PROPERWOFTHE


NATIONAL CENTER series 3 

For HEALTH STATISTICS INumber 6 

PUBLICATIONSBRANCH 

EDITORIALLIBRARY 

VITAL and HEALTH STATISTICS 

ANALWICAL STUDIES 

International Comparison of


Perinatal and Infant Mortality: 

The United States and 

Six West European Countries 

Comparison of the components of perinatal and infant mortality in 

the United States with those of six west European countries, including their registration systems, demographic characteristics, 

mortality experience, and certain selected aspects of medical and 

obstetric care. 

Washington, D. C. March 1967 

U.S. DEPARTMENT OF 

HEALTH, EDUCATION, AND WELFARE 

John W. Gardner 

Secretary 

Public Health Service 

William H. Stewart 

Surgeon General 
Public Health Service Publication No. 1000-Series 3-No. 6 
NATIONAL CENTER FOR HEALTH STATISTICS 

FORREST E.LINDER, PH.D.,Di~ecto~


THEODORE D.WOOLSEY, Deputy Director 

OSWALD K.SAGEN,PH.D.,Assistant Director 

WALT R.SIMMONS,M.A.,.$kztistimzl Advisor 

ALICE hi. WATERHOUSE, M. D.,Medical Consultant 

JAMES E.KELLY, D.D.S.,Dental Advisor 

LOUISR.STOLCIS,M.A.,Executive O//icer 

DONALD GREEN, bz/ormation O//icer 

OFFICEOF HEALTH STATISTICS ANALYSIS 

IWAOM. MORIYAMA,PH.D., Cbie/ 

D1VIS1ONOF VITAL STATISTICS 

ROBERT D. GROVE,PH.D.,Chief 

DIVISION OF HEALTH INTERVIEW STATISTICS 

PHILIPS.LAWRENCE.Sc.D.,Cbie/


DIVISION
OF HEALTH RECORDS STATISTICS


MONROE G. SIRKEN,PH.D., Chief


DIVIS1ON
OF HEALTH EXAMINATIONSTATISTICS 

ARTHUR J.MCDOWELL, Chief 

DIVISION OF DATA PROCESSING 

LEONARD D. MCGANN, Chic/ 

Public Health Service Publication No. 1000-Series 3-No. 6 

Library of Congress Catalog Card Number 66-60008 
PREFACE


This report is one of a group of analytical studies designed to 

delineate the perinatal and infant mortality problem in the United 

States. Since 1950, there has been a notable change inthe trend in 

infant mortality—rates are no longer declining at their former pace 

in this country as well as in a number of other countries. 

Although the primary concern is perinatal and infant mortality 

in the United States, it was felt that much could be learned from the 

experience of other developed countries with advanced medicals ystems. 

The National Center fdr Health Statistics contracted with investigators in some west European countries to analyze their own infant 

and perinatal mortality experience. Completion of these studies 

culminated in the Conference on the Perinatal and Infant Mortality 

Problem of the United States which was held in Washington, D.C., 

May 13-14, 1965. The present report is a direct result of the conference: it compares the experience of six west European countries 

and the United States with regard to this important problem. 

The author is indebted to the investigators and the vital statistics offices of the countries included in this report. Much of the 

European data which is included was derived from the following: 

Backer, J. E., and Aagenaes, d.: “Infant Mortality problems in 

Norway” 

de Haas-Posthuma, J. H., and de Haas, J. H.: “Infant Loss in the 

Netherlands” 

Douglas, C. A.: “Perinatal and Infant Mortality in Scotland” 

Hirst, K. M., Butler, N. R., and Davlcim, M JR.: “Infant and perinatal Mortality in England and Wales” 

Matthiessen, P. C., Trolle, D., and Zachau-Christiansen, B.: “Infant and Perinatal Mortality in Denmark” 
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CONTENTS 

Page 

Preface


I.


H. 

III. 

Intrtiuction 

Selected Countries


Population


Medical Care ----------------------------------------------------

Evaluation of Basic Data -------------------------------------------

Definitions of Live Birth


Informant -


Administration


Comparison of RegistiationMethods


Netherlands


Norway


United States


Registration of Fetal Deatk


SWtistical Practice


Computation of Rates


Infant Mortality


Perinatal Mortality


Fetal Mortality


Neonatal Mortality


Postneonatal Mortali~-------------------------------------------


Relative Importance of llifferences


Perinatal and Infant Mortality by Age--------------------------------

Infant Mortality


Perinatal Mortali~------------------------------------------------


Fetal Mortality


Mortality Under l~y--------------------------------------------


Mortality l-6 Days -----------------------------------------------


Components of Perinatal Mortality


Mortality 7-27 Days -----------------------------------------------


Pos~eonatal Mortali~---------------------------------------------


Summary


i 

1 

2 

2 

5 

8 

8 

10 

10 

11 

12 

12 

13 

14 

17 

19 

19 

20 

20 

20 

21 

21 

22 

22 

24 

24 

28 

30 

30 

32 

33 

34 
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CONTENTS—Con. 

IV. Infant Mortality by Cause


Leading CauseSof Death, 1959-61-----------------------------------


Infant Mortality by Cause, l95O-64----------------------------------


Neonatal Mortality by Cause, 1950-64--------------------------------


Postneonatal Mortality by Cause, 1950-64----------------------------


Discussion


V. Assmiated DemographicFactors


Geographic Variation


Color


Sex ---


Maternal Age and Parity


Low BirthWeight


Mortality by Birth Weight -----------------------------------------


Incidence of Low Birth Weight Infants


Other Related Factors


Previous Loss


Socioeconomic Differences


Illegitimacy


Discussion


Summary


VI. Medical Care and Obstetric Practice


Medical Care


Prenatal Care


Place of Mlivery


~ration of HospitalStay


Attendant


Postnatal Care-


Obstetric Practice


Cesarean Section


Forceps


Episiotomy


Analgesia andAnesthetics


Discussion


Page 

36 

36 

40 

41 

46 

48 

50 

50 

53 

55 

55 

59 

61 

62 

64 

67 

67 

69 

70 

71 

73 

73 

73 

76 

76 

78 

79 

79 

80 

80 

81 

81 

81 
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CONTENTS—Con. 

Page 

VII. Possible Areas ofhvestigation 83


ProminentCause Groups 83


Low Birth Weight and Prematurity 85


Medicaland ObstetricCare 85


Registration 85


Conclusion - 86


VIII. Summary and Conclusion 87


References 89


Appendix. Medical Care Programs, 1964--------------------------------- 92 
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IN THIS REPORT, thepevinatal andinfant mortality expedience of the 

United States is compared with that of a group of west European countries having advanced medical systems and well-established vital statistics systems. The countyies selected for study we~e Denmark, E~­

land and Wales, the Netherlands, Norway, Scotland, and Sweden. In 1964, 

the infant moytality rate foy the United States was highest among the 

seven countvies, and 75 peycent highev than the lowest rate, that for 

Sweden. Even when the comparison was limited to white infants in the 

United States, its rate was 52 peycent highey than thatfoy Sweden. Clearly, 

the highev Yate in this countvy cannot be attributed entiyely to nonwhite 

infhnts. 

In each of the countries, tvends for the components of peyinatal and infant moytality have declined moye slowly since 1950 than between 1935 

and 1950. Fu?’theYmoYe, in recent yeans the pe?’inatal mortality Yate for 

the Unites States has declines moye slowly than those of all of the othey 

countyies except Norway. 

In the United States, mortality in the fimt 24 hours of life has failed to 

decline in tandem with the rates of decline in fetal mo?+ality OY in the 

components of the Yemainder of the fimt yeay of life. Since 1950, the experience of the United States suggests increasing trends in neonutal 

moytality foy postnatal asphym”a and atelectasis, and the cause .gYOUp 

which includes hyaline membrane disease and respiratory distyess syndrome. In addition, the United States Yanks high in postneonatal mortality foy diseases of the YespiratoYy and digestive systems and fov accidents. 

Associations between leveling trends OY decelerated yates of decline and 

the available demographic information a~ pattevns of medical and obstetm”c care do not fully explm”n the changes which were noted. MoYe intensive clinical and epidemiolo~”c study of certain causes of death, 

low biyth weight, and pyematwity, along with national data on medical 

ca?’e and obstetric practices and moye detailed comparisons of vital 

YecoYds and re~”stvation systems aye needed to clarifi the situation, to 

offer leads to fwthev investigation, and to direct pyogram planning. 

SYMBOLS 

Data not available-------------+----------

Category not applicable . . . 

Quantity zero -

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

I Figure does not meet standards of 

* reliability or precision 
INTERNATIONAL COMPARISON OF 

PERINATAL AND INFANT MORTALITY 

Helen C. Chase, Dr. P. H., Office of Health Statistics Analysis 

t. INTRODUCTION 

One of the notable health accomplishments in 

the 20th century has been the decline in infant 

mortality. Over the first half of the century the 

rapid decline in mortality among infants became an 

accepted component of the Nation’s health. In the 

past decade, it has become difficult to adjust to the 

idea that infant mortality in the’United States is no 

longer declining at its former rate. 

In 1960, Moriyamai called attention to an 

apparent basic change in the infant mortality trend 

which began around 1950. No longer were the rates 

continuing downward at their former pace. The 

trend for the country as a whole was a reflection 

of the mortality of white infants which constituted 

about 86 percent of the live births in 1950, but 

applied to nonwhite births as well. It appeared 

that the change occurred a few years earlier for 

postneonatal mortality than for neonatal mortality 

for both white and nonwhite infants. Data for a 

number of other countries suggested similar 

configurations. 

Shapiro and Moriyama2 expanded on these 

observations in 1963 by comparing the components 

of perinatal mortality and postneonatal mortality 

for 11 countries of low mortality. The rates for a 

number of countries continued to decline until the 

midfifties and then appeared to follow the leveling 

trend observed 5 years earlier for the United 

States. Similar patterns were observed for neonatal mortality. ‘Ihe change in rate of decline for 

postneonatal mortality occurred before 1950 in 

the United States while the rates for other countries continued their decline throughout the period covered by the report, i.e., through the early 

1960’s. 

The deceleration of the rate of decline in infant mortality is not peculiar to the United States. 

Although the change seems to have occurred here 

around 1950, in other countries the phenomenon 

seems to h&e occurred a few years later. For 

example, similar changes in trend have appeared 

in data for Australia, Canada, Czechoslovakia, 

England and Wales, New Zealand, Norway, Scotland, and Sweden. Since 1960, a similar change 

is suggested by data for France as well. 

In an attempt to identify problem areas and 

to lend direction to future investigations, the 

National Center for Health Statistics entered into 

contracts with investigators from the Netherlands 

in 1962, Norway and the United States in 1963, and 

Denmark, England and Wales, and Scotland in 

1964. Each investigator undertook a study of the 

infant mortality experience of his own country 

and prepared a report on the subject. The contract reports included a common core of tabulated data which would be useful for comparative purposes. 

The present report represents a consolidation 

of data for the six countries mentioned above and 

for Sweden. Except for Sweden and the United 

States, it is based chiefly on the reports submitted by the contractors. Often, their information 

was supplemented by data derived from official 

publications and special studies. Information for 

1

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Sweden was obtained from official publications 

from Sweden and the World Health Organization, 

and for the United States from the Division of 

Vital Statistics, National Center for Health Statistics. 

SELECTED COUNTRIES 

According to the latest information from the 

Statistical Office of the United Nations, in 1964 

infant mortality in the United States exceeded that 

in a number of other countries: 

Sweden 14.2 

Netherlands 14.8 

Norway 16.4 

Finland 17.0 

Iceland 17.7 

Denmark 18.7 

Switzerland 19.0 

New Zealand 19.1 

Australia 19.1 

England and Wales 19.9 

Japan 20.4 

Czechoslovakia (provisional) 21.2 

Ukrainian SSR----------------- 22.0 

France 23.3 

China (Taiwan)--------=------ 23.9 

Scotland 24.0 

Canada 24.7 

United States of America 24.8 

All six of the countries selected for comparison 

with the United States had rates whichwerelower 

than that experienced in this country. Three of 

them (Sweden, the Netherlands, and Norway) had 

the lowest infant mortality rates in the world. 

The selected countries have many factorsin 

common with the United States. All are in the 

north temperate zone and climatically are subject to pronounced seasonal variations. Their 

populations are predominantly white although 

some of the countries have experienced immigration of nonwhite groups since World WarII. 

‘l%eyhaveshared a common industrial expansion 

which had its beginnings inthe 19th century. All 

were deeply affected economically by the great 

depression of the 1930’s. Since thecloseofWorld 

War II, these countries have continued toindustrialize and have experienced a rising standard 

of living and generally favorable economic conditions. All have experienced relatively stable 

governments in this century except for the war 

periods. They were physically affected by World 

War IIto varying degrees: Denmark, the Netherlands, and Norway became occupied countries and 

all but Sweden were belligerents. 

The United States has shared similar developments. The depression had a significant effect on the Nation’s economy. Since then, industrialization has continued. The Nation has enjoyed 

a rising standard of living and generally favorable 

economic conditions for a long period of time. The 

physical damage associated with bombings or 

invasions of the Second World War did not reach 

the mainland of the United States, but a large 

segment of its young adult male population served 

in the Armed Forces at home and abroad. 

Population 

The selected countries are quite variable in 

area, population size, and density (table 1). When 

the land area and~pulation are considered jointly, 

England and Wales and the Netherlands are relatively densely populated, Norway, Sweden, and the 

United States are relatively sparsely populated; 

and Denmark and Scotland occupy a midposition. 

All of the countries have experienced population growth. Except for the war years, they have 

shared a pattern of generally declining mortality, 

with particular advances incommunicable disease 

control. Birth rates declined in the first quarter 

of the 20tb century at the same time that industrialization progressed. During the depression of 

the 1930’s, the crude birth rates varied from 13.8 

for Sweden to 20.2 for the Netherlands. 

From 1935 to 1950, the trend lines of the birth 

rates for these seven countries presented somewhat similar contours (fig. 1). There were irregular, but marked, increases reaching their 

maxima toward the close of World War H or soon 

thereafter. The highest rates for Sweden were in 

1944 and 1945, for Denmark in 1945 and 1946, for 

the Netherlands and Norway in 1946, and for England and Wales, Scotland, and the United States in 

1947. Following these peaks, the rates for all 

seven countries showed some decrease with the 

United States retaining the highest position through 

1964. Since 1950, there have been marked differ2 
I 

United States I 

,/’, : f /4 r

\

ii \ 

:/\. J ‘\: -> , Netherlands fl\
 / ‘\__ / / k

~. / —Ay\/N_\ \ 

~>.( / :,, 

Scot land ......... . .. %. .. . /$ ‘ ~, ‘\\ ... ... .. . . . . . .. ... . ..’... .. ‘1 ; *\* ‘.....y.’w”y ... .,, +. 

1- / I IO ~i ..... 

\] == .... \\,,,O---_d---_ d.”..- /. \ ... \\

\ ““” ““”’.””’’..”” ‘-----\ 

‘/

\, 

\, ----- / d 

Denmarl 

i~ \, .8 

\L.\ /En@and mdWales / 

‘b---- \ /’ 

s::e;\./”’ 

1 1 1 1 

or I I I I T I I I I T I I I I T I I I I T I I I I l-. I I I I 

1935 1940 1945 1950 1955 196!3 I 

YEAR 

Figure 1. Crude birth rates: selected countries, 1935-64. 

3 
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Table 1. Land area, population density, 1948 and 1962, and census population, 1960 or 

1961: selected countries 

Land area 

Country (square miles 

in thousands)l 

Denmark


England and Wales


Netherlands


Norway


Scotland


Sweden


United States


Population density Population


per square milel in thousands2


1948 1962 1960
 I 

171 171


44


:; 52


I 

lSOURCE: United Nations, Statistical Yearbook, 1949-50 and 1963. 

2For the United States, data are from the U.S. Census of Population, 1960. For all


other countries, data are from the U.N. Demographic Yearbook, 1963.


31961 population.


4As of 1962.


ences in the trends. The rates for England and 

Wales, andScotlandhaveexhibitedincreases since 

1955. The rates for Denmark, the Netherlands, 

Norway, and Sweden declined from almut 1950 to 

1955. Since then, the rates for the Netherlands 

and Norway have been relatively more stable, 

while those for Denmark and Sweden suggest 

increasing rates. Therates for the United States 

increased irregularly from 1950 to1957andsince 

thenhave declined sharply. 

At present, the crude birth rates for Denmark and theNetherlands areapproximately equal 

to those in the midst of the depression in1935. 

In the remaining countries (England and Wales, 

Norway, Scotland, Sweden, andthe United States), 

the rates are considerably higher than thoseof 

1935. 

Crude birth rates are affected by the age 

distribution of women in the population, their age 

at marriage, and their childbearing patterns. 

Marriage rates and live birthrates areconsiderably higher in the United States than in the other 

countries for young women under 20 and 20-24 

years ofage. To facilitate comparison among the 

seven countries, the age-adjusted birthrates for 

females 15-49 years of age are shown in table 

2. During the 1950’s, the highest rates wereobserved for the Netherlands and the United States, 

but their positions relative to each other have 

reversed, with the United States assuming the 

highest rate. In recent years, the rate for Scotland has been approaching them. In 1962 the 

ratesforSweden andDenmarkwere approximately 

65-75 percentof those ofthe United States. 

The age structures of the populations of 

these selected countries are affectedbythedyTable 2. Age-adjuste birth ratesl: selected countries, 19 1, 1957, and 1962 

Country 

Denmark --------------
 England and Wales---­


‘Netherlands


Norway ---------------
 Scotland


Sweden ---------------
 United States


1


IT1950 1957 1962 

78.7 78.0 ;;.; 

67.0 75.1 

;:.: :3.: 96:8 

88,2 

78;1 83:6 92.2 

70.1 69.4 68.6 

91.5 112.7 105.4 

Rates per 1,000 females ages 15-49


years. Births are adjusted to United


States standard population of females,


distributed by age , as enumerated in 1950


census,using the direct method.


4 
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Table 3. Percentage distribution of enumerated population, by age: selected countries 

and years 

Age 

Country Year 

All Under 20 20-44 45-64 65 years 

ages years years years and over 

Percentage distribution 

Denmark	 1950 ioo.o 33.2 36.1 21.6 

1960 100.0 33.5 32.3 23.6 1::; 

England and Wales :;:: 100 � o 28.3 ;:.: 24.1 11.0 

Netherlands


Norway -------------------


Scotland


Sweden -------------------


100.0 29.8 � 25.7 11.9 

11950 100.0 37.3 35.8 19.2 

1960 100.0 38.6 32.7 20.1 M 

1950 100.0 30.6 37.8 22.0 

1960 100.0 33.0 32.3 23.7 1::! 

1951 100.0 31.7 35.9 22.4 10.0 

1961 100.0 32.8 32.8 24.0 10.4 

1950 

1960 

100,0

100.0 

29.4 

29.9 

37.2 

32.6 

23.2 

25.5 

10.2 

12.0 

United States	 1950 100.0 33.9 8.1 

1960 100.0 38.5 Al_?!!! 9.2 

1

Based on estimated population. 

SOURCE: United Nations, Demographic Yearbook, 1955 anc L962. 

namicsof population growth (table 3).Eachcountryhas shownan increase in the proportionunder 

20 years of age in the decade between 1950and 

1960. Arithmetic increases ranged from 0.3percent for Denmark to 4.6 percent for the United 

States. Simultaneously, each of the countries 

experienced relative declines in the childbearing 

segment of the population 20-44 years ofage. In 

theolde~ adult years,45-64and 65yearsand over, 

the proportions increased withoneexceptiow the 

United States showed asmalldecrease inthegroup 

45-64 years ofage. 

Medical Care 

Differing philosophies have resulted unpronounced contrasts between the west European 

countries and the United States with regard tothe 

financing— of medical care. Each ofthe Eurouean . 

countries has enacted its ownplanofsocialinsurante to provide medical and/or cash benefits. 

These programs vary in their benefits for sickness, maternity, and family allowances (seeappendix). 

In contrast, the usual pattern in the United 

States is privately financed prepaid hospital or 

medical insurance for maternity and sickness. 

Government-sponsored sickness or maternity 

benefits are less fully developed thanin the west 

European countries .The FederalGovemment has 

enacted legislation to provide medical care for 

certain groups: railroad employees, merchant 

seamen, veterans, welfare and scwial security 

recipients, and so forth. In addition, four States 

(California, New Jersey, New York, and Rhode 

Island) have enacted disability insurance for em5

ployees of industry and commerce. In this country, 

there are no goyernment-sponsored plans providing family allowances for civilians other than 

those provided to welfare recipients. Only New 

Jersey and Rhode Island include some form of 

maternity benefits in their disability insurance 

plans. 

During World War II, the supply of physicians 

to civilians was limited for most of the countries 

considered in this report. However, by 1950, the 

major emphasis of the medical profession was 

once again nonmilitary. At the same time, population increases in this postwar period challenged 

the rate of increase of new physicians. The decade 

from 1950 to 1960 showed decreased population to 

physician ratios for Denmark, England and Wales, 

the Netherlands, Norway, and Sweden (fig. 2). 

On the other hand, for the United States the ratio 

of population to physician remained relatively unchanged (672 and 675 per physician) and the ratio 

of civilian population to private physician increased from 914 to 1,018. Nevertheless, among 

the countries selected, the United States retained 

a favorable position with regard to its population 

to physician ratio. 

In the United States, over 96 percent of births 

were delivered in hospitals in 1960, and it is assumed that virtually all of these were attended by 

physicians (obstetricians, general practitioners, 

residents). Some of the European countries have 

quite different patterns (table 4). Of particular 

interest is their continued use of a corps of 

trained nurse-midwives for normal deliveries. 

Jn the Netherlands, only 27 percent of live births 

were delivered in hospitals in 1960. This proportion is low because, in addition to other factors, the insurance system will not reimburse a 

family for hospital costs for a normal delivery. 

Of all births in that country in 1963, 35 percent 

were attended by midwives and 65 percent by 

general practitioners or obstetricians.s In Norway, about 95 percent of births occur in hospitals 

or maternity wards. Confinements are generally 

conducted by midwives without medical assistance 

although it is available for deliveries in hospitals 

Denmark: Population per active physiclant 

YeOr 

1= 

1960 

England and Wales: Population per physlcianl 

1951 

1960 

Netherlands: Population per active physlcianl 

1950 

1960 

Norwom Population per registered physician] 

1951 

1960 

Sweden: Population per .xtlve physician’ 

1950 

1960 

United States Population per physlclon (M.D. and 0.0.)2 

1950 

1960 

United States:	 Civlli.m population per privotc 

physician (M.D. ond D. O.)z 

1950 

1960 

20URCES: 

lWorld Hwllh Organizatim, Annual Ep.demiologhd and Vital S(ali.lioa, 1958, 1080, 

and 1961. 

2U.S. Dep.nmnt of Health, Edumtion, and Welfare, Publio Health Service; IIeolth 

WanPOtoerS..,.. .kmk, COCti.r,18, 1964. 

igure 2. Ratio of population to physicians: se1 ected countri es, 1950 and 1960. 

6 
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Table 4. Percent of births, live births, and fetal deaths occurring in hospitals: selected countries, 1960 

Country Births Live births Fetal deathsl 

Percent in hospitals 

Denmarks ---1 

England and V7ales2 --------

Netherlands2 

64.7 64.3 

27.0 

83.3 

56.9 

Norway %3------------------------------------ 94.3 94.3 94.4 

Scotland4------------------------------------ 74.4 

Sweden2-------------------------------------- ‘33.; 

United States5------------------------------- 96.6 . 93.9 

lFetal deaths of 28 weeks and over	 gestation — plus those with gestation not stated.

2Returnsto questionnaire on “Registration and Statistical Practices Related to


Fetal Deaths and Infant Deaths” sent to selected countries from the National Center


for Health Statistics, spring 1962.


31ncludes small maternity wards.


SOURCES: 

4ScottishHome and Health Department, Scottish Health Statistics, 1963, Edinburgh,


Her Majesty’s Stationery Office, 1964, p. 52.


‘U.S. Department of Health, Education, and Welfare, Public Health Service;Yl!l


Statistics of the United States, 1960, Vol. I and Vol. II, Part A.


ifneeded.4 In Scotland, about 20 percent ofbirths 53 percent and pupil midwives delivered another 

in 1963 occurred at home, but less thanl percent 28 percent~ Recently, there has been increased 

of these was delivered without the services ofa interest in the United States in training nursegeneral practitioner. In England and Wales, 33 midwives to attend normal deliveries. Less than 

percent of all births occurred athome. Froma 500 nurse-midwives were known to exist inthe 

special studyit isestimatedthat doctorsdelivered United States in1963 ,andfewofthemare actively 

14percent ofall births while midwives delivered engaged in midwifery. 

7

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Il. EVALUATION OF BASIC DATA 

The purpose of this report is to compare the level of registration of births and deaths in all of 

perinatal and infant mortality experience of the the States of the United States was considered 

United States with that of a number of west sufficiently complete and accurate to permit inEuropean countries in order to obtain guides for clusion of their statistics in national data. At 

future study or action. The primary source of that time, the data included 48 States and the 

information for studying the infant mortality of District of Columbia, and these were augmented 

nations is their vital statistics. Since registration by data for the States of Alaska (1959) and Hawaii 

of marriages is not of immediate interest, the (1960) as they achieved statehood. 

following comments relate to live birth, fetal The methods ofregistering vital events vary 

death, and death registration only. among the countries included in this study. Some 

The vital statistics systems of the six west of these differences are relatively unimportant 

European countries are well established and of while others may have a significant effect on the 

long standing (table 5). It was 1933 before the	 vital statistics. In most instances, quantitative 

measures of the effect of specific practices are 

. unavailable and reliance must beplaced on subTable 5. Date of compulsory national civ- jective estimates. 

il registrat~on law governing registra­ tion of live births, deaths, and still-


births: selected countries. as of Janu- DEFINITIONS OF LIVE BIRTH


ary 1, 1950 

The distinction between a live birth and fetal 

Country Live 

birth Death stillbirth 

death isone of the basic decisions invitalregistration. This decision conceding aspecific birth 

determines whether it is included among live 

births, among fetal deaths, orexcludedfrom both. 

Denmsrk---------’-- 1646 1646 1646 Definitions of vital events to be included as live 

England and Wales- “1875 1875 1927 United States to some variation at the State level. 

Netherlands 1811 1811 1811 The definitions rest onspecifying which signs of 

Norway ------------ 1685 1685 1685 

life constitute classifying a newborn infant as 

live born. 

Scotland 1855 1855 1939 Over aperiodof decadestheLeague ofNations 

births are subject to national variation ,andinthe 

and the World Health Organization haveattempted 

Sweden ------------ 1686 1686 1686 to promote uniform vital statistics through recUnited States2---- 1933 1933 1933 ommended definitions whichcouldbe usedasmodels. Jh 1925, the recommendation of the League 

1

Civf.1 registration was introduced i.n of Nations Health Committee mentioned only 

1837. but it was not until 1875 that re~- “breathing’’a sac riteriono flive,birth. However, 

istr&tion became a statutory duty impos;d at an earlier date, professional organizations in 

on the informant. England and the United States were already ad2

Completionof the birth and death reg- vising that evidence of lifeshould include actionof 

istration areas,respectively. No national heart, breathing, or movement ofvoluntary mus­ registration law. 

cles. 

Vital

SOURCE: United Nations, Handbook of In 1950, the Third World Health Assembly Statistics Methods, Studies in MethXX& Seri,es F, No. 7, April 1955, pp. 20- adopted the recommendation of the Expert Corn21. mittee on Health Statistics with regard todefini-
------------------------------------

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

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

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

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

I 

tions of live birth and fetal death.G A live birth 

was defined as follows: 

Live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duvation of pvegnanqy, which, aftev such separation, breathes 

or shows any other evidence of life, such as 

beating of the heavt, pulsation of the umbilical covd, OY definite movement of voluntavy 

muscles, whether or not the umbilical cord 

has been cut OYthe placenta is attached; each 

product of such a birth is considered live 

bovn. 

The definition of fetal death was recommended 

to complement that of live birth: 

Foetal death is death prior to the complete 

expulsion OYextraction from its mother of a 

product of conception, irrespective of the duration of pregnancy; the death is indicated by 

the fact that after such separation, the foetus 

does not bveathe OY show any other evidence 

of life, such as beating of the heart, pulsation 

of the %mbiticat cord, ov definite movement 

of voluntary muscles. 

Table 6. Effect of WHOdefinition of live 

These definitions of live birth and fetal death 

omitted mention of duration of pregnancy and 

terms such as abortion, miscarriage, or stillbirth. 

Despite the action of the World Health Assembly, changes in the laws of the various 

countries were not achieved immediately or 

uniformly. For example, the change in definition 

of live birth to include “beating of the heart, 

pulsation of. the umbilical cord, or definite movement of voluntary muscles” in addition to “breathing” as evidence of life was not adopted in Sweden 

until 1959. Even at present, Denmark has no legal 

definition of “signs of life. ” Furthermore, changes 

in law or regulation are not immediately transposed into action. Practices followed by physicians 

or midwives regarding their understanding, interpretation, and implementation of the law are 

difficult to assess. European practice continues to 

prefer “stillbirth” to “fetal death.” 

The effect of these variations in definition 

appears to be relatively small for some countries. 

From English data for 1946-47,7 it was estimated 

that limiting the criteria of life to “breathing” 

alone resulted in a decrease of 1.5 percent in infant deaths and a corresponding rise of 3 percent 

in stillbirths. 

birth on components of infant deaths: Sweden, 

1956 

Swedish practice 

Event 

Number Rate 

Live births 107,960 .*. 

Perinatal deathsl 

Stillbirths 

Deaths under 1 week~-------------------------

Deaths under 28 days2 ---, 

Deaths under 1 year2 

lllates per 1,000 births (liveborn and stillborn). 

2Rates per 1,000 live births. 

3,106 28.3 

1,836 16.7 

1,270 11.8 

1,427 13.2 

1,871 17.3 

WHOdefinition 

Number Rate 

108,081 .*. 

3,106 28.3 

1,715 15.6 

1,391 12.9 

1,548 14.3 

1,992 18.4 

9 
Sweden investigated the criteria of life in 

relation to the registration of the eventas alive 

birth or as a stillbirth in that country.s According 

to the law prevailing in Sweden until 1959, fetuses 

of at least 35 centimeters in length which did 

not breathe after birth were considered stillborn. 

However, it was recognized that use of the word 

“breathe” was subject to varied interpretations. 

To some, it means a single gasp of breatk to 

others, regular breathing of some minutes. From 

the special study in Sweden, it was found that 

among the more than 1,800 stillbirths in 1956, 

about 700 infants died in birth. Information on 

criteria of birth was obtained on 646 of these, 

and 83 percent of them were born with no sign of 

life. Based on their gestation periods, this group 

corresponds to the WHO definition of “late” fetal 

deaths. The remaining 17 percent breathed or 

showed some other sign of life and should have 

been classified as live births and neonatal deaths 

by WHO definition. It is estimated that correction 

of these registrations should have decreased stillbirths by 7 percent, and increased the deaths 

under 1 week by 10 percent, neonatal deaths by 

9 percent, and infant deaths by 7 percent (table 6). 

INFORMANT 

Consistent terminology is basic to an understanding of the differences in registration practices and the resulting statistics. The informant, 

as used here, is the person responsible for reporting the fact of the occurrence of the vital 

event. In the six west European countries which 

were considered, the parent (usually the father) 

is the informant and is responsible for reporting 

the birth or death of an infant. In the United States, 

the responsibility for notification of birth is 

usually placed on the attending physician, and for 

death, on the funeral director. In a few States, the 

responsibility has been placed on the hospital. This 

is a basic difference in registration between the 

United States and the European countries. 

In the west European countries, there are 

certain financial advantages which promote registration by the informant. The maternity benefits 

and family allowances included in their social 

insurance systems represent significant personal 

advantages. Their administration is often predicated on the presentation of a birth certificate, 

thus stimulating registration on the part of the 

parent. In the United States, hospitals and physicians are generally paid by private insurance 

companies on presentation of a claim by the hospital or physician, or directly by the patient. In 

either instance, payment is not contingent on the 

presentation of a birth certificate. In this country, 

the parent is responsible for registration of a live 

birth only when the delivery is not attended by a 

physician or midwife. 

ADMINISTRATION 

Another source of difference is the administrative relationship between the agencies involved 

in the registration process and the statistical aspects of the vital registration system (table 7). 

In England and Wales and in Scotland, a single 

administrative agency has national responsibility 

for registration as well as the statistical endproduct. This single organization structure has 

the advantage of responsiveness to the statistical 

needs of the system and administrative decisions. 

In the Scandinavian countries (Denmark, Norway, 

and Sweden), the responsible local registration 

agency is ecclesiastical. Historically, this system 

developed from recording services of baptisms 

and burials of parishioners into the registration 

of all births and deaths. The national statistical 

responsibility in each of these countries is in a 

Central Bureau of Statistics which, in Denmark 

and Sweden, is under the Ministry of Finance. 

In the Netherlands, local registration is conducted 

by the Registry of Civil Status and national statistical responsibility rests with a Central Bureau 

of Statistics in the Ministry of Economic Affairs. 

In the United States, with one exception (Massachusetts) the registration process is administered by the health authorities of the individual 

States and a few cities, and the responsibility 

for national statistics is in the Public Health 

Service of the U.S. Department of Health, Education, and Welfare. 

The administration of the vital registration 

and statistical process by nonmedical agencies 

in the European countries has resulted in the 

development of auxiliary record systems to obtain medical information for health purposes. 

10

-------

--------

------

--------

Table 7. Agency of government reported to be responsible for civil registration function at local and national levels and for compilation of national statistics on live 

births, deaths, and stillbirths:selected countries, as of January 1, 1950 

Regi.strati,on 

Country 

Denmark 

England and 

Wales--------

Netherlands---

Norway 

Scotland 

Sweden 

United StatesAgency responsible 

at local level 

Parish Regi,stry

Civil Registry 

Local Register Office 

(Subdistrict) 

Registry of Civil 

Status (Municipal) 

Parish Registry 

Local Registrar’s 

Office (District) 

Parish Registry 

Local Registrars and 

State Departments of 

Health 

Agency directly

responsibleat 

national level 

None 

General Register

Office 

None 

None 

Central Office of 

National Registration (CentralBureau 

of Statistics,Ministry of Finance) 

None 

Statistics 

Agency responsible 

at national level 

StatisticalDepartment

(Ministry of Finance) 

National Health Service (cause-of-death 

statisticsonly) 

General Register Office 

Central Bureau of Statistics (Ministryof 

Economic Affairs) 

Central Bureau of Statistics 

General Registry Office 

Central Bureau of Statistics (Ministryof 

Finance) 

Public Health Service 

(U.S. Department of 

Health, Education, and 

Welfare) 

SOURCE: United Nations, Handbook of Vital StatisticsMethods, Studies in Methods, 

Series F, No. 7, April 1955, pp. 27-31. 

Examples ofsuchparallel activities arenotificationofstillbirths by physicians inhospitalsorby 

midwivestohealthagenciesinDenmarkandNorway, and notification of stillbirths by midwives

in the Netherlands. These parallel activitiesare 

used as cross-checks toassesscompleteness of

notification andregistration. IntheUnitedStates,

medical and legalpurposes are accomplished 

by a singledocument,and ongoingopportunities 

forcross-checksarelimited. 

COMPARISON OF 

REGISTRATION METHODS 

Three countries were selected formore detailedescriptions oftheirregistrationsystems: 

theNetherlands,Norway, and theUnitedStates. 

They were selectedtodemonstratebasicdifferences in theinformant, theadministrationfthe

system,and thekindsof informationavailable 

for study.This shouldadd to theunderstanding 

11 
of some of the subsequent data. Much of the information is drawn from the Handbook of Vital Statistics Methods, g reports of two of the contractors ,4, 10 and comments of the contractors. 

Netherlands 

In the Netherlands, only about 30 percent of 

live births occur in hospitals; about 60 percent 

of all births are attended by physicians (general 

practitioners or obstetricians) and the remainder 

by midwives. Notification of birth to the Registry 

of Civil Status must be made witbin 3 days of 

birth. The responsible informant is the father 

(or his deputy) who notifies the local registrar 

in the town hall of the child’s birth. The informant is requested to provide the following information: date of birth, religion, nationality, name 

of physician or midwife attending the delivery, 

name of hospital (if any), single or multiple birth, 

parity, legitimacy, and Christian name of chil~ and 

name, age, date of present marriage, occupation, 

and residence of parents. The registrar prepares 

the certificate of birth and sends an enumeration 

card to the Central Bureau of Statistics. 

Notification of birth to the Registry is the 

parents’ responsibility and, except in cases of inability of the parents to act, neither the physician 

nor the midwife is involved. Consequently, it is 

impossible. to obtain medical information for 

births from the civil registration system of the 

Netherlands. Information such as birth weight, 

gestation period, complications of pregnancy or 

labor, or congenital malformations is not available for live births but must be obtained from 

special surveys. Thiss ystem prevails for all liveborn children surviving at the time of registration and covers over 90 percent of all births. 

Registration of this group is felt to be quite complete. 

In those instances in which a liveborn infant 

dies before registration, the notifier (usually the 

funeral-undertaker) presents the confidential 

death certificate which was prepared by the physician and simultaneously provides information 

relating to the birth. From the death certificate 

prepared by the physician, some medical information may be obtained, e.g., cause of death, infant’s birth weight and birth length, and duration 

of pregnancy. Complications of pregnancy or labor 

are available only when the physician considers 

them important in connection with the cause of 

death. It is believed that some liveborn infants 

(predominantly small premature) who are considered nonviable by the physician may escape 

registration to spare the cost of a funeral. However, without registration no maternity benefit 

from the social insurance system would be 

granted. This grant is felt to be a stimulus to 

registration of these events. The number of 

omissions in registration is believed to be 

small, but the extent of undernotification is not 

known. 

Registration of fetal deaths is required for 

those with gestations of 28 weeks or more. The 

father (or his deputy) registers the fetal death 

when he presents the fetal death certificate prepared by the physician. The certificate includes 

the cause of death and duration of pregnancy and 

labor, but it does not include birth weight. In a 

borderline case (26-28 weeks’ gestation), there 

may be a tendency for the dmtor to consider the 

event as an early fetal death in order to spare 

the family the trouble and cost of a funeral, but 

again without registration no maternity benefits 

would be granted. 

In some instances, religious precepts may 

cause a fetus which dies late in labor to be considered a live birth in order to be baptized. This 

may shift some fetal deaths to early neonatal 

deaths but would not affect perinatal deaths. In 

other instances, liveborn infants of more than 28 

weeks’ gestation may die very soon after birth 

and be registered as fetal deaths. This may shift 

some early neonatal deaths to fetal deaths but, 

again, would not affect perinatal deaths. For the 

Netherlands, the net effect of these errors in 

notification and registration is believed to be a 

slight understatement of fetal and perinatal mortality although it has not been quantified. 

Norway 

In Norway, the official civil register of 

births and deaths is maintained by the clergy. 

Reporting of births must be made to church 

officials within 4 weeks of birth. The civil 

birth register consists of all liveborn and 

stillborn children (after 28 weeks of pregnancy) regardless of the religious denomination of parents. Reports of these events are 

forwarded to the Central Bureau of Statistics 

12 
which is responsible for the official vital 

statistics, 

In contrast to the Netherlands where less 

than one-third of deliveries occur in hospitals, 

over 95 percent of deliveries in Norway occur in 

hospitals or maternity wards. Although notification of a legitimate birth ( Iivebom or stillborn) 

in Norway is the responsibility of the parent or 

other person present at delivery, if birth occurs 

in a hospital, clinic, or nursing home, the institution is responsible for notification to the official 

registrar. Notification of an illegitimate birth is 

the responsibility of the physician, midwife, or, in 

the absence of such attendants, the mother. 

The notification of a legitimate birth contains 

facts related to multiplicity of the birth; parity; 

and the occupation, religion, birth date, place of 

birth, nationality, and year of marriage of mother 

and father. The notification of an illegitimate 

birth contains, in addition, the infant’s length, 

birth weight,, and period of gestation. 

Notification of live births by parents and 

institutions and civil registration by the clergy 

is felt to be generally satisfactory y in Norway. As 

in the Netherlands, certain financial benefits in 

the form of maternity benefits and family allowances depend upon official registration. Registration of stillbirths, however, is known to be 

somewhat deficient on the part of parents. Crosschecking of the registered event against the physician’s or midwife’s notification to the public 

health officer for stillbirths and deaths within 24 

hours of birth is used to improve registration. 

With regard to death, the physician completes 

a medical certificate of death which is given to 

the informant in a sealed envelope. Notification 

of death must then be made to a probate court, 

which issues the civil certificate for registration. 

The civil certificate (without cause of death) is 

presented to the local parish official who registers the death in the death register and forwards 

the certificate to the civil population registry. 

This civil certificate contains no information on 

the cause of death. The medical death certificate 

is signed by the probate court and sent to the public health officer in the community where the 

death occurred. Public registrars submit lists of 

deaths to the Central Bureau of Statistics, while 

,- the public health officers transmit medical death 

certificates containing the causes of death to the 

same Bureau. Death registration is felt to be 

fairly complete, but information on causes of 

death among infants born in the northern rural 

areas of Norway is still considered a problem. 

United States 

In the United States, births and deathe are 

registered by the health agencies of 49 States, the 

District of Columbia, and three independent cities 

(Baltimore, New Orleans, and New York City). 

In the 50th State, Massachusetts, vital events are 

registered by the- Office of the Secretary of the 

Commonwealth. Vital registration is administered 

by individual State authorities under legislation 

enacted by the 50 State legislatures, Therefore, 

statements relative to registration must, to some 

degree, be generalizations. The period within 

which registration is required varies from 24 

hours to 15 days. 

In 1963, 97.4 percent of live births occurred 

in hospitals, and an additional 0.8 percent which 

occurred outside hospitals were attended by physi. 

cians. The responsibility y for notification of birth 

is generally placed on the attending physician. 

In some States, the responsibility for reporting 

the occurrence of births is placed on the superintendent or administrator of the hospital in which 

delivery takes place rather than the attending 

physician. If there is no physician in attendance, 

the responsibility rests with the midwife, parent, 

or some other person in attendance. 

Reporting the occurrence of a death for 

registration is usually the responsibility of the 

funeral director. It is he who presents the death 

certificate (which includes the medical certification prepared by the physician, medical examiner, 

or coroner) to the local registrar in order to obtain a burial permit. 

Fetal deaths most generally follow the procedure for deaths, although States which require 

the registration of all products of conception have 

found it necessary to ascribe some of the registration responsibility y for fetal deatha to physicians, 

hospitals, midwives, and parents as well. 

Demographic information is obtained from 

one of the parents by the physician, hospital, or 

undertaker. Medical information is supplied by 

the physician or hospital. The first point of contact between a vital record and a registration 

official is a local registrar who receives the 

live birth, fetal death, or death certificate from 

13 
the physician, hospital, funeral director, orother 

person, as the case may be. These local registrars are usually nonmedical part-time deputies 

of the State registrars. They are sometimes civil 

officials such as county, city, town, or village 

clerks. In turn, local registrars forward the original vital records to State health departments 

where the y are kept on permanent file, and State 

statistical reports are prepared. Microfilm copies 

are forwarded by the States to the Public Health 

Service, U.S. Department of Health, Education, 

and Welfare, which is responsible for the national 

vital statistics but has no statutory registration 

responsibilities. 

Having registration and the administration of 

the vital statistics system in the hands of the 

medical profession and health departments results in a single document, and, in contrast to 

the west European countries, little responsibility 

is assigned to the parents. It obviates the necessity for dual notification by physicians and lay 

persons. Furthermore, it presents opportunities 

for obtaining medical as well as demographic 

information. The certificates of birth include 

birth weight, gestation (or sometimes first day 

of last menstrual period), number and order of 

multiple birth, parity, and often the complications 

of pregnancy, labor, and delivery, birth injuries, 

congenital malformations, and so forth. 

Fetal death certificates, with a few exceptions, require the same information as birth 

certificates. In addition, fetal death certificates 

require the causes of fetal death. 

Death certificates request information on 

causes of death in addition to demographic information but do not require detailed information 

about birth. 

Registration is required for all live births 

and deaths. However, the requirements for the 

registration of fetal deaths vary widely among 

the States. All States but one base the requirement 

for registration of fetal deaths on gestation; the 

one exception (Kansas) requires registration of all 

fetal deaths weighing over 350 grams. Thirtynine States and the District of Columbia relate 

their requirement for fetal death registration to 

a near-equivalent of 20 weeks (after 5th month, 

20 weeks or more, or after 20 weeks); one State 

(Pennsylvania) requires registration at 16weeks; 

and nine States and New York City require registration at all periods of gestation. Usually, 

national tabulations include fetal deaths of 20 

weeks or more and those with gestation unspecified. This national minimum is 8 weeks earlier 

than the minimum for the west European countries, 

Wherever possible in this report, data for the 

United States have been limited to fetal deaths of 

28 weeks or more and a proportion of those with 

gestation not specified to facilitate comparisons. 

The completeness of registration of live 

births in the United States has been evaluated 

through comparison with records obtained by census enumerators. In 1950, 97,9 percent of infants 

born in January through March were found to have 

been registered as live births. There has been 

no national test of registration completeness of 

fetal deaths and deaths, and none for live births 

since 1950. The registration of live births and 

deaths is believed to be quite complete while 

registration of fetal deaths is probably quite incomplete. 

REGISTRATION OF FETAL DEATHS 

There is relatively little information available on the degree of underregistration of fetal 

deaths. The six west European countries included 

in the study require registration of fetal deaths 

at a minimum of about 28 weeks. Because of the 

dual notification in these countries, cross-checks 

have been made and inquiries initiated whenever 

discrepancies exist. This checking has promoted 

their confidence in the registration system and 

investigators have expressed their opinions that 

fetal death registration as required by law is 

good. Nevertheless, some incompleteness in registration on the part of parents in the Netherlands 

and Norway, at least, is admitted. 

In the United States, it is generally conceded 

that fetal death registration is incomplete for the 

periods required by the several State laws. The 

nationwide minimum period of required registration is 20 weeks or some near-equivalent, 8 weeks 

earlier than the west European countries. There 

have been no national studies of the completeness 

of fetal death registration. Therefore, estimates 

of completeness must be based on special studies 

and inferences from routine data. 

For the United States, estimates of the numbers of fetal deaths at all periods of gestation are 

available from a few sources. Three are selected 

here because their methods of collection should 

14 
------------------

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

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

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

Table 8. Estimates of completenessof fetal death registration, based on special stud­


ies: Onondaga County, N.Y., Kauai, Hawaii, and New York, N.Y.


Area Year 

Onondaga Countyl 1951-52


Kauai~----------------------------1953-56


New York3------------------------- :;;;’


New York*-------------------------


Onondaga Countyl 1951-52


Kauai2----------------------------1953-56


New York3------------------------- 1950


New York&------------------------- 1963


Onondaga CountyI 1951-52


Kauai~----------------------------1953-56


New YorkS------------------------- 1950


New York4------------------------- 1963


Onondaga CountyI 1951-52


Kaua$2----------------------------1953-56


SOURCES:


Gestation


Total


Under 20-27 28 weeks


20 weeks weeks and over


Number of fetal deaths


1,456 1,083 135 238 

370 305 

16,405 12,629 1>3% 2,3;; 

22,329 17,775 2,031 2,523 

Ratio to fetal deaths 28 weeks or more


6.12 4.55 .57 1.00 

10.28 8.47 .81 1.00 

6.84 5.26 .57 1,00 

8.85 7.04 .80 1.OO 

Percentage distribution


100.0 74.4 9.3 16.3


100.0 82.4


100.0 77.0 ;:; 1::;


100.0 79.6 9.1 11.3


Ratio of survey to registered


... 2.45 1.11 

1:4; I 2.21 1,61 1.06 

lE. R. Schlesingeret al., “Fetal and Early Neonatal Deaths in Onondaga County, New


York,” Public Health Reports 74:1117-1122,Dec. 1959.


~F. E. French and J. M. Bierman, “Probabilitiesof Fetal Mortality,” Public Health


Reports 77:835.-847,
Oct. 1962.


SC. L. Erhardt,’’Reportingof Fetal Deaths in New York City,” Public Health Reports 

67:1161-1167,Dec. 1952. 

‘U.S. Department of Health, Education, and Welfare, Public Health Service; Vital


Statistics of the United States, 1963, Vol. II, Part A.


give better indicationsof thedegreeof under­


registration:
 OnondagaCounty,NewYork(1951­


52),the Islandof Kauai,Hawaii(1953-56),
and


New YorkCity(1950and 1963).


Three different
methods of datacollection


were involved,
In OnondagaCounty,a thorough


review was made of allrecordsources in the 

hospitals located in that county. 11 This is a county 

with a high concentration of obstetric service, 

and a history of interest in maternal and child 

health studies. The investigation didnot, getreports from private physicians or individuals if 

the events did not come to the attention of the 

hospitals. In Kauai, physicians, hospitals, public 

health nurses, and the general public were requested to report each pregnancy as soon asit 

was noted.la The authors of the Hawaiian report 

comment on the level of obstetric and hospital 

care on the Island and compare it favorably with 

the general overall experience on the mainland. 

In New York City, registration or notification is 

required for all products of conception, and the 

city has been actively promoting the program for 

many years,~s 

The three sets of data show rather striking 

similarities when one considers the differences 

15 
in the populations, in time, and in methods of data 

collection (table 8). The higher ratios between 

fetal deaths of shorter gestations to those of 28 

weeks or more in the Kauai data are to be expected because reports were solicited from the 

entire population. Neither the Onondaga County 

nor the New York City data contain such reports. 

The results obtained from these surveys may 

be used to derive a rough estimate of registration compliance in the United States. The surveys 

provide ratios between fetal deaths identified 

using survey methods to registered fetal deaths 

for specified broad gestation intervals. A crude 

estimate of underregistration may be obtained 

by applying these gestation-specific ratios to 

fetal deaths registered in the United States for 

two groups of fetal death registration areas: 

(1) those which require the registration of all 

products of conception, and (2) all others. Having 

used this approach, the estimated number of fetal 

deaths which should be registered in accordance 

with the laws of the States, but which are not 

registered, amount to a minimum of 65 percent 

of those which are registered. However, the 

surveys indicate that the degree of underregistration decreases as the period of gestation increases. For gestations of 20 weeks or more, 

which is the interval for which data are shown 

in the annual national statistics, it is estimated 

that unregistered fetal deaths amount to perhaps 

one-third of registered fetal deaths. For more 

limited periods for which registration is required 

by the west European countries included in this 

report (28 weeks or more), unregistered fetal 

deaths are at least 10 percent of those registered. 

If the idea is extended a step further, one can 

estimate only very roughly the total number of 

fetal deaths in the United States including those 

which are not required to be registered. Using 

two alternate estimates for those under 20 weeks, 

it would’ seem that the estimated number of fetal 

deaths of all gestations in 1963 in the United 

States is, at the minimum, three to five times the 

94,000 which were registered in 1963. Yerushalmy 

and Bierman estimated all fetal losses to approximate 500,000 at a time when 75,000 to 80,000 

were registered.11 Other estimates run considerably higher. i ~ 

Several conclusions may be reached from 

these observations. First, even under present 

registration requirements, there is gross underregistration of fetal deaths in the United States. 

Second, registration of events associated with 

hospitalization are more complete than those 

which are not. The Kauai data indicated that 

fetal deaths associated with hospital admissions 

(either for delivery or after delivery) were registered over 90 percent of the time. For those 

which were not hospitalized, the estimates are 

based on small numbers and should be regarded 

cautiously. The percent registered declined from 

61 percent (11 of 18) of those under 20 weeks 

which were pathologically confirmed, to 2 percent (2 of 101) for those for which pregnant y was 

not confirmed by a physician. 

Third, as one approaches the minimum period of required registration, the greater the degree 

of underregistration. During the decade 1950-60, 

a number of States in the United States changed 

their requirements for fetal death registration. 

Ten States changed the minimum level at which 

fetal deaths were required to be registered from 

20 weeks (in one instance 5 1/4 months) to all 

periods of gestation. Data for Arkansas and Hawaii 

are incomplete and are omitted from the States 

which made such a change (table 9). One State 

(Pennsylvania) changed its requirement to a 

minimum of 16 weeks. For comparison, the four 

most populous registration areas in the country 

which made no such change are also shown. 

It has been hypothesized that when registration is compulsory at some given period of gestation, it remains incomplete at gestations which are 

above, but close to that minimum level. By 

examining the ratio of intermediate fetal deaths 

(20-27 weeks) to late fetal deaths (28 weeks or 

more) before and after the changes, some indication is obtained of the incompleteness at the 

earlier period of gestation. 

For each of the States which made a change 

in registration during the decade, the increase in 

the ratio of intermediate to late fetal deaths was 

marked. The increase was notable even when 

Pennsylvania changed from a minimum of 20 weeks 

to 16 weeks. On the other hand, for the four control States, the ratios remained relatively unchanged. The data indicate that a change in the 

minimum gestation at which fetal death registration is required results in substantial improvement even at those gestations which were for16

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

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

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

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

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

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

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

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

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

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

Table 9. Effect of changes in fetal death registration on completeness ofregistration:


selected Statea of the United States and selected years


Year
 Change in registration of
 requirement and area change


Changed to all periods of gestation


Vermont


Mississippi


Oregon


South Dakota


Colorado


Georgia


Maine


Virginia


Chamzed to 16 weeks


Pennsylvania


No chanzea


Illinois


New York (excl.New York Ci.ty)------


Ohio--------------------------------


Texas-------------------------------


1951


1952


1952


1953


1954


1954


1955


1960


1954


...


...


...


...


Registration requirement


in year prior to changel


5 1/2 months


After at least 20 weeks


After at least 20 weeks


Reached 20 weeks


Reached 20 weeks


After at least 20 weeks


After at least 20 weeks


Advanced to 20th week


After at least 20 weeks


Advanced to 5th month


After at least 20 weeks


At least 4 1/2 months


Advanced to 5th month


Ratio2


Be’fore After


change change


17.1 31.4


22.3 31.4


26.0 36.8


24.2 40.5


19.7 45.2


23.4 40.2


18.6 36.5


31.0 48.8


29.8 38.1


24.2 25.2


24.2 26.7


35.1 34.7


27.0 30.6


~MLnimum period of gestation for which fetal death registrationwas required.


2Fetal deaths of 20-27 specifiedweeks’ gestation per 100 fetal deaths of 28 speci­


fied weeks or more.


3Data presented relative to control year 1954.


merly above theminimum requirement.
These


observations lead to the question,
here unre­


solved,of thepossibleeffecton thenumber of


registeredfetaldeathsof 28 weeks or more


gestationif the European countrieswere to


changetheirminimum registration
 requirements


to20 weeksor more.


For the purposesof thisreport,thechief


concernis theregistration
 of thoseeventswith


gestations
of 28 weeks or more, sinceitisthis


group of fetaldeathson whichcomparisonswill


be based.??orthisgestation period,
theOnondaga


Countyand Kauaidataindicate
 about90percent


completeness,There are no dataavailable
for


estimatingthe completenessof registration
 of


fetal deathsintheothercountries involved
 inthis


study.


STATISTICAL PRACTICE 

In additionto variations in definitions
 and


registration practices ,thestatistical
 management


of dataderivedfrom thebasicrecordsissub­


jectto variationfrom one countryto another.


In the Netherlands,
ithad been thepolicy


as earlyas 1924 to registeralllivebirthsand


to countthosechildrenwho were dead at time


of registration as botha livebirthanda death.
16


However,in 1950,thispolicywas changed.Live


birthswere still requiredto be registered,
 but


thosewhichwere oflessthan28weeks’gestation


and had died by thetime of registration
 were


excludedfromtabulationsof livebirthsand
 deaths.


This policyremained in effectfortheperiod


17

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

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

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

Table 10. Effect of inclusion of live births with gestations of less than 28 weeks on
 components of infant mortality: Netherlands, 1962


Excluding live births Including live births


with gestations with.gestations


under 28 weeks under 28 weeks
 Event


Number
 ==I== Rate 

Live births 245,739 . . . 246,150 . . . 

Perinatal deathsl 6,004 24.1 6,415 25.7 

Stillbirths] 3,645 14.6 3,645 14.6 

Deaths under 1 week2------------------- 2,359 9.6 2,770 11.3 

Deaths under lmonth2-------------------- 2,732 11.1 3,143 12.8 

Deaths under 1 year2--------------------- 3,763 15.2 4,174 17.0 

.


‘Rates per 1,000 births (livebornand stillborn).


2

Rates per 1,000 live births.


SOURCE: world Health Organization, “Study of the Effect of Including in Vital Sta­


tistics Live Born Under 28 Weeks of Gestation and Dying Before Registration,”WHO/HS/


Nat.Comm./l6l,April 24, 1964. 

1950-6:;, lmtrevertedtotheearlierpolicy
 in1964.


Whereverpossible,
 thedatasince1950havebeen


revisedto includetheeventsomittedfrom vital


statistics. These adjustmentswere possible
for


alltablesexceptthoseby cause.An estimateof


theeffectof thischangein statistical
 policyis


shownintable10.The differences
 inthenumbers


of deathswere sizable:10.9percentin infant


deaths,15.0percentinneonatal deaths,
and 17.4


percentindeathsunderlweek.


A second variation instatistical practice
is


thetabulation of deathsofinfants
who diewithin


thefirstfew days oflife.
Denmark,theNether­


landa,and Sweden tabulate
deathswhich occur


soon afterbirthon thebasisof calendardays,


i.e.,
thosewhich dieon thefirstday are those


whose birthand death occurredon the same


calendarday.Englandand Wales,Norway,Scot­


land,andtheUnitedStatesdeterminethenumber


of hours betweenbirthanddeathandtabulate
 as


first-daymortalitythese deathswhich occur


duringthefirst24 hours oflife.
Becauseofthe


highlevelof mortality
neartothetimeofbirth,


thesedifferences in tabulating
 practicehave a


considerable
ffecton deathratesforthefirst


few daysoflife. Aspecialinquiry
intheNether-


lands in 1958-59showed thatthedeathswithin


24 hoursof birthexceededthedeathswhichoc-


curredonthecalendardayofbirthby37 percent


(table11).A studyin Norway yieldedsimilar


results:40 percent in 1949-51and 1959-61. 

Using a distributionf birthsby hours forthe


Stateof Indiana, andanexponential
rateofdying


under1 day,Greenberghasestimatedthediffer-


entia1fortheUnitedStatestobeabout28
 percent~7


These estimatesproved helpfulin considering


mortalityunder 1 day in theseveralcountries


included
here.


18

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

Table 11. Relationship of deaths occurring within 24 hours of birth to deaths occurring on calendar day of birth: Netherlands and Norway, selected years 

Year 

Netherlands 

1958-59--------------

1.958-----------------------

1959-----------------------

Norway 

1949-1951------------

1949-----------------------


1950-----------------------


1951-----------------------


1959-1961------------

1959-----------------------


1960-----------------------


196L


Deaths occurring: 

Within On calen24 hours dar day 

of birth of birth 

(Col. 1) (Col. 2) 

2,968 2,172 

1,439 1,084 

1,529 1,088 

1,281 916 

496 326 

386 305 

399 285 

1,069 763 

381 271


349 248


339 244


Percent of deaths Ratio of deaths 

within 24 hours occurring within 

of birth which 24 hours of 

occur on calendar birth to deaths 

day of birth occurring on 

calendar day 

I of birth 

73.2 I 1.37 

75.3 1.33 

71.2 1.41 

71.5 1.40


65.7 1.52 

79.0 1.27 

71.4 1.40 

71.4 1.40 

71.1 1.41 

71.1 1.41 

72.0 1.39 

SOURCE : Unpublished data from Central Bureaus of Statistics for the Netherlands 

and Norway. 

COMPUTATION OF RATES 

Infant Mortality 

During periods of rapidly changing numbers 

of births, the computation of infant mortality 

rates based on deaths under lyearandlive births 

in the same calendar year gives biasedestimates 

of the risk of death. If births arerising, the estimate of the risk of dying expressedby the infant 

mortality rate is artificially deflated. Conversely, 

the infant mortality rate is inflated in periods when 

births are declining rapidly. 

These biases can be overcome by relating 

infant deaths to the number of live births which 

gave rise to the group subject to dying under 1 

year of age (’’related births”). England andWales 

made it a practice to compute their rates based 

on “related births” for the period 1935 through 

1956. The largest differenceintherates computed 

19

by the two methods was in 1946 when the number 

of live births increased sharply. Infant mortality 

based on live births in the calendar year was 40.9 

per 1,000, while infant mortality based on “related births” was 42.9. 

When comparing a number of countries 

whose rates do not vary widely, such differences 

in the statistical practices of only one country 

may prove confusing. For that reason, the rates 

for England and Wales for the period 1935-56 

have been recomputed based on live births in the 

appropriate calendar years. This method was 

used by all of the other countries. 

Perinatal Mortality 

The vital events which are to be included as 

perinatal deaths are based on gestation for fetal 

deaths and age at death for neonatal deaths. For 

ease of comparison, the perinatal mortality rates 

in this report have been computed as follows: 

Deaths under 7 Fetal deaths of 28


days (or within + or more weeks of


7 calendar days gestation


of birth)
 x 1,000 Fetal deaths of28 

Live births + or more weeks of 

gestation 

The early neonatal deaths for England and Wales, 

Norway, Scotland, and the United States are based 

on age at death, i.e., elapsed period since the 

hour of birth. For the remaining countries, early 

neonatal deaths are based on the number of calendar days which have elapsed since the date of 

birth. When the entire first week’s events are 

combined the difference caused by this variation 

in statistical practice is relatively small. 

Fetal deaths of 28 or more weeks of gestation 

are included in perinatal deaths. Until 1960, in 

Sweden the criteria for registering fetal deaths 

was based exclusively on fetal length, i.e., 35 

centimeters or longer, rather than gestation 

period. Thereafter, the primary variable became 

the gestation period, i.e., after the end of the 28th 

week of pregnancy. In the absence of knowledge 

of the duration of gestation, fetal length is still 

used. For the remaining European countries included in this report, fetal deaths are required 

to be registered in the 29th week of pregnancy or 

later (Denmark), after the 28th week of pregnancy 

(England and Wales, Norway, and Scotland), or 

with gestation periods of 28 weeks or more (the 

Netherlands). The fetal death statistics used in 

this report include all of the registered events 

for these countries. 

For the United States, the detailed official 

vital statistics are published for fetal deaths with 

gestation periods of 20 weeks or more beginning 

with 1942. The perinatal mortality rates in this report were standardized to include only those 

fetal deaths of 28 or more weeks of gestation and 

a proportion of those with the duration of gestation unspecified. 

Fetal Mortality 

The computation of the fetal mortality rates is 

subject to the same limitations outlined above. 

For this report, they have all been standardized 

so that they are probabilities and not ratios: 

Fetal deaths of 28 or more weeks of 

gestation x 1,000 Fetal deaths of 28 

Live births + or more weeks of 

gestation 

Neonatal Mortality 

Earlier in the century, the neonatal period 

was considered the first month of life. 

Since months have varying numbers of days 

from 28 to 31, in more recent years the 

neonatal period has been defined to include 

the first 4 weeks of life. lhe difference 

caused by this change in definition is small 

since the risk of death declines rapidly 

from birth throughout the first month of 

life. Therefore, in this report, no distinc20 
tion is made between neonatal rates based 

on the first month or the first 28 days 

of life. 

Neonatal mortality rates and their components (under 1 day, 1-6 days, and 7-27 days) are 

computed per 1,000 live births. 

Postneonatal Mortality 

The postneonatal rates include the remainder 

of the first year of life, i.e., either 1 through 11 

months or 28 days through 11 months of age, 

depending on the definition of the neonatal period. 

No distinction is made between postneonatal rates 

based on these two time periods in this report. 

Problems of definition of live birth are 

minimal in this period, and death registration is 

probably more complete in the postneonatal than 

the neonatal period. 

Postneonatal mortality rates are computed 

per 1,000 live births. 

RELATIVE 

OF DIFFERENCES 

Each of the sources of difference in the basic 

data was considered independently by the participants at the conference held in Washington in 

May 1965.18 Where estimates of their statistical 

effect existed, it was felt that they were not 

sufficiently large to account for the observed 

differences in mortality. In some instances where 

evidence was unavailable, e.g., completeness of 

registration, it was pointed out that internal crosschecks and the impetus of social insurance benefits favored complete registration among the west 

European countries. 

The estimates presented here will be referred 

to again as the mortality data are presented. Their 

magnitude will be considered in the light of their 

relationship to the observed differences between 

the infant mortality experience of the United States 

and the other countries. 

21 
Ill. PERINATAL AND INFANT MORTALITY BY AGE 

INFANT MORTALITY delivery, and low utilization of services even in 

those areas in which they are available. 

Infant mortality has long been considered an The seven countries included in this study 

index of the level of health of a community. High shared the achievement of markedly reducing their 

rates are associated with low socioeconomic con- infant mortality in this century. Even since 1935, 

ditions, problems of environmental health, limited the reductions have been significant, ranging from 

medical facilities and resources and concomitant 55 to 72 percent during that period (fig. 3 and 

low levels of prenatal and obstetric care at table 12). The period of World War H (1939-45) 

100.0 

80.0 

6Q0 

I 

al


z


~ 40.0


z


u


>


i 

o 

0 30.0 0 

_. 

a 

u 

L 

w 

1-

a 

a 

20.0 

10.0 

—World Warn —-l 

_ Denmark 

— Englond ond Wales


—— Netherlands


----Norway


, . . . . . . . .. Scotland 

—.-Sweden 

_ United Statee 

(Deaths under I year of oge) 

\, 

\. ‘—’ ,,, \ 

-“+’-

\ \ — --2<--- -- “-’\.4.\ *--+ 

‘L.y”\:\-’< “ 

.-. 

?’ 

I I I I I 

1935 1940 1945 1950 1955 1960 19( 

YEAR 

Figure 3. Infant mortal i ty rates: selected countries, 1935-6W. 

22 

I 
--------

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

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

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

I 

Table 12. Infant mortality rates and percent reduction: selected countries, 1935, 1950, 

and 1962 

Infant mortality ratek Percent reduction 

I 

Country 

1935 1950 1962 1935 to 1935 to 1950 to 

1962 I 1950 I 1962 r 

Denmark ------------------ 71.0 

England and Wales 56.9 

Netherlands 40.0 

Norway ------------------- 44.2 

Scotland 76.8 

Sweden ------------------- 45.9 

United States 55.7 

lRates per 1, 000 live births. 

7 Despite the exigencies ofthe depression and 

3 World War II, the rates of decline were most 4 

1 precipitous in the 1930’sand1940’s. During this 

1950 I period, the United States assumed a midposition: 

I in 1935 itrankedfourthamongthe sevencountries, 

showed irregularities in theratesandthedisturbRonk 1935 ante was especially notable in the Netherlands 

6 where the rate almost doubled inthe yearbetween 

5 1944 and1945.The followingyearthe ratereturned I to its previous level. 2 

6 

s andin 1950 the rank was the same(fig. 4). More2 over, the countries which had rates lower than 

3 the United States in 1935 retained that position in 7 

I 1950; this was the case with the countries with 4

I

t 

higher rates aswell. 

1962 I Since 1950, the relative position oftheUnited 

States with regard toinfantmortality haschanged: 4 itnowranksseventh amongthisgroup ofcountries, 5 

2 with arateof24.8in 1964. The trend line for the 

3 United States has leveled off markedly, thus 7 

I changing its relative ranking. Since 1950,therate 

6 of decline has been less for theUnitedStates than 

30.7 20.0 72 57 35 

29.9 21.7 62 47 27 

26.7 17.0 57 33 36 

28.2 17.7 60 36 37 

38.6 26.5 65 50 31 

21.0 15.3 67 54 27 

29.2 25.3 55 48 13 

r 1 1 1 

0 50 100 150 

INOEX 

Figure !. Ratios of infant mortality rates of selected countries to those of the United States: 

1!+35, 1950, and 1962. 

for anyofthe other countrit?s. l%epercent decline 

in the United States between 1950 and1962is only 

about one-half to one-third of the decline in the 

other six countries. 

However, countries other than the United 

States are also showing evidence of a change in 

the trend line for infant mortality. For example, 

23 
the trend for Scotland since 1954 differs from that 

in earlier years, and the slope of the trend line for 

Norway since 1952 is less than it was in the period 

1941-52. In recent years, the trend for Sweden as 

well seems to have leveled off. But infant mortality 

in Denmark, England and Wales, and the Netherlands appears to be declining steadily. 

PERINATAL MORTALITY 

The relative influence of specific causes of 

fetal and infant death varies with infant’s age and 

the period surrounding birth is particularly 

hazardous. Placental and cord conditions in the 

fetus, and prematurity alone or in association 

with congenital malformations, birth injuries, 

postnatal asphyxia and atelectasis, or pneumonia 

of newborn are the leading causes of fetal and 

neonatal mortality. In the postneonatal period, 

pneumonia, congenital malformations, and accidents are the leading causes of death. 

Causes of fetal and early neonatal death are 

closely related. The view has been expressed that 

in individual deliveries, it is often problematical 

whether a fetus will die in utero shortly before 

delivery, or whether the fetus will be born alive 

and succumb within the first minutes or hours 

after delivery. This view is allied to the concept 

of viability, i.e., the ability of the newborn to 

survive as a separate being once it has been 

delivered. Perinatal rates have been devised to 

permit consideration of fetal deaths and neonatal 

deaths simultaneously, and as the term is used 

in this report, it combines fetal deaths of 28 or 

more weeks’ gestation and neonatal deaths under 

7 days of age. 

In the early 1960’s as in 1942, the perinatal 

mortality rate of the United States was higher than 

those of the Scandinavian countries and the 

Netherlands; only England and Wales and Scotland 

had higher rates (fig. 5). However, for a brief 

period in the early 1950’s, it was second lowest; 

only Norway claimed lower perinatal mortality 

rates. If the rates are ranked with the lowest rate 

in first position, the rank of the United States rose 

from fifth in 1942 to second in the early 1950’s 

and fell back to fifth in the early 1960’s. These 

changes were due to a temporary elevation of 

perinatal mortality in Denmark, the Netherlands, 

and Sweden in the early 1950’s. 

Perinatal mortality declined during the past 

three decades in each of the seven countries. 

However, for none of them has the rate of decline 

since 1950 equaled the decline of the earlier 

period. Between 1945 and 1955, there was an 

apparent increase in the rates for Denmark and a 

leveling off for England and Wales, the Netherlands, and Scotland. Since 1955, the trend for 

England and Wales and for Scotland has resumed 

a faster rate of decline. However, the rate of decline for the United States has not been similarly 

accelerated. 

Fetal Mortality 

Fetal death (or stillbirth) registration is 

probably less complete or accurate than the 

registration of infant deaths. Evidence from 

special studies shows that the registration of 

fetal deaths in parts of the United States is incomplete. From data of three such special studies, 

incompleteness was estimated to be 6, 11, and 14 

percent for fetal deaths with gestation periods of 

28 or more weeks. 11-13 Unregistered events for 

the country as a whole are probably somewhat 

higher since these estimates are based on data 

from three Registration Areas which are considered to have good registration systems. 

Although similar estimates for the west 

European countries are unavailable, the registration of stillbirths in those countries was felt to be 

“good” by the contractors who prepared data used 

in this report. They pointed to the long history of 

registration in their countries and to cross-checks 

made between registered vital events and notifications made to health authorities as conducive to 

complete registration. Nevertheless, it was suggested that some understatement of stillbirths 

exists in the official statistics of Denmark, the 

Netherlands, and Norway, at least. 

Two viewpoints were expressed on this subject at the Center’s Conference on the Perinatal 

and Infant Mortality Problem of the United States. 

Since only stillbirths with gestation periods of 28 

or more weeks are generally required to be 

registered in the west European countries, those i 

investigators felt that registration at this period ‘ 

of fetal development is probably more complete 

than in the United States where the minimum period 

at which registration is generally required is 20 

24 
(Fetol deaths of 28 or more weeks’ gestation and deaths under 7 days) 

r V.u 

. . . . . . . 

. . . . 

,..0 

. ... 

60.0 .,.. 

...-

.... 

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

So,o 

11 - “’”-..... 1 .... ...... -.. .... ............. \ .. -1 

30.0


20,0


+World WarlI— 

—Denmark 

—Englond and Wolee 

__ Netherlands 

--__. Morwoy 

............ Scotland 

—.—Sweden 

— United States 

10.0 I I I I I I I I I I I I I I I I I I I I I I 

1935 1940 1945 1950 1955 1960 1965 

YEAR 

Figure 5. Perinatai mortality rates: selected countries, 1935-6!. 

weeks (or perhaps, 5 months), or- in some 

Registration Areas—regardless of the period of 

gestation, 

On the other hand, in the United States underregistration could be estimated separately for 

those gestations of 20-27 weeks or 28 or more 

weeks for areas in which either the minimum 

requirement for registration was 20 weeks or no 

minimum period was specified and all products of 

conception were to be registered. The conclusion 

was that unregistered events increased as one 

approached the minimum cutoff point at which 

registration is required. Therefore it was hypothesized that in the gestation group of 28 or more 

weeks, fetal deaths would be more completely 

registered in the United States than stillbirths in 

the same period in the other countries. No firm 

conclusion could be reached. However, it seems 

25 
----

------

------

---

------

-----

reasonable to assume thatsomeunderstatementof 

stillbirths exists in the west European countries 

as well asinthe United States, butits magnitude is 

unknown. 

Fetal mortality has proceeded generally along 

a downward course since 1935 except in Denmark 

which exhibited higher fetal mortality during the 

years 1949 to 1956 (fig. 6A). Throughout these 

three decades, the highest fetal mortality was 

experienced in England and Wales and in Scotland. 

The rates for the United States were lowest 

through the major part of this time span (1945-63). 

However, since about 1956, there has been a leveling off of the trend for the United States with the 

result that by 1964, this country could no longer 

claim to have the lowest rate. In each of the 

other six countries, the declines between 1955 and 

1963 appeared to be more precipitous than in the 

United States regardless of whether they were 

expressed in arithmetic or relative terms: 

Fetal mortality I Differ-1 Percent ra country ence decline 

1955 1963 

Denmark. 17.9 11.4 6.5 36.3 

England and 

Wales 23.2 17.2 6.0 25.9 

Netherlands- 17.o 14.3 2.7 15.9 

Norway 14.9 12.6 2.3 15.4 

Scotland- 24.6 19.1 5.5 22.4 

SwefLen 16.7 12.0 4.7 28.1 

United 

States 12.6 11.3 1.3 10.3 

These observations are based on recorded data, 

with no allowance for underregistration. 

Assuming, for the moment, that no underregistration of stillbirths exists in any of the 

west European countries, what is the effect of 

the estimated underregistration in the United 

States? If underregistration across the country is 

assumed to be 15 percent throughout this period, 

and recorded events are increased by 12 percent 

to allow for this underregistration, the level of 

the trend line would be raised (fig. 6B). The span 

of consecutive years over which this country had 

the lowest fetal mortality would be reduced from 

19 years (1945-63) to 5 years (1955-59). However, 

the rates would not nearly approach those for 

England and Wales and for Scotland. Even with 

an increase of 20 percent of registered events, 

which implies 50 percent underregistration in 

the United States and is highly unlikely, the 

rates for the United States would have remained 

significantly below those for England and Wales 

and for Scotland since 1942. 

If some allowance is made for underregistration in the west European countries as well as in 

the United States, the relationships among the 

United States, England and Wales, and Scotland 

would be unchanged; fetal mortality in the United 

States would remain consistently below that of 

England and Wales and of Scotland since 1942. 

Any underregistration existing in Great Britain 

would only serve to increase the estimated 

difference between these countries and the United 

States. With regard to the other countries, the 

conclusions cannot be stated with as much confidence. 

Even more difficult to assess are the differences related to definition. According to definition, registered live births in Sweden (until 1960) 

included only those infants who breathed, omitting 

those whose only sign of life was pulsation of the 

umbilical cord, movement of voluntary muscles, 

and so forth. These latter births were included 

in fetal deaths. Using English data for a basis, 

Stocks has estimated that the use of breathing 

alone as a criterion of live birth instead of the 

more encompassing definition would decrease 

infant deaths by 1.5 percent and increase fetal 

deaths by 3 pe~cent.7 Adjustment of the Swedish 

rates for this difference would not disturb the 

relative position of the United States. 

Another factor which may be affecting fetal 

mortality is obstetrical care. In the United States, 

since World War II and more especially since 

1950, there has been considerable effort to prolong gestation for those pregnancies which 

give indication of terminating prematurely. It has 

been hypothesized that this preventive care has 

increased the likelihood of producing a liveborn 

infant. Theoretically, if practice of the preventive 

regime were sufficiently widespread, it could 

result in lower overall fetal mortality rates. 

Existing data cannot be used to substantiate or ~ 

refute this hypothesis because they reflect the 

combined effect of changes in legislation and 

improved registration, as well as the alleged 

effect of prolonging the period of gestation. 
---

---

------

.......

(Fetal deaths of 28 or more weekd gestation) 

50 I I 

A. Recorded rates 

40 

30 — 

\ \ 

Z 

~ . 

: 20’ 

mId 

a 

% — Oenmark K — England and Woles 

$ ——- Nether lands 

+ Norway 

3 .. . .. . . . .. . . . . Scotland 

L —.— Sweden o _ United States 

m 

z 

l’-

; 10 I I I 

n 1935 1940 1945 1950 1955 1960 1965 

A 

: YEAR Ill 

u. 

250 ~—---- B. Esiimoled rotes 1‘-”--””-----”-”---—” for the United States and recorded rates for other countrfas

m


x


1- k ‘-”-” ....


E 40 ....... 

m ““..... .... 

... 

... 

%.

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

%.

..... I 

~k>””””mm>-­ . 

‘\.,~ ~-. 20 ‘N 

\ —/ 

~> 

. ,*---- \ -.. 

‘., ‘h:\:,~­

“-. 

I I“craasad 12 percent for undsrregistration \ 

[ ==1 8\ 

10 I I I i I I I I I I I I I I I 

1935 1940 1945 1950 1955 1960 1965 

YSAR 

Figure G. Fetal mortality rates: selected countries, 1935-64. 

27 
Furthermore, there is no documentation of the 

- extent to which these preventive regimes are 

practiced in this or other countries, or their 

success or failure in improving the likelihood of 

live birth. 

In the United States, tax advantages have also 

been mentioned as a possible source of faulty 

registration. The birth of a liveborn infant entitles 

the parents to an additional exemption on their 

income tax return in the year of birth even if 

the infant dies shortly after birth. If the fetus is 

stillbmn, no such exemption applies. Thus, in 

instances when an infant may have either been a 

fetal death or survived only a few minutes, its 

registration as a live birth would deflate the fetal 

death statistics. While the plan would have advantages for the parents, it would be illegal. Furthermore, it is generally felt that physicians would 

not favor this practice because it would require the 

completion of two vital records (live birth and 

death) rather than one (fetal death). While there 

is no direct evidence to s“upport the premise, 

in the Onondaga County study, no instance of 

faulty registration of a fetal death as a liveborn infant was found. 11 

According to available evidence and estimates 

from special studies, fetal mortality for the United 

States appears to be lower than that of the other 

countries. The many qualifications explored above 

reaffirm the need to educate medical and hospital 

personnel so that they will thoroughly understand 

the definitions and implement them to the best of 

their abilities. 

Mortality Under 1 Day 

Closely related to the problems associated 

with fetal mortality are those related to the period 

soon after birth. Early neonatal deaths (deaths 

in the first week of life) are not uniformly 

classified by the countries included in this report; 

Denmark, the Netherlands, and Sweden classify 

age at death by calendar days from date of birth, 

while England and Wales, Norway, Scotland, and 

the United States classify age by elapsed time from 

hour of birth. This difference has the greatest 

effect on death rates closest to the time of birth. 

For the purposes of this re~rt, deaths in the 

period soon after birth are termed “early postnatal deaths” and include those on the calendar 

day of birth for Denmark, the Netherlands, and ‘


Sweden; and deaths within 24 hours of birth for


England and Wales, Norway, Scotland, and the


United States. The latter group includes deaths


for a longer time span (24 full hours), while the


former contains, on the average, only part of


the first 24 hours of life for each live birth.


Mortality rates for the first 24 hours of life 

for the United States have been highest among 

this group of countries since 1935 (fig. 7A). When 

the comparison is limited to those countries which 

tabulated deaths in the first 24 hours of life 

(fig. 7B), mortality in the United States remains 

highest, although the difference is not so great. 

The rates for Scotland and the United States were 

proximal for a few years until 1954. Thereafter, 

the rates for the United States turned upward, 

while those for Scotland seem to have achieved a 

slightly lower level. The rates for England and 

Wales appeared to increase somewhat after 1950 

but reverted to the midcentury level in 1963. 

The rates for Norway declined during the early 

1950’s, but suggest increases thereafter. 

Using fetal and early postnatal mortality in 

combination, the earlier observations regarding 

the position of the United States can be reexamined. 

First, the problems associated with the definition of live birth are pertinent to early postnatal 

mortality as they were to fetal mortality. The 

statistical effect of various definitions would be 

relatively small on the denominator of live births, 

while the effect on fetal deaths or deaths in the 

first day (or first 24 hours of life) would be 

greater. However, if fetal deaths and early postnatal deaths are combined, the question of 

definition of live birth is minimized. 

Second, with regard to the tabulation of early 

postnatal deaths, for the Netherlands van den Berg


estimated that deaths occurring on the calendar


day of birth should be increased by 20 percent to


estimate the deaths within 24 hours of birth. 17


Using data from Indiana and North Carolina, -


Greenberg estimated that deaths within 24 hours


of birth exceeded deaths which occur on the date


of birth by about 28 percent. 18 Tabulations of


actual deaths in the Netherlands (1958-59) and


Norway (1949-51 and 1959-61) indicated the excess


for these countries to be 37 to 40 percent,


respectively (table 11). For present purposes


if the deaths on the calendar day of birth for


28 
--

---

------- ----

----

(Deaths within 24 hours of birth or an calendar day of birth) 

A. Deaths within 24 hours of birth or en aalendar day of birth I 

10.0 -

8,0 - \ ,+,/----+ 

= 

m 

~ 4,0 I I I I I I I I I I I I I I I I I I I I 1 I I I 

~ 1935 1940 1945 1950 1955 1960 3 

o 

0 

0 

Eo.o 

a 

~ 

: 

K 

/’”... 

,..” 

-“””” ”%.....” 

10.0 – 

\ 

8.0 – 

\ /-----

YEAR 

B. Deaths within 24 haure of birth 

v -\ 

\ \ /’\\ ,/--, 

\/@*--\/’ * ‘\\ 

6.0 – 

Oeaths ancalenderr day of birth 

_ Denmark 

—_ Netherlands 

-.— Sweden 

\ \ ,%,/---, 

\ \ \ 

‘< ---< 

/--., / 

‘\% /* 

Deoths within 24 hours of birth 

— England and Wales 

Norway 

.......... Scatlond 

— United States 

4.0 I I I I I I I I I I I I I I I I I I I I I I I I 

1935 1940 1945 1950 1955 [960 1965 

YEAR 

Figure 7, Early postnatal rnortali’ty rates: selected countries, 1935-6!. 

1965 
----------

-------

-----------

----------

-----------

------

Denmark, the Netherlands, and Sweden are increased 40 percent, estimates of the deaths in the 

first 24 hours of life are made comparable to the 

data provided by the other countries (England and 

Wales, Norway, Scotland, and the United States). 

While this adjustment may seem high, the difference between the extremes (from 20 percent 

to 40 percent) of the four estimates is approximately 1.0 per 1,000 live births in the rates. 

Allowance can be made for a third bias by 

increasing the count of fetal deaths for the United 

States by 12 percent for underregistration. Although it would be desirable to make adjustments 

for the other countries as well, estimates of the 

magnitude of their underregistration of fetal 

deaths are unavailable, and no adjustments have 

been made in their data for this fact. Because of 

the cross-checking between registered events 

‘ and notifications, the adjustments should probably 

be smaller than that for the United States. 

After these adjustments are made, the estimated combined fetal and early postnatal mortality 

rate for the United States (23.0 in 1962) was still 

considerably higher than those for the Scandinavian countries and the Netherlands, and was exceeded by those for England and Wales and for 

Scotland. The position of the United States relative 

to the other countries remained unchanged, but 

the range of the rates was reduced from 16.7-

29.1 to 18.6 -29.1 per 1,000 live births and fetal 

deaths: 

Registered Estimated 

Denmark 16.7 18.6 

England and Wales- 25.4 25.4 

Netherlands 20.0 22.1 

Norway 19.0 19.0 

Scotland 29.1 29.1 

Sweden 17.8 19.9 

United States 21.7 23.0 

These estimates present as comparable a set of 

statistics as can presently be devised for the 

period immediately surrounding birth. They avoid 

the discrepancies due to the definitions of live 

birth and fetal death. The rates have been adjusted 

for the estimated underregistration of fetal deaths 

in the United States, and for the variance in 

tabulation of the early postnatal deaths in Denmark, 

the Netherlands, and Sweden. They represent 

averages between fetal mortality where the United 

States had the lowest rates, and mortality for the 

first 24 hours of life where the United States had 

the highest rates. In this ranking, the estimated 

rate for the United States remains considerably 

higher than those for Denmark, Norway, and 

Sweden. 

Mortality 1-6 Days 

The third component of the perinatal mortality rate consists of the remainder of the first 

week of life. Again, it has a built-in bias due to 

the two methods of tabulation: deaths in terms 

of calendar days since birth in Denmark, the 

Netherlands, and Sweden; and in terms of elapsed 

time since birth in the other countries. The rates 

for Denmark, the Netherlands, and Sweden are 

overstatements compared with those for remaining countries (fig. 8A). Estimates of the overstatement are approximately 1.0 per 1,000 live 

births. If allowance is made for this difference, 

the mortality at this age for the United States is 

exceeded only by that of Denmark. 

When the comparison is limited to three 

other countries which tabulate their deaths in the 

same manner as the United States, the relative 

position of the United States has changed since 

1935 (fig. 8B). The relationship with Norway remains unchanged: throughout the three decades, 

the rates for Norway have been consistently lower 

than those of the United States. The change has 

been in the relationship of the rates for England 

and Wales, Scotland, and the United States. In the 

midthirties and throughout the war, the rates 

for the United States were lower than those for 

England and Wales and for Scotland. However, 

since 1955, the rates for England and Wales have 

fallen below those of the United States. In 1959, 

the rates for Scotland and the United States 

were the same. Since then, the rates for these 

two countries have fluctuated, merging once 

more in 1963 and 1964, 

Components of Perinatal Mortality 

Available evidence shows that the United 

States occupies fifth position among the study 

countries with regard to perinatal mortality. It 

appears to have some advantage in fetal mortality, 

30 
.

.. ----

(Deaths from I-6 days of age. Exaludes early postnatal mortality) 

I 5,0 

A. Deaths I-6 daye after birth or lst-6th calendar day following birth 

u) 

E 

cc 

z 

u 3.0 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 1935 1940 1945 [950 1955 [960 1965 

0


0


0


;“ I 5.0 

Ik.1 B. Deaths I-6 days otter birth 

. .. .. ..- .. -.””’ -....,... ..,. Deaths on calendar days from birth 

%. �—e Denmark ... Netherlands .... -—.= Sweden ...... 

10.0 k,. 

...... .

““.....

.... .“”” ...

“..

“.....

%. 

Deaths within elapsed time from birth 

j 

%.”” — England and Wales 

Norway 

.. . . . . .. . Scotland ... — United States I 

B.O - ---~, 

\\ 

\ \/O”\ 

\ 

\ 

\ 

\ 

\ ,P\ 6.0 - \ \ \ \

\ . . /’ \

\ /\\ 

\ ,------ \\/~ \\,/”\ --> \ \v/ \ 

\ /’ ‘% \.-. /---

\ /’ %, 1 %. 

%%/ %./’ 

4.0


t i 

3,0 I I I I I I I I I I I I I I I I I I I I I I I I 

1935 1940 1945 1950 I 955 1960 1965 

YEAR 

Figure 8. Early neonatal mortality rates: selected countries, 1935-6!. 

31 
..

.. .. .

.

(Deaths 7-27 doye of age) 

20.0 

.. . ........ .. -. /

/ . . /“ .. 

... ... / .. 

......)..”” 

10.0— 

8.0 — 

w 

x 

1-

E 6.0 — m 

w 

> 

3 

0


0


~. 4.0 —


a


Ill


0.


w


1-


a


E


Denmark 

=England 

2.0I 

\ 

‘.


....””””’”””..


and Wales 

__ Netherlands 

._-_. Norway 

........... Scotland 

—.—Sweden 

—United States 

“\ 

Lo I I I I I I I I I I I I I I I I I I I I I I 1 I I 

1935 1940 1945 1950 1955 1960 1965 

YEAR 

Figure 9. Late neonatal mortal iiy rates: selected countries, 1935-64, 

but this is offset by higher mortality during the country and England and Wales or Scotland would


first 24 hours of life and the remainder of the not be eliminated.


first week, Even the advantage in estimated fetal


mortality may be somewhat illusory because the MORTALITY 7-27 DAYS


estimates of underregistration which were used


are based on studies in areas with good registra- Discharge from the hospital represents a sig­


tion. Underregistration of fetal deaths of 28 or nificant change in the infant’s life—there is a


more weeks of gestation may be higher than-the pronounced change in environment between the


estimate of 12 percent used here. In that case hospital and the home environment. The period


the differential between the United States and from 7-27 days, fo; the most part, is spent at


some of the Scandinavian countries would be home by those infants who were born in hospitals


eliminated, but the differential between this as well as those who were born at home. ‘l%ey


32 
-------

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

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

are, however, still vulnerable to the effects of 

neonatal disorders: congenital malformations 

(particularly of the heart), pneumonia of newborn, 

postnatal asphyxia and atelectasis, and immaturity 

predominate among the recorded causes of death. 

In addition, in this age interval, accidents begin 

to emerge as a more frequent cause of death 

than in the first week of life. 

Rates in the period 7-27 days are lower than 

those nearer birth, and the risk of death is also 

much lower. For example, in the United States 

(1959-61) the daily rate in the interval 7-27 days 

is about one-tenth the daily rate in the interval 

1-6 days, which in turn is abut one-tenti tie 

rate in the interval under 24 hours: 

Under 24 hours 1,029.9 

1-6 days 106.5 

7-27 days 9.6 

Mortality in this age group has been somewhat 

erratic over the past three decades (fig. 9). During 

the depression of the 1930’s, the rates were somewhat elevated. Thereafter, the countries which 

were severely Immbed or were invaded in the war 

showed pronounced increases at some time between 1939 and 1945: Denmark, England and Wales, 

the Netherlands, and Norway. The unusually 

high mortality in the Netherlands was associated 

with severe food shortages just before and after 

the close of the war. Scotland which was closely 

affected by the events in England also showed 

increases. Only Sweden and the United States 

continued to have generally declining mortality 

in this age interval during the war. 

Beginning with 1950, there appeared to be a 

definite change in trend for a number of countries. 

For all of them, the rate of decline since 1950 

is not comparable with that of the preceding years, 

although the point of inflection occurs indifferent 

years. The change appears to have occurred 

around 1950 for Denmark, England and Wales, 

and the United States, and a few years later in 

Norway and Scotland. The change in trend for 

the Netherlands is, at present, inconclusive. 

The relative position of the United States 

has changed during these three decades. In the 

1930’s, it occupied fourth or fifth position. The 

Scandinavian countries and the Netherlands seem 

to have had somewhat better records. During the 

1940’s, because of increased mortality in a number 

of countries, only Sweden had lower mortality 

than the United States for these infants. However, 

except for Denmark, since 1950 the countries have 

generally resumed the relative ranks they held 

in the thirties. Sweden has occupied the prime 

position since 1941. 

POSTNEONATAL MORTALITY 

In the postneonatal period, pneumonia and 

congenital malformations continue to be leading 

causes of death. Malformations of the heart are 

predominant among the malformations as they 

were in the interval 7-27 days. Accidents and 

diseases of the digestive system also rank high. 

Other important causes of neonatal mortality such 

as postnatal asphyxia and atelectasis and immaturity are less important. 

There are many similarities between the 

trends in this and the preceding age interval 

(fig. 10). ‘The effects of the depression and the 

ensuing war are similar. The pronounced peak 

in the Netherlands in 1945 is again evident. The 

trend for the United States made a decided change 

between 1945 and 1950. From a pattern of rapid 

decline, it shifted to an increase in 1948 and 1949, 

with relatively little decline thereafter. While the 

rate declined by 9.4 per 1,000 in the 10-year 

interval between 1935 and 1945, it declined only 

1.4 per 1,000 between 1950 and 1960. 

The United States has dropped from second 

best among this group of countries in the years 

1941-51 to sixth place in the years 1958-64. The 

rates for other countries such as Denmark, the 

Netherlands, and Norway are declining at so rapid 

a pace that they have overtaken and bypassed the 

United States. The rates of decline for Denmark, 

the Netherlands, Norway, and Sweden are abut 

equal although the relative positions of the trend 

lines differ. England and Wales was also proceeding at a similar pace until the midfifties when a 

decided change in trend took place. This change 

is reminiscent of that in the United States about 

5 years earlier. 

33 
(Deaths 28 days-n months of age) 

60.0 

1- — I

— ,. 

....+. 

%. ,., I -, \ . . . ~. \\ . .... I 

s 

i \ .—. 

o 

g 10.0 

_. 

lx 

~ 8.0 — 

u 

+ 

a 

E 6.0 — ‘— . 

—World War ~~ \ 

-t. -

‘\ 

—Denmark 4.0 – England and Wolee 

‘ti-\ 

‘\. —_ Netherlands 

.----Norway \ ‘\ . . . . . . . . . .. Scotland 

‘—.. -Sweden \+/. —--y, -

— United States \ 

2.0 I I I I I I I I I I I I I I I I I I I 1935 I 940 1945 1950 1955 1960 1965 

YEAR 

Figure 10. Postneonatal mortality rates: selected countries, 1935-64. 

SUMMARY 

Perinatal mortality (fetal deaths of 28 or more 

weeks’ gestation and deathsunder7 days)declined 

during ‘tie past several decades in each of the 

countries includedinthisreport. For eachofthem, 

the rate of decline since 1950 has been slower 

than for the earlier period. In recent years, all 

except Norway show evidence ofdecliningmore 

rapidly than the United States. 

In the United States, during the decade 1949-51 

to 1959-61, gains were madeinreducingperinatal 

mortality despite the deceleration inthe rate of 

decline (table 13). Perinatal mortality declined13 

percent and sizable reductions were observedin 

its components with one exception, namely, mortality under 24 hours of age. ‘Ihe salient point is 

that mortality for this age interval increased 2 

percent while mortality for all of the other com- /,/ 

ponents decreased 17-29 percent. I 

34 
-------

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

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

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

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

Table 13. Infant	 and perinatal mortality rates, change in rates, and percent change, 

by age at death: United States, 1949-51 to 195g-61 

Component 

Infant deaths (under 1 year)l 

Perinatal deaths2-------------------

Fetal deaths2---------------------

Under 24 hoursl 

1-6 daysl 

7-27 daysl 

28 days-n monthsl 

lRates per 1,000 Mve births. 

Rate 

1949-51 1959-61 

29.6 25.9 

32.2 28.1 

14.6 11.6 

10.1 10.3 

7.7 6.4 

2.8 2.0 

9.0 7.2 

Change in rate 

(1;;;;5;1:0 

I 

-3.7 

-4.1 

-3.0 

+0,2 

-1.3 

-0.8 

-1.8 

Percent change 

(1;::;5:1;0 

-12.5 

-12.7 

-20.5 

+2.0 

-16.9 

-28.6 

-20,0 

2Rates per 1,000 live births and fetal deaths 28 weeks and over and a proportion of 

those with gestation not stated. 

In the United States, most registered fetal 

and infant deaths occur inhospitals. Thiscircumstance increases theirresearchpotential .In1963, 

95 percent of registered fetal deaths occurredin 

hospitals and other institutions. Furthermore, 

since 97 percent of live births occur ininstitutions, a high proportion of deaths in the first 

24hours oflife must also occur inthese settings. 

After the first week of life, death often occurs 

outaide hospitals (40.6 percent in 1958).Nevertheless research is needed on this group aswell 

because of the leveling off ofthe mortality trends 

forinfants7-27 daysand28days -llmonthsof age. 

35 
IV. INFANT MORTALITY BY CAUSE 

In addition to data on mortality by age, each 

of the contract investigators provided tabulations 

of infant deaths by cause of death. Standard 

tabulations for the west European countries were 

derived from basic data prepared by contractors 

or, in a few instances, data derived from official 

publications. The tabulations are presented using 

the World Health Organization International Statistical Classification of Diseases, Injuries, and 

Causes of Death (ICD). During the years 1950-64, 

the sixth and seventh revisions of this classification were in use in the United States and the 

changes between them were relatively minor. 

Furthermore, because the period since 1950 is 

the primary focus of attention, data by cause of 

death are limited to that period. 

Certain limitations of the data are worthy of 

further comment. At the Center’s Conference on 

the Perinatal and Infant Mortality Problem of the 

United States, it was pointed out that recorded 

causes of fetal and neonatal death are regarded 

with caution in the Netherlands .18Similar reservations are held in the United States, although 

larger proportions of registered fetal and early 

neonatal deaths occur in hospitals in this country. 

It is recognized that within countries as well as 

between countries, there are certain customs of 

reporting causes of death. Use of the term 

“respiratory distress syndrome” in the United 

States is one such example. Nosologists at the 

National Center for Health Statistics have noted 

increasing use of this term on death certificates, 

and statisticians face the ensuing problem of 

trying to determine whether this represents a 

true increase in the disease or a terminological 

vogue. Superimposed on trends of this kind within 

one country are international differences in usage 

of terms. To some extent, the effect of such 

practices can be minimized by grouping causes 

which may be reported differently, e.g., influenza 

and pneumonia, including pneumonia of newborn. 

A further limitation of the data is related to 

statistical practices in the Netherlands. During 

the period covered by these trends, the practice 

in that country was to exclude from their live 

birth as well as infant death statistics all deaths 

among infants with gestations of less than 28 

weeks which occurred before registration. In 

the previous section on mortality by age, this 

omission has been rectified, but in the data by 

cause, the deaths are deficient by that number. The 

effect of this deficiency is, of course, greater on 

neonatal deaths than on the infant deaths, while the 

effect on postneonatal deaths is probably negligible. In some instances, this omission may account 

for abnormally low rates for certain cause groups 

for the Netherlands, particularly those groups 

where the toll is highest soon after birth. For 

this reason, in comparisons with other countries 

the neonatal trends by cause for the Netherlands 

should be disregarded or regarded with caution. 

A major gap in mortality data for the United 

States, and one which precludes international 

comparisons, is the unavailability of national 

statistics on fetal deaths by cause. This information is tabulated by a number of States and the 

results suggest that between 20 and 50 percent 

of fetal deaths with gestations of 20 or more 

weeks are certified as dying of ill-defined or 

unspecified causes. Much improvement is needed 

in certifying causes of fetal death before they 

will be generally useful. In any event, since the 

United States does not tabulate data by causes 

of fetal death, these deaths are omitted in the 

following comparison. 

LEADING CAUSES OF DEATH 

1959-61 

Infant deaths in the United States are largely 

concentrated in five groups which account for almost three-fourths of all infant deaths (table 14). 

These five groups include postnatal asphyxia and 

atelectasis, immaturity, congenital malformations, influenza and pneumonia, and the residual 

category of diseases of early infancy. Yet, even 

among these categories, there are hidden associations which are not obvious from the statistics. 

The thread of prematurity and/or immaturity 

runs through a number of these causes. 

The seven countries fall into two distinct 

groups with regard to influenza and pneumonia: 

36 
-------------------------------

----------

--

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

--------

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

---

---

---

---

---

---

---

---

Table 14. Percentage distribution of infant, neonatal, and postneonatal deaths by cause of death: selected countries,
 1959-61


Cause of death Denmark %;yd Nether- Nomay Scotland Sweden United 

Wales lands States 

Infant deaths Percentage distribution 

All causes-------------------------------------- 100.0 100.c 100.0 100.0 100. C 100.0 100.0 

Infective and parasitic diseases-------------(OOl-l38) 1.3 1.1 1.0 1.8 1.2 0.7 1.3 Influenza and pnaumonia, including 

pneumonia of nawborn--------------------(48O-493,763) 6.5 13.: 6.8 10.5 13.2 5.0 12.0 All other diseases of respiratory 

systm------------------------------(47o-475,5oo-527) l.g 2.7 0.8 1.4 1.7 1.0 2.4 Gastritis, duodenitis, enteritis, and colitis, including diarrhea of new- born--------------------------------(543,571,572,764) 2.0 2.c 0.9 2.0 3.C 1.2 2.7 All other diseases of digestive 

system----------------------(530-542,544-570,573-587) 1.5 Congenital malformations--------------------- 2::; 2::: 2;:; 1?:: 2::: 2::; 14.1 Birth injuries [%:% 11.8 11.2 19.7 11.1 10.1 15.4 Postnatal asphyxia and atelectasis--------------- 22.0 15.7 10.4 20.1 2:.$ $; 

Hemolytic disease of nawborn (erythroblastosis)--[;% I ;:: 1.5 Irmnaturity,unqualified--------------------------(776) 1;:8 1::; 11.6 19.5 1$: 17:7 17:5 All other diseases of early 

infancy-----------------------------(765-769,77l-774) 12.1 7.3 4.4 8.6 1;.; Symptoms and ill-defined conditions------793,-793,795 1.7 5:; ::: 0.1 Accidents----------------------------------(E800-E9621 ;:; ::; 3:4
 All other causes-------------------.--------(Residual) ::: $; ::: 5.1 3.0 i:: 3.5


Neonatal deaths


All causea-------------------------------------- 1100.0 100.0 100.0 100.0 100.0 100.0 100.0


Infective and parasitic diseases-------------(OOl-l38) 0.4 0.1 0.1 0.0 0.0 0.2 0.3
 Influenza and pneumonia, including


pneumonia of nswborn--------------------(48O-493,763) 1.5 6,0 4.6 4.2 4.9 2.2 4.6
 All other diseases of respiratory


system------------------------------(470-475,500-527) 0.4 0.1 0.1 0.1 0.1 0.4


Gastritis, duodenitis, enteritis, and
 colitis, including diarrhea of naw­
 bon--------------------------------(543.57l.572.764) 0.4 0.4 0.2 0.3 0.8 0.3 0.6 All other diseases of digestive - - . ‘ - system----------------------(530-542,544-570,573-587) 1.3 1.4 1.0 Congenital malformations----------. (75O-759 J:: ii:: 21.7 15.2 19.3 1::2 1;:; Birth in~uries-------------------------------[76O.76l {
 15.9 ;;.: 27.0 16.8 14.7 19.0 12.8
 Postnatal asphyxia and atelectasis----------------762 2;.: . 10.8 l;.? 28.9 24.9 24.1


Hemolytic disease of newborn (erythroblastosis) 770
 Immaturity, unqualified--------------------------{1
776 2::: 1::2 29:1 13:: 21:: 2::I
 All other diseases of early


inEancy-----------------------------(765-769,77l-774 7.4 9.6 5.9 10.1 13.3
 Symptoms and ill-defined conditions------793,-793,795 0.4 ::: 0.2
 Accidents----------------------------------(E800-E962 I
 0.2 ::; ~:~ 0.2 1.0 o.; ;:?


All other causes----------------------------
 .(Residualj 1.3 0.9 1.2 1.8 1.3


Postneonatal deaths


All causes 1100.0 100.0 100.0 100.0 100.0 100.0 100.0 

Infective and parasitic diseases-------------(OOl-l38) 3.9 3.4 3.2 5.1 3.8 3,0 4.1 

Influenza and pneumonia, including 

pneumonia of newborn--------------.-----(48O-493,763) 21.0 33.3 12.3 22.5 31.5 16.7 31.2 

A~;~;~er diseases of respiratory 

------------------------------(470-475,500-527) 8.3 2.4 3.8 5.2 4.5 7.6 

Gastritis, duodenitis, enteritis, and colitis, including diarrhea of new- born--------------------------------(543,571,572,764) 6.3 6.1 2.8 5.2 8.0 5.2 8.1 All other diseases of digestive 

system----------------------(53O-542,544-57O,573:587) 3.0
 Cotigenitalmalformations----.--------i [;gg~;;;) 3::: 2M 3::; 23.3 2::I 4::: 1;:!?


Birth injuries------------------------------- 0.2 0.0 0.7 0.3 0.0 0.5 0.1


Postnatal asphyxia and atelectasis 762 1.0 0.5 0.3 0.8 0.4 1.6 0.9


Hemolytic disease of newborn (erythroblastosis) 770 0.4 0.1 0.3 0.4 0.1 0.2


Immaturity, unqualified--------------------------{1
776 0.2 0.3 1.2 0.1 0.7 M


A~~f~;~ diseases of early


-----------------------------(765-769,771-774) 6.4 2.6 2.5


Symptoms and ill-defined conditions------793,-793,795 5.2 ::: 13.0 M 0.4 ::;


Accidents---------------------.------------(E8OO-E962 ~
 5.8 7.5 ;:$ 13.9 10.3


All other causes---------------------------~(Residual) 9.4 15.5 ~;;; 7.0 1?: 9.3


lFiguree do not add to total because data for each cause group are not available for Denmark.


37 
.

(Deaths under I year of oge) 

200”0~ 

I

....... A. Infective and parasitic diseases (001-138) 

....

$. I I 0.0 

8.0 

6.0 

4.0 

L \l.b~-.......y~ -“n 

I \. 

2.0 . .. 

1.0 \/v+ . . -\,/ 

w 

> 

i 0.4 I I I I I I I I I I I I 

o 1950 1955 1960 1965
 0


0 YEAR


Q 

u


f+ “5, C. 6ostritis, duodenitis, enteritis and colitis,


w ..+. including diorrheo of newborn 

lx I...

... % (543, 571,572, 764)

20.0 1- -’....-

10.0 

8.0 

60 

4,0 

2.0 

LO 

0.8 1 I I I I I I I I I I I I 

1950 1955 1960 1965 

YEAR 

B. Influenza and pneumonia, including pneumonia 

of newborn (480-493, 763) 

100.0 

80.0 

E 

60.0w’... 

. 

. 

20.0 

10.0 — 

8.0 — 

\ 

6.0 t- ‘, 

4.0 I I I I I I I I I I 

1950 1955 1960 1965 

YEAR 

D. All other diseases of digestive system 

(530- 542, 544-570, 573-587 ) 

t 

10.0 — 

8.0 — 

6.0 — .-. 

2.0 

m 

Q8 I I I I I I I I I I I I 

1950 1955 1960 1965 

YEA R 

Figure Il. Infant mortality rates by” cause: selected countries, 1950-64. 

38 
------

(Deaths under I year of oge) 

‘“”””~ E. Congenital molformotions (750-759) 

‘“”’”~E Birth injuries (760,761) 

100.0 100.0 

80.0 80.0 

60.0

k 

— 600

1

.--\--— 

40,0 L x, 4 

/ 

20.0 2Q0 — 

%. 

100 10.0 

8.0 I 8.0 

m 1- 1 

6.0 

E 

!--

4.0 I I I I I I I I I I I I 

i 1950 1955 1960 1965 1950 1955 1960 19


0
 0 YEAR YEAR


0 

g“ 

~ 30.0 u 

& G. Accidents (E800-E962) 

~ 20.0 

u 

u 

/ .%“..%. .......... 

..-”””’”... .,,,,...” . ................. 

... ..... 

--%.. ..........” 

........ I 

12.0 

8.0 — Denmark 

6.0 Englond ond Wales 

-—— Netherlands 

4.0 Norw 

............... Scatlond 

-. —.- Sweden 

2.0 _ United Stotes 

1.0 

0.8 k 

0.6 I I I I I I I I I I I I 

1950 1955 1960 1965 

YEAR 

Figure Il. Infant mortality rates by cause: selected countries, 1950-64—Con. 

39 
between 5.0 and 6.8 percent of infant deaths in 

Denmark, the Netherlands, and Sweden are attributed to these causes while for England and Wales, 

Scotland, and the United States about twice the 

proportion of deaths are concentrated here (12.0-

13.8 percent). These infectious respiratory diseases are apparently still a problem in the United 

States and the magnitude of their effect is not 

demonstrated in these data. In addition to the 

number of instances in which influenza or pneumonia is identified as the underlying cause of 

death, they appear frequently as contributory 

causes as well~g In contrast to the respiratory 

diseases, lower concentrations of infant deaths 

attributed to congenital malformations and birth 

injuries were recorded in the United States than in 

the Netherlands or Sweden. 

In the neonatal period, deaths are even more 

concentrated by cause: five cause groups account 

for almost 90 percent of the deaths in the United 

States during this period. Among neonates, the 

influence of prematurity or immaturity affects 

many of the causes. The strong association of 

postnatal asphyxia and atelectasis, birth injuries, 

and congenital malformations with low birth 

weight has been demonstrated.20 In early 1950, 

neonatal mortality from these causes among infants weighing 2,500 grams or less at birth was 

many times the mortality among heavier infants. 

Overall mortality among low birth weight infants 

was about 20 times the mortality among infants 

of heavier birth weight. In the neonatal period, 

the adverse effects of prematurity or immaturity 

are especially pronounced. 

In the postneonatal period, the majority of 

deaths are more widely distributed among the 

various causes. Deaths attributed to influenza and 

pneumonia, congenital malformations, and accidents account for the majority of postneonatal 

deaths. The distributions show the United States to 

be among the countries with high concentrations 

of deaths due to diseases of the respiratory and 

digestive systems and to accidents. In this period 

as well as in the neonatal period, the statistics 

conceal a number of hidden factors. It has been 

suggested that deaths due to accidents include a 

number which are not truly accidental suffocation 

but which are due to a fulminating infection or 

to an allergic reaction. 

INFANT MORTALITY BY CAUSE, 

1950-64 

Taken together, postnatal asphyxia, atelectasis, and immaturity contributed 35.1 percent to 

infant mortality in the United States. Numerically 

these are important causes of death but because 

of the nonspecificity of the diagnoses, little can 

be learned from them. Postnatal asphyxia and 

atelectasis are associated with prematurity, and 

the rates for the United States are high among 

this group of countries for these causes and 

for immaturity as well. 

In the United States, deaths due to congenital 

malformations contributed 14.1 percent of the 

infant deaths in 1959-61. This is an important 

cause of death in the first year of life. ‘The 

constancy and narrow range of the trends for each 

country are notable (fig. 1lE). These trends may 

depict estimates of the irreducible minimum of 

infant mortality with the application of past knowledge. However, even this level of mortality may 

be amenable to further reduction in the future upon application of the results of present intensive 

research in genetics and drugs. 

Influenza and pneumonia were also major 

contributors to infant mortality in this country; in 

1959-61, 12.0 percent of infant deaths were 

attributed to these causes. The pneumonias constitute by far the major proportion of these diseases 

of the respiratory system—as much as 97 percent 

in the United States in 1963. Trend lines for the 

three Scandinavian countries and the Netherlands 

strongly suggest decreasing trends, while those 

for, England and Wales, Scotland, and the United 

States do not (fig. llB). The trend for the United 

States appears to have been almost horizontal 

since 1950. In England and Wales, mortality 

appears to have declined until about 1957, when 

it apparently leveled off. A similar change appears 

to have occurred in Scotland around 1953. Since 

1957, the rates for England and Wales, Scotland, 

and the United States have been about double or 

triple those of Denmark, the Netherlands, and 

Sweden. Because of the high level of these rates, 

mortality from influenza and pneumonia greatly 

affects the overall mortality trends. Other diseases of the respiratory system contribute an 

additional 2.4 percent to infant mortality. 

40 
. 

Other major contributors to infant mortality 

were birth injuries which accounted for 9.2 percent of infant deaths in this country in 1959-61. 

Trends for this group have been generally downward (fig. 1lF). The rate of decline for the United 

States appears less rapid than those of the 

Netherlands or Scotland, but more so than the 

other countries. 

The remaining causes are relatively less 

important numerically. In the first year of life, 

accidents caused 3.4 percent of deaths. Except 

for Scotland, the rates for this country have been 

higher than for any of the other countries since 

1956 (fig. llG). Since 1961, the rates for the United 

States have been I elatively stable, while those 

for England and Wales and for Scotland have increased. This cause group includes deaths due to 

accidental mechanical suffocation in bed and 

cradle (sometimes called “crib deaths” or “cot 

deaths”). Some investigators believe these data 

to be inflated with deaths due to some cause other 

than accidental. While the magnitude of the’ ‘misdiagnosis” is unknown, at most it cannot be more 

than the total of deaths due to accidental mechanical suffocation. 

Other deaths are distributed among a number 

of diagnostic categories. With regard to infective 

and parasitic diseases, the general trend for 

each of the countries between 1950 and 1963 

is downward (fig. 11A). These causes contributed 

only 1.3 percent to infant mortality in the United 

States around 1960. At the same time, inflammatory gastrointestinal diseases contributed 2.7 

percent to infant deaths. Although the trend for 

these gastrointestinal diseases is downward in 

this country, the rates are approximately three 

times those of the Netherlands and Sweden 

(fig. llC). Mortality from other diseases of the 

digestive system is relatively less-important than 

those mentioned above, contributing only 1.5 

percent to infant mortality (fig. llD). 

NEONATAL MORTALITY BY CAUSE 

1950-64 

There is a marked difference between the 

proportionate distributions of deaths in the neonatal and postneonatal periods (table 14). For 

example, while influenza and pneumonia account 

for only 4.6 percent of neonatal deaths, they 

account for 31.2 percent of postneonatal deaths. 

Similarly, accidents, which cause less than 1 percent of neonatal deaths, are responsible for 10.3 

percent of postneonatal deaths. 

At the Center’s Conference on the Perinatal 

and Infant Mortality Problem of the United States, 

there was considerable discussion of the reliability of the recorded causes of neonatal death. 

There are serious problems of diagnosis which 

are impossible to resolve in the absence of 

autopsy, and which may not be completely resolved 

even with autopsy. The recording of causes of early 

neonatal deaths, particularly, is reminiscent of 

that for causes of adult deaths of several decades 

ago when “high fever” was not uncommon as a 

recorded cause of death. Despite such crude beginnings, the identification of a number of health 

problems and, eventually, greater specificiW in 

recorded causes of death ensued. Similar progressive development is needed with regard to causes 

of fetal and neonatal deaths. 

The patterns of childbirth and neonatal care 

in the United States theoretically provide a climate 

for obtaining good cause-of-death information. 

Most births (96 percent in 1958) occur in institutions (general hospitals, maternity hospitals, and 

other hospitals and institutions). In the same year, 

the major portion of neonatal deaths (94 percent) 

also occurred in institutions (table 15). When 

the five cause groups with the highest proportions 

of neonatal deaths were combined, they accounted 

for 86.3 percent of deaths in that age period. Over 

95 percent of the deaths in each of these five 

groups occurred in institutions-their combined 

rate was 96.5 percent. Thus, by far the major 

portion of neonatal deaths in this country occur 

in situations which are conducive to obtaining 

the best available diagnostic information. 

Yet, causes of neonatal death are not recorded 

with great specificity in the United States—in 1958, 

almost one-fifth of recorded neonatal deaths were 

allocated to “Immaturity, unqualified” because of 

the lack of more specific information on death 

certificates. The high proportion of certificates 

with nonspecific causes may be indicative of 

incomplete recording of the cause-of-death information or of a genuine lack of knowledge among 

the medical profession regarding the causes of 

41 
---------------------

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

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

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

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

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

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

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

Table 15. Percentage distributionand percent of deaths occurring in inati.tutionsin


the neonatal and postneonatalperiods, by cause of death: United States, 1958


Percentage distri- ?ercentof deaths


bution of deaths in institutions


Cause of death


Post- Post-
 Neonatal leonatal leonatal Ieonatal


Infective and parasitic diseases-----(138)l38)


Influenza and pneumonia, including pneuonia


of newborn (480-493, 763)


All other diseases of respiratory


system (470-475,5oo-527i


Gastritis, duodenitis, enteritis, and colitis,


including diarrhea of


newborn (543, 571, 572, 764)


All other diseases of digestive


system (530-542,544-570, 573-587)


Congenitalmalformations-------------(75O-759)


Birth injuries----------------------(76O,
761)


Postnatal asphyxia and atelectasis-------(762)


Hemolytic disease of newborn


(erythroblastosLs) (77O)


Immaturity,unqualified------------------(776)


All other diseases of early


infancy--------------------(765-769,
771-774)


Symptoms and ill-defined


conditions (780-793,795)


Accidents (E800-E962)


All other causes (Residual)


100.0 100.0 94.0 52.9 

0.3 4.5 77.3 67.3 

4.8 30.9 78.0 42.3 

0.4 7.6 66.2 33.9 

0.7 8.3 80.8 72.2 

1.2 2.1 97.1 84.9 

12.5 16.7 95.8 79.0 

13.6 0.1 97.0 64.5 

24.6 1.0 97.5 59.9 

2.9 0.1 97.8 53.6 

24.3 0.5 95.7 64.9 

11.5 3.7 95.9 59.7 

1.4 5.1 36.6 13.1 

0.8 10.3 45.5 24.4 

1.3 9.0 87.3 75*1 

death.lle answertothisproblemcanbeobtained


throughfurtherquestioning of physicians,
 who


certify
causesof death,andnursesandmedical


librarians, who sometimescooperate
inentering


themedicalcertification on deathcertificates
 for


thedoctor’s
reviewandsignature.


When thispointof accuracyof information


is pursuedone stepfurther,
one observesthat


theproportion ofautopsies
amongneonataldeaths


isnotveryhigh.ICD categories
 760-776(Certain


diseasesofearlyinfancy)accounted
 for82percent


of neonataldeathsin 1958.For the same year,


aboutone-fourth of allcertificates allocated
to


thesesame causesdidnotindicate
 autopsystatus.


Among theremainingcertificates containing
 the


information,
therewas an autopsyrateof only


44 percent. These shortcomings strongly
suggest


thattheinformation
on causesofdeathwouldbe


amenableto improvementwithadditional
 autop­


sies.Nevertheless, it would be unrealistic
 to


expect diagnosticinformationon allneonatal


deathsfor pathologists
 pointoutthatthetrue


causes of some neonataldeathsare unknown


despite thebestpathological
 evaluation.


As was pointed outearlier,
 theinternational


comparisonspresentedhere are furthercom-


42

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

----

------ ----

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

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

-----

---- -----

plicated by differences in use of terms over time 

and between countries. This is truly one of the 

unexplored areas in fetal, neonatal, and infant 

mortality statistics. The following comments 

on neonatal mortality are limited to a few trends 

which seem to show consistent interrelationships. 

Trends have been disregarded for the Netherlands, 

as the rates are probably too low because of the 

omission of deaths which occurred prior to 

registration. 

The largest single group among neonatal 

& deaths, postnatal asphyxia and atelectasis, ineluded 24.1 percent of all neonatal deaths in the 

United States in 1959-61. Among the countries 

included in figure 12B, Denmark, Scotland, and 

the United States present the highest rates. 

Second in order of magnitude among causes 

of neonatal mortality in the United States is the 

residual category “All other diseases peculiar to 

early infancy. ” These deaths accounted for 13.3 

percent of neonatal deaths around 1960. The 

trend for the United States is diametrically 

opposite to those of Norway and Scotland 

(fig. 12D). In the United States, the increase is 

recognized to be associated with more frequent recording of terms such as ‘‘hyaline membrane disease” or “respiratory distress syndrome” on 

death certificates. Internationally, there may also 

be some difficulties between this group and postnatal asphyxia and atelectasis, based on choice of 

terms used by the certifiers. The classification 

of a given death depends on the terms used by 

the physician. If he enters the term ‘‘atelectasis” 

on the certificate, the death is included in 

“Postnatal asphyxia and atelectasis”; if he uses the 

term “respiratory distress syndrome, ” the death 

is included among the residual group “All other 

diseases of early infancy.” 

The rates for the United States are high for 

both postnatal asphyxia and atelectasis, and all 

other diseases of early infancy (table 16). Moreover, the association of these groups with prematurity has also been mentioned, and for the 

group “Immaturity, unqualified,” as well, the rate 

for the United States is highest. Disregarding the 

Netherlands whose rate is artificially deflated, 

when these three cause groups are combined, the 

rate for the United States is considerably higher 

than that of Norway or Sweden and it remains 

the highest of this group of countries: 

Neonatal movtality per 

100,000 live bivt?z.s 

Denmark 989.2 

England and Wales 819.0 

Netherlands 426.4 

Norway 658.3 

Scotland 1,003.3 

Sweden --------- 747.4 

United States 1,150.3 

The causes in this combined category are composed largely of nonspecific causes and symptoms 

rather than etiologic causes: immaturity, postnatal asphyxia and atelectasis, and the category “All 

other diseases of early infancy” which is composed 

largely of respiratory distress syndrome. Together, these causes represent almost two-thirds 

of all neonatal deaths in the United States. The 

relative position of the United States would remain 

unchanged even if all deaths allot ?ted to symptoms 

and ill-defined causes were added to these groups 

as well, i.e., this country would still maintain 

the highest neonatal mortality. Deaths from symptoms and ill-defined causes accounted for only 

1.3 percent of neonatal deaths in the United States; 

smaller proportions in Denmark, England and 

Wales, Scotland, and Sweden; and higher proportions in the Netherlands (2.5 percent) and Norway 

(4.6 percent). 

Congenital malformations and birth injuries 

are also major causes of neonatal mortality. In 

the United States, they contributed 12.7 and 12.8 

percent, respectively—over one-fourth of all 

neonatal deaths. Despite their numeric impxtance, the general trend in neonatal mortality 

from these causes was downward for this country. 

Influenza and pneumonia occupy a lesser role 

in the neonatal period (4.6 percent). This cause 

group consisted almost exclusively of pneumonia 

of newborn (99 percent). The rates of the Scandinavian countries range between 2 and 5 per 10,000 

live births, substantially below that of the United 

States (fig. 12A). The rates for England and Wales, 

Scotland, and the United States are consistently 

43 

i 
L 

-----

(Deaths under 28 days of age) 

20.0 80.0-

A. Influenzo and pneumonia (480- 493, 763) B. Postnatal asphyxia and afals.ctosis (762) ...””““””-...

“., 60.0 — 

‘.%0 ... ........ 

FL “.. . .. ..... ..... ....-...”” . 

10.0 — 

8.0 

/ “-* 6.0 – / i 

l~\ ‘ ‘“ .—’ 

‘\ 20.0 –’ .&A /’ 

/ \ 177%? 

4.0 – 

‘i

\

1, ,,~ 

)\/ 

1, , 

/’ ‘~,, $, /’ 

H- .*/ /“--*~ 

/ i, 

\ 

L-”) 

/’ 

\~ 

1,,0 

\

\ // :(\ /’ 

, / 4—N 

“ � \ p ‘i 

/\\ // 

In 8“ ‘d’ ‘ 

\ 10.0 /’ ‘\/\ 

/“ x

i-lx 1 t

/’ ‘\_/ 

= 2.0 ao 

w 

> 

i 1.5 Mlk, 6.0 :,,,,,,,,,,,,,, 

s 1950 1955 1960 1965 1950 1955 1960 . 19 o 

g 

s

c 

w 

n. 

P 

: I0.0 600 

- C. #wII;jytlc dlseose of newborn (erythroblostosls) D. All other diseases peculiar to eorly Infancy 

8.0 – i (765-769, 771- ?74) 

\ 

\ 40.0 – \ 

\ 

6.0 – \

\ \ 

\

\

\

\

\ 

\ 

20.0 – 

\ 

2.0 * 

10.0– 

8.0 – \ 

i. 

1.0 I I I I I I I I I I I 6.0 I I [ I I I I I I I I I 

1950 I955 1960 1965 1950 1955 1960 19 

Denmark — Norwoy 

England and Woles — Saotland . . . .. . . . .. . . 

Netherlands —— Sweden —-— 

United states — 

Figure 12. Neonatal mortality rates by cause: selected countries, 195d-6L 

44 
--------------------------------------

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

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

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

---------

---

Table 16. Average annual infant, neonatal, and postneonatal mortality rates by cause of death: selected countries,
 1959-61


Cause of Lleath Denmark Ew&d Nether- ~omay Scotland Sweden United 

Wales lands States 

Infant deaths Rate per 100,000 live births


All Causes 2,191.7 !,181.0 1,622.8 L,846.5 2,686.0 L,633.6 ?,590.5 

Infective and parasitic diseases-------------(OOl-138) 28.7 23.2 15.5 32.5 32.1 12.2 34.2 Influenza and pneumonia, including 

~umonia of newborn.---.-.------------(480-493,763) 143.5 301.5 109.6 193.1 353.3 81.6 310.3 A 1 other diseases of respiratory I �yatam.............................(470-475, 500-527) 40.2 58.0 12.6 25.6 44.7 15.7 62.1 

P Gaetrltia, duodenitia enteritis, and colitis, including diarrhea of new- born-----------------------------(543, 571, 572, 764) 42.8 44.7 14.8 36.8 81.2 20.2 69.2 All other diseases of digestive 

�yatam--------------------(530-542, 544-570, 573-587) 26.5 42.6 27.0 36.3 41.1 33.7 37.8 Congenital malformations.--------------------(75O-759) 447.4 450.0 429.7 331.3 542.9 342.9 364.0 II	 Birth in urges.-..-.-.-....-.....-.--.------(76O. 761 259.2 243.9 “320.3 205.4 271.5 252.4 239.2
 Postnata1 asphyxia and atelectasis 4s3.1 342.5 12s.o 191.5 539.3 332.6 456.9


Inenaturity,unqualified......................----(776) 261.7 365.3 188.3 360.6 359.3 289.3 453.8 All other diseases of early 

infancy............................(765-769, 771-774 2::.; 121.8 142.1 135.0 118.7 140.9 275.3 Symptoms and ill-defined conditions-----(793,793, 7951 63.9 1;:.; 34.8 57.s (E800-E962 36:2 5;:; 34.4 134.9 1::; 8S.2 

Heraelyticdisease of newborn (erythroblaatoais)--[% ) 43.7 45.5 41.8 27.7 51.4 24.7 50.4


Accidenta----------------------------------
 All other cauaes-----------------.----.-----(Residual1 76.4 79.7 94.6 93:4 80.9 66.1 91.5


Neonatal deatha


All causes---J 1,624.7 .,557.3 1,172.9 L,214.3 1,850.4 L,317.7 !,871.4


Infective and parasitic diseases-------------(OOl-l38) 6.6 2.3 1.2 0.5 0.3 2.6 4.7


neumonia of newborn ..................(480-493, 763) 24.7 93.9 54.3 50.7 89.8 28.9 85.8 

All other dieeasea of respiratory 

system-----------------------------(470-475, 500-527) 

Gaatritia, duodenitis, enteritis, and 

-.. 6.1 1.6 1.6 1.0 1.6 7.2 

colitic, including diarrhea of new- born---...--.-----.-.------------(543.571. 572. 764) 7.1 6.8 2.3 3.7 14.6 3.9 10.9 

A~;a~~ar dia~ses of digestive ‘ - - “ - --------------------(530-542, 544-570, 573-587 13.7 21.6 15.6 17.1 18.2 19.3 23.7 

Influenza and pneumonia, including


Congenital melfOrmetiOns---------------------(75O-759 258.S 2S4,3 254.7 184.1 358.0 214.8 238.0


Birth iniuries---------.. (76O. 761I 257.9 243.6 317.3 ;:;.; 271.1 250.8 238.8


Postnatal aephyxia and atelectasis 762- 477.4 339.2 126.5 535.6 327.5 450.1


Hemolytic disaase of newborn (erythroblastosia)--{1
770 41.5 44.7 40.6 25:1 50.4 24.1 50.0


Itmnaturity,unqualified--------------------------776) ..- 364.2 186.8 353.2 358.6 287.0 450.8


All other diseases of early


infancy..---.--.--..-.-------------(765-769, 771-774 115.6 113.2 1;:,; 109.0 132.9 249.4


Symptoms and ill-defined conditions-----(793,793, 795 6.6 2.2 29.6 23.8
 Accidents.-.-.....---..-..------.. (E8OO-E9621 3.1 11.9 2:7 1::: 13.9
 All othar causes---------------.-----------~(Residual) -.. 20.9 2::; 10.7 22.2 2;:; 24.4


Postneonatal daaths


All causes-------------------------------------- 1567.0 623.7 449.9 632.2 S35.6 315,9 719.1


Infective �nd parasitic diaeasea-------------(OOl-l38) 22.1 20.9 14.3 32.0 31.8 9.6 29.5 

Influanza and pneumonia, including 

neumonia of newborn-------------------(480-493, 763) 118.8 207.6 55.3 142.4 263.5 52.7 224.5 

A!1 other diseases of respiratory 

system-----------------------------(470-475, 500-527) ... 51.9 11.0 24.0 43.8 14.1 54.9 Gastritis, duodenitis, enteritis, and
 colitis, including diarrhea of new­
 born-----------------------------(543, 571, 572, 764) 35.8 37.9 12.5 33.1 66.6 16.4 58.3


All other disaaaes of digestive


system----.-.--.----.-----(53O-542, 544-570, 573-587 12.8 21.0 11.4 19.2 22.9 14.4 14.1


Congenital melformetions---------------------(750-759 1
 188.6 165.6 175.0 14:.: 1s4.9 128.1 126.0


Birth injuriea------------------------------(760,761) 0.3 3.0 0.3 0,4
 Postnatal �ephwia and atelectasis------------.---(762. ::; 3.4 4:s 3.6 ::: 

Hemelytic diseasa of newborn (erythroblaatosis)-- 2.2 0.s ;:: 2.7 1.0 0.6 ;:: 

Inmuturitv. unqualified......................----[;;:1 .-. 1.2 7.5 0.6 2.2 3.0 

A~:f::r-dieeaaes of early ............................(765-769, 771-774) .-. 6,2 28.9 16.5 8.0 ;:.; 

Symptoms �nd ill-defined conditions-----(793,793, 795) 29.6 34.3 82.2 3::: 

Accidents----------------------------------(E8OO-E962) 33.1 4;:: 30.2 36.3 116.3 1+:; 74;3 

All other cauaea---.-.----------------------(Residual) .-. 58.7 69.8 82.7 58.7 44.0 67.1


1 

Figuree do noc add to total because dats for each cause group are not available for Denmark. 

45 
higher and range from 7 to 10 per 10,000. Another 

lesser cause of neonatal mortality, hemolytic 

disease of newborn, accounted for only 2.7 percent 

of neonatal deaths in the United States during the 

same period. The trend is generally downward for 

all countries, but the United States has had among 

the highest rates since 1956 (fig. 12C). Continued 

improvement is expected in this category because 

of the state of knowledge concerning its cause and 

the availability of specific diagnostic and therapeutic techniques. 

Deaths from accidents occupy a relatively low 

position among causes of neonatal death (0.7 

percent in the United States in 1959-61). Almost 

half of the deaths in this class were due to inhalation and ingestion of food or some other object 

causing obstruction or suffocation, and accidental 

mechanical suffocation in bed and cradle (crib 

deaths). Although this last category may include 

a number of ‘‘mis-diagnosed” deaths, their proper 

allocation would probably not alter the ranking 

of the countries for other causes since these 

deaths contributed only about 0.3 percent to 

neonatal mortality. 

POSTNEONATAL MORTALITY 

BY CAUSE, 1950-64 

The shift in levels of mortality and the changes 

in the infant’s exposure to external risks produce 

pronounced changes in the distribution of deaths in 

the postneonatal period. In the United States, the 

rate in the neonatal period (18.7 per 1,000 live 

births in 1959-61) was about 2?4times the postneonatal rate (7.2). When converted to a daily 

base, the risk in the neonatal period was over 

30 times the risk in the posmeonatal period. During 

the posmeonatal period, environmental causes are 

more prominent than developmental or biologic 

causes. 

There is also a realignment of the important 

causes of death in the postneonatal period 

(table 14). No longer do birth injuries, posmatal 

asphyxia and atelectasis, immaturity, and other 

diseases of early infancy occupy prominent positions. While these four groups constituted almost 

three-fourths of neonatal mortality, they account 

for only one-twentieth of posmeonatal deaths. 

Congenital malformations increased slightly in 

relative importance (12.7 percent of neonatal and 

17.5 percent of posmeonatal deaths). Two groups 

emerged as relatively more important: influenza 

and pneumonia, which increased from 4.6 percent 

of neonatal to 31.2 percent of posmeonatal deaths, 

and accidents which increased from 0.7 percent 

of neonatal to 10.3 percent of postneonatal deaths. 

Influenza and pneumonia constitute the largest 

component of posmeonatal mortality in the United 

States; around 1960, 31.2 percent were attributed 

to these causes and 96 percent of these were due 

to pneumonia. The trend for the United States has t 

been almost horizontal since 1950 in contrast to 

the three Scandinavian countries and the Nether­

* lands which strongly suggest downward trends 

(fig. 13B). Although the rates for England and 

Wales and for Scotland were declining until about 

1956 or 1958, the rates for those countries as 

well appear to have leveled off. Because of the 

magnitude of the rates, the divergence in trends 

between these two groups of countries is particularly significant. 

The residual group of diseases of the respiratory system contributes another 7.6 percent to 

postneonatal mortality in the United States. As 

with influenza and pneumonia, posmeonatal mortality for these diseases appears to maintain 

a lower level in the Netherlands, Norway, and 

Sweden. In the United States, it seems to be 

increasing. In Great Britain (England and Wales, 

as well as Scotland), the rates have shown rather 

wide fluctuations in recent years (fig. 13C). 

When the diseases of the respiratory system 

are taken together, they reinforce each other in 

demonstrating a basic difference in trends between 

the United States and Great Britain in comparison 

to the three Scandinavian countries and the 

Netherlands. This contrast suggests one possible 

target area for further research into the reasons 

for the change in trend in the United States. 

Congenital malformations accounted for 17.5 

percent of posmeonatal mortality in the United 

States around 1960, ranking second to the respiratory diseases. The trend for this country has 

declined rather slowly but steadily since 1950, 

and the rates were generally more favorable 

than those of Denmark, England and Wales, 

and the Netherlands. 

46 
.

. ... ...

.

-----

(Deaths 28 days-n months of age) 

30.0- 60.0 ,. 

... 

..O A. Gastritis, duodenitis, enleritis, ond colitis B. Influenza ond pneumonia to 

20.0 — ‘... (543, 571,572, 764) 40.0 (460-493, 763) 

.. 

... 

10,0 — 

6.0 —’i 

\ 

s 4,0 — 

) 

v 

m 2.0 

: 

a 

G 1960 196! 

y YEAR 

i 

“\/”i 

\ / \w/’ \/ “ 

g “o z 30.0 \/ 

2“ 0.6 

a 20.0 ~ 0,6 I I I I I I 1 I I I I I # 

1950 1955 1960 1965 . .. . . .. ... . .. . . . . . . . . .. .. .. u 

1-

< YEAR ... ... .. 

..,.=” 

. . 

.. . ..... . . a ...... / “....... 

9.0 . ...

%. .... 

P D. Accidents (E600-E962) 

. C. All other diseases of respiratory system 10.0 — 

6.0. — .. 

.. 

.. . . ...-’ 

4.0 — ‘\ 

2,0 \ 

I ,0 

0,6 I I I I I I I I I I I I I I 1.0 t I I I I I I I I I I I I I 

1950 1955 1960 1965 1950 1955 1960 196 

YEAR YEAR 

Denmark — Norway 

England and Wales — Scotland . . . . . . . . . . . . 

Netherlands —— Sweden —.— 

United States — 

..


Figure 13. Postneonatal mortality rates by cause: selected countries, 1950-6!.


47

Following the diseases of the respiratory 

system and congenital malformations, accidents 

constitute the next largest cause-of -death group 

in the postneonatal period (10.3 percent in 1959-

61). Except for Scotland, rates for the United 

States have been consistently higher than those 

for any of the other countries for each year 

since 1952 (fig. 13D). Rates for the other countries 

are somewhat erratic with the trend for Denmark 

apparently on the decline; in 1962, the rate 

for Denmark was less than half of that of the 

United States. In this age group, almost onefourth of the deaths resulted from accidental 

mechanical suffmation in bed and cradle. In 

recent years, two causes have been incriminated 

as possible etiologic causes: fulminating infection 

and allergic reaction, possibly to milk. 

In the United States, the diseases of the digestive system rank next in order of importance. 

The inflammatory gastrointestinal diseases 

(gastritis, duodenitis, enteritis, and colitis) comprised 7.6 percent of postneonatal mortality in 

1959-61. Although the trend has been downward 

throughout the period 1950-64, postneonatal mortality from these causes has been high and several 

times the rates for the Netherlands and Sweden 

(fig. 13A). Although the residual group of diseases 

of the digestive system is at a lower level (2.0 

percent), postneonatal mortality from this group 

has failed to assume a generally downward trend 

since abut 1956. The diseases of the digestive 

system contribute to the unfavorable postneonatal 

mortality in the United States. 

With regard to other infective and parasitic 

diseases, the postneonatal rates for the United 

States declined consistently from 1950 to 1957, 

but thereafter increased in 1958 and again in 1962. 

The overall trend since 1957 is no longer continuing its former rate of decline. 

DISCUSSION 

Comparison of the trends by cause for the 

United States with those of the west European 

countries raises questions in need of answers. 

Prominent among them is the determination of 

reasons for the relatively high level of the rates 

in this country for causes which are associated 

with the environment and which should be preventable. For example, in the posmeonatal period the 

United States ranks high for diseases of the 

respiratory and digestive systems and for accidents. Epidemiologic as well as medical research 

is needed to give direction to programs of prevention and therapy. 

Secondly, the neonatal trends for posmatal 

asphyxia and atelectasis, and the cause group 

which includes hyaline membrane disease and 

respiratory distress syndrome mark the experience of the United States as differing from 

that of other countries. Together, these cause 

groups represent a considerable portion of neona- ? #, 

tal mortality in the United States, and they appear ‘{ to be increasing in contrast to experience elsewhere. Although there is doubtless some confounding among the cause groups due to international differences in terminology and coding, 

consolidation of a number of groups failed to 

eliminate the differences. The association of each 

of these causes with prematurity implicates that 

variable as one in need of further research. 

One criterion of the level of certification is 

the proportion of deaths allocated to symptoms 

and ill-defined conditions. While the United States 

did not have a high proportion of deaths in this 

group in the neonatal period, it exceeded those 

of Denmark, England and Wales, Scotland, and 

Sweden. Medical certification in the United States 

may be said to be less specific than in those 

countries when measured by this criterion. Continued effort is needed to increase autopsies of 

fetal and neonatal deaths in a search for more 

specific information. Continued vigilance is 

needed to incorporate autopsy information into 

the vital statistics. 

Research is needed to determine whether the 

level of medical certification can be improved for 

fetal deaths of 20 or more weeks of gestation as 

well as for neonatal deaths. Investigation of 

certification problems could be carried out 

simultaneously with ongoing medical research 

into causes of posmatal asphyxia and atelectasis, 

hyaline membrane disease, and respiratory distress syndrome. 

While the fundamental etiologic agents cannot 

presently be identified in available vital statistics, 

certain broad conclusions leading to further study 

are possible. Whatever the reasons, changes in 

48 

4 
the basic trends in the United States are evident death certificates. In the medical and epidemifor a number of underlying cause groups in the ologic fields, continued intensive research in 

1950’s. In the health statistics field, further early posmatal respiratory problems, diseases of 

contribution to our knowledge could come from the respiratory and digestive systems in the 

considering multiple causes of death certified posmeonatal period, and accidents are needed to 

on death certificates, by including more autopsy determine etiology and point the way to improved 

information in final statistics, and by generally preventive and therapeutic measures. 

improving the diagnostic information entered on 

49 
v. ASSOCIATED DEMOGRAPHIC FACTORS 

The literature contains a vast number of 

investigations into factors associated with fetal 

or infant mortality. Among the earliest statistical information on infant mortality is that of 

Graunt. 21 The noted British vital statistician 

William Farr is credited with having “inaugurated the statistical discussion” of infant mor - 22 Since his time ~ tality two centuries later. 

infant mortality statistics have become part of 

the published data of almost all countries, and 

literally thousands of studies of fetal mortality 

and of infant mortality and its components have 

appeared in the literature. 

Shortly after its founding in 1912, the U.S. 

Children’s Bureau undertook a series of investigations into infant mortality. Because infant mortality was then higher in American 

cities than in rural areas, 10 cities were selected for study. The major results were combined and summarized by Woodbury.23 These 

studies combined information from vital records 

and additional environmental and socioeconomic 

data obtained on home interview. DePorte used 

information for 1916-21 for States in the Birth 

Registration Area to analyze interracial variation 

in infant mortality. 24 Other studies of more 

limited geographic areas included those of Eastman in New York State, 25 Collins in Baltimore, 26 and Green in Cleveland. 27 Among the 

most extensive studies in the United States 

are those associated with Yerushalmy, some 

of which relate to data for New York State~-33 

and some of which relate to data for the United 

States. 33 These statistical studies analyze the 

relationship of neonatal and infant mortality to 

factors such as mother’s age, father’s age, 

parity, and previous reproductive loss. More 

recently, special reports of the National Office 

of Vital Statistics (NOVS) concentrated on birth 

weight and its relationship to neonatal mor ­

tality.’~ 3436 In recent years, a number of 

British investigators have expanded their horizons to include socioeconomic variables, byt 

recent national studies of infant mortality related to socioeconomic levels for the United 

States are unavailable, Available data for large 

population groups have been published for only 

a few States. 37J38 The most comprehensive 

recent report of infant mortality in the United 

States is that of Shapiro, Schlesinger, and Nesbitt 

which was prepared for the Center’s Conference 

on the Perinatal and Infant Mortality Problem of 

the United States .39 

For the purposes of the present report, 

the availability of statistical publications of 

the United Nations, most particularly of the 

World Health Organization, was particularly 

fortuitous. These international statistics, in addition to the reports of the contractors, af. 

ford a unique opportunity to examine correlates 

of infant mortality. The primary purpose is to 

determine from the data, if possible, whether 

certain factors are associated with the differences in perinatal and infant mortality experience between the United States and the other 

countries. 

GEOGRAPHIC VARIATION 

For several decades, geographic variations 

in infant mortality have been recognized in 

the United States. The highest rates (fetal, 

neonatal, and postneonatal) are found in the 

southeastern part of the country (fig. 14). There 

is considerable variation as well among the 

geographic subdivisions of the other countries 

involved in this report (table 17). Compared 

with geographic subdivisions of other countries, 

the rates for the States of the United States 

tend to be low in the fetal period and high in 

the infant and neonatal periods. The maximum 

State rates in the infant and neonatal period~ 

50 
F ETAL 

Figure I\, Average annual fetal, neonatal, and postneonatal mortality rates: geographic divisions of the 

United States, 1961-63. 

51 
---------------- ----------------

Table 17. Average annual birth rates, and fetal death, perinatal,and infant mortality rates with


ranges for geographic subdivisions:selected countriesand years


Infant mortality4


Country and years


Denmark, 1960-62-------------


England and Wales, 1960-62---


Standardregions (10)------


Netherlands,1960-62---------


Provinces (11)-------------


Fetal Perinatal
 Birthsl mortality~ mortality3 “under~ 1


Under 28 days-


year 28 days 11 months


Rate


12.3 26.0 21.1 16.0 5.1


18.9 31.9 21.6 15.3


16.0-22.6 27.6-37.3 18.1-25.6 13.2-17.7 4.9-::?


14.8 24.6 15.8 11.5


13.4-18.7 22.4-29.7 14.3-18.6 10.5-13.4 3.5-:::


14.3 24.5 19.9 12.4


11,8-17.7 22.1-27.7 16.0-32.3 9.9-15.9 4.6-1;:?


20.8 36.7 26.3 18.0


17.5-22.5 29.9-39.1 20.8-29.8 14.5-20.1 6.0-!:;


13.7 25.2 16.3 13.2


11.2-16.4 21.3-28.7 13.6-20.6 10.8-15.6 2.1-M


11.5 27.8 25.3 18.3


9.8-14.4 25.0-32.3 :;.;-:;.$ 16.8-20.9 5.3-1:::


7.6-18.1 21.5-38.1 .-. 14.2-25.8 4.5-15.2


16.0


17.6


16.5-18.5


20.9


18.6-23.9


Norway, 1956-60--------------- 17.9


Counties (20)-------------- 13.7-22.5


Scotland, 1960-62------------ 19.7


Regions (4)---------------- 17.2-21.3


Sweden, 1959-61-------------- 13.9


Counties (25)-------------- 12.3-17.7


United States, 1961-63------- 22.5


Regions (9 20.4-25.1


States (501 20.1-31.7


lLive births per 1,000 population.


2Fetal deaths of 28 or more weeks’ gestationper 1,000 live births and fetal deaths of 28 or
 more weeks’ gestation.


31nfant deaths under 7 days and fetal deaths of 28 or more weeks’ gestationper 1,000 live


births and fetal deaths of 28 or more weeks’ gestation.


4Rates per 1,000 live births.


(39.7 and 25.8, respectively) exceedthemaximum 

for the geographic subdivisions of any of the 

other countries. In the postneonatalperiod,the 

maximum State rate (15.2) exceeds that of. geographic subdivisions of every country except 

Norway. 

Urban-rural differentials in perinatal and 

infant mortality in the United States have been 

modified since the turn of the century. ‘Ihese 

changes have been associated with greater availability and improved distribution ofhospital and 

medical facilities, the rising standard of living, 

ppulation migration, and so forth. In the early 

part of the century, infant mortality wasparticularly high in cities of the United States. A series 

of investigations by the Children’s Bureauidentified some of the associated conditionsin anumber of cities in the United States. By the time of 

the late 1920’s and 1930’s, the situation hadreversed and children in most urban settings had 

lower mortality. At present, the situation in a 

number of major cities in the United States is 

once again reverting to the old pattern: neonatal 

mortality among 90fthe101argest cities inthis 

country is higher than amongthose infants living 

outside these cities but in the same States. ~ 

52 
In the 1950 decade, there wasageneral deterioration of and considerable movement into 

and out from most major cities of the United 

States. This fact was made evident by the 1960 

Census of Population which showed that the total 

populations of a number of the largest cities in 

the country had declined during the decade. This 

net loss was often composed of two mainstreams: 

an in-migration of economically deprived persons 

in search of better opportunities, and an out-migration of economically privileged to the suburbs. 

The many elements in the interrelationship of 

infant mortality among the migrating groups are 

difficult to unravel because of the lack of quantitative information specific for them. While census 

data are available for the population which moved, 

data are not available concerning its childbearing 

and mortality experiences. In many cities, the 

feeling is that some increase in perinatal and 

infant mortality has accompanied the population 

change. 

Comparison with data for other countries is 

complicated by lack of standard definitions of 

“urban” and “rural.” Even in the United States, the 

characteristics of urban areas in the 1920 or 

1930 censuses do not compare with those of later 

censuses. A far more informative type of analysis 

is to study mortality in relation to identified characteristics of individuals rather than characteristics of geographic areas. 

COLOR 

Among the countries involved in this report, 

only the United States presents data specific for 

color (or race). In the other countries, the nonwhite populations are too small to represent 

groups of special interest. In the United States, 

11.4 percent of the population and 15.4 percent of 

live births in 1960 were nonwhite. This nonwhite 

group consisted of approximately 90 percent 

Negroes and 10 percent other races. In many 

ways, this nonwhite population is economically 

deprived: their median income is less, their 

median year of education is lower, their level of 

unemployment is higher. In fact, at present, the 

white-nonwhite differentials are regarded as primarily socioeconomic in nature rather than racial 

per se. 

Recorded mortality differentials in the fetal, 

neonatal, and postneonatal periods have been to the 

advantage of the white population since data have 

been available. For the past 20 years, the fetal 

death ratio of the nonwhite group has been almost 

double that of the white group. The following table 

gives the ratios of fetal deaths of 20 or more 

weeks’ gestation per 1,000 live births for both 

white and nonwhite births and their ratios: 

Fetal death ratio 

Year 

= 

1945 -------- 21.4 42.0 

1950-------- 17.1 32.5 

1955-------- 15.2 28.4 

1960 -------- 14.1 26.8 

1963-------- 13.7 26.7 

1964-------- 14.1 28.2 

Rationonwhite 

to white 

1.96 

1.90 

1.87 

1.90 

1.95 

2.00 

In the first 24 hours following birth, the rate 

for nonwhite infants reached their lowest point 

(12.7) in 1945 and 1951 (fig. 15). Since 1945, mortality mends among the white and nonwhite infants 

in this age group have proceeded differently. The 

trend for nonwhite infants has been upward with 

some fluctuation since 1945. The trend for white 

infants was downward until about 1954, although 

since then the trend has also been upward. The 

following table gives rates for white and nonwhite 

deatha under 24 hours of age per 1,000 live births 

as well as their ratios. Over almost 30 years, the 

differential between the two groups has increased: 

Rate Rat io— 

Year nonwhite 

White Nonwhi.t e to white 

1935---------- 14.8 16.2 

1940 ---------- 13.6 16.0 

1945---------- 11.0 12.7 

1950 ---------- 9.7 13.0 

1955---------- 9.3 13,9 

1960 ---------- 9.6 14.4 

1964---------- 9.3 15.0 

1.09 

1.18 

1.15 

1.34 

1.49 

1.50 

1.61 

53“. 
.

.

A. Under 24 hours . .. . . 

%...”....., ... .. 

... ,.+” 

.. ,,. ., . . . . . ’” ” ”” ”....... 

“.. . . . ...

. . . . .,+ . ...’” . . . . . . . . . . . . . 

Nonwhite 

10.0 White 

=J 

8.0 -

6.0 – 

4.0 

1935 1940 1945 1950 1955 1960 1965 

n 

5 15.0 

z, 

5 ..% .: ii C. 7-27 days .. > 

~ I 0.0 — ... . . . . . .. . . 

.. D 

D ; 

.... 

$ 8.0 – . . . . . .. 

.. 

... Y 

i.! — ‘.. 

L 

.. 

a 

z : — 

4.0 – ..$+ 

%. 

....... 

— 

2.0 – 

1.0 1111111 1111 I Ill II I I I I 1111111 

B. I-6 days 

..... .. .. 

.. 

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

.. 

.. 

.. 

.. . . 

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

%.. Nonwhite .. .... 10.0 %... .... ..... .... .. .. .... ... 

.. 

... 

. . . . . . . . . 8.0 – 

[ 

White 

I


6.0 

F= 

4.0 Ill 1111111111 1111111111111111 1935 1940 1945 1950 1955 1960 1965 

60.0 

t O. 28 days-n months 1 50.0 

I

/%... 

40.0 .... 

-. 

.. . .......“.. 

.. 

.... 

...... Nonwhite 

... 

1: I 

I 

1935 I940 1945 1950 1955 1960 1965 1935 1940 1945 1950 1955 1960 1965 

YEAR YEAR 

Figure 15. Infant mortality rates by color and age at death: United States, 1935-6k


54

While part of the increase in ratios in the earlier 

years may have been due to greater improvement 

in completeness of death registration among the 

nonwhite population, the increases in these ratios 

in the later years probably represent a widening 

gap in mortality experience. 

In the age group 1-6 days, changes in trend 

are not readily discernible. There have been 

periodic increases at various times from which 

the trends did not recover. For example, the 

rates of decline for white infants in the periods 

1935-43, 1946-56, and 1958-63 are approximately 

equal. However, each time there was an increase 

in mortality (1943-46 and 1956-58), the trend 

line did not recapture the level it would have 

achieved had the 1936-43 trend continued uninterruptedly. The same observation pertains to the 

nonwhite rate before and after the increase of 

1956-58. 

In the remainder of the neonatal period (7-27 

days), the downward trends were interrupted for 

nonwhite infants around 1950, and for white infants 

around 1956. In recent years, although the rates 

seem to be generally declining, the trends are 

diverging, 

In the postneonatal period, again, there were 

changes for both white and nonwhite infants. 

Trends for both groups proceeded in an overall 

downward direction until approximately 1945 for 

nonwhite infants and 1950 for white infants. The 

deceleration in the trend for nonwhite infants 

around the close of World War II was marked, 

while that for white infants was much less pronounced. 

Despite these differences in mortality between white and nonwhite infants, the trend lines 

for the combined group are determined by the 

trends for the white infants since they represent 

about 85 percent of births. Part of the increased 

differential between white and nonwhite infants 

in this country is attributable to an earlier 

leveling off of the mortality among nonwhite infants, and for some age groups to a reversal in 

trends among nonwhite infants. 

A detailed study of the complex interrelationships in white-nonwhite differentials is not 

pertinent here. The issue is whether the contribution of the higher nonwhite mortality is sufficient 

to change the position of the United States relative to the other countries. Or, put in another way, 

if the comparison were made between the west 

European countries and only the white births of 

the United States, would the comparative trends 

still exist? 

The separate trends for white infants were 

plotted and examined in relation to the other 

countries, and the same changes in rates of decline in the 1950’s were evident. The position of 

the United States relative to the other countries 

remained essentially unchanged. While higher 

mortality among nonwhite infants in the United 

States is not to be minimized, the position of the 

trends for the entire infant population in the 

United States relative to those of the west European countries cannot be attributed to the inclusion of nonwhite infants. 

SEX 

A higher proportion of live births are males, 

and mortality among them is higher than among 

females for all age groups in the infant period. 

There are variations in the sex ratios at birth 

within countries as well as between countries 

(table 18). From these data it maybe seen that 

countries with higher sex ratios than the United 

States (e.g., the Netherlands and Sweden) have 

lower infant mortality rates. Furthermore, when 

the trends were examined separately for males 

and females the patterns which were noted earlier 

for both sexes combined were still evident. The 

differences in sex ratios do not explain the differences in infant mortality between the United 

States and the other countries included in this 

report. 

MATERNAL AGE AND PARITY 

Reproductive loss is associated with matemal 

age at time of delivery and the trends by maternal 

age vary with type of loss. In the United States, 

fetal mortality follows a “J” curve; that is, it is 

somewhat elevated among mothers under 20 years 

of age, is at an optimum low level between 20 

and 29 years, and rises sharply thereafter. Fetal 

mortality among mothers 40 years or older is 

55 
-- - -- -- --- - -

---

---

---

--- ---

Table 18. Sex ratio of live births: selected countries, 1950-64 

[Male births per 1,000 female births] 

Year 

1964------------

1963------------

M;------------

1960------------

1959------------

1958------------

1957------------

1956------------

1955------------

1954------------

1953------------

1952------------

1951------------

1950------------

Denmark 

En~~dnd Nether - Norway Scotland Sweden United 

Wales lands States 

1,062 1,060 ;,:(); 1,047 

1,056 1,063 1,053 1>053 

1,050 1,060 1,050 1,058 1,070 1;057 1,048 

1,051 1,062 1,050 1,070 1,056 1,061 1,050 

1,050 1,061 1,055 1,055 1,053 1,052 1,049 

1,057 1,063 1,051 1,068 1,062 1,073 1,049 

1,062 1,059 1,057 1,055 1,053 1,069 1,049 

1,066 1,060 1,058 1,053 1,057 1,049 1,051 

1;063 1;057 1,061 1,050 1,056 1,079 1,051 

1,070 1,060 1,053 1,065 1,056 1,060 1,051 

1,061 1,059 1,065 1,048 1,056 1,064 1,051 

1,072 

1,062 

1,059 

1,055 

1,064 

1,065 

:, ())$ 1,063 

1,048 

1,066 

1,067 

1,053 

1,051 

1,072 1,060 1,065 1:076 1,063 1,064 1,052 

1,049 1,060 1,066 1,066 1,070 1,070 1,054 

several times the mortality under 20. Neonatal 

and postneonatal mortality is more nearly “U” 

in shape with the rates in the older groups (40 

years and over) perhaps only about 10 percent 

above that among mothers less than 20 yearsof 

age. However, as for fetal deaths, the optimum 

maternal ages are from 20t030 years. 

Since maternal age is selectively associated 

with fetal and infant mortality, the age distribution of women giving birth affects the mortality 

rate. The distribution of live births bymother’s 

age shows significant differences between the 

United States and the other countries understudy: 

the age distribution of mothers for the United 

States is skewed to the younger ages (table 19). 

This country has ahigherproportion oflivebirths 

in the groups under 25 years thananyofthe other 

countries. In the age group under 20yearsof age, 

when fetal, neonatal, and postneonatal mortality 

are somewhat elevated, the proportion ofbirths 

in the United States is almost 50 percent higher 

than that of the next highest country, Denmark. 

Lower proportions in the United States are found 

ineachage group beginning with age25. 

The relative effect of these differences in 

maternal age distributions on fetal mortality is 

demonstrated in table 20. Fetal death ratios by 

mother’s age wereadjustedtothe live birth distribution by mother’s age in the United States in 

1950. The adjusted rates represent hypothetical 

ratios which would have prevailed in a standard 

population subjected tothematernal age-specific 

fetal mortality ratios of the several countries. 

For this table, it was necessary to use United 

States data for fetal deatha of 20 weeks or more 

since distributions and rates by maternal age 

for gestations of 28 weeks or more are not available. 

The table shows relatively little change in 

ranking and level of ratios brought about by the I 

process of age adjustment. The adjustment lowered the ratios for the west European countries 

bringing them closer to the United States. Al- 1 

though the adjusted ratios for the United States are 

not directly comparable to the others because of 

the difference in gestation (20 weeks or more 

rather than 28 weeks or more), the adjustment 

for mother’s age made no difference in the ratios. 

56 
------

Table 19. Total live births and percentage distributionof live births, by age of mother: se­
 lected countries,1950, 1957, and 1962


—-

Age of mother


Total


Countryand years live 45


births All ~der 20-24 25-29 30-34 35-39 40-44 years un~om
 20


ages years years years years years years and


over 

Denmark Percentagedistribution 

1950----------------

1957----------------

79,558 

75,246 

100.0 

100.0 N 28.0 30.4 19.4 11.2 3.5 

32.4 28.8 18.1 8.9 2.6 

0.2 

0.2 

1962---------------- 77,808 100.0 11.3 34.6 28.7 15.8 7.3 2.1 0.1 

Englandand Wales 

1950----------------

1957----------------

697,097 

723,381 

100.0 

100.0 

4.4 

5.7 

27.3 32.8 19.7 11.9 3.5 

29.3 31.9 19.9 10.4 2.7 

0.2 

0.2 

0.3 

(1) 

1962---------------- 838,736 100.0 8.0 31.1 30.6 18.4 9.1 2.7 0.2 

Netherlands~


1950---------------- 229,369 100.0 2.2 16.2 31.7 25.3 17.4 6,7 0.5


1957---------------- 233,608 100.0 18.2 33.1 25.5 14.8 0.4


1962---------------- 245,739 100.0 $; 21.9 32.6 23.9 13.1 z:: 0.3


Norwav3


1950---------------- 62,410 100.0 19.7 29,7 25.6 15.5 0.6 0.1


1957---------------- 63,063 100.0 ::; 24.3 29.0 22.4 14.3 ::; 0.4 0.0


1963---------------- 62,254 100.0 8.4 30.5 26.7 19.0 11.1 4.1 0.3 0.0


Scotland4


1950---------------- 92,530 100.0 4.3 26.7 31.5 20.5 12.9 3.7 0.2


1957---------------- 97,977 100.0 5.2 29.9 31.5 19.8 10.6 2.7 M 0.1


1962---------------- 104,334 100.0 6.7 31.3 30.9 18.6 9.4 2.7 0.2 0.1


Sweden


1951---------------- 110,168 100.0 7.1 25.4 29.4 21.7 12.1 4.1 0.3 0.0


1957---------------- 107,168 100.0 26.8 29.2 20.5 11.4 3.4 0.3 0.0


1962---------------- 107,284 100.0 1?:: 30.1 28.5 18.0 9.0 2.8 0.2


United States


1950----------------3,554,149 100.0 11.9 31.8 28.8 16.8 8.3 2.1 0.1 0.2


19575.........- 4,254,784 100.0 13.1 32.0 26.8 17.2 8.6 2.1 0.1 0.1


19626........-.----- 4,167,362 100.0 14.6 34.7 25.1 15.3 8.0 2.2 0.1 (1)


lBirthsfor which age of mother was not statedhave been distributedaccordingto known age


proportions.


%ncludes births occurrinzoutside countryifone Or both parents are inc~~dedin a Netherlands


populationregister.


3Ageof mother Obtainedby subtractingyear of birth Of mother from Year ‘f birth of child.


4Data tabulated by year of registration rather than occurrence.


5Based on a so-percentsystematicsample Of births.


SOURCE:United Nations,DemographicYearboo&1959, 1963,and1964, except for the gnited States.


Data for United States taken from Vital Statisticsof the United States, 1950, 1957, and 1962.


57

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

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

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

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

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

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

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

--- ---

Table 20. Fetal death ratios adjusted for age of mother: selected countries, 1950 and \ 1957 

Unadjusted ratiol Adjusted ratio2 

Period of gestation and country 

1950 1957 1950 1957 

28 weeks or.more 

Denmark


England and Wales----------------------------


Netherlands


Norway


Scotland


Sweden


United States


20 weeks or more


United States


18.8 15.5 17.9 15.1 

23.1 23.0 21.8 22.3 

19.7 17.2 16.5 15.2 

16.4 14.9 14.1 13.9 

27.6 24.3 25.7 23.4 

319.6 15.9 317.9 15.0 

14.8 12.1 

19.2 16.3 19.2 16.3 

1

Based on fetal deaths of specified gestations per 1,000 live births. 

2Adjustedto distributionof live births by age of mother in the United State% 1950, .. usi~g the direct method.


Ratio is for 1951.


It seems unlikely that a similar adjustment 

limited to those of 28 weeks or more gestation 

would produce very different results. 

Objective population data bymother’s ageare 

less readily available for the components ofinfant mortality than for fetal mortality. To obtain 

the desired information, composite records are 

needed of the two vital events for individual 

infants: for example, the data concerning cause 

and age at death from the death record mustbe 

related to maternal age, parity, birth weight, and 

so forth, from the birth record. For the United 

States such linked data are available for neonatal 

mortality for births during 3 months in 1950.36 

The preparation ofa matched set of infant deaths 

and 1960 births in the United States is now in 

progress at the National Center forHealthStatis -

tics. Their completion will greatly assist the 

study of demographic factors and neonatal and 

infant mortality in this country. For England, 

Scotland, and Wales, the British Perinatal Study 

provided linked information for all births inone 

week (March 3-9, 1958); and all stillbirths and 

neonatal deaths throughout the months of March, 

April, and May, 1958. 5 

Similar trends in neonatal mortality associated with maternal age and birth order are reported in both studies. The United States data 

showed elevations for first births and high order 

births, and elevations among mothers under 20 

years andover 30years (table 21).Similarelevations are notedin the British data. 

58

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

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

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

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

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

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

Table 21. Neonatal mortality rates by age of mother and total-birthorder: United


States, January l-March 31, 1950


[Excludes data for Massachusetts] 

Total-birthorder


Age of mother


Al1


orders 1 2 3


P 

15-19


20-24


25-29


30-34


35-39


40-44


4	 5 or
 more


births


21.1 26.9


45.2 68.8


24.9 35.8


19.6 25.5


18.8 25.5


21.5 26.1


23.6 28.0


All ages---------­


years


years


years


years


years


years


20.0


23.8


19.0


17.6


20.0


23.6


27.2


Rate per 1,000 live


19.1 17.8 19.7 

21.2 28.1 35.3 

16.6 18.2 22.0 

17.3 14.3 17.7 

24.1 16.1 16.9 

28.7 20.3 19.8 

30.9 25.3 26.4 

SOURCE: National Center for Health Stati.stks,“Weight at Birth and Survival of the


Newborn, by Age of Mother and Total-Birth Order,UnitedStates, Early 1950,” by J. Loeb,


Vital and Health Statistics,Series 21, No. 5, Public Health Service, Washington,D.C.,


July 1965, pp. 54-56. (reprint)


Inconsidering thegroupofcountries
inthis


report, thequestion iswhetherthedifferences
 in


ratesby maternalage(orparity, etc.)
couldac­


countfor theoveralldifferences
 notedbetween


thecountries, To exploretbisaspect,
 dataforthe


Netherlands
andtheUnitedStateswerecompared


sincethese two countriesshowed thegreatest


differences inmatemal ageandbirthorder
 distri­


butions. Only aboutone-fifth
 ofthedifferencein


neonatalmortalitycouldbe accountedfor by


maternalageandbirthorder:


Unadjusted Adjusted 

Netherlands,
 1962-63-- 12.4 12.9


UnitedStates,
1963---- 18.2 17.6


Itmaybe concluded, therefore,
 thatdifferencesin


thematernalageandbirthorder
distributionsac­


countforpartbutnotallofthedifference
 inneo­


natal mortalitybetween these two countries.


LOW BIRTH WEIGHT 

In recent decades,premature birth has


emergedas theprimarydeterminantinrelationto


fetaland neonatalmortality.
For a number of


years,itwas thepractice
toequatethedividing


linebetweenmatureandprematurebirths
 to2,500


grams.41However, theNOVS studiesof births


in the UnitedStatesduring3 months in 1950


showed thatthegestation-birth
 weightdistribu­


tionsof population
subgroupsvary.Inmorere­


cent years,thepreferredpracticehas been to


avoiduse oftheterm’’premature’’whenreferring


toinfants
weighingunder2,501grams,buttouse


the more accurateterm “lowbirthweight.’ti42


The variableof
 primaryconcernis,ofcourse,


thephysicaldevelopmentand maturationof the


infant. Whileitwould be preferable
to use the


durationof gestation, thedetermination
 of this


item for thecountryas a whole is quiteinac-


curate. Therefore, mortality studies
intheUnited


Stateshave concentrated
on birthweightrather


59

--- - - - --

-------- --

-- -- - - - --

----------

----------

------- ---

----------

----------

--------

Table 22. Neonatal mortality rates, by birth weight, color, and sex: United States, 

January l-March 31, 1950 

I 

[Based m deaths within the first 28 days after birth rmmg children horrr JmI. 1 toMar. 31, 1950. Rates per 1,000 live births. 

Births and deaths with birth weight not stated are distributed. Excludes data for Massachusetts] 

Total White Nonwhite 

Birth weight I 

Both Male Female Both Male Female Both Male Female 

sexes sexes sexes 

All weights--- 20.0 22.7 17.1 18.9 21.6 16.0 26.7 29.4 23.9 

l&~O;e~ams 

871.7 894.2 848..0 883.3 905.0 861.0 821.4 849.9’ 789.0 

1,001-1,500 

551.3 621.8 478.2 562.1 643.1 474.5 507.0 524.7 491.6 

1YO?2,000 - 211.0 265.0 160.5 214.6 271.9 160.4 195.7 235.1 161.1 

2~;~2,500 

grams 50.4 67.4 36.6 50.6 69.1 35.5 49.5 60.0 41.2 

2,501-3,000 

grams 12.6 16.6 9.5 12.0 15.9 9.1 15.4 19.9 11.8 

3,001-3,500 

6.7 8.1 5.3 6.2 7.6 4.9 9.7 10.9 8.4 

33:?4,000 

5.6 6.4 4.6 4.9 5.6 4.1 10.5 12.2 8.4 

45%4,500 

grams 7.5 7.7 7.2 6.7 6.9 6.4 12.5 13.1 11.4 

4,501 grams or 

more ----------- 14.2 13.7 15.1 12.0 10.8 14.7 20.2 23.1 16.0 

2,500 grams 

or less 173.7 213.9 138.9 175.8 218.8 138.4 164.7 192.8 141,3 

2,501 grams 

or more -------- 7.8 9.1 6.4 7.1 8.3 5.8 11.9 13.9 9.7 

SOURCE: National Center for Health Statistics, “Weight at Birth and Survival of the 

Newborn, United States, Early 1950,” by S. Shapiro and J. Unger, Vital and Health Statistics, Series 21, No. 3, Public Health Service, Washington, D.C., July 1965, p. 15. 

(reprint) 

than gestation, regarding thisas anindex offetal records. In England, Scotland, and Wales, birth 

maturity. weight has been included instillbirthregistration 

International studies involving birth weight since October 1, 1960. It is not includedon the 

are seriously hampered by the scarcity of birth live birth certificate, but the birth weight of preweight information from the west Europeancoun- mature infants is reported on notifications by 

tries. Denmark has added the item of birth physicians and midwives totheMinistryof Health. 

weight to its live birth and fetal death (stillbirth) For the United States itself, although distriburecords in recent years, but as yet nonational tions of births by birth weight are available andata are available . The Netherlands ,Norway,and nually, there are limited mortality data by birth 

Sweden do not have this item on their official weight. The most comprehensive and direct 

records, but the Swedish Boardof Health isplan- national data relating neonatal mortality to a 

ning to collect the information from hospital 

60 
-----------------

---------

-----------

-----------

-----------

-----------

-----------

---------

/ 

Table 23. Relationshipof fetal, infant, and early childhood mortality to infant’sweight at


birth: New York State, exclusive of New York City, 1950-52


[Rates per1,000 smvivomamongsingle
 white births] 

Deaths


Tots1 28 days- Infant’sbirth weight births1 Feta1? Under 28 days 11 months 1-4 years 

Number Rate Number Rate Number Rate Number Rate


Total 435.937 6.898 15.8 6.998 16.3 2.246 5.3 — _ 

1,500 grams or less 6,144 2,303 374.8 2,809 731.3 52 50.4 5 

1,501-2,000grams 5,277 713 135.1 957 209.7 94 26.1 ::; 

2,001-2,500grams 19,681 962 48.9 843 45.0 225 12.6 1;: 5.9 

2,501-3,000grams 80,315 844 10.5 816 10.3 524 303 

3,001-3,500 grams 170,947 1,149 899 792 ‘V 539 ::: 

3,501-4,000 grams 117,605 548 ::; 489 ::; ;:: 3.7 371 3.2 

4,001 grams or more--------- 35,968 379 10.5 185 5.2 3.6 116 3.3 

2,500 grams or less 31,102 3,978 127.9 4,609 169.9 371 16.5


2,501 grams or more--------- 404,835 2,920 7.2 2,389 5.9 1,875 4.7
 2!!LE 

lExcl~des103 births tith birth weight and gestationnQt stated.


220 or more weeks’gestation.


SOURCE: H. C. Chase, “Relationship of Certsin Biologic and Socio-EconomicFactors to Fetal,


Infant, and Early ChildhoodMortality, IL Father’s Occupation,Infant’s Birthweight snd Mother’s


Age,t!New york State Department of Health, Albany, New York, 1962.


number of birthcharacteristics
refer toevents 

in 3 months of 1950. Additional data are available only from studies of smaller geographic 

areas.43-45 

Mortality by Birth Weight 

In the 1950 study ofneonatal mortality in the 

United States, it is shown that mortality varied 

as much as 100-fold for various birth weight 

groups (table22 ). Mortality inthe groupweighing 

3,001-3,500 grams at birth is at its optimum 

(6.7 per 1,000), while in the group weighing 1,000 

grams or less, it is 871.7. When all infants 

weighing less than 2,501 grams (sometimes 

termed ’’premature’ ‘) arecombined, theirmortality (173.7) is over 20 times the mortality among 

infants weighing 2,501 grams ormore(7.8).These 

relative variations far exceed those for other 

variables. They have been shown to exceed those 

of maternal or paternalage, birthorder,race, 

socioeconomic level,or previous10SS.37Y38 

Similar results have been reportedat other 

age levels as well. Among single white births in 

Upstate New York (the State exclusive of New 

York City) variations by birth weight were almost as great for fetal deaths of 20 weeks and 

over as for neonatal mortality (table 23). This 

study also showed that the handicap of low birth 

weight carries over to posmeonatal mortality, 

but the magnitude of the differences is notnearly 

so great. 

When the dataof the Perinatal Study forEngland, Scotland,and Wales were extrapolated tosn 

annual base, estimates of perinatal mortality 

showed similar variation: about 900per 1,000for 

infants weighing less than 1,000 grams at birth, 

and about 10 per l,OOOfor those in the optimum 

survival group 3,501-4,000 grams. Theperinatal 

mortality rate in the group weighing less than 1,000 

61 
----------------------

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

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

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

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

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

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

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

---

---

---

---

---

---

---

---

---

-----

------

Table 24. Percentage distributionof births by birth weight: Great Britain, 1958; Eng­


land and Wales, 1963; and United States, 1960 \


Birth weight


All weights


2,000 grams or less


2,001-2,500grams


2,501-3,000grams


3,001-3,500grams


3,501-4,000grams


4,001 grams or more--------------------
 Not stated -.--------------


2,500 grams or less


2,501 grams or tnore


Not stated


Great England


Britain, and Wales,


19581 19632


=


Percentage distribution


100.0 100.0	 100.0 100.0 100.0 — 

::: 

18.0 

3! 

18.4 ;:2 17.2 2%: 

35.9 37.8 38.0 36.9 

27.0 26.7 28.1 18.8 

9.3 9.0 5.8 

3.6 0.4 ::!! 0.7 

7.4 12.7 

9::; 9::! 86.6 

0.4 0.3 0.7 

4.5


IN. R. Butler and D. G. Bonham, PerinatalMortality E. & S. Livingston, Ltd., 

Edinburgh and London, 1963. Based on single live births a~d stillbirthswhich occurred 

in the week of March 3-9, 1958.


2Englandand Wales Ministry of Health, personal communication. Based on notf.fica­


tions of live births and stillbirths by physicians and midwives to the Ministry of


Health.


8Based on a 50-Percent systematic sample of registered liV6! births. 

grams atbirthwas about90 timestherateinthe


optimum period.Mortalitymay be saidtovary


widelywithfetaldevelopment, andoverall
rates


willtherefore be affected
by evensmalldiffer­


encesinthedistribution ofbirthsbybirth
weight.


Incidence of Low Birth Weight Infants 

For theUnitedStates, distributions
 ofbirths


by weightare publishedannually.Since1953,


such statistics have alsobecome available
for


premature infants from thenotifications
 to the


BritishMinistryofHealth,
andanotherestimate


isavailable from thePerinatal
StudyforEngland,


Scotland,
andWales.Datashownintable24 sug-


gestthattheproportionof low birthweightinfantsbornaliveintheUnitedStatesexceedsthat 

among livebirthsandstillbirths in Great Britain. 

Unofficial estimatesoftheproportion
oflowbirth


weightinfants in othercountries
tendtobe even


lower: Netherlands, 5.5percent,lo
and Sweden,

5.04percent.A6


New Zealand,although
nota Europeancountry,has an infantmortalityrate(19.1 in 1964) 

which compares favorably with that of the United 

States (24.8), Beginningwith1965,statisticsby 

birthweighthavebecome available
 forthatcoun­


try.
47 For the entire population (including the 

Maoris) the proportion of low birth weight infants 

was as follows: 

Pet-cent Percent 

recovded estimated 

less than under 

5 lbs., 9 OZ. 2,500grams 

Total births 5.5 6.2 

Live births 5.0 5.6 

Stillbirths (28 

weeksor more)-- 52.6 55.2 

62

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

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

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

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

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

---------

---------

---------

---------

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

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

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

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

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

The experience of the Netherlands, Sweden, 

and New Zealand may be used to define a “low 

rate” country as one in which immature liveborn 

infants (those weighing 2,500 grams or less at 

birth) constitute 5 percent of its live births. Such 

a country would have a “low rate” of immaturity. 

Although the difference between this estimate of 

5 percent versus an observed rate of 8.0 percent 

for the United States in 1962 may appear small, 

its possible statistical effect on neonatal mortality is considerable. By using standard neo-’ 

natal mortality rates derived from the NOVS study 

of 1950, the effect of this difference in birth 

weight distributions may be estimated. 

Countryand year


“Low rate” country-


United States,


1962


United States,


Jan.-Mar., 1950---


“Low rate” countryUnited States, 

1962 

Birth weight


~


Percentage distributionof


live births


100.0 5.0 95.0 

100.0 8.0 92.0 

Standati neonatal mortality


rate


. . . n 173.7 7.8 

Expected neonatal mortality


rate


16.1 8.7 7.4


21.1 13.9 7.2


Thus, an arithmetic increase of 3. Opercentinlow 

birth weight infants could result in an increase of 

5.0 per 1,000 in neonatal mortality. In 1962, the 

observed neonatal rates were: 

Netherlands 12.8 

Sweden 12.4 

United States 18.3 

The difference in neonatal mortality presented in 

the table above (5. O) would constitute 85-90 percent of the observed difference between the 

Netherlands or Sweden and the United States. Thus, 

theoretically, differences in birth weight distributions of this magnitude could account for 85-90 

percent of the difference in neonatal mortality 

between the United States andthese twocountries. 

This presentation is conjecture rather tban 

evidence. In the first place, the estimate for’’low 

rate” countries is based chiefly on unofficial 

estimates. As data by birth weight become 

available for other countries (e.g., Denmark, 

New Zealand, and Sweden), further exploration 

of international differences in infant mortality with 

regard to birth weight will become possible. 

Secondly, the estimated neonatal mortality rates 

shown in the preceding table are the weight-specific rates derived from the 1950 NOVS study. 

Later data would have been preferred but are 

presently unavailable. 

Turning from international comparisons to 

the United States alone, examination of data shows 

small but consistent increases in the proportion 

of low birth weight infants among live births in 

recent years. These have occurred in each weight 

group up to 3,500 grams (table 25). With regard to 

the group under 2,501 grams, this proportionate 

increase’ cannot be explained by decreasing proportions of unknowns. While the proportion of 

live births with weight unspecified has remained 

fairly constant, the proportion of low birth weight 

infants has increased almost each year. 

Percent Percent Percent 2,500 2,501 

not 

ov less 

gvams 

or more stated 

1959 7.7 91.8 0.5 

1960 7.7 91.9 0.4 

1961 7.8 91.9 0.3 

1962--------- 8.0 91.7 0.3 

1963 8.1 91.4 0.5 

1964--------- 8.2 91.6 0.2 

gyams 

Similar data may be derived from notifications 

submitted to the Ministry of Health for Great 

Britain. These data do not suggest increases in 

the proportion of low birth weight infants similar 

to the experience in the United States. 

Percent 2,500 

gvams OY less 

1953 -57---------------------- 6.8 

1958------------------------- 6.9 

1959 6.7 

1960 6.7 

1961 6.7 

1962 6.7 

1963 6.6 

63 
--------------

------

--------

--------

--------

--------

--------

--------

--------

--------

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

------

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

Table 25. Percentage distribution of live births by birth weight: United State% 1959-64 

Year 

Birth weight 

Total 

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 

3,501-4,000 grams 

4,001-4,500 grams 

4,501-5,000 grams 

5,001 grams or more ------

Not stated 

2,500 grams or less 

2,501 grams or more ------

Not stated 

1964 1963 1962 1961 1960 1959 

Percentage distribution 

100.0 100.0 100.0 100.0 100.0 100.0 

0.6 0.6 0.6 0.5 0.5 0.5 

1.5 1.5 1.5 1..4 1.4 1.4 

5.4 5.4 5.3 5.2 5.1 5.1 

19.3 19.3 19.1 18.8 18.4 18.5 

38.2 38.1 38.0 38.0 37.9 37.9 

25.8 25.7 26.0 26.4 26.7 26.6 

7.0 6.9 7.1 7.3 7.4 7.4 

1.3 1.2 1.3 1.3 1.4 1.3 

0.2 0.1 0.2 0.2 0,2 0.2 

0.2 0.5 0.3 0.3 0.4 0.5 

8.2 8.1 8.0 7.8 7.7 7.7 

91.6 91.4 91.7 91.9 91.9 91,8 

0.2 0.5 0.3 0.3 0.4 0.5 

1 

0.7 0.7 0.6 d0.6 0.6 0.6 

SOURCE: U.S. Department of Health, Education, and Welfare, Public Health Service; 

annual report, Vital Statistics of the United States. 

The problem of fetal development at birth 

(gestation as well as birth weight) anditsrelationship to mortality is in need of further clarification. If thedifferences indistribution by birth 

weight are real, they may account foraconsiderable part of the differential in mortality between 

the United States and some of theothercountries. 

At the present level of mortality in the United 

States, an arithmetic increase of 1 percent in 

infants weighing less than 2,501 grams causes 

a relative increase of 10 percent in first-week 

mortality. To more fully understand therelationsbip between fetal and infant mortality to birth 

weight wouldrequire objectiveinformation related 

to birth weight for other countries and for 

mortality data correlated with birth weight for 

all of these countries including the United States. 

Recent investigations have pointedto thenecessity for the simultaneous analysisof databy 

gestation as well as birthweight.48 Thisprospect 

highlights the need for vast improve”ment in the 

quality of gestation information for the United 

States. Except for afewareas which request the 

“firstday,last normal menses ,“gestationinformation is inaccurately reportedon live birth and 

fetal death certificates in multiples of4 weeks. 

Furthermore in some States high proportionsof 

records with unknown periods of gestation are 

registered. 

Other Related Factors 

For live births inthe United Statesin 1950, 

the incidence of low birth weight was shown tobe 

related to anumber ofother variables (table 26). j 

The greatest relative differential is for infants I 

with gestations less than 37weeks and thoseborn 

in plural deliveries. Next highest areinfantsborn 

64 
----------

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

------

Table 26. Incidence of low birth weight among subgroups of live births: United States, January 1-


Ma=ch 31, 1950


[Excludes datafor
Massachusetts]


Item


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


Type of countyl


Urban----------------------


Rural----------------------


Metropolitan---------------
 Nonmetropolitan------------


Size of Place (hosp&l


irths only~


Urban


250,000 or more


50,000 tO 250,000--------


10,000 to 50,000---------


2,500 to 10,000----------


Rural----------------------


Sexl

— 

Male


Female---------------------


Colorl


white


Nonwhite-------------------


Pluralitvl


Single birth


Plural birth


SOURCES:


Percent


2,500 grams Index
 or less


7.4 10C 

2; 105 

91


104


93


8.3 112


7.7 104


7.4 100


99
 ::; 93


6.7


8.1 1%


95


131


7?:


Item


Gestation2


Under 28 weeks


28-31 weeks


32-35 weeks


36 weeks


37 weeks and over


Total-birth order3


First


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


Third


Fourth


Fifth and over


Age of mother3


15-19 years


20-24 years


25-29 years


30-34 years


35-39 years-----------------


40-44 years


Outcome of previous


——
 del~veries +*


No previous fetal death-----


Previous fetal death--------


Attendantl


Physician, in hospital


Physician, not in hospital-­


Midwife, other, not


specified------------------


Percent


2,500 grams Index
 or less


94.4 1,276


87.8 1,186


62.9 850


12.3 166


4.2 57


7.7 104


6.9 93


7.2


7.5 1:;


7.7 104


;.; 122 

99 

6:7 91 

;:; la


7.7 104


1::; 1:2 

101


93


86


lNational center for Health Statistics, “Weight at Birth and Survival of the Newborn, by Geo­


graphic Divisions and Urban and Rural Areas, United States, Early 1950,”by J. Unger, Vital and


Health Statistics, Series 21, No. 4, Public Health Service, Washington, D.C., July 1965.~


2National Center for Health Statistics, “Weight at Birth and Survival of the Newborn, United


Early 1950,”by S. Shapiro and J. Unger; Vital and Health Statistics, Series 21, No. 3,


~~?~’Health Service, Washington, D.C., July 1965. (reprint)


~National Center for Health Stat%sti,cs> ‘Weight at Birth and Survival of the Newborn, by Age


of Mother and Total-Birth Order, United States, Early 1950,” by J. Loeb, Vital and Health Statis­


tics, Series 21, No. 5, Public Health Service, Washington, D.C., July 1965. (reprint)


4Based on multiparous mothers of single live births.


65

---

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

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

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

---

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

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

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

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

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

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

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

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

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

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

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

Table 27. Incidence of€low birth weight among subgroups of single white births: New 

York State, exclusive of New york City, 1950.52 

Characteristic 

Total ----.......-......------.--.....-.-------.----.----

Father’s occupation group 

Nonagricultural 

Professional --------- .........................---------------

Managerial -------- --------

Sales workers -------- --.-----

Clerical workers ---------------------------------------------

Craftsmen ------.- --------

Operatives -------- ................--------.........-------

Service workers ----------------------------------------------

Nonfarm laborers 

Agricultural 

Farmers ------- -------.......-.-------.----

Farm laborers 

Not classified -------------------------------------------------

Age of mother 

Under 20 years ------------.----

20-24 years -------. 

25-29 years ---.----

30-34 years --.----

35-39 years ------. --.----

40 years and over 

Gestation 

Under 37 weeks -------- -------- .--------

37-40 weeks ------------.---

41weeks and over 

Percent 

2,500 grams Index or less 

7.1 100 

6.1 86 

6.5 92 

6.9 97 

6.7 

7.1 l% 

7*5 106 

7.6 107 

8.1 114 

6.0 1:: 

1::; 162 

8.9 125 

6.9 97 

6.5 

7.1 1% 

117 

135 

59.2 

3.7 

1.6 

SOURCE: H. C. Chase, “The Relationship 

tors to Fetal, Infant, and Early Childhood 

fant’s Birthweight and Mother’s Age,’f New 

York, 1962. 

to mothers who had previouslyexperiencedfetal 

deaths, nonwhite infants, and infants born to 

mothers 15-19 years of age. 

Turning to the Upstate New York data, once 

again the greatest relative differentialintheincidenceof low birth weight infantsis forthose with 

gestation under 37weeks (table 27). Thisgroupis 

followed by those with father’s occupation not 

specified (probably mostly illegitimate births), 

those born to mothers 40 years and older, and 

infants of agricultural laborers. With regardto 

social class, these findings aresimilartothoseof 

the British Perinatal Study. That study showed a 

“steady increase in the incidence of curtailed 

of Certain Biologic and Socio-Economic FacMortality, Part 11, Father’s Occupation,InYork State Health Department, Albany, New 

pregnancy (28-37 weeks) as family social class 

fall;. ” The “ highest incidence of curtailed pregnancy in that study was found among unmarried 

mothers. 

The United States and New YorkState studies 

are based on births in January-March 1950andin, 

1950-52, respectively. Completion of the U.S. 

study relating to 1960 live births whichis currently in process at theNationalCenterforHealth 

Statistics will provide data a decadelater thanthe 

1950 studies. It willbepossibletoanalyzechanges 

which have occurred between 1950and 1960, the 

decade in which infant mortality appears tohave 

changed its course. 

66 
PREVIOUS LOSS 

In addition tothefactors already mentioned, 

a history of reproductive loss in previous pregnancies is correlated with outcome in ensuing 

pregnancies. Among women whose current pregnancy terminates in a loss (fetal or neonatal 

death), the previous loss rate is higher than among 

women presently delivering infants who survive 

the neonatal period. Furthermore, the type of loss 

is selective. Women whose current pregnancy ends 

in fetal death have higher previous fetal loss rates 

than women whose current pregnancy results in 

neonatal death; these women in turn have rates 

which are higher than for women whose current 

newborn infants survive the neonatal period. There 

is similar correlation between neonatal loss in the 

current delivery and death among prior liveborn 

infants. 28) 38 These relationships persist in all 

socioeconomic levels and are not attributable to 

that characteristic alone. 

Other studies have shown the relationship to 

be even more complex. According to Butler, infant loss (stillbirth or neonatal death) is also more 

likely among mothers who previously had premature live births. ~ From a health insurance plan 

population, Shapiro has shown that women whose 

last immediate pregnancy terminated in a fetal 

death or low birth weight infant had higher rates 

of loss in succeeding pregnancies. lo In this study, 

“loss” was used to characterize any pregna~cy 

which resulted in a fetal death, a neonatal death, 

an infant of low birth weight, or one born with 

congenital anomalies. Furthermore, women whose 

preceding pregnancy had ended in premature birth 

had higher risks of premature birth in their 

ensuing pregnancies. 

Except for special studies outlined above, 

there are no nationwide data for the United States 

on this subject, or on the contribution of such 

high-risk groups to the international differences. 

There has emerged the concept of a group of 

women who, for unknown reasons at the present 

time, have a higher risk of unfortunate outcomes 

in successive pregnancies. This may be related 

to genetic or constitutional characteristics of this 

group of individuals or to other factors which 

affect individuals in such a way as to generate 

repeated occurrences of reproductive failure. 

This phenomenon has found acceptance in medical 

circles in the United States. Under the auspices 

of the Children’s Bureau, there are currently 

underway 51 projects in 34 States and the District 

of Columbia whose purpose is to identify highrisk groups of pregnant women and to afford 

them hospital care which they might not otherwise 

be in a position to obtain. It is too early to report 

any results from these projects. Under the National Health Service in Great Britain, national 

policy has been established for hospital care for 

delivery based on the concept of high-risk groups. 

Births to mothers in certain age groups, to 

mothers of high parities, and to mothers with adverse prenatal histories are eligible for hospital 

care under the National Health Service. These 

are considered priority groups in need of hospital care at time of delivery. 

SOCIOECONOMIC DIFFERENCES 

Since 1911, British statistics have repeatedly 

shown an inverse relationship between parental 

social class (determined from the father’s occupation) and fetal and infant mortality. The British 

Perinatal Study provides similar data, b and other 

studies have been extended to include variables 

such as maternal stature and sccial class of the 

maternal father.bo 

With the initiation of the National Health 

Service in Great Britain, a common base of 

antepartum, partum, and postpartum care became available to the entire childbearing population. Although there were significant declines in 

infant mortality in each of the social classes in 

the first half of this century, the relative differences between the classes have not decreased. 

In fact, the British Perinatal Study suggests 

that the gap between the classes may have widened 

even at a time when medical care was readily 

available to the entire population. 5 

Comparable data for the entire United States 

are unavailable. However, studies for Upstate 

New York in 1950-52 (table 28) and California 

in 195937>38 have provided data by father’s occupation group. These studies reaffirm an inverse 

relationship between mortality and the level of the 

father’s occupation group similar to the British 

experience. 

In the United States, medical care for deliveries is arranged on a private basis with a 

67 
--------------------------------

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

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

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

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

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

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

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

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

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

Table 28. Percentage distributionof live births, and fetal, neonatalz and postneo­


natal mortalitv rates. bv father’s occupation: New York State, exclus~ve of New York


City, 1950-52 - “ -


[Based cm single white births] 

?ercentage


distri-
 Father’s occupation at time bution of
 of infant’s birth
 live


births


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

Nonagricultural


Professional 14.1


Managerial 9.4


Sales workers 5.8


Clerical workers 6.1


Craftsmen 24.3


Operatives 20.0


Service workers 3.4


Nonfarm laborers 8.5


Agricultural


Farmers 4.8


Farm laborera 0.7


Not classified----------:-- 2.9


Mortality rates


Fetal! Neonata12 Post- 3 

3eonatal 

I 

15.9 16.3 5.3


! 

12.8 14.1 3.7 

13.3 15.2 3.5 I 

14.3 15.0 4.6 

14.9 14.3 3.9 

15.5 16.0 5.0 

17.8 17.4 6.0 

17.8 18.3 5.6 

18.0 18.8 9.6 

17.7 15.9 6.4


18.1 20.4 8.3


22.7 22.8 6.8


~20 weeks or more gestation per 1,000 live birtha and fetal deaths.


$Jnder 28 days per 1,000 live births.


28 days-n months per 1,000 survivors to 28 days among births.


SOURCE: H. C.-Chase, “The Relationship of Certain Biologic and Socio-EconomicFactors to Fetal, Infant, and Ea,;lyChildhood Mortality, I, Father’s Occupation,Parental 

Agel and Infant’sBirth Rank, U.S.Department of Health, Education, and Welfare,Child­ ren s Bureau, 1964.


generalpractitioner o obstetrician.
 Itisusually


onlyin casesofrestricted finances
thatpatients


attendprenatal clinics
runby healthdepartments


or hospital outpatient departments.
Among lower


socioeconomic
groups,medicalcareisoftenrele­


gatedto a position outside
therangeofthefam­


ily’sfinancial
 resources.In some groups(e.g.,


lowestpartofthenonwhitesegmentoflargecily


populations),as
many as 30 to40 percentmay


havehadno prenatal
careatthetimeofdelivery.


, 

Untilfurtherdatabecome available
forthe


UnitedStatesasawhole,itisimpossible
 topursue


thequantitative
 magnitudeof thesocioeconomic


differences withoneexception-the
 nonwhitepop­


ulation.
 This separatesocialgroupconsistently


has infantmortalityrateswhichareaboutmice


thoseof itswhitecounterpart.
 This contrasts


greaterthanthatby father’s occupation
groups


among whiteinfants
alone.


68

-------

-------

-------

-------

-------

-------

-------

-------

-------

-------

-------

-------

-------

-------

-------

--- ---

ILLEGITIMACY 

The attitude ofsociety towardillegitimacy
 has


become more tolerant inthepastseveral
decades,


more so insome countries thaninothers.
These


attitudes
affectthe qualityand, in fact,the


availability y ofstatistical
 information.


International
 comparisonsof mortalityand


illegitimacy are,atpresent, virtually
 impossible


becauseof lackofstandarddefinitions
 andcom­


parabledata.In the UnitedStates,a birthis


termed “legitimate”
 iftheparentsaremarried


attimeoftheinfant’s birth.
 Forsome oftheother


countries, legitimacy isdetermined
bythemarital


statusattimeofconception.
 These andotherdif­


ferencesmake international
 comparisonsvir­


tually
impossible.


However,forindividual countries,it
ispossi­


bletocompare trendsinmortality
among illegit­


imate and legitimate infants, regardless
oftheir


definitions.
 In Denmark, forexample,perinatal


mortality
in1962‘was24.1per1,000forlegitimate


birthsand34.1forillegitimate
 births.


AccordingtotheBritishPerinatal
Mortali~


Survey,perinatal “mortali~inillegitimate
 babies


over2,500grams isconsiderably
 aboveaverage,


andindeedis20percenthigherthanthat
ofsocial


class 5“ (the lowest rankingsocialclass).s


Furthermore,women withnohusbandshaveapre-


maturityrateof10.8percentwhichwas30percent


higherthanthatof thelowestscxialclass.The


totalillegitimacy
 rateamong singlebirthswas


4 percent.


Table 29. percent illegitimate live births: selected countries, lg50.64


United States4


England
 Year Denmark and Wales Norway Sweden


1964


1963


1962


1961


1960


1959


1958


1957


1956


1955


1954


1953


1952


1951


1950


+


Percent


..- 7.2 5.4 13.1 24.5 

1.6 12.6 ;:? 23.6 

8.3 ::: 2 ; 12.4 2.8 23.0 

8.0 6.0 ::: 4.6 11.7 22.3 

7.8 5.4 1.4 4.4 11.3 $:; 21.6 

7.3 1.4 4.2 10.4 2.2 21.8 

Z:& 4.1 10.2 2.1 21.2 

::; ?:$ 4.1 10.1 2.0 20.7 

::: 1.2 4.3 10.2 1.9 20.4 

2:; 4.7 1.2 4.3 9.9 1.9 20.,2 

4.7 4.5 1.8 19.9 

::; 4.7 ::: ;:: 19.1 

6.8 4.8 1.4 ::: ::; 18.3 

7.0 4.8 1.4 5.1 1::? 1.6 18.3 

7.4 5.1 1.5 5.2 9.8 i.7 18.0 

~”’Illegitimacy’refers to legal i.llegi,timacy
 recorded on the birth record,that is,


it is a characteristicof a child ‘born out of legal wedlock, as determinedbylaws of


each country.” See U.N. DemographicYearbook, 1959, pp. 39-40.
 .


‘Includes births occurring outside country if one or both parents are included in


Netherlands population register.


sData tabulated by year of registrationrather than occurrence.


4Refers only to births occurring within the United States, Alaska beginning 1959,


and Hawaii, 1960. Data on illegitimacyare estimated from a varying number of States


with this information.Based on a 50-percent sample except for 1950 and 1955. Figures


by color exclude residents of New Jersey for 1962 and 1963.


69

IE the United States, a number of States 

prohibit any entry concerning legitimacy on their 

vital records. Therefore, for this country, information is available for only a limited number of 

States. Estimates of the incidence of illegitimate 

births increased during the period 1950-64 (table 

29). Gne of the outstanding contrasts in the data 

is the marked difference in the incidence of illegitimacy between the white and nonwhite groups 

of the population. If the differentials in mortality 

which have been observed in Denmark and in 

England and Wales exist in the United States as 

well, the effect on the rates for nonwhite infants 

would be significant. 

DISCUSSION 

Excess fetal and infant mortality are associated with a number of demographic variables, 

and the relationships have been documented in a 

number of studies. For some of the characteristics, international comparisons are virtually impossible because of the lack of common definitions, e.g., urban-rural, illegitimacy y. In the 

United States, the population is steadily gravitating toward urban centers, and in a number of 

these infant mortality is higher than in the surrounding areas. However, it is difficult to compare a city like New York or Los Angeles, each 

with a population of more than 6 million in 1960, 

with cities like Copenhagen, Amsterdam, or Edinburgh. A second characteristic, illegitimacy, is 

not uniformly defined in the various countries 

and the statistics are not directly comparable for 

that reason. Estimates based on a limited number 

of States in the United States suggest that the rate 

of illegitimate births is increasing, and mortality 

among illegitimate infants is known to be higher 

than among legitimate births. For these characteristics, statistically comparable international 

data are nonexistent. 

Inverse relationships between mortality and 

socioeconomic levels are generally accepted. 

However, there are no national data for the 

United States except for the division between 

white and nonwhite infants. Despite their higher 

mortality, the increasing proportions of nonwhite 

infants are not sufficiently large to account for the 

deceleration in trend in the United States. Furthermore, the relationship between this country and 

other countries is not changed materially when 

that comparison is limited to white infants in the 

United States. 

Studies of fetal and neonatal mortality related to previous loss are consistent in pointing 

to a group of high-risk women having repetitive 

losses. However, it is not completely clear 

whether these losses are associated with biologic 

or socioeconomic factors; both have been implicated. 

The neonatal mortality among low birth 

weight infants is over 20 times as high as that of 

infants weighing more than 2,500 grams at birth. 

Although fully documented evidence of the international distributions is lacking, there are suggestions that the incidence of low birth weight 

infants may be significantly higher in the United 

States than in the Netherlands or Sweden. At 

present, this may be considered a hypothesis 

for further exploration. The effect of the difference, if found to be true, may account for a considerable portion of the difference in neonatal 

mortality between the United States and these 

countries of low infant mortality. 

The incidence of low birth weight infants is 

higher among low socioeconomic groups, among 

young mothers under 20 years of age, in highly 

populated urban areas, and particularly among 

infants with curtailed gestations. This higher 

incidence of low birth weight infants may account 

for part of the associated elevated mortality in 

these groups. Because of lack of factual evidence, 

these issues cannot be resolved at present. 

For only a few demographic characteristics 

can definite statements be made. With regard to 

color, in the United States similar changes in 

trend were observed for nonwhite as well as white 

infants. With regard to sex of the infant, the differences in sex ratios between the countries included in this report cannot account for the variations which were found in mortality. With regard 

to mother’s age and parity, the variations in births 

related to these factors may account for part. 

but not all of the difference between the Netherlands and the United States, the two countries 

which are most divergent with regard to these 

characteristics. 

Examination of all of these demographic 

characteristics does not identify any single characteristic which completely explains the varia1 

1 

70 
tions in mortality. Data permitting, these various 

characteristics can also be considered for their 

combined effect on mortality. Pending such studies, the results cannot be estimated by adding 

the separate effects because of the intercorrelation. For example, high parity births, older 

mothers and fathers, low socioeconomic levels, 

and low birth weight infants are positively correlated, Effects of two or more characteristics 

can be obtained by cross-tabulation of a number 

of variables, a procedure which demands a large 

volume of data for study. 

Since postneonatal mortality has progressively become a smaller part of infant mortality, 

fetal and neonatal mortality have assumed relatively greater importance. As a consequence, 

those factors which are associated with higher 

fetal and neonatal mortality also assume greater 

importance. 

Prominent among the correlates of elevated 

fetal and neonatal mortality are multiple birth, 

older mothers, low birth weight, and short gestations, Although the relative mortality among 

multiple births is markedly higher, their incidence 

is relatively low (2.1 percent in the United States 

in 1958). 

The relationship with regard to mother’s age 

is somewhat different. Fetal and neonatal mortality are somewhat higher among mothers 30 years 

or older than for all ages combined. Although 

about 25 percent of births in 1963 were to mothers 

in these ages, the excess mortality is not as 

marked as for multiple births, and the combined 

effect of incidence and elevated mortality is not 

great. 

The pattern with regard to low birth weight 

and gestation is different also. The relative 

mortality among small or prematwre infants 

is markedly higher than among infants weighing 

more than 2,500 grams, or those with gestations 

of 37 weeks or more. Furthermore, these low 

birth weight infants comprise almost 8 percent 

of live births, and the combined effect of the * 

incidence and mortality experience is greater for 

prematurity y and/or immaturity than for mother’s 

age or multiple birth. 

Pursuit of international studies of prematurity would require widespread effort. Most 

European countries do not request birth weight information on birth records. Further progress in 

this area may be expected in accord with the 1961 

recommendation42 of the WHO Expert Committee 

on Maternal and Child Health: 

The Expevt Committee, thevefore, vecomnzenak that biyth re~”stration should be as 

complete as possible and that, as soon as 

is practicable, birth weight be added to the 

o~cial birth certificate used in each country. 

At least two of the countries included in the report (Denmark and Sweden) are collecting and will 

be tabulating data by birth weight. 

In addition to obtaining birth weight, there is 

need for reliable information on gestation as 

well. An examination of the recorded weeks of 

gestation for fetal deaths in the United States 

implied gross misreporting in comparison with 

gestations which are computed from the first 

day of the last normal menses. 51 Changes in this 

item for U.S. certificates require revision of the 

vital records of a large number of States. Among 

the other countries, revision of official records 

would also be required, but would be somewhat 

simplified because a common record is used 

throughout each country. 

Improved information on birth weight and gestation would permit studies of the incidence of 

low birth weight or curtailed gestation. However, 

the crucial element would be the establishment 

of combined death and birth records. This can be 

accomplished in the vital statistics office after 

registration, as in the United States, or through 

the design of a combined neonatal death and birth 

record as proposed by the Medical Statistics Committee on Australia. 52 

In the United States, emphasis is needed on 

improved recording of gestation information and 

on analyses of mortality in relation to indexes 

of prematurity and immaturity. More intensive 

investigation of these variables seems to be the 

most promising lead to unraveling the reasons 

for changes in mortality trends. 

SUMMARY 

The association of fetal and infant mortality 

with selected demographic factors has been well 

established. Higher mortality is associated with 

very young and old mothers, first and high order 

births, prematurity, mother’s previous repro71 
ductive loss, lowsocioeconomic levels, andillegitimac y. Associations with father’s age after 

cross-tabulation with mother’s age have been 

supported by several studies in the United 

States 33, 38 but unsupported by similar studies 

of fetal mortality in New Zealand. 53 

Although variations in mortality exist in 

relation to these variables, the point at issue 

is whether these differentials could account for 

international differences in mortality. As each 

of the variables was examined and discussed in 

turn at the Center’s conference, the results were 

found to be inconclusive. A comparison of available data with regard to geographic variation, 

color, sex, maternal age and parity, low birth 

weight, previous loss, socioecon~mic levels, and 

illegitimacy failed to demonstrate any single factor as clearly responsible for the deceleration in 

trend in the United States. Prematurity and/or 

immaturity evolved as a hypothesis for future investigation. 

72 
VI. MEDICAL CARE AND OBSTETRIC PRACTICE 

Good prenatal medical care is commonly 

accepted as one of the cornerstones of infant and 

maternal health. Although the countries included 

in this comparison have generally been characterized as having “advanced” medical education 

and medical care, differences exist among them 

in medical care associated with pregnant y, delivery, and infancy. Some of the chief differences 

have been suggested by Rutstein. 54 The number 

of prenatal visits, place of delivery, attendant at 

birth, and period of confinement vary considerably. Some of these characteristics can be documented from available data. For more precise 

information, such as that on anesthetics, surgical 

intervention, and resuscitation of the newborn 

infant, international data are unavailable. 

MEDICAL CARE 

One of the outstanding differences in maternity care between the United States and the west 

European countries is the use of nurse-midwives. 

In the west European countries, a great deal of 

prenatal care is supervised by nurse-midwives, 

and sizable proportions of births are delivered 

by them. Midwifery is regarded as a “specialized 

branch of the nursing profession” in England. 55 

In England and Wales, a nurse-midwife is a registered nurse with an additional year of training in 

hospitals and home midwifery. She is required to 

call for medical aid for any abnormality during 

pregnancy, labor, or the puerperium. Her license 

is withdrawn if she fails to practice for 6 months, 

and it can be reinstated only after a period of retraining. A 3-year period of training is required 

in Denmark and the Netherlands. In the latter 

country, once midwives have been licensed, they 

are permitted to practice quite independently of 

physicians. As in England, midwives are required to refer complicated cases to physicians 

and are restricted as to the care they may render—in effect, caring for women with uncomplicated pregnancies and attending normal deliveries. 

In the United States, the term “midwives” 

has had a different connotation. In the past, midwives consisted of two groups: one, a group of 

largely untrained women who immigrated with the 

large influx of migrants in the early part of this 

century; and the second, another group, also with 

limited training, who lived predominantly in the 

rural areas of the country. The immigrant midwives have largely disappeared due to their aging, 

but a group of practicing midwives is still to be 

found among the nonwhite rural population. In 

1963, for example, 0.3 percent of white live births 

and 9.1 percent of nonwhite live births in the 

United States were attended by midwives. 

In recent years there has been increasing 

interest in programs for training nurse-midwives. In 1963, there were only 495 known nursemidwives in the United States and only 15 percent of a sample of these were practicing or 

teaching nurse-midwifery. 56 Because of their 

limited numbers, nurse-midwives have little 

effect on the overall mortality experience in 

the United States. 

Prenatal Care 

In the United States, the recommended practice has been for a woman to seek medical attention as soon as she suspects she is pregnant. 

Thereafter, a regular program of periodic visits 

to a physician or obstetrician, followed by delivery in a hospital with the advantages of medical 

attention close at hand, is advised. This pattern 

of maternity care has been advocated for several 

decades and is generally accepted as desirable 

by a majority of women. 

Prenatal care is usually a matter of private 

arrangement between the patient and the physician, 

and when prenatal care is sought, it is generally 

provided under the supervision of a physician. 

For those unable to pay for care by a private 

physician, prenatal clinics are available. These 

clinics, which emphasize preventive care, are 

conducted under the auspices of local governments (cities or States), voluntary agencies, or 

hospitals. In some of these clinics, small fees 

are charged but services are predominantly 

free. Such clinics are often crowded. 

73 
Inpatient maternity care in hospitals at time 

of delivery is generally covered in part by some 

form of hospital insurance which is purchased 

by the family, sometimes witli partial payment 

by the employer. However, insurance benefits 

for maternity care are not adequate to meet the 

entire costs in most instances and must be supplemented with personal or other funds to make 

up the difference. The benefits are often limited 

to a flat fee of $75 or some such stipulated 

amount. For women without hospital insurance 

or those who are unable to pay for hospital 

delivery, such services are obtainable from public hospitals but these facilities are usually overcrowded. 

In the west European countries, prenatal care 

for the insured population is provided through 

their social insurance systems. In Denmark and 

the Netherlands, for example, the insured are 

entitled to a specified number of prenatal visits 

according to a predetermined schedule for normal pregnancies. Additional free visits are permitted for pregnancies with complications. As 

an example, in Denmark pregnant women are 

allowed nine free consultations during pregnancy: 

three with a physician and six with a midwife.s? 

The scheduling is as follows: 

Physician—first visit, as early as possible 

second visit, 25th week of pregnancy 

third visit, 34th-36th week 

Midwife—six visits in the 20th, 30th, 33d, 37th, 

38th, and 39th weeks 

In England and Wales, the schedule of prenatal 

visits is monthly until 28 weeks, then every 14 

days until 36 weeks, and thereafter weekly until 

delivery. 58 The selection of a physician or midwife who will provide prenatal care is left to 

mutual agreement between physician and patient 

at the first prenatal visit. 

In addition, in each of the west European 

countries certain maternity leave, food and milk, 

and cash benefits as well as family allowances 

are included in the social insurance systems 

(see appendix). In the Netherlands, health insurance is compulsory for the lowest income groups, 

but optional for higher income groups. In Great 

Britain, all persons are covered by the National 

Health Insurance and hospitals are under government control. Medical care is supported by national taxation, weekly contributions by taxpayers, 

local taxes, and limited charges. Physicians are 

paid on a per capita basis for each patient enrolled. 

Data relating to prenatal care from a special 

study in Great Britain together with those for a 

few areas of the United States are shown in 

table 30. Although the grouping of weeks of gestation is not uniform, the data indicate the wide 

variability which is to be found in the timing of 

the first prenatal visit even in parts of the United 

States. For example, the proportion seeking 

“early” prenatal care (first 3 months of pregnancy) varied from less than 50 percent in 

Washington, D.C., to about 65 percent in Kansas 

and about 70 percent in Iowa. These percentages 

are affected by the nature of the population, but 

suggest that although the majority of women seek 

prenatal care early in pregnancy, a sizable proportion do not. In this country, prenatal care is 

generally understood to mean a visit to a physician or to a clinic in contrast to some of the west 

European countries where prenatal care includes 

care by a nurse-midwife. In the Netherlands, “half 

of pregnant women place themselves under supervision of doctor or midwife before 18 weeks of 

gestation, the first visit usually being earlier 

when attending a doctor. ”10 The association between prenatal care and the overall neonatal & 

infant mortality experience has been studied in 

the United States, but the conclusions are controversial, 59, 60 Nevertheless, there is general 

agreement in the United States as in the other 

countries of the value of early prenatal care as 

a screening device for identif ying pregnant women 

who should be under closer medical supervision 

or who should be booked for hospital delivery. 

Although it seems that a majority of women 

in the United States seek prenatal care in the 

first trimester of pregnancy, also of interest 

are those women who wait until late in pregnancy I 

for their first visit or those who have no pre- ‘ 

natal care by the time they are delivered. Following are the proportions who either seek care 

74 
---------------------------------------------------------------

----

------

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

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

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

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

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

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

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

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

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

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

---

Table 30. Number and percentage distribution of births, by duration of pregnancy at first pre. 

natal visit: Great Britain and selected areas of the United States 

Area and duration of pregnancy at first prenatal visit


GREAT BRITAIN (March 3-9, 1958)1


Total—single live births and stillbirths--------------------------


1-7 weeks 

8-15 weeks----------------------------------------------------------

16-23 weeks-------------------------------------------------------

24-31 weeks-------------------------------------------------------------

32-35 weeks-----------------------------..--

36 weeka or more


No prenatal care--------------------------------------------------------
 Not stated--------------------------------------------------------------


UNITED STATES


California (1959)2—live births


Third trimester or no prenatal care-------------------------------------


Iowa (1963)3


Total—live births------------------------------------------------


1-3 months -----.


4-6 months


7 months or more


No prenatal care


Not stated--------------------------------------------------------------


Kansas (1960-61)4


Total—live births------------------------------------------------


First trimester---------------------------------------------------------


Second trimester-----------------------------=--------------------------


Third trimester----------------------------------


At delivery-------------------------------------------------------------


Not stated--------------------------------------------------------------


Washington, D.C. (1963)!


Total—live births ---.----------------


Under 14 weeks


14-27 weeks


28-35 weeks


36-39 weeks


40 weeks or more


No prenatal care-------.--.---------------------------------------------


Not stated---------------------------------.--------.-------------------


SOURCES : 

Births


Number Percentage


distribution


16,994


662 

7,634 

5,460 32.1 

2,146 12.6 

392 

152 ::; 

100 0.6 

448 2.6


10.2 

56,183 100.0 

40,641 72.3 

12,636 22.5 

2,450 4.4 

116 0.2 

340 0.6 

97.547 100.0 

62,965 64.5


25,512 26.2


6.250 6.4


1:548


1;272 ?::


33.095 100.0 

1$;;:	 42.3 

26.3 

3:080 9.3 

620 1.9 

109 

3,463 1::: 

3,107 9.4 

IN. R. Butler and D. G. Bonham, Perinatal Mortality, E. & S. Livingstone, Ltd., Edinburgh and


London, 1963.


2State of California Department of Public Health, Perinatal Mortality and Survival, 1949-59.


~Iowa State Department of Health, Division of Vital Statistics; Iowa Annual Report, 1963.


4Kansas State Department of Health,Divisions of Vital Statistics and Maternal and Child Health;


Kansas Perinatal Casualty Report, 1960-61.


‘District of Columbia Department of Public Health, Vital Statistics Smnnnary,1963.


75

---------

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

---------

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

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

----------

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

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

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

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

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

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

---

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

-----------

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

---

in about the last trimester or those who have 

received no such care at time of delivery: 

Peycent 

England and Wales 5 (24 weeks or 

more, or no prenatal care) 16.4 

United States 

California 37 (third trimester, or no 

prenatal care)-------------------- 10.2 

Iowa 61 (7 months or more, or no 

prenatal care)-------------------- 4.6 

Kansas 62 (third trimester, or at 

delivery) 8.0 

Washington, D.C. 63 (28 weeks or 

more, or no prenatal care) 22.0 

Data from the States of California, Iowa, and Kansas suggest smaller proportions of women postpone their first prenatal visit until “late” in pregnant y than is the case in England and Wales. The 

rate for Washington, D.C., is less representative 

of the United States as a whole, since about 70 

percent (1963) of its live births are nonwhite. 

Place of Delivery 

There are marked differences between the 

United States and some of the other countries with 

regard to the proportion of births which cccur in 

hospitals, at home, or elsewhere. Hospitals are 

by far the predominant place of delivery in the 

United States, and virtually all registered live 

births as well as fetal deaths occur in hospitals. 

With Norway and Sweden, the United States stands 

near the top of this group of nations in the percent of deliveries occurring in hospitals or maternit y units. The proportions of births occurring 

in specified locations are as follows: 

Denmark -1962 

Private clinics 10 percent 

General hospitals 21 percent 

Obstetric departments 23 percent 

Home ------------------------- 46 percent 

England and Wales -1958 

Hospitals 49 percent 

Maternity units 11 percent. 

Home ------------------------- 35 percent 

Other and unknown 6 percent 

Netherlands -1960-62 

Hospitals or maternity homes 

All births 

Live births 

Stillbirths 

Nonvay -1962 

Hospitals or maternity wards 

Scotland -1963 

Hospitals 

Sweden -1960 

Hospitals, Jive births 

United States -1963 

Hospitals 

Live births 

Registered fetal deaths (20 or 

more weeks of gestation) 

29 percent 

28 percent 

60 percent 

1 

96 percent , 

79 percent 

I 

97 percent \ 

94 percent 

In the Netherlands, the home is the predominant 

place of delivery. In part, this lower proportion 

may be the result of health benefits provided by 

the sickness funds, since the family is not reimbursed for a normal delivery which occurs in a 

hospital. Yet, despite the large proportion of home 

deliveries, the Netherlands enjoys a favorable infant mortality rate. 

Duration of Hospital Stay 

There are several cooperative statistical 

systems in the United States collecting data from 

a number of hospitals and producing statistical 

information for the use of their members and other 

interested individuals. These include the Obstetrical Statistical Cooperative, the Perinatal Study 

of the Foundation for Medical Research, and the 

Professional Activity Study of the Commission 

on Professional and Hospital Activities. In addition, the Collaborative Perinatal Research Project of the National Institute of Neurological Diseases and Blindness is able to supply similar 

data. Each of these studies compiles statistics 

relating to childbirth in a hospital setting; none 

purports to use a scientific sample of the population. While such selected samples are generally 

not useful in establishing national rates, they 

are useful in estimating experience with regard 

76 
-----------

---------

-------

----

----

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

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

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

-----------

----------

to certain medical practices associated with 

deliveries, which, in this country, are highly 

concentrated in institutions. 

The Collaborative Project of the National 

Institute of Neurological Diseases and Blindness 

is based on data from 14 leading medical centers 

distributed across the United States. By 1965, 

50,000 women had been enrolled in the study. 64 

The Obstetrical Statistical Cooperative consists of a group of 18 hospitals, also distributed 

across the United States. These hospitals are 

either associated or affiliated with a medical 

school and therefore may have an incidence of 

complications which is higher than the rate in all 

hospitals, or in the general population. In one 

year, 1962, the Cooperative’s data were based on 

59,884 deliveries. The patients are described as 

“a mixture of private and service patients of the 

more ‘difficult kind.’ ‘‘G~ 

The Perinatal Study of the Foundation for 

Medical Research is based on data from about 

150 hospitals distributed over 43 States, the 

District of Columbia, and Puerto Rico. The group 

varies from large urban teaching institutions to 

small community hospitals, and includes 17 medical school hospitals. Each hospital has 500 or 

more deliveries per year. Four years’ experience 

(1.961-64) included 659,001 deliveries. 66 

The Professional Activities Study of the Commission on Professional and Hospital Activities 

(PAS) collects coded information from member 

hospitals and provides them with statistical data 

for their own use. In 1963, the 267 hospitals 

constituting the PAS group were located in over 

30 States, with over half in the North Central 

States. They were predominantly nonprofit institutions. The majority of the hospitals fell in the 

100-4 99-bed categorfi total discharges were 

2!4million that year;f37 

The average period of hospital stay for 

confinement is affected by the proportion of deliveries occurring in hospitals, the supply of 

hospital beds, and the availability of financial 

resources for women needing such care. For 

f,	 example, in the United States, the period 

of hospital confinement for delivery was 

8-10 days in the 1930’s. Under the pressure of 

a rapidly increasing birth rate and like hospital 

construction during World War II, the average 

length of hospital stay gradually grew shorter. 

Despite an extensive hospital construction program in the 1950’s, the hospital stay for maternity care continued to decline. This was probably 

related to increased early ambulation of maternity patients as well as other patients. Based on 

July 1963-June 1964 data from the Center’s 

National Health Survey, the average hospital 

stay in the United States was as follows: 68 

All deliveries 4.2 days 

Cesarean sections 8.6 days 

All other deliveries 4.0 days 

Survey data for July 1960-June 1961 show that the 

average stay increased with family income: 69 

Age 17-24 yeavs 

Income under $4,000------- 3.7 days 

Income $4,000 and over 3.9 days 

Age 25-44 yeavs 

Income under $4,000------- 3.4 days 

Income $4,000 and over 4.3 days 

By regions, the average stay varied from 3.2 to 

4.6 days: 69 

Northeast 4.6 days 

North Central 4.2 days 

South --------------------- 3.5 days 

West 3.2 days 

In a study of 21 hospitals which were part of 

the group subscribing to the Commission on Professional Activities study in January-March 1964, 

the average stay among 12,377 normal delivery 

patients varied by hospital from an average of 

3.0 to 5.3 days .70 The following distribution by 

length of stay was found: 

3 days or less 39 percent 

4-6 days ---------------- 52 percent 

7 days or more 9 percent 

There was wide variation among hospitals in the 

percent of delivery patients who stayed 3 days or 

less: the proportions ranged from a high of 83 

percent to a low of 9 percent, withan overall rate 

of 39 percent. 

Data from the Perinatal Study of the Foundation for Medical Research based on 659,001 ma77 
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-------------

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

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

ternit y patients in 1961-64 showed a similar pattern: 66 

3 days or less 31.3 percent 

4-6 days 59.6 percent 

7days or more 9.0 percent 

Maternity patients, even more so than other 

patients, are caught in the crosscurrents of 

rising hospital costs and rigid insurance benefit 

limitations. Uniform benefits of$75 per normal 

delivery, which exist in many health insurance 

policies, will often cover no more than 3days of 

inpatient care. Additional costs must be borne by 

the patient, who may press for early release from 

the hospital for this reason. 

What is the effect of early discharge from the 

hospital? At the Center’s Conference on the Peri -

natal and Infant Mortality Problem of the United 

States, it was pointed out that the “trend in this 

country, regardless of the availability of hospital 

beds has been to keep the period of confinement 

to a much lower period of time and we have 

thought this was a distinct advantage to mother, 

to baby, and to hospital to shorten the stay, although not to unreasonable periods.”17 The reversal in trend of early neonatal mortality raises a 

question concerning the neonate’s welfare. How 

much of the increase may be associated with discharges very soon after delivery? Hospital stays 

as short as 18 hours were indicated to occur frequently in some large institutions. Are these very 

early discharges associated with such severe 

financial and home problems that sending the 

neonate home soon after birth may be harmful? 

For the west European countries, the average 

period of confinement for mothers whose infants 

are delivered in hospirals is generally longer 

than for the United States: 

England and Wales-- 10 days 

Netherlands 10-12 days 

Scotland 9 days 

United States 4 days 

In the European countries listed above, because 

of national policy and patterns of maternity care, 

hospital deliveries consist of higher proportions 

of complicated deliveries and high-risk groups 

than in the United States. For example, national 

policy in Great Britain stipulates that mothers 

who experienced complications in previous pregnancies constitute one among several high-risk 

groups which are eligible for hospital benefits 

under the National Health Service. In the Netherlands, under the provisions of sick funds, families are not reimbursed for ‘hospital care for 

normal deliveries. Hospital deliveries in that 

country consist of complicated pregnancies, cases 

of difficult labor or other obstetrical problems, 

and normal deliveries among those willing to pay 

their own hospital costs. Under these circumstances, the period of confinement would be expected to k longer in these countries than in the 

United States where normal deliveries far outnumber complicated deliveries in hospitals. 

At fendant 

Since over 97 percent of live births and 94 

percent of registered fetal deaths are delivered 

in hospitals in the United States, it may be assumed that a physician was in attendance at the 

majority of these. The term “physician” as used 

here is intended to include obstetrician, general 

practitioner, or resident. In view of the relatively 

few nurse-midwives in this country, they cannot 

have a significant impact on the large number of 

deliveries. 

In England and Wales, the woman generally 

consults a general practitioner when she suspects 

she is pregnant. It is then decided whether she 

will have her baby at a hospital, a General Practitioner Unit, or at home, and whether her prenatal and delivery care will be under a physician 

or midwife. ss General Practitioner Units are 

small maternity units, usually having fewer than 

25 beds and staffed by midwives, to which one 

or more physicians send their patients for delivery. Data from the British Perinatal Study 

show that a midwife was the senior person present at the actual delivery of about 70 percent of 

births whether the births occurred in hospitals, 

in General Practitioner Units, or at home. 5 

In the Netherlands, although only 30 percent 

of live births are delivered in hospitals, about 

60 percent of all births are attended by physicians 

(general practitioners or obstetricians). It is 

obvious from these proportions that a significant 

portion of home deliveries are attended by physicians. For normal pregnancies or deliveries, 

78 
insurance benefits are available for the service 

of a midwife, or for a physician if no midwife 

is practicing in the area. However, forcomplicated pregnancies or difficult deliveries, physicians’ services are approved. 

In Norway, although 96 percent of births occur in hospitals and maternity wards, as a rule 

they are attended by midwives. However, in hospitals, physicians are available for difficult or 

complicated deliveries. 

The relationship of factors of hospital delivery, period of hospital confinement, and attendant at birth to fetal mortality and mortality 

during the first weeks of life is not entirely 

clear, Some countries with lower mortality than 

the United States have higher proportions of 

births occurring outside hospitals, and these 

births are attended by persons other than physicians. Although the periods of confinement are 

longer than in the United States, it cannot be 

immediately concluded that this factor is responsible for the lower rates because deliveries 

in hospitals in these other countries consist of 

higher concentrations of difficult cases. 

Postnatal Care 

In the Netherlands, in addition to nurse-midwives, there is another group of young women 

called “Maternity Home Helpers” who play apart 

in postnatal care. These young women receive 

15 months of training in the care of the mother 

and/or her child, cooking, washing, and other 

household duties. Their training also includes 

care of older children ‘and basic elements of 

obstetrics and newborn pathology. 10 These helpers serve for 10 hours a day for 10 days. Onehalf of the home deliveries, or about 35 percent 

of all births, have Maternity Home Helpers. 

With regard to infants, about 74 percent attend 

infant welfare centers. The first visit is generally between 3 and 8 weeks of age and an average of 10-11 visits are made in the first year. 

These are comparable to the “well baby clinics” of 

the United States in that they offer examinations of 

healthy infants, including vaccinations, and nutritional advice to the mother, but no treatment. 

In England and Wales, the British Central 

Midwives’ Board considers the lying-in period 

to be at least 10 days. In cases of home delivery, the midwife is responsible for providing 

care for that period. For women who are del 

livered in hospitals and who return home before 

the 10th day, home care by a midwife is provided 

up to 10 days after delivery. In 1960, 22 percent 

of babies went home on the seventh day or earlier, 

and these early discharges are increasing. 71 

Home help for household services is available for 

a fee. 

In Denmark, nine free examinations of children are provided. ST These are ac 5 weeks, 5, 

10, and 15 months, and annually for the following 

5 years. At these visits, immunizations are 

scheduled. These include protection against 

smallpox, diphtheria, tetanus, poliomyelitis, and 

pertussis. In addition to these services, public 

health nurses make home visits 10 times during 

the first year, but only one-third of Denmark is 

covered by such service. 

In the United States, although almost all 

births occur in hospitals, the average hospital 

stay is relatively short—about 4 days. When the 

new mother returns home, her care is largely 

an individual matter. For a fairly large proportion, although the exact magnitude is unknown, 

the assistance of some family member or friend 

is obtained for a short period immediately following discharge from the hospital. In some 

areas, a public health nurse tries to visit the 

home to determine whether special care is needed, 

to provide health information, and to demonstrate 

techniques of infant care. However, becatfse of 

increased demands on their time, such visits are 

generally on a selective basis, e.g., primiparae, 

complicated deliveries, congenitally malformed 

infants, prematurely born infants. These are 

State or local programs and, consequently, practice across the United States is not uniform. 

Postnatal care of the infant is provided by a family physician, a pediatrician, or a government 

or hospital clinic. 

OBSTETRIC PRACTICE 

The statement is sometimes made that obstetric care in the European countries is more 

“conservative” than in the United States. Is there 

any statistical evidence to support such a statement? The basic problems in considering this 

question are comparability of information and 

79 
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----------

--

uniformity of definitions from one country to 

another. Only a few characteristics can be assumed to have standard meanings for the several 

countries. Among these are cesarean section, 

use of forceps, episiotomy, and the administration of anesthetics, each of which is an overt 

act’associated” with delivery. 

Cesarean Section 

In the British Perinatal Study, 2.7 percent 

of single deliveries were by cesarean section. ~ 

In the Netherlands, an estimated 1.25 percent of 

all deliveries in 1958 were by cesarean section. 10 

Several estimates are available for States of the 

United States, and groups of hospitals. Based on 

birth records for single. live births in Upstate 

New York for 1964, 4.4 percent were by cesarean 

section .72 Similar data for Kansas in 1962 yielded 

a rate of 3.3 percent for single live births as 

well as all live births; the rate increased to 3.4 

percent when fetal deaths were included. 73 

Following are data from several of the cooperative statistical studies. 

Collaborative project, 1959-Nov. 

196474 

Professional Activity 

Study, 196275 

I?erinatal Study, 

1961 -6466 -----------

Obstetrical Statistical 

Cooperative, 196276 --

White 

Nonwhite 

‘Single deliveries only. 

Number Pevcent 

of cesarean 

deliveries section 

‘16,954 4.2 

142,437 4.3 

659,001 4.6 

59,884 5.7 

42,840 5.8 

17,044 5.2 

All of these estimates exceed those for England 

and Wales and the Netherlands. 

The data for England and Wales are based 

on single births occurring during one week 

(March 3-9, 1958). The three statistical cooperatives and NINDB’s Collaborative Project are 

based exclusively on hospital populations and lack 

information relating to deliveries outside hospitals, an omission which probably is not serious 

in connection with cesarean sections. The data 

for Kansas and Upstate New York are based on 

vital records. From special studies conducted in 

New York, it was found that the reporting of 

cesarean sections on birth records is about 95 

percent complete. Thus the estimated rate of 

cesarean sections in Upstate New York would increase from 4.4 to 4.6 percent for single live 

births. Based on these data, it seems that cesarean 

sections are conducted more frequently in the 

United States. In order for the British rate of 

2.7 percent for single deliveries to reach 4.0 

percent (a compromise among the three United 

States estimates), the number of cesarean sections 

among plural deliveries in Britain would have to 

exceed the number of plural births. 

Breech extractions were reported for 2.2 

percent of single births in England and Wales, 5 

1.4 percent of deliveries in 152 hospitals in the 

United States in 1961,7s and 2.1 percent of single 

deliveries in 39 U.S. hospitals in 1964.77 TO 

some extent, lower rates of breech extractions 

in the United States may be offset by higher rates 

of cesarean sections. For, with higher proportions 

of hospital deliveries and closer availability of 

obstetric care in hospitals, operative procedures 

would probably be used more readily in the United 

States. 

Forceps 

According to a report from England and 

Wales, “II-Igeneral, forceps are not used in this 

country except in the presence of a specific indication for assisted delivery. ” 58 The British 

Perinatal Study indicated that forceps were used 

in 4.7 percent of deliveries, but failed to further 

subdivide the type of forceps used. 5 

Based on a Professional Activity Study of 

142,437 deliveries in 1961 at 152 hospitals in the 

United States, 75 the proportions were: 

Pevcent of Range 

deliveries among hospitals 

Low forceps- - 33.7 19.8 -37.3 

Midforceps- 0.9 0.3-1.0 

High forceps - 0.03 0.02-0.06 

80 
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---

The use of low forceps appears much more common in the United States. A larger PAS series of 

325,812 delivery patients discharged in 1963 

yielded arateof 35.4 percent for deliveries with 

low forceps .78 

Among the other cooperative statistical systems, the overall rates of forceps deliveries 

were of similar magnitude: 

Pevcent 

Collaborative Project, 1959-

Apr. 196274 #37.2 

Perinatal Study, 1961-64 G6------ 36.2 

Obstetrical Statistical Cooperative, 196276 34.2 

White ----- 37.9 

Nonwhite 24.8 

#single deliveries only. 

The reporting of this item on vital records is 

not sufficiently complete to be useful. 

Episiotomy 

The British Perinatal Study reported that 

episiotomy was performed in about 16.Opercent 

of deliveries (41.2 percent of hospital deliveries, 

11.3 percent of home deliveries). In Great Britain, 

a midwife ispermitted to perform anepisiotomy, 

but its repair requires the services of aphysician, 

For the United States, the rates apparently 

are considerably higher. A study of 325,812 delivery patients dischargedin 1963 from hospitals 

contributing information to the Commission on 

Professional and Hospital Activities showed that 

67.4 percent of them hadreportedepisiotomies, 

and this item is not felt to be completely reported.7g More specifically: 

Number Pevcent 

. Episiotomy without low 

forceps 113,944 35.0 

Delivery by low forceps 

with episiotomy 105,571 32.4 

Delivery by low forceps 

without episiotomy--- 9,668 3.0 

The Obstetrical Statistical Cooperative yielded 

reported rates of 65.0 percent: 71.3 percent for 

white patients and 49.4 percent for nonwhite 

patients. 76 

Analgesia and Anesthetics 

Analgesics and volatile anesthetics are rather 

widely used in Great Britain and the United 

States, but less in the Netherlands. In the PAS 

study of 211 hospitals in the United States, 82.7 

percent of patients discharged from materni~ 

services used some form of anesthetic. The 

most common form was inhalation anesthetic 

which was used in more than half of all deliveries 

requiring anesthesia. 80 According to the Collaborative Project, 82.9 percent of 17,244 single 

birth records which were processed between 

January 1959 and November 1964 reported the 

use of some form of anesthetic-gaseous, intravenous, or conduction .74 

In the British Perinatal Study, 78.6 percent 

used some form of volatile anesthetic, and 24.6 

percent used at least one of a specified list of 

analgesics. 5 The presentation of the British data 

precludes elimination of any overlap between the 

groups receiving anesthetics and analgesics. 

However, the most striking difference is the 

selfadministration of inhalation analgesia (primarily nitrous oxide and air) reported in the 

Perinatal Study. Under existing practice, this is 

permitted in home deliveries with midwives in 

attendance. 

In the Netherlands, “analgesia is hardly practiced and not preferred by mothers. ” 10 

DISCUSSION 

Judgmental decisions of the value of these 

various obstetric techniques require studied investigation of comparable information. It is clear 

that differences in obstetric practice do exist, 

but it is not always clear that practice reflects 

the best scientific thinking. In part, practice may 

reflect tradition such as a preference for delivery at home in the Netherlands, or use of 

anesthetics in Great Britain or the United States. 

In part, practice may reflect a compromise with 

existing situations such as the gradual reduction 

in the length of hospital stay for maternity pa81 
tients in the United States. Or, practice may 

reflect an inertia which accompanies the initiation of new ideas in any nation. Assuming the 

necessary financial and personnel resources, the 

relative merits of various patterns of medical and 

obstetric care are amenable to investigation on 

an international scale. 

The relative effect of socioeconomic and medical factors is also amenable to further investigation. While reported studies from a number of 

countries leave no doubt that differentials in infant mortality exist in relation to socioeconomic 

differentials, it is also true that for individual 

infants identified developmental or obstetric conditions increase the risk of death to an even 

greater degree: the twin pregnancy, the low 

birth weight baby, the malformed fetus present 

hazards which exceed those associated with 

socioeconomic differentials. 

In the past two decades, attempts to reduce 

the socioeconomic differentials have been approached in an organized fashion in some countries. In the west European countries, social insurance was felt to answer many of the health 

problems associated with socioeconomic differentials. Nevertheless, in England and Wales, it has 

been recognized that after almost two decades of 

universal medical care, the socioeconomic differentials in infant mortality have not been eliminated. 

In addition to socioeconomic factors, medical 

care, and obstetric practices, another hypothesis 

which has been proposed to explain some of the 

differences in infant mortality between the United 

States and the west European countries relates to 

heredity. It has been hypothesized that the populations of west European countries are largely 

homogeneous populations and, except for the periods of war and invasion, have not been affected 

to any great extent by immigration. The population of the United States, on the other hand, is 

described as a heterogeneous, multiracial, multiethnic population. While this is generally true, 

~, 

there remain a few clusters of descendants of 

homogeneous immigrant populations in the United 

States. The northern States of the Great Plains 

have concentrations of Scandinavian immigrants. 

Counties with high proportions of individuals 

of Scandinavian origin in Minnesota and North 

Dakota show more favorable birth weight distributions than counties with low proportions 

of individuals of Scandinavian origin. 18 The relationship is associative, having been derived 

from census and vital statistics data. It is, 

therefore, impossible to take other factors into account. Nevertheless, in other forms of 

animal life, selective breeding is used to generate 

desired characteristics in the offspring.17 Among 

breeds of cattle, gestation length is said to 

be inherited. Is it possible that through many 

generations of low immigration to some west 

European countries, certain genetic characteristics have become concentrated? Could length 

of gestation or birth weight represent such 

inherited characteristics? It has been demonstrated from U.S. data that recurrent losses are 

concentrated in a small group of women, 30) 38 

but not enough research has been completed to 

decide whether these are the result of inherited 

characteristics or other factors. Before such 

questions can be approached, it will be necessary 

to determine whether or not there are significant 

differences ;n the gestation or birth weight of 

infants in the’ countries concerned. Although birth 

weight and gestation are but two of the variables 

of interest, they are prime determinants of infant survival. Their effect extends beyond the 

neonatal period into the whole first year of life. 

Answers to these questions will not be found 

through comparison of disconnected studies with 

varying study designs. Although a few comparisons 

may be possible fortuitously, they lack the assurance which is to be derived from a well-designed study planned to give answers to specific 

questions. 

82 
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---------------------

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

VIII. POSSIBLE AREAS OF INVESTIGATION 

The future course of infant mortality in the 

United States, as in the west European countries, 

remains to be unfolded. Commendable as advances during the first half of the 20th century 

were, they are part of the past. More realistic 

guides to future trends should be based on more 

recent experience. By 1950, the adverse effects of 

World War II were subsiding, and the 13-year 

period of observation (1950-62) provides a suitable base for fitting trend lines. Events such as 

war, epidemics, and major therapeutic or preventive advances cannot be predicted and are 

omitted from consideration here. 

If the rates of decline which were experienced 

during the period 1950-62 continue, 10 years hence 

the infant mortality rates for the countries considered in this report would be: 

Denmark 13.0 

England and Wales 14.0 

Netherlands 9.4 

Norway 11.1 

Scotland 16.5 

Sweden 10.7 

United States 22.0 

White 18.5 

Nonwhite 38.6 

By 1975, therate forthe United States would exteed those of all of the other countries-in fact, 

the rate for the white infants alone would exceed 

those of all of the other countries (fig. 16). 

Furthermore, the rate for the white infants would 

be about double that of the Netherlands and would 

not yet have declined to the 1960 level of the 

rates for the Netherlands, Norway, or Sweden. 

Independent estimates of the future course 

of infant mortality in the Netherlands indicate that 

by 1970 the rate may approach il-13 per 1,000, 

and by 1975 it may drop below 10 per 1,000.10 The 

authors conclude that cutting the infant mortality 

in half between 1950 and 1970 is “not optimistic 

or pessimistic, but realistic. ” For the United 

States, Shapiro and others believe a rate of 20.0 

is a realistic goaL 39 

Although the arithmetic differences between 

the projected rates may not appear large, the 

number of infant deaths in the United States represented by these differences is imposing. The 

difference between the actual number of infant 

deaths in the United States and those expected to 

occur if this country experienced the current 

mortality rate of the Netherlands or Sweden 

represents about 40,000 infants annually. 

PROMINENT CAUSE GROUPS 

Remedies, however, are even more elusive. 

than the facts. The assumption of a constant rate 

of decline implies that the net effect of gains and 

losses in the next 10 years will be such that the 

net rate of decrease will be the same as in the 

period 1950-62. To accelerate this rate of decline in the overall infant mortality rates, major 

breakthroughs will be needed in medical research. 

For example, while postnatal asphyxia and atelectasis are significant contributors to infant mortality, progress in the identification of causative 

mechanisms has been slow. For this group, 

actual agents have not yet been identified. The 

association with prematurity has been observed 

but the terms used to describe causes of death 

are often symptoms rather than causes. There 

may be a number of causative agents involved 

and consequently future progress in this area 

may continue to be slow. 

A second large segment of infant deaths is 

ascribed to immaturity for lack of additional 

diagnostic information. For these, additional 

information about conditions associated with an 

immature fetus or premature birth would be important to a better understanding of the problem. 

Improved medical certification or verification of 

the absence of additional diagnostic information, and study of family situations (e.g., nutrition, family size expectations) may shed further 

light on the subject. 

A third major segment of infant mortality is 

associated with congenital malformations. Already, a number of diverse agents have been 

implicated infectious diseases, drugs, and radiation. Others are yet to be identified. The problem 

of gene mutation and the prevention of undesirable 

83 
------

Fitted Trend Projected Trend 

50 

45 

40 

35 

30 

25 

20 

I 

1 

,... 

. ..... 

““.... ..... 

“%. ...+O. 

. . . . . . 

~ 

— 

1970 1975 1965 ..- YEAR 

Figure 16. Fitted and projected infant mortality trends: selected countries, 1950-75. 

mutations need clarification. The multicausal 

nature of congenital malformations precludes 

rapid advances. 

With regard to environmental causes (including infectious diseases) more than oneapproachmust reconsidered. The lackoftherapeutics for certain viruses and the developmentof 

microbial strains resistant to antibiotics pose 

clinical problems and may requirenew drugs for 

clinical use. Other environmental causes suchas 

water, food, housing, and crowded conditions require different approaches: alleviationofpoverty, 

health education ,publichousing— allmajorundertakings already in process of development. Only 

time will reveal the benefitsto infants whichmay 

accrue from special programs of the Federal 

Government such as the Maternity andInfantCare 

Programs and other less directprograms suchas 

those of the Office of Economic Oppxtunity. 

Among accidents ,continuedclinical andepidemiologic investigation of crib deaths may produce 

etiologic leads. 

84 

I 
LOW	 BIRTH WEIGHT AND 

PREMATURITY 

In addition to pathology, low birth weight 

and premature birth are prominent hazards 

facing the fetus and newborn infant. Although, 

in this report, no single factor was demonstrated 

to account for the entire difference between the 

United States and countries of low infant mortality such as the Netherlands or Sweden, the 

hypothesis that the estimated differences in 

birth weight distributions could account for most 

of the differences in neonatal mortality was tenable. This hypothesis is in need of verification or 

refutation. 

With the amount of raw data on birth weight 

already available on vital records in the United 

States, this variable is a candidate for prompt 

investigation. Two aspects, the incidence of low 

birth weight and the relationship of mortality to 

birth weight, are amenable to early study through 

record linkage. Studies related to gestation are 

presently less promising because of the gross 

misreporting of gestation on vital records. Considerable improvement may be expected in time 

if the item “weeks of gestation” on the vital 

records is replaced by “first day, last normal 

menses,” Continued surveillance of the incidence 

of low birth weight and premature deliveries 

will be needed to establish whether or not they 

are increasing in this country. 

In comparison with the other countries, the 

incidence of low birth weight infants in the United 

States seems high. Some of these countries (e.g., 

Denmark and Sweden) are currently gathering 

,.	 birth weight information, but relatively little 

published information is available. It would be 

helpful to have data for countries like Norway 

and Sweden where large proportions of infants 

are born m hospitals or maternity units. The 

quality of information which could be obtained 

in other countries like the Netherlands is 

less promising because of the large number 

of home deliveries and questionable reliability 

of the raw data. Information on both the 

incidence of low birth weight infants and 

mortality associated with birth weight in 

countries with low infant mortality would 

help clarify the question of whether higher 

proportions of poor-risk fetuses are born 

alive in the United States because the risk of 

prenatal death has been reduced. 

MEDICAL AND OBSTETRIC CARE 

Possible studies of the Nation’s status with 

regard to medical and obstetric care are more 

remote in time. The development of medical 

demography in the United States to obtain basic 

population characteristics such as those of the 

perinatal study in Great Britain would bring into 

focus certain characteristics which are presently 

estimated from biased groups or surmised. On 

an international basis, it would help to evaluate 

the benefits to be derived from prenatal care, 

home or hospital delivery, specific obstetric 

procedures, or short or prolonged hospital stay, 

At the Center’s Conference on the Perinatal and 

Infant Mortality Problem of the United States, 

numerous other questions were raised concerning 

the effects of analgesia, drugs, induced labor, and 

resuscitation practices on the condition of the 

neonate. 17 The lack of such information for the 

United States was emphasized. 

REGISTRATION 

While the registration of live births is 

relatively complete in the United States, the 

registration of fetal deaths is not. It is generally 

accepted in medical circles that when all periods 

of gestation are included, fetal deaths outnumber 

infant deaths. If all fetal deaths of 20 or more 

weeks of gestation were registered, they alone 

would probably almost equal infant deaths. Promotion of complete registration of fetal deaths 

in accordance with legal requirements could be 

undertaken without establishing any new record 

systems. Although the registration of infant 

deaths is felt to be more complete than the 

registration of fetal deaths, there have been no 

tests of their registration completeness comparable to those for live births. 

In addition, certain items on live birtb and 

fetal and infant death records are deficient. A 

concerted effort to improve the information 

on these records with regard to three items 

(i.e., birth weight, gestation, and causes of death) 

would greatly improve the utility of vital records 

in the next decade. 

85 
International comparisons of definitions, 

registration methods, anddiagnostic terms would 

greatly assist the interpretation of statistics presented in this report. Documentation of the 

practices used by physicians in applying thedefinitions of live birth and fetal death in the process 

of registration would be valuable in assessing the 

relationship between fetal and first-day mortality. 

As infant mortality declines, these technical aspects surrounding birth assume increasing importance. However, even without such studies, 

available data for the United States point to certain subclasses of infants, such as those of low 

birth weight, which experience excess mortality. 

More intensive study of these groups is needed to 

stimulate inquiry, to identify problems, and to 

promote knowledge. 

CONCLUSION 

Despite the vast numbers of studies which 

have been conducted, it is disquieting to realize 

how little is known concerning the reasons for the 

change in trend in infant mortality in this country 

since 1950. Equally perplexing are the reasons for 

similar changes occurring in the west European 

countries, although some are at significantly 

lower levels. Some investigators believe that the 

basic reason for decelerating rates of change may 

be identical in all of these countries. Despite this, 

the infant deaths represented by the differentials 

between this country and the other countries of 

lower mortality should be preventable in the 

United States as well. 

86 
Vlll. SUMMARY AND CONCLUSION

Infant mortality in the United States is lower 

than it has ever been: 24.8 per 1,000 live births 

in 1964. Although this is a major accomplishment, 

the rates appear to have leveled off since about 

1950; the rate of decline since 1950 has been 

slower than during the first half of the century. 

As a result, a number of other countries which 

had rates higher than the United States in the early 

part of the 20th century tcday have rates which 

are lower. Although the infant mortality trend of 

the United States has been declining in comparison 

with the other countries included in this study, it 

has been gradually losing ground. According to the 

Statistical Office of the United Nations, in 1964 its 

infant mortality rate was the highest among the 

seven countries included in this report. 

The failure of this country to keep pace with 

the rate of decline of others prompted this study 

of the experience of seven countries: Denmark, 

England and Wales, the Netherlands, Norway, 

Scotland, Sweden, and the United States. In climate, 

age composition of the population, level of industrialization, medical education, personal and 

environmental health, they constitute a fairly 

homogeneous group. Comparison of the experience 

of the United States with such a group of countries 

increases the opportunities for sharper comparisons. 

In analyzing the problem of infant mortality, 

the basic measures are drawn from vital statistics. Each of the selected countries included in 

this report has a well-established vital registration system, antedating the national coverage of 

birth and death statistics for the United States. Although there are variations in definitions, registration practices, and statistical procedures, as 

far as could be determined these differences are 

not large enough to alter the general relationship 

between infant mortality in the United States and 

the countries concerned. 

A number of highlights emerged from the 

study. In spite of the decelerating decline in the 

United States, gains were achieved in fetal and 

infant mortality in the United States after 1950. 

However, these were not uniformly distributed 

over all age groups. For example, fetal mortality 

and mortality at 1-6 days of age decreased21 and 

17 percent, respectively, between 1949-51 and 

1959-61. In contrast, mortality in the intervening 

interval, the first 24 hours after birth, increased 

2 percent. Thus, while declines were occurring in 

the period before birth, and the last 6 days of the 

first week of life, there was an increased risk of 

death in the period immediately following birth. 

Since over 97 percent of live births occur in 

hospitals or other institutions, a high proportion 

of these deaths in the first 24 hours of life may be 

assumed to have been born in hospitals or other 

institutions. Thus, the focus of attention is drawn 

toward this vulnerable age period (the first 24 

hours of life), and toward these locations (hospitals and other institutions). Since these observations are based on data for the United States alone, 

they are not affected by international differences. 

When the trends by age are compared with 

those of other countries, it appears that the United 

States generally has the lowest rates in the fetal 

period and highest rates in the period just after 

birth. These observations may be somewhat 

clouded by variations in the application of definitions of fetal death and live birth, but when fetal 

mortality and mortality in the first 24 hours of life 

are combined, the mortality rate for the United 

States continues to be relatively high. Thus, in 

comparison with other countries, attention is again 

focused on the period immediately surrounding 

birth. 

In considering causes of death, significance 

can be attached only to broad groups. Each of these 

countries classifies deaths according to the International Statistical Classification of Diseases, Injuries, and Causes of Death. Nevertheless, it is 

recognized that patterns of medical certification, 

coding,and tabulation can affect the resulting statistics. A number of cause groups contribute to the 

changing relationship between the United States 

and the other six countries. The increasing trends 

in neonatal mortality for postnatal asphyxia and 

atelectasis and the cause group which includes 

hyaline membrane disease and respiratory dis87 
tress syndrome appear to be diametrically opposite when the United States is compared with other 

countries. These groups should be considered together since there is variation in the way the condition is certified on death certificates: some physicians prefer the term “postnatal asphyxia, ” 

while others prefer the term “respiratory distress 

syndrome.” Mortality allocated to immaturity 

without further qualification is also high for the 

United States and is related to the cause previously 

mentioned. In the postneonatal period (1-11 months 

of age), mortality is lower than that observed in 

the neonatal period and environmental causes generally predominate, In the postneonatal period, 

mortality from respiratory and digestive diseases 

is also notably high in this country in comparison 

with the other countries. 

A number of demographic factors were examined to assess their possible statistical effects 

on the infant mortality rates. It appears that factors such as age of mother and the infant’s birth 

order have relatively little effect in explaining the 

difference between the United States and countries 

of low mortality, such as the Netherlands or 

Sweden. Of the factors considered, only birth 

weight is felt to have sufficient effect on the rate 

to suggest it as a possible hypothesis for future 

investigation. The effe~s caused by apparent 

differences in the incidence of low birth weight 

infants are of such a magnitude that it is possible 

that they could account for a considerable proportion of the difference between the United States 

and countries of low infant mortality. Available 

data suggest that the United States has a higher 

proportion of low birth weight infants and that these 

proportions have been slowly increasing. This observation is consistent with the increasing death 

rates within 24 hours of birth and increasing rates 

for causes known to be associated with immaturity 

or prematurity, e.g., postnatal asphyxia and atelectasis, hyaline membrane disease, and respiratory distress syndrome. 

The relationships of infant mortality to medical care and obstetric factors are less clear-cut, 

The general philosophy concerning maternal and 

child care is similar in many respects in all of ‘ 

these countries: early and continued prenatal care, 

referral of complicated pregnancies to medically 

competent physicians or to hospitals, hospital 

delivery for all complicated pregnancies and bighrisk groups, and postnatal supervision of mother 

and infant. However, there is a contrast between 

the United States and the west European countries 

in the financing and administration of medical 

care. Because of their social insurance systems, 

medical care in these west European countries has 

been spread to their lower socioeconomic groups 

which could not otherwise afford it. Tnthe United 

States, the major proportion of medical care associated with childbirth is privately financed. 

In spite of the widespread availability of medical care, proportionally fewer births are delivered 

in hospitals or other institutions in some of these 

west European countries than in the United States. 

Yet at least one of them, the Netherlands, is experiencing low infant mortality rates, despite the 

low rate of hospital deliveries. Similarly, relatively more infants are delivered by physicians in 

the United States. By this criterion, the United 

States has an advantage, but this variable is”not 

inversely related to the level of the infant mortality 

rates. As for hospital stay, the average stay is 

shorter among mothers hospitalized for deliver y 

in the United States, but this observation is difficult 

to interpret because these patients include many 

with uncomplicated deliveries who may not need 

extended hospital stays. Although there are also 

suggestions of differences in obstetric practices 

between the United States and some of these west 

European countries, the unavailability of adequate 

data precludes any conclusions but emphasizes the 

need for quantitative information relating to these 

factors. 

In times of dynamic change, for the United 

States to maintain its present level of perinatal 

and infant mortality is to lose ground in comparison with other countries of similar economic 

and medical development. In the light of present 

knowledge, perinatal and infant mortality cannot 

be eliminated completely, but the attainable levels 

seem to be somewhat lower than those presently 

achieved in the United States. There is a need to 

determine whether the levels achieved elsewhere 

are realistic for this country and whether the 

resources which are needed to achieve these goals 

are available. Although the infant mortality in this 

country is the lowest it has ever been, the estimated excess loss of 40,000 infants annually 

suggests there may be room for improvement. 

88 
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32Y6rushalmy, J., and Sheerer, S. E.: Studies on twins, 

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33Yerushalmy, J.: Age of father and survival of offspring. 

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37California Department of Public Health: Perinutal Mortatity and Survival, Califwnia, 19&9-1959, rev. Berkeley, 1963. 

38New York State Departrnentof Health: The Relationship 

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Part II. Father’s occupation, infant’s birthweight, ad 

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PartIII. Previoue loss (1963) 

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1965. 

40 Children’e Bureau: T?ends in Infant and Childhood Mortality, 1961, by E. P. Hunt and S. M. Goldetein. Welfare Admini etration. Washington, D. C., 1964. 

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Oct. 1950. 

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Health. Tech. Rep.Ser. Wld Htth Org., No. 217. Geneva, 1961. 

43Taback, M,: Birth weight and length of gestation with 

relation to prematurity. J. A.M.A. 146(10):897-901, J UIY 7, 

1951. 

44Schlesinger, E. R., and Allaway, N. C.: The combined 

effect of birth weight end length of gestation on neonatal mortality among eingle premature births. Pedidtics 15(6):698-

704, June 1955. 

45Erhnrdt, C. L., et al.: Influence of weight and gestation 

on perinatal and neonatal mortality by ethnic group., Am .J. 

Pub.Health 54(1. L):1841-1855,Nov. 1964. 

46 Rose, R. J.: Infant and Foetal Lees in New Zealand. 

New Zealand Depsrtmentof Health Speoial Report No. 17. Oct. 

1964. 

47New Zealand Depsrtmentof Statistic: Unpublished data. 

48Yerushalmy, J., et 02.: Birth weight and gestation as indices of “immaturity’’--neonatal end congenital rmomalies of 

the “immature.” Am.J.Di.s .Chitd. 109(1):43-57, Jan. 1965. 

49$jhaPiro, $jC,Ross, L*J., and Levine, H. S.: Relationship 

of selected prenatal factors to pregnancy outcome and congenital anomalies. Am. J. Pub. HeaZth 55(2):268-282, Feb. 1965. 

~OBaird, D.: preventive ~~cine in Obst,etrice. New EngZand J. Med. 246(15):561-568, Apr. 10, 1952. 

~lchase, H: C.: The current status of fetal death regisWation in the United States. Am.J. Pub. Health 56(10):1734-1744, 

Oct. 1966. 

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 of the cOIIUUif,teeS 

on vital and health statistics or their equivalen~ during 1964. 

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53fjutherland, I.: Stillbirths, Their Epidemiology and SOciaz Significance. London. Oxford University Press, 1949. 

54Ruts@in, D+: Why do we let these babies die? Reader’s 

Digeet 85:56-60, Aug. 1964. 

55National cen~r for Health Sbtistice: Infant and perinatal mortality in England and Wales, by K. M. Hirst, N. R. But-1 

ler, and M. J. R. Dawkine. VitaZ and Health Statistics. Seriee 3. 

public Health Service. Washington, D.C. In prepSrQtion. 

56 Children$s Bureau: The Practice of Nurse-Midwifery in 

the United States. Children’s Bureau Pub. No. 436. Department of Health, Education, and Welfare. Washington. U.S. 

Government Printing Office, 1965. 

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and B. Zachau.Christianson. Vital and Health Statistics. 

Series 3. Public Health Service. Washington, D.C. In preparation. 

58 Dawkins, M. J. R.: Obstetric aspects of perinatal mortality. Unpublished manuscript. 1965. 

59Schwart~, S.; Perinatal care, prematurity, and neonatal 

mortality. Am. J. Obst. & Gynec. 83(5):591-598, Mar. 1, 1962. 

60MontgomeV, T. A., H~mersly, M., and Lewis, A.: Perinatal mortality and eurvival, part 11, Compari sone between population groups in 1959. Calif.’s Hlth, Vol. 21, No. 9, Nov. 1, 

1963. 

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Iowa State Department of Health. Des Moine~, Iowa. 

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Health, 1960-61. ‘lTopeka, Kans. 

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Statistics Summary, 1963. Washington, D.C. 

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disorders of the brain and nervous system. Resemch Profile 

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Education, and Welfare. Washington. U.S. Government Printing Office, 1965. 

65Kohl, S. G.: Personal communication. 

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PAS hospitals. The Record, VOL 1, No. 11, Apr. 15, 1963. 

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90 
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3. Public Health Service. Washington. U.S. Government Printing Office, July 1963. 

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6, Sept. 25, 19.64. 

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Chief Medicsl Officer to Ministry of Health, 1963. 

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73Kansas State Department of Health: Unpublished data. 

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75Commission on Professional and Hospital Activities: 

Delivery procedures. The Record, VOL 1, No. 15, Oct. 1, 

1963. 

760 bstetrical Statistical Cooperative: 1962 combined report. Downstate Medical Center, Brooklyn, N.Y. I 

77 Commission on Professional and Hospital Activities: 

1964 MAP perinatal study. Dec. 27, 1965. 

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The fifty most frequentoperations, 1963. The Record, Vol. 3, 

No. 2, July 2, 1965. 

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Unpublished data. 

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U.S. Government Printing Office, 1964. 

000 

91 
APPENDIX. MEDICAL CARE 

DENMARK 

Datea of Basic Laws and Types 

of Programs I Coverage 

SICKNESS AND MATERNITY 

First law: 1S92. 

Current law: 1960. 

Semi-voluntary social insurance 

system (cash and medical 

benefits) 

(1 crown equals 14.5 U.S. cents) 

FAMILY ALLOWANCES 

First and cm-rent law: 1952. 

Universal public system 

SICKNESS AND MATERNITY 

First law 1913. 

Current laws: 1929 (cash benefits) and 1941 (medical benefits). 

Social ineumn ce system (separate but interlocking g programs of cash and med]cal 

benefits) 

(1 guilder equals 27.6 U.S. 

cents) 

FAMILY ALLOWANCES 

Fkst laws: 1939 (employees) 

and 1951 (eelf-employed). 

Current laws: 1962 

Dual employment-related and 

general systems 

Medical benefits: All regidents may 

voluntarily become active member 

of local sickness fund (children 

under 16 covered by parent’s membership). Residents not active 

members must become passive 

Tembers of fund and pay 24 crewm 

a year, but receive no benefits. 

Cash benefits: All employees who are active members of fund compulsorily covered for cash benefits 

Other active members under age 45 

may insure for such benefits voluntarily. 

Special system for railread employees. 

Residents with 1 or more children. 

Snurce of Funds 

Insured person: Abeut 100 crowns 

a year, on average (varies according to fund and cash benefit rate 

for which insured); cnvers abrmt 

70% of cost. 

Employer: 3 ore per employee-hour. 

Govemmenti Subsidies to sioknew 

funds by national and local goverr ments. Include 5 omwns a year 

per active membe~ 25% of cost of 

medical treatment, dental cs~e, 

borne nursing and cash benef]ts; 

over 90% of cost in public hospital; 75% of extra cost of cbromc 

car% and full cost of vital medicines such as insulin, cash mater nity benefits, transport, and contribution of needy members. 

Insured person: None. 

Employer: None. 

Government Whole’cost. 

Qualifying Conditions 

‘ash sickness and maternity 

benefits: Active membership 

in sickness fund (passive member may become active member 

and qualify for benefits after 6 

months); and 40 hours of employment in Iaet 4 weeks (nmremployee 3 months of insurance 

for such benefits). 

ledical benefits: Active membership in sickness fund (passive 

member mav become active 

member and qualify for benefits after 6 months). 

~amily allowances: Child must be under age 16. 

fickness and maternity benefits: 

Membership in approved sick­ ness fund (i.e., in covered 

employment or voluntary member~ no minimum contribution 

peried. 

%.rnilyallowances: Child must 

be under age 16 (27 if student 

or invalid). 

kdf-employed must earn less 

than 4,000 guilders a year to 

receive allowances for 1st and 

2nd child. Non-employed receive allowances only fmm 3rd 

child. 

NETHERLANDS 

Employees earning notmoretban 

10,9~Oguilders a year. Must enmll maproved sickness fund. 

Voluntary coverage for medical 

benefits available to other persons and pensioners, if annual 

income below specified levels. 

i@ecial systems for miners, railroad employees, public employeeg, 

seamen, and certain other groups. 

lmployees, self-emplo ed persons 

of limited income, anr! sociel insursnce beneficiaries, with lor more childreq and all other residents with 3 or more children. 

Insured psrsnn: 3.4%of earnings. 

Pensionera, 5.5or11guilders a 

mcntb, according tomantal status 

Employe~ Fmm about 3% to 9% of 

payroll, according to risk in industry. 

Government None, exce@ subsidy 

for mluntary low-income contributors. 

Insured person: Employee, none. 

Sslf:employed and non-employed, 

2% of net income. 

Employen 5.3% of payroll. 

Government Whole coat of allowances for 1st and 2nd child of 

self-employed persons, and for 

pensioners. 

Maximum earnings for contribution 

prrrp09ss: 10,900 guilders a year 

9.2 
PROGRAMS, 1964 

DENMARK 

Cash Benefite for Insured Workers Permanent Disability and Medical 

(ex.ept permanent disability) Benefits for Insured Workers 

Sickness benefik 16 crowns a Medical benefits: Service benefits, 

day, plus 5 crowns for 1 depend- ordinarily provided by doctors and 

mrt (non-employees, 5-21 hospitals under contract with sad 

crowns a day, according tn rate paid directly by sickness funds. 

insured aga~nst). Maxi~um, 60% “ 

of earnings. General practitioner care, specialist care, hospitalization in public 

Payable after l-week waiting hospital, 75% of cost of vital 

period (non-employees, !2 medicineg, maternity care by midweeke), for up to 26 weeks in wife or doctor, home nursing, limany 12 monthe or 78 weeks in ited dental care, and tran-sport. 

any 3 yeare. Fund members whose income above 

Maternity benefits: 16 crowns a that of skilled worker pay part of


day, plus 5 crowns for 1 depend- ~O~t Of doc~r~> fees.
 mrt (non-employees, 5-21


crowns a day, according to rats DuratiOn: NO limit.


insured sgainst). 

Payable for up te 14 weeks, inoluding 8 weeks before confinement (non-employees, payable 

for 2 weeks after confinement). 

Family allowance: 400 crowns a year fpr 1st child, 450 crowns 

each for 2nd to 4th ohild, and 

500 crowns fo~ 5tb and each 

other eligible child. 

Slcknees benefiti 80% of earnings. 

Psyable eftsr S-day waiting 

period for up to 52 weeks. 

Maternity benefiti 100% of earnings, payable for 6 weeks before and 6 weeks after confinement. 

Maternity grant: Lump sum of 55 

guildere. 

Family nlIowance: 19.50 guilders 

a month for 1st child, rising to 

92.50 guildbrs a month for 6th 

and each additional cldld. 

NETHEI 

Medicrd benefits: Service benefits 

pmvlded by doctors, hospitals, and 

dru~ists under contract with and 

paid directly by sickness funds. 

General and specialist care, ~ospitalization, laboratory serw ces, 

medicines, limited dental care, obstetric care, appliances, and transportation. 

Patient shares cost of sanatorium 

care, artificial limbs, and trans­ portation. 

Maximumduration: No limit, except 

70 days for hospitalization. 

Survivor Benefits and hiedical 

Benefits for Dependents 

Iedical benefits for dependents: Wife or other adult dependent not 

eligible for medical ben?fits as 

dependent, but must insure in own right. 

:hildren mrder 16 usually oovered 

by insurance of parent, and receive same medical benefits. 

LNDS 

Medical benefits for dependents Same as for insured person. 

tfaternity grsnti Lump sum of 55 

guilders payable to wife of ineured man. 

Administrative Organization 

iinistry of Social Affairs, general supervision. 

lirectoratm of Sickness Fu~ds, 

in hiinistry, direct supermmon 

of program, including approval 

of rules of funds and granting of 

subsidies. 

fickness funds, usually one for 

each locality, administer contributions and benefits. Funds 

must be officially approved, 

and are mansged by elected 

officials; grouped into county 

and national federations. 

MinieJry of F]nance, national 

admnnstratmn of program; 

allowances usually credited 

against income taxes due from 

recipients. 

Local communal govemmen ts 

pay difference annually in cash to recipients, if allowance exceeds tax Iiabllity, and are then 

reimbursed by national gevem­ ment. 

Ministry of Soci id Affairs and 

Public Health, general supervision. 

Industrial association for each 

industry, administration of 

caeh benefits withhr industry; 

a proved joint em loyer-empf’oyee imdies wlt ! compulsory 

nationwide memberebip and bipartite governing bards. District and Ioc+ offices of assoc­ iations rece]ve and pay clalms. 

Approved sickeees funds, administration of medical benefits; supervision by tripartite 

Sickness Funds Council. About 

115 funds now operating. 

hfinistry of Social Affairs and 

Public Health, general supervision. 

ndustrial associations, administration of allowances within 

each industry; larger employers 

pay allowances to own emplOyees and settle surplus or deficit of contributions due with 

association. 

!ocial Insurance Bsak, administration of allowances for nOnemployees sad pensioners, 

with assistance of regional 

Labor Councils. 

93 
APPENDIX. MEDICAL CARE PROGRAMS, 1964CON. 

NORWAY 

Dates of Basic Laws snd Types 

of Programs 

SICKNESS AND MATERNITY 

First Iaw: 1909. 

Current law: 1956. 

Social insurance system (cash 

and medical benefits) 

(1 crown equals 14 U.S. cent9) 

FAMILY ALLOWANCES 

First and current lam 1946. 

Universal public system 

SICKNESS AND MATERNITY 

First laws: 1891 (cash benefits) 

and 1931 (medical benefice). 

Current law! 1962. 

Social insurance systsm (cash 

and medical benefits). 

(1 crown equals 19.3 U.S. cents) 

FAMILY ALLOWANCES 

First and currentlavc 1947.. 

Universal public syetem 

Coverage 

Medical benefits: Allresidente (dependent spouse earning below 

1,000 crowne ayear and children 

under 18 covered by ineuranceof 

family head). 

Cash benefits: All employees 

covered compulsorilfi nonemployees maybe covered voluntarily. 

Special systems for seamen, fisher. men, and public employees. 

tesidents with 2 or more children. 

Source of Funds 

Insured persorr: From 2.20to 10 crowne a week, according to annu al-income claes. Self-employed 

pay additional, premium if covered 

voluntarily forcasb benefits. 

Pensioners exempt from contributions, unless non-pension income a!mve 1,000 crowns a year. 

Employer: 75%of contributions of 

employees. 

Government National government, 

20% of contributions of insured 

persons; locsl governments, 25% 

of same. 

Insured person: None. 

Employe~ None. 

GovernmentiWhcde cost. 

SWEDEN 

;ash benefits: Gainfully occupied [neured person: In Stockholm 75 

persons earning 1,800 crownsa crowns a year for medical beneyear or more, and most housewives. fits; and70-269cmwns ayear for 

iedical benefits: All residents 

(children under 16 covered by 

parents’ insurance). 

A1l.reeidents, with Ior more 

childrsn. 

cash benefits, according to income. 

Elsewhere, about l/51ess., on 

average. No contribution If income utier 2,400 crowns a year or if pensioner. (Covers about 

l/2 of cost.) 

Employev 1.5% of payroll, excludin 

wages abuve 22,000 crowns a 

year. (Covsre about 1/4 of cost.) 

Government 50% of cost of basic 

cash benefits, refunds of doctors’ 

fses, and maternity grants; most 

hospital costs; part of medicine 

costs; contributions of Iow-incomf 

persons; and other subsidiss. 

(Covers ahuut 1/4 of cost.) 

Insured person: None. 

Employe~ None. 

Government Whole cost, 

Qualifying Conditions 

Cash sickness and maternity 

benefits: 14 days of insumace 

(nonemployees, 6 weeks). 

Mj~~gfl benefits: Currently inFsrnily llowanqee. Family must normalfy contain ~ or more children under age 16. 

[f botb parents aliens, child or 1 

parent must have 6 months of 

residence in country. 

iickness and medical benefits 

and maternity granti No mini- mum qualifying period. 

;ash maternity benefik Insursd 

for 9 months prior to confinement at earnings rate of 2,600 

crowns a year or more. 

Family allowances: Child must be under age 16 (19 if student). 

94 
APPENDIX. MEDICAL CARE PROGRAMS, 1964-CON. 

NORWAY 

Cash Benefits for Insured Workers 

(except permanent disability) 

Sickness bcmefiti 3.19crowns a 

day, aooord irrg to annual-income 

class, plus i? crowns a day for 

d~pondent spouse and each 

ch]ld under 18. 

Payable after 3-day waiting period for up tm 104 w?eks (unlimited for tuberculosis, cancer, 

arthritis, and poliomyelitis, if 

undnr treatment). 

Maternity benefiti 3-19 crowns a 

day, according to annual-income 

class, plus 2 crowns e day for 

dependent husbrord and each 

child under 18. 

Payable for 6 weeke before and 

6 weeks after confinement. 

Family allowanoe: 400 crowns n y~ar for 2nd ohild under age 

16, 500 orowns for 3rd, 600 

crewns for 4th, etc. (rate rises 

100 orowns for eaoh additional 

child under age 16). 

Allowmrce payable for 1st child 

also if orphan, invalid, or 

parents divorced. 

Sickness benefiti 5 crowns a day 

(all covmmd pereons), plus 

supplement of 1-23 crowns a 

day according to 13 income 

classes (far persons earning at 

least 2,600 crowns a year). 

Child’s supplements: 1 crown a 

day for 1.9 children under 16, 

2 crewns for 3-4, and 3 crowns 

for 5 or more. 

Payable aftsr S-day waiting period, for duration of illness. 

Maternity benefk 1-23 crowns a 

day, acoording to 13 inoomeclasses, payable for up to 180 

days. 

Matqrnity granti Lump sum of 

900 omwns. 

Family allowatroe: 500 crowns 

a year for each eligible ohlld, or 600 omwns if student age 

16-18. 

Permanent Disability and Medical Survivor Benefits sad Medical 

Benefits for Insured Workers Benefits for Dependents 

ledioal benefits: Cash refunds of Medical benefits for dependents:


part or all of medical exDenses. or Same as for insured.


iess commonly service tienefit;


furnished by providers under con- Wife of insured employee also re-


tract with funds. ceives maternity grant of 200
 crowns, unless treatment provided 

6-75% of cost of doctors’ fees, den. in maternity clinic.


tal care, and trsnsporG free cere


in public hospital, maternity clinic


snd sanatorium; and listed vital


medicines and labratcry services.


luration: No limit while in receipt


of remedial treatment.


SWEDEN 

[edical benefits: Cash refunds of ‘ ,dedical benefits for dependents: 

part of medicrd expenses’, and some Snme as for family head. 

service benefits. 

;efund of 75% of doctors’ and out-’ iaternity granti Lump sum of 900 

patient fees, according to schedule, crowns. 

and of travel cost% free hospitalization in ward of public hospital; 

free medicines for some ohronic 

diseases, and other medicines at 

half price; cost of confinement, including care in matsrnity ward; 

limited dental car:, including free care for school children; and specified appliances. 

Iuration: No limit, except 180 days 

for hospitalization if age 67. 

Administrative Organization 

Ministry of Social Affairs, general supervision. 

Nationsl Insursnce Institution, 

nstional administration of program,supervision of local 

funds, equalization of costs by 

distribution of Government contribution, and approval of contracts with doctors. 

Local insurance funds? administration of contributions and 

benefits locally. 

Ministry of %cid Affairs, gen­ ersl supervision. 

National Insurance Institution, 

national administration of pmgmm and supervision of local 

funds. 

Locsl insursuce funds, administration of allowances locally. 

Ministry of f+mcialAffairs, general supervision. 

National Social Insurmrce Board, 

administration of progrmn 

through regional and local 

social insurance bodies. 

Contributions of insured persons 

paid with income tax. 

National Social Welfare Board, 

national administration of program. 

Local social welfare offices and 

ci+ld-welfsre hoards, administration of allowances locally. 

95 
APPENDIX. MEDICAL CARE PROGRAMS, 1964-CON. 

UNITED KINGDOM 

Dates of Basic Laws and Types 

of Programs 

SICKNESS AND MATERNITY 

First law: 1911. 

Current laws: 1946 (national 

insurance and national health 

service laws). 

Dual social insurance (cash 

benefits) and national health 

service (medical care) 

systems 

(El equalsU.S. $2.80; 1s. equal: 

14 cents; Id. equals atsmt 1 

cent) 

FAMILY AI.LOWANCES 

First and cument law: 1945. 

Universal public system 

SICKNESS AND MATERNITY 

Four State laws only Rhode 

Island, 194% California, 

1946; New Jersey, 1948; and 

New York, 1949. 

Limited social ineurance ~ys­ tem (cash s]ckrress benefits 

mainly) 

FAMILY ALLOWANCES 

None 

Coverage 

Cash sickness and maternity benefits: Employed and self-employed 

persons (coverage optional for 

married women, and for self-employed persons whose income below S208 a year). 

kfatmnity grants: All mothers. 

Medical care: All residents. 

lesidents, with 2 or more children. 

Source of Funds 

[nsured person: For cash benefits, 

employee, 8s3j$d men) or 7s21~d 

(women) aweek,~us4fi%ofweekly 

wages between S -18 (contractedoutmen, 10s8}~d;women, 8s8)~d). 

Self-em Ioyed, 13s4d (men) or 1Is 

m~]~~jemP’”Yed,10s2d
 (womerr). For national health service, 2s8>\d a week


(male employee , 2sO\~d(female em­
 ployee), 2s10d (other men), or 2s2d


(other women).


Employeu For cash benefi ts, 8s3\jd


(men) or 7s2)~d (women) a week,


plus 4~% of weekly wages between


!d9-18(contmcted-outmen, 10s8)4m
 women, Ss8~d). For national health


service, 7\~dper employee a week.


Govemmenti For cash benefits,
 amount equal to ?~of ahnvs flat con­
 tributions (l/3 for self and non-em­
 ployed); lump-sum subgidw and full


costofnational assistance. For


national health service, aheut80%


Oftotal cost.


Above flat and gevemment contribu­


tions also finance cash old age, in-


validity, death and unemployment


benefits.


;nsured person: None.


?mploye~ None.


?overnmenti Whole cost.


Qualifying Conditions 

Cagh sickness benefiti 26 

weeks of paid contributions as 

employee or self-employed, and 

50 weeks paid or credited in 

Iaet year reduced benefit if 

26-49 wee\ s). 

Cash maternity benefiti 26 

weeke of paid contribution in 

last year as employee or selfemployed, and 50 weeks paid 

or credited (reduced benefit 

if 26-49 weeks). 

Maternity grants: 26 weeks of 

paid contributions by woman or 

husband, and 26 weeks paid or 

credited in last year. 

Medical care: Residence in 

country (no other conditions). 

hmily allowmrc es: Child must be under age 15 (16 if invalid, 

19 if student). 

!6 weeks of residence in last 12 

months (aliens must have, in 

addition, 156 weeks of residence in last 4 years). 

Sickness benefiti $300 of insured eaminge in laet year 

(California); 17 weeks of employment in last year (New 

Jersey); employment during 

last 4 weeks (New York); and 

20 weeks of employment in 

last year (Rhode Island). 

Medical and maternity benefits: 

Same as above, where provided 

(provided only on limited 

scale). 

UNITED STATES OF AMERICA 

Employees in jndu$try and com­ merce in Callfornla, New Jersey, 

New York, and Rhode Island. 

Exclusions: Agricultural employees 

(except California); domestic em­ ployees; employees of nonprofit 

institutions; and employees of firm$ 

with 3 or less workers (New Jersey] 

Three States (excluding Rhode 

Island) permit employer to substitute equivalent private plan or 

self-insurance for State coverage. 

Special national systems for railIUSd employees (cash benefits) 

and Federal employeee (medical 

expenses) and Federal-State sys. 

tern for aged persons of limited 

means (medical expenses). 

Insured p?rson: 1% of earnings 

(Califorma and Rhode Idand), or 

0.5% (New Jersey and New York). 

Employen None (California and 

Rhode Island); O.1-0.75% of payroll according tmrisk (New Jersey); and any benefit costs 

above O.5% of earnings (New 

York). 

Govemmenti None. 

Maximum earnings for contribution 

and benefit purposes: $3,000 a 

year (New Jersey and New York); 

$3,600 (Rhode Island); and 

$5,600 (California). 

96 
APPENDIX. MEDICAL CARE PROGRAMS, 1964-CON. 

UNITED IUNGDOM 

Crmh Bmrefits for Insured Worker: 

(except porman ent disability) 

Sickness bcmefiti S3 7s.6d. a 

wtwk, plus E!2Is(Id, for 1 adult 

depmrdent, S1 for 1st child, and 

12s. for aaoh other child. 

Pa able af$$ 3-day w+ting peri­ oJ (no wa]tmg period ]f 12 days 

lost	 within 13 weeks), for up to 62 ~nek~; duration ~nlimjted 

after 156 woeke of contribution. 

Maternity benefits: 2J37s.6d. a wuek, plus !d2 ls,6d. for 1 adult 

dependent, 2,1 for 1st child, and 

1:s. for each other child; payable for 11 w,eeks before and 7 

weeks after confinement. 

Also, lump-sum maternity grant 

of .C16, plus an additional S6 

if confinement in home or at 

own expense. 

Family allowance: 8s. a week 

for 2nd ohild, and 10s. for 3rd 

and mob other child. 

sickness benefik 50% of weekly 

earnings New York), 65% 

(Rhode Is\ and), or 61-6’7%(New 

Jersey); or 4-7% of quarterly 

earnings a week (CrJiforni a). 

Supplement of $3 a week per 

ahdd for up to 4 children payable in Rhode Island only. 

Payable after 7-day waiting period (none in California when 

hospitalized), for up tn !?6 

weeke. 

Maternity benefik In Rhode 

Ieland, 56% of earnings payable 

for up to 14 weeks. In New 

Jerse ,, 61-67% of earnin s payable )or up to 8 weeks. &her 

States, none. 

Permanent Disability and Medical 

Benefits for Insured Workers 

Medical benefits: Medical services 

provided by doctors and druggists 

under contract with and paid 

directly by national health service, 

and by public hospitals. 

General practitioner care, specialist 

services, hospitalization, maternity care, dental care, medicines, 

appliances, and home nursing. 

Patients pay 1s. for each prescription item, S 1 for each dental treatment (except children and expeotant or new mothers), 10s. for each 

spectacle lens, and about 50% of cost of dentures. 

Duration: No limit. 

Survivor Benefits and Medical 

Benefits for Dependents 

Jedical benefits for dependents: 

Same ae for family bead. 

Wife also receives same lump-sum 

maternity grant9 as workhg 

woman. 

Administrative Organizati&r 

flinistry of Pensions and National Insurance, administration of 

contributions and cash benefits 

through its regional and Iooal 

offices. 

tiinistry of Health, general administration of medical services 

through national health service. 

ilsdical services administered 

locally by Executive Council 

for each local health authority area (general medical, dental, 

and pharmaceutical services); 

about 15 Regional Hospital 

Boards; and local health authorities (home nursing, midwifery, 

etc.), 

Minis@y of Pensions and 

National Insurance, administration of program through 

its regional and 10CSI 

offices. 

Departments of State Govern­ ments administering unemployment insurance, administration 

of program in 3 States (California Department of Employment , New Jersey Departrnnnt 

of Labor end Industry, and 

Rhode Island Department of 

Employment Security). 

Workmen’s Compengaticm Board, 

administration of program in 

New York. 

UNITED STATES OF AMERICA 

tiedical benefits: In California, tedical benefits 

cash refund of $12 a day toward None provided. 

hospital expenses for up to 20 

days. In New York, medical benefits may b? pr?vided under a pri­ vate plan m lleu of caeh sickness 

benefits up to prescribed maximum 

Dther Statee: No medical benefits 

provided. 

(Medical services provided b aged 

persons unable to pay for own care 

in about 30 States under FederalState program.) 

for dependence: 

Abstracted from: Social Security Programs Throughout The World, 1964. U.S. Department of Health, Education,znd Welfare, Social Security 

Administration, 1964. 

97 

* V.s. GoVER?4MEttT PRINTING OF,, GE -,,70- a>,,, P. 0. , , 
. OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS 

Public Health Service Publication No. 1000 

Se~ies 1.€ Programs and collection firoceduves.— Reports which describe the general programs of the National 

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, 

and other material necessary for understanding the data. 

Series 2.	 Data evaluation and methods ve.search. —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. 

Sevies 3.€ Analytical 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. 

Series 4.	 Documents and committee Yepoyts. — 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. 

Series 10.€ Data fvom 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. 

Se7ies 11.	 Data from the Health Examination Suvvey. —Data from direct examination, testing, and measurement of national samples of the ~pulation provide the basis for two types of reports: (1) estimates 

of the medically defined prevalence of specific diseases in the United States and the distributions of 

the population with respect to physical, physiological, and psychological characteristics; and (2) 

analysis of relationships among the various measurements without reference to an explicit finite 

universe of persons. 

Series 12. Data from the Institutional Population Suvveys.— Statistics relating to the health characteristics of 

persons in institutions, and on medical, nursing, and personal care received, based on national 

samples of establishments providing these services and samples of the residents or patients. 

Series 13.	 Data from the Hospital Discharge Suvvey. —Statistics relating to discharged patients in short-stay 

hospitals, based on a sample of patient records in a national sample of hospitals. 

Series 20.	 Data on mortality. —Various statistics on mortality other than as included in annual or monthly 

reports-special analyses by cause of death, age, and otier demographic variables, also geographic 

and time series analyses. 

SeYies 21.	 Data on natality, marviage, anddivoyce. —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. 

SeYies 22.	 Data fvom the National Natality and Mortality Surveys. — Statistics on characteristics of births and 

deaths not available from the vital records, hsed 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. 

For a list of titles of reports published in these series, write to: Office of Information and Publications 

National Center for Health Statistics 

U.S. Public Health Service 

Washington, D.C. 20201