 2:; 0.0 

0.0 

1::; 1::; 1::; 3:4 ::: 42.2 41.6 24.9 15.8 ::: 

;:: 0.0 

3;:: 32:; 2;:! 1::: 1.1 0.2 

24.0 22.6 10.6 10.2 1.4 

2.8 1.1 0.5 0.4 ;:! 1.6 

7.3 1.1 0.1 :.: 0.6 

8.1 2.3 0.7 . 0.8 ::; 

141.7 139.5 83.2 48.2 8.1 2.2 

425.3 268.6 143.3 85.3 40.1 156.7 

7.9 1.5 0.1 0.3 1.1 6.4 

75.3 19.2 2.2 6.5 10.4 56.1 

11.3 0.6 10.1 

23.0 i:; ::; ::: 3.6 19.1 

0.4 0.8 

3;:: 1::; 6.4 ;:: 4.6 1;:2 

26.9 26.8 16.9 8.9 ;.: 

11.2 11.2 5.6 M 

15.7 15.6 1::: 3.4 ;.: 0:1 

64,8 63.5 4;.; 20.0 

0:3 ~:; 

7$:: 7::: 51:6 2;:: 4.3 . 

46.7 38.0 18.2 14.0 5.8 

22.2 9.2 3.8 3.2 2.2 1!?:! 

17.0 0.4 1.1 14.0 

15.0 ;:: 1.0 1.1 ::2 11.4 

241.1 230.0 130.9 71.5 27.5 11.2 

‘Includes gastritis and duodenitis., gastroenteritis and colitis,except ulcerative, age 4 weeks


and older; chronic enteritis and ulcerative colitis; diarrhea of newborn.


21ncludes neonatal disorders arising from certain diseasesof the mother during pregnancy; ill-


defined diseases peculiarto early infancy; immaturity with mention of other subsidiary condition;


and other diseases peculiar to early infancy not already shown. Ill-defined diseases peculiar to


early infancy accounted for 62 percent of these deaths.


Source: Special tabulations of the National Vital Statistics Division, National Center for


Health Statistics, Public Health Service, U.S. Department of Health, Education, and Welfare.


76

--------------------

-----------------------

-----------------------

-----------------------

-----------------------

-----------------------

-----------------------

--------------------

-----------------------

-----------------------

-----------------------

-----------------------

-----------------------

-----------------------

--------------------

-----------------------

-----------------------

-----------------------

-----------------------

-----------------------

Table LO. Percent	of live birthsatbirth weigh~s of 2,500 grams or less,by age of mother, color,


and total-birthorder: United States, January-March 1950


[Total-birth order refers to number of children ever born h nmtber, including fetal deaths. Excludes data for !dassaclmsetts] 

Birth order


Age of mother and color Total


First Second Third Fourth Fifth


and over


Total 

I All ages 7.4 7.7 6.9 7.2 7.5 7.7 

15-19 years 9.0 8.5 9.6 12.0 13.9 18.3


20-24 years 7.3 6.9 6.9 8.0 9.1 10.5


25-29 years 6.7 7.1 5.9 6.5 7.2 8.0


30-34 years 7.2 9.1 6.6 6.5 6.8 7.6


35-39 years 7.7 11.0 8.1 7.2 6.9 7.1


40-44 years 7.7 13.7 8.2 7.0 7.8 6.8


White


All ages 7.0 7.2 6.5 6.9 7.4 7.4


15-19 years 8.0 7.6 8.6 12.5 16.7 a


20-24 years 6.9 6.5 6.5 7.8 9.2 10.7


25-29 years 6.5 6.9 5.7 6.4 7.1 8.0


30-34 years 7.0 8.9 6.4 6.3 6.8 7.3


35-39 years 7.5 10.9 8.1 7.1 6.8 6.7


40-44 yeara 7.5 13.1 7.9 6.5 7.6 6.7


Nonwhite


All ages ‘9.7 11,8 10,1 8.9 8.3 8.5


L.5-L9yeara 12.0 12.2 11.5 11.5 12.4 16.3 

20-24 years 9.6 11.1 9.6 8.6 .8.7 L.O.2 

I 25-29 years 8.4 11.0 8.9 8.0 7.4 7.9 

30-34 years 8.8 11.6 9.8 9.1 7.5 8.3 

35-39 years 9.0 13.2 8.3 9.8 8.4 8.7 

40-44 years----=------------------ 8.9 a 13.0 16.2 10.0 7.5 

I 

aRates not computed, less than 10 deaths.


NOTE; Figures for birth weight, birth order, and age of mother not stated are distributed.


Figures for age of mother under 15 years of age and 45 years and over are not shown separately


but are included in totals for groups.


Source: National Office of Vital Statistics: Weight at birth and survivalof newborn, by age


of mother and total-birthorder, by J. Loeb. Vital Statistics—SpecialReports, VO1. 47, No. 2.


Public Health Service.Washington,D.C., 1958.


77 
--------------------------

--------------------------------

--------------------------------

-------------------------------

--------------------------

--------------------------------

--------------------------------

-------------------------------

--------------------------

--------------------------------

--------------------------------

-------------------------------

Table 11. Neonatal mortality rates by total-birth ordeq color, and age of mother: IJnitedStates,


January-March 1950


[Based IX deaths under 28 days anmng children bmn Jautimy 1 to March 31,1950. ‘1’ottd-birth order refers to number of children over born tI, 

mother, including fetal deaths. Excludes data for Massacbusettsl 

II Age of mother 

Birth order and color All ages 

Total 

Total


First


Second-------------------------------


Third


Fourth


Fifth and over-----------------------


Total


First


Second-------------------------------


Third


Fourth


Fifth and over-----------------------


Nonwhite 

Total 

First


Second-------------------------------


Third


Fourth


Fifth and over----------------------­


‘Rates not computed, less than 10 deaths. 

15-19 20-24 25-29 30-34 

years years years yeara 

II I I 1 EEl__5 

Rates per 1,000 live births in specified group


20.C 23.8 19.0 17.6 20.0 23.6 27.2 —- —. 

19.1 21.2 16.6 17.3 24.1 28.7 30.9 

17.8 28.1 18.2 14.3 16,1 20.3 25.3 

19.7 35.3 22.0 17.7 16.9 19.8 26 .:+ 

21.1 45.2 24.9 19.6 18.8 21.5 23.6 

26.9 68.8 35.8 25.5 25.5 26.1 28.1) 

18.9 22.3 18.0 16.7 18,9 22.6 26. I. —. 

17.8 19.8 15.5 16.4 22.3 28.1 29, [I 

16.9 27.2 17.5 14.0 15.2 20.2 26.:1 

19.3 41.4 22.5 17.1 16.8 19.9 25. !I 

20.: 49.0 25.9 18.8 18.5 20.1 22.1. 

26.0 a 37.5 25.9 24.4 24.9 26.!i 

26.7 28,3 24.8 24.6 28.7 29.9 35.[1 —-

28.9 26.6 27.7 31.8 49.2 37.2 a 

25.4 29.9 23.5 20.3 32.6 22.5 a 

22.3 28.6 20.5 23.9 18.7 19.0 a’ 

25.0 43.2 22.9 23.6 21.7 38.3 a. 

29.1 a 34.3 24.9 28.7 30.3 34.! 

‘1 

NOTE : Figures for birth order and ageof mother not stated are distributed. Figures for age of 

mother under 15 years of age and 45 years and over are not shown separately but are included ir 

totals for groups. 

Source: National Office of Vital Statistics: Weight at birth and survival of newborn, by age 

of mother and total-birth order, by J. Loeb. Vital Statistics—Special Reports, Vol. 47, No. 2. 

Public Health Service. Washington, D.C., 1958.


78

------------------------

-------------------------------

------------------------------

-------------------------------

------------------------------

-------------------------------

----------------------

-------------------------

-------------------------------

------------------------------

-------------------------------

------------------------------

-------------------------------

----------------------

-------------------------

-------------------------------

------------------------------

-------------------------------

------------------------------

-------------------------------

----------------------

Table 12. Average fetal death rates by age o;9~tl&, color,and total-birthorder: United States,


[Imdudwonly fetal deaths for
which the period of gestation was giwm =S W weeks (or 5 months) or more cmwas not stated. Total-birth order 

refers to number of children ever born @mother, includirrg fetal deaths] 

Age of mother


Color and birth order All agesl


Total


Total


First


Second


Third


Fourth


Fifth


Sixth and over


White


Total


First 

Second


Third


Fourth


Fifth


Sixth and over


Nonwhite


Total


First


Second


Third


Fourth


Fifth


Sixth and over


15-19 20-24 25-29 30-34 35-39 40-44


yeara years years years years years


Rates per 1,000 live births and fetal deaths


in specifiedgroup


15.8 13.7 11.9 14.2 19.0 26.8 38.5 

15.5 13.8 13.0 17.8 30.0 46.6 60.2 

11.2 12.2 9.4 10.7 14.6 21.0 32.2 

13.2 16.3 11.3 11.5 14.5 21.4 32.2 

16.0 23.1 14.4 13.9 15.8 21.9 31.0 

19.1 47.3 17.3 16.2 18.7 23.8 33.0 

28.8 72.7 23.3 22.4 25.2 31.6 43.4 

13.9 11.7 10.6 12.6 16.6 23.4 34.3 

13.8 12.1 11.8 16.3 26.9 41.8 56.2 

10.1 10.0 8.5 9.9 13.3 19.2 29.7 

12.1 12.7 10.2 10.6 13.4 19.7 30.3 

14.7 17.4 12.6 12.7 14.6 20.3 29.4 

1.7.5 30.4 15.1 14.6 16.7 22.0 30.7 

24.0 41.2 20.3 19.0 21.0 26.3 37.5 

26.2 20.9 19.7 24.1 33.1 45.5 61.7 

26.5 21.2 25.1 32.4 57.6 88.4 96.7 

19,0 18.3 16.4 19.5 27.9 39.3 63.3 

20.5 22,1 16.3 20.6 27.5 41.6 54;6 

23.3 28.7 19.5 21.7 27.9 39.0 50.0 

26.1 60.1 21.0 22.0 31.5 38.4 57.4 

36.5 101.0 26.2 27.7 34.4 46.4 62.4 

lInclu&s data for age groupa under 15 yeara and 45 Years and over. 

NOTE: Data for Massachusettsare included only in the totals by age of mother because this


State did not require the reportingofbirth order. Figures for birth order not stated (for States


other than Massachusetts)and for age of mother not stated are distributed.


Source: Annual volumes Vital Statistic of the United States, National Center for Health Sta­


tistics,Public Health Service,Washington,U.S. GovernmentPrinting Office.


79

-----------------------------------

-----------------------------------------

-------- ---------------- --------

----------------------------------- -------------

-------------------------------------------------------

---------------------------------------------------------

-------------------------------------------------------

-------------------------------------

-------------------------------------------------

----------------------------------------------------

---------------------------------------------------

---------------------------------------------- ---

APPENDIX TABLES 

Table I. Percent distributionof the population,by educational attainmentand family income:


United States, 1940, 1950, 1960


Educationalattainmentand family income 1960	 I 1950 I 1940 I I 

Years of school completed Percent distribution


Persons 25 years and over 100.0 

No school years completed


Elementary school:


6 years or less ------.- ---.---- -


7-8 years .------


High School:


1-3 years


4 years


College:


1-3 years


4 years or more-------------------------------------------------


Median school years completed


Family income


0.9


8.1


17.0


21.9


32.6


10.1


9.4


11.7


All incomes 100.0


$2,000 or less 13.1


$2,OOO-$3,999----------------------------------------------------- 17.8


$4,ooo-$5,999-----------------------------------------------------23.3


$6,OOO-$6,999----------------------------------------------------- 10.7


$7,ooo-$9,999-----------------------------------------------------20.1


$10,000 or more 15.0


Median family income $5,657


100.0 100.0 

1.1 2,2


12.6 L7.4


23.5 32.9


20.6 18.3


26.2 17.3


8.7 6.5


7.3 5.4


10.5 8.4


100.0 11OO.O 

29.3 49.9


38.6 33.1


19.9


I


4,3 , 14.7


4.9 1


3.1 2.3


$3,083


lBasedon 1942 study by Office of Price Administration
, which based its estimateson income of


all civilian consumersexcept those in institutions.


NOTE: All data are for conterminousUnited States.


Source:Decennial census reports of Bureau of Census, U.S. Departmentof Commerce.


80

I 

Table II. Estimated rattos of illegitimate live births, by color and illegitimacy rates: United


States, 1940, 1945, and 1950-62


Year


L962;'4-------------------------------------------------


1961’]
 .--------------.------------------------------.---.


1960’] .---.-------------
-.------------------------------.


19593------------------.------------------.------------


l958---------------------------------------------------


l957---------------------------------------------------


l956---------------------------------------------------


l955---------------------------------------------------


l954---------------------------------------------------


L953---------------------------------------------------


l952---------------------------------------------------


1951---------------------------------------------------


1950---------------------------------------------------


l945------------------------------------------Y--------


1940---------------------------------------------------


‘Per 1 000 total live births in specified group.


Ratiol


.ate2


Total White Nonwhite


58.8 27.5 229.9 21.5


56.3 25.3 223.4 22.6


52.7 22.9 215.8 21.8


52.0 22.1 218.0 22.1


49.6 20.9 212.3 21.0


47.4 19.6 206.7 20.9


46.5 19.0 204.0 20.2


45.3 18.6 202.4 19.3


44.0 18.2 198.5 18.3


41.2 16.9 191.1 17.0


39.1 16.3 183.4 15.6


39.1 16.3 182.8 15.1


39.8 17.5 179.6 14.1


42.9 23.6 179.3 10.1


37.9 19.5 168.3 7.1


~Per 1~000 unmarried female population aged 15-44 years,enumeratedas of April 1 for 1940,1950,


and 1960, and estimated as of July 1 for all other years.


3Alaska included beginning 1959; Hawaii, 1960.


‘Figures by color exclude data for residents of New Jersey because this State did not require


reporting of the item.


Source: Annual volume Vital Statiaticsof the United States, National Center for Health Statis­


tics, Public Health Service, Washington, U.S. Government Printing Office.


81

-----------------------------

------------------------------

------------------------------

------------------------------

.-

Table 111. Live births and birth rates by color: United States, 1935-62 1


[Rates for1940,1950, .snd 1960basedonpopulation emmemtedm ofApril 1;fordlother yews estimated
 asofJuly1]


Number Hates per 1,000 population*


Year


Total White Nonwhite Total White


196223----------------------------
 4,167,362 3,394,068 641,580 22.4 21.4


19612-----------------------------
 $>268,326 3,600,864 667,462 23.3 22.2


19602 $>257>850 3,600,744 657,106 23.7 22.7


19592-----------------------------
 4,244,796 3,597,430 647,366 24.o 22.9


1958------------------------------
 $,203,812 3,572,306 631,506 24.3 23.2


1957------------------------------
 $>254,784 3,621>456 633,328 25.0 23.9


1956 $,163,090 3,545,350 617,740 24.9 23.8


1955------------------------------
 $,047,295 3,458,448 588,847 24.6 23.6


1954------------------------------
 4,017,362 3,443,630 573,732 24.9 23.9


1953------------------------------
 3,902,120 3,356,772 545,348 24.7 23.7


19!)2------------------------------
 3,846,986 3,322,658 524,328 24.7 23.9


1951------------------------------
 3,750,850 3,237,072 513,778 24.5 23.6


1950------------------------------
 3,554,149 3,063,627 490,522 23.6 22.7


1949------------------------------
 3,559,529 3,083,721 475,8o8 23.9 23.2


1948------------------------------
 3,535>068 3,080,316 454,752 24.2 23.5


1947------------------------------
 3,699,940 3,274,620 425,320 25.8 25.5


1946------------------------------
 3,288,672 2,913,645 375,027 23.3 23.0


1945------------------------------
 2,735,456 2,395,563 339,893 19.5 19.1


1944------------------------------
 2,794,800 2,454,700 340,100 20.2 19.8


1943------------------------------
 2>934,860 2,594,763 340,097 21.5 21.2


1942------------------------------
 2,808,996 2,486,934 322,062 20.8 20.6


1941 2,513,427 2,204,903 308,524 18.8 18.4


1940------------------------------
 2,360,399 2,067,953 292,446 17.9 17.5


1939------------------------------
 2,265,588 1,982,671 282,917 17.3 16.9


1938------------------------------
 2,286,962 2,005,955 281,007 17.6 17.2


1937------------------------------
 2,203,337 L,928,437 274,900 17.1 16.7


1936 2,144,790 1,881>883 262,907 16.7 16.4


1935------------------------------
 2,155,105 1,888,012 267,093 16.9 16.5


lFor lgL1-46 based on population including Armed Forces abroad .
 2Alaska included beginning 1959; Hawaii, 1960. 

3Figures by color exclude data for residents of New Jersey because this State did not require


reporting of the item.


Source:Annual volume Vital Statisticsof the United States,NationalCenter for Health Statis.


tics, Public Health Service,Washington,U.S. GovernmentPrinting Office.


82

Table IV. Birth rates by live-birth order and color: United States, selected years, 1940-60


~l~atcw amlive births per1?000 female population aged15-44 years, enumerated asof April 1 for 194G, 195G, and 1960, and”estimated as of July

1 for other years. Live-hmth order refers to number of children born alive to mother. Figures for births of order not stated are distributed, including births that occurred in Massachusetts] —.. ——. ..— .— 

Live-birth order 

Year and color Total


Total


1960--------------------


1955--------------------


1950--------------------


1945--------------------


1940--------------------


White


1960--------------------


1955--------------------


1950--------------------


1945--------------------


1940--------------------


NonwhLte


1960--------------------


L955--------------------


1950--------------------


1945--------------------


Sixth Eighth 

First Second Third Fourth Fifth and and 

seventh over 

118.0 31.1 29.2 22.8 14.6 8.3 7.6 4.3


118.0 32.7 31.7 23.0 13.3 7.2 6.3 3.8


106.2 33.3 32.1 18.4 9.2 4.8 4.7 3.6


85.9 28.9 22.9 13.4 7.5 4.5 4.8 4.0


79.9 29.3 20.0 10.9 6.4 4.1 4.8 4.3


113.2 30.8 29.2 22.7 14.1 7.5 6.1 2.8


113.3 32.5 31.9 22.8 12.5 6.2 4.9 2.5


102.3 33.3 32.3 17.9 8.4 4.1 3.7 2.5


83.4 29.0 23.3 13.2 7.0 3.9 4.0 3.0


77.1 29.4 20.0 10.5 5.9 3.6 4.1 3.5


153.6 33.6 29.3 24.0 18.6 14.1 18.4 15.6


154.8 34.8 30.5 24.4 19.2 14.5 17.3 13.9


137.3 33.8 30.3 22,9 15.3 10.4 12.6 12.0


106.0 27.9 20.1 14.7 11.3 8.7 11.3 11.9


J.940-------------------- 102.4 28.6 19.6 14.1 10.5 7.8 10.4 11.3


NOTE: Rates for 1960 are based on registered births. Rates for all other years are adjusted


for underregistration.


Source: Annual volume Vital Statistics of the United StatesJNational Center for Health Statis­


tics, Public Health Service, Washington, U.S. Government Printing Office.


83

--------------------

------------

-------------------------------------------------------

-------- -----------------

--------------------------- ---------------------------

------------------------ -------------------------

---

---

---

Table V. Percent distribution of female population,by labor force status and educational attain­


ment: United States, 1940, 1950, 1960


= 

Labor force status and educational attainment


Labor force status


Total female population aged 14-44 years


In labor force----------------------------------------------------


Not in labor force------------------------------------------------


With own children under 6 yeara of age


Married women, husband present, aged 14-44 years


In labor force----------------------------------------------------


Not in labor force------------------------------------------------


Educational attainment: years of school completed


Total female population aged 25-44 years--------------------


NO school years completed-----------------------------------------


Elementary school:


8 yeara or less-------------------------------------------------


High school:


1-3 years


4 years --.-..=..- ------------------.-----


College:


1-3 yeara
 -


4 years or more


Median school years completed-------------------------------------


1960 1950 1940


Percent distribution 

100.0 100.0 100.0 —-—. 

36.7 33.0 30.3


63.3 67.0 69.7


100.0 100.0
 —._


19.1 10.5


80.9 89.5


100.0 100.0 100.,) —.—. 

0.7 1.0 l,lj 

20.5 31.3 45.1


22.4 21.4 19.7


39.3 31.2 2(3*1)


10.2 9.0 7*.i


6.9 6.1 4.”7
 —-


11.8 11.1 9.()


Source: Decennial census reports of Bureau of Census, U.S. Department of Commerce.


84

-------------------------------

-----------------------------------------------------------

-------------------------------

Table VI. Percent distribution of the population, by residence 5 years prior to census date and


color: United States, 1960


Residence in 1955 Total White Nonwhite


Percent distribution


Population aged 5 years and over, 1960--------------------------- 100.0 100.0 100.0 

Same house as in 1960------------------------------------------ 49.9 50.1 48.0 

Different house in United States 47.3 47.2 48.4 

Same county-------------------------------------------------- 29.8 28.9 37.6 

Different county--------------------------------------------- 17.4 18.3 10.7 

Same State------------------------------------------------- 8.5 9.0 4.7 

Different State-------------------------------------------- 8.9 9.2 6.1 

Abroad 1.3 1.3 1.0 

Moved, 1955 residence not reported 1.6 1.4 2.7 

Source: Decennial census report of Bureau of Census, U.S. Department of Commerce.


85

-----------------------------------------------------------

------------------------------------------------ --------

-----------------------------------------------------------

---------------------------------------------------------------------

--------------------------- ---

---------------------------------------------------------------------

-----------------------------------------------------------

---------------------------------------------------------------------

---------------------------------------------------------------------

-----------------------------------------------------------

--------------------------- --------------------------- ---------------

--------------------------------------------------

---------------------------------------------------------------------

--

Table VII. Percent distribution of the population,by type of area and color: United States, 19(,o
 — — 

Type of area and color


Total


All areas


Metropolitan areas


Nonmetropolitan areas-----------------------------------------------------


Total


All areas


Urban


Within urbanized areas--------------------------------------------------


Central cities--------------------------------------------------------


Urban fringes---------------------------


Outside urbanized areas-------------------------------------------------


Rmal


White


All areas


Urban


Within urbanized areas--------------------------------------------------


Central cities--------------------------------------------------------


Urban fringes---------------------------------------------------------


Outside urbanized areas-------------------------------------------------


Rual


Nonwhite


All areas


Urban


WithinUrbanized areas


Central cities--------------------------------------------------------


Urban fringes---------------------------------------------------------


Outside urbanized areas-------------------------------------------------


Raal


Percent distributioxl


100,0— 

63,0


37 0


100.0 

69,9


53.5


32,3


21,1


16,4


30,1


100,0
 —


69,5


52,7


30,0


22,8


16,8


30,5


100,0
 —


72,4


58,9


50,5


8,4


13,5


27,6
 —


Source: Decennial census report of Bureau of Census, U.S. Department of Commerce.


86

---------------------------------------------------------

-----------------------------------------------------

--------------------------------------------------------------

---------------------------------------------------------

-----------------------------------------------------

-------------------------------------------------------------

--------------------------------------------------------------

---------------------------------------------------------

-----------------------------------------------------

-------------------------------------------------------------

--------------------------------------------------------------

Table VIII. Percent distribution of the population, by geographic region and color: United States,


1940, 1950, 1960


Region and color 19601 I 1950 I 1940 

United States Percent distribution


All regions------------------------------------------------- 100.0 100.0 100.0 

Northeast 24.9 26.1 27.2


North Central 28.8 29.4 30.4


South------------------------------------------------------------- 30.7 31.2 31.5


West 15.6 13.3 10.9


White


All regions------------------------------------------------- 100.0 100.0 100.0 

Northeast 26.1 27.7 29.2 

North Central 30.2 31.2 32.7 

South 27.4 27.3 26.8 

West 16.3 13.8 11.3 

Nonwhite 

All regions------------------------------------------------- 100.0 100.0 100.0 

Northeast 15.4 13.2 10.5


North Central 17.6 14.9 11.2


South 56.1 65.7 74.4


west 10.8 6.3


1


Includes Alaska and Hawaii.


Source: Decennial census reports of Bureau of Census, U.S. Department of Commerce.


87


U.S. GOVERNMENT PRINITNG OFFICE :1965 0- 76 S-022 

4.0 
OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS€

Public Health Service Publication No. 1000€

Sevies 1. 

Series 2. 

Series 3. 

Series 4. 

Series 10. 

SeYies 11. 

SeVies 12. 

Sevies 20. 

SeVies 21. 

bevies 22. 

Pvog~ams and collection p~oceduves. —Reports which describe the general programs of the Nation~l 

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and 

other material necessary for understanding the data. 

Reports number 1-4 

Data evaluation and methods reseavch. —Studies of new statistical methodology including: experimental 

tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, 

objective evaluations of reliability of collected data, contributions to statistical theory. 

Reports number 1-12 

Analytica[ studies. — Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. 

Reports number l-4 

Documents and committee vepo)’ts.-Final reports of major committees concerned with vital and health 

statistics, and documents such as recommended model vital registration laws and revised birth and 

death certificates. 

Reports number 1 and 2 

Data From the Health Interview Survey .—Statistics on illness, accidental injuries, disability, use of 

hospital, medical, dental, and other services, and other health-related topics, based on data collected in 

a continuing national household interview survey. 

Reports number 1-23 

Data From the Health Examination Suvvey.—Statistics based on the direct examination, testing, and 

measurement of national samples of the population, including the medically defined prevalence of specific diseases, and distributions of the population with respect to various physical and physiological 

measurements. 

Reports number 1-11 

Data F~om the Health Reco~ds Su~vey. —Statistics from records of hospital discharges and statistics 

relating to the health characteristics of persons in institutions, and on hospital, medical, nursing, and 

personal care received, based on national samples of establishments providing these services and 

samples of the residents or patients. 

Reports number 1 and 2 

Data on mortality. —Various statistics on mortality other than as included in annual or monthly reports— 

special analyses by cause of death, age, and other demographic variables, also geographic and time 

series analyses. 

No reports to date 

Data on natality, rnan’iage, and divorce. — Various statistics on natality, marriage, and divorce other 

than as included in annual or monthly reports— special analyses by demographic variables, also geographic and time series analyses, studies of fertility. 

Reports number 1-6 

Data From the National Natality and Mortality Surveys. —Statistics on characteristics of births and 

deaths not available from the vital records, based on sample surveys stemming from these records, 

including such topics as mortality by socioeconomic class, medical experience in the last year of life, 

characteristics of pregnancy, etc. 

Reports number 1 

l-or a list of titles of reports published in these series, write to:	 National Center for Health Statistics 

U.S. Public Health Service 

Washington, D.C. 20201