Child 

Health 

USA

2014

March 2015

U.S. Department of Health and Human Services

Health Resources and Services Administration
Child Health USA 2014 Table of Contents 2

PREFACE AND READERS GUIDE 3

SUMMARY OF KEY FINDINGS 4

POPULATION CHARACTERISTICS 5

Population of Children 6

Children in Poverty 8

Children of Immigrant Parents 9

Rural and Urban Children 10

Family Structure 12

Parental Employment and Child Care 14

Children with Special Health Care Needs 16

HEALTH STATUS AND BEHAVIORS 18

Fetal Mortality 19

Infant Mortality 21

Preterm Birth and Low Birth Weight 25

Birth Defects 29

Sleep-Related Sudden Unexpected Infant Death 31

Safe Sleep Behaviors 33

Smoking Before and During Pregnancy 35

Binge Drinking Before and During Pregnancy 37

Breastfeeding 39

Child Overweight and Obesity 41

Child Nutrition 43

Child Abuse and Neglect 44

School Readiness 46

Math and Reading Achievement 48

Sexual Activity and Contraceptive Use 50

STIs and HIV/AIDS 52

Adolescent Childbearing 54

Adolescent Overweight and Obesity 56

Physical Activity and Sedentary Behavior 58

Adolescent Nutrition 60

Mental Health 61

Violence 63

Bullying 65

Cigarette Smoking 67

Substance Use 69

High School Completion 71

HEALTH SERVICES FINANCING AND UTILIZATION 73

Health Insurance 74

Prenatal Care 76

Immunizations: Early Childhood 78

Immunizations: Influenza 80

Immunizations: Adolescents 82

Well-Child Visits 84

Developmental Screening 85

Mental Health Treatment 87

Dental Care 89

Usual Source of Care 91

Medical Home 93

Quality of Care 95

SPECIAL FEATURES 97

Child Mortality 98

Nonfatal Injury 100

Adverse Childhood Experiences 102

Flourishing and Resilience 104

Affordable Care Act 106

Federal Programs to Promote Child Health 108

CONTRIBUTORS 111

This publication was produced for the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child 

Health Bureau by the Altarum Institute under HRSA contract number GS10F0261K. 

The views and content in these resources have not been formally approved by the U.S. Department of Health and Human Services (HHS) or the Health 

Resources and Services Administration (HRSA). Neither HHS nor HRSA endorses the products or services of the listed resources.

Child Health USA 2014 is not copyrighted. Readers are free to duplicate and use all or part of the information contained in this publication; however, the 

photographs are require permission to be reproduced. All photos used in this publication are copyright www.thinkstockphotos.com.

Pursuant to 42 U.S.C. § 1320b-10, this publication may not be reproduced, reprinted, or redistributed for a fee without specific written authorization from HHS. 

This and previous editions of Child Health USA are available online: http://www.mchb.hrsa.gov

Suggested Citation: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 

Child Health USA 2014. Rockville, Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/ 
Child Health USA 2014 Preface and Reader’s Guide 3

PREFACE AND READERS GUIDE

The Health Resources and Services Administration’s Maternal and 

Child Health Bureau (MCHB) is pleased to present Child Health USA 

2014. Now in its 24th year, Child Health USA provides a centralized 

resource for data on the health and well-being of America’s infants, 

children, and adolescents. MCHB envisions a Nation in which the right 

to grow to one’s full potential is universally assured through attention 

to the comprehensive physical, psychological, and social needs of the 

maternal and child population. To assess the progress toward achieving this vision, MCHB has compiled this resource of secondary data 

for more than 50 health status and health care indicators. It provides 

both graphical and textual summaries of relevant data, and addresses 

long-term trends where applicable and feasible.

All of the data discussed within the text of Child Health USA are 

from the same sources as the information in the corresponding 

graphs, unless otherwise noted. In general, only statistically significant 

differences are commented on; however, not all significant differences 

are discussed. Data are presented for the following target population 

groups of the Title V Maternal and Child Health Block Grant: infants, 

children, adolescents, and children with special health care needs. 

Child Health USA 2014 addresses health status and health services 

utilization within this population, and offers insight into the Nation’s 

progress toward the goals set out in the MCHB’s strategic plan—to 

assure quality of care, eliminate barriers and health disparities, promote an environment that supports maternal and child health, and

improve the health infrastructure and system of care for women,

infants, children, and families.

Child Health USA is designed to provide the most current data 

available for public health professionals and other individuals in the 

public and private sectors. The website, available at http://mchb.hrsa.

gov/chusa14/, has a succinct format that is intended to facilitate the 

use of the information as a snapshot of children’s health in the United 

States.

Population Characteristics is the first section and presents statistics on factors that influence the health and well-being of children, 

including poverty, education, geographic location, and the presence of 

special health care needs. The second section, entitled Health Status 

and Behaviors, contains vital statistics and health behavior data for 

the maternal and child population presented by developmental stage. 

Health Services Financing and Utilization, the third section, includes data regarding health care financing and utilization of selected 

health services, on topics ranging from health insurance coverage to 

immunization. The final section, titled Special Features, highlights 

topics of special significance to children’s health and well-being such 

as exposure to adverse childhood experiences and flourishing in childhood and adolescence.

Child Health USA is not copyrighted and readers may duplicate 

and use all of the information contained herein; however, the photographs are copyrighted and permission may be required to reproduce. All editions of Child Health USA since 1999 are available online. 

The Child Health USA 2014 website provides users the opportunity to 

compare statistical estimates between subpopulations.
Child Health USA 2014 Summary of Key Findings 4

SUMMARY OF KEY FINDINGS

Child Health USA 2014 is the latest in the series of annual reports 

on the health status and service needs of America’s infants, children, 

and adolescents. The following summary outlines the key findings 

pertaining to population characteristics, health status and behaviors, 

health services financing and utilization, and other special features impacting U.S. children.

Population Characteristics

There were approximately 74 million children under 18 years of age 

living in the United States in 2013, representing 23.3 percent of the 

population.

• More than 16.5 million children (22.3 percent) lived in households 

with incomes below the U.S. Census Bureau’s poverty threshold 

($23,834 for a family of four in 2013). 

• Racial and ethnic diversity continued to increase, particularly for 

Hispanic children who represented more than 24 percent of all 

children in 2013 (up from 8.8 percent in 1980).

• In 2011–2012, 19.8 percent of U.S. children under 18 years of 

age had a special health care need as defined by having a chronic medical, behavioral, or developmental condition lasting 12 

months or longer and experiencing a service-related or functional 

consequence.

Health Status and Behaviors

Indicators of child health and well-being are essential for identifying 

priority areas for the development and assessment of health interventions.

• In 2012, approximately one in five adolescents had a mental 

disorder and the increased risk for struggles with school, use of 

drugs and alcohol, and the development of chronic illnesses in 

adulthood.

• Alcohol is the most commonly used substance among adolescents aged 12–17 years, with 12.9 percent reporting past-month 

use in 2012. In 2012, 9.5 percent of adolescents reported using 

illicit drugs, with marijuana the most commonly reported.

• In 2011, 24,001 U.S infants died before their first birthday, representing a rate of 6.07 deaths per 1,000 live births. Conditions 

related to prematurity accounted for more than a third of these 

infant deaths.

• In 2011−2012, nearly 30 percent of children aged 2−11 years 

were overweight or obese, 66.9 percent were of normal weight, 

and 3.4 percent were underweight. The prevalence of overweight 

and obesity was highest among Hispanic children (40 percent).

• In 2013, 42 percent of fourth-graders and 36 percent of 

eighth-graders were at or above proficiency in mathematics, 

while 35 percent and 36 percent, respectively, were at or above 

proficiency in reading.

• According to preliminary data for 2013, the overall birth rate for 

adolescents aged 15–19 years was 26.6 births per 1,000 females, representing an 11 percent decline from 2012 (29.4 per 

1,000) and an historic low for the United States.

• In 2013, only 27.1 percent of high school students reported 

meeting the 2008 U.S. Department of Health and Human Services guidelines for participation in physical activity. 

• Nearly 20 percent of high school students reported being bullied on school property and 14.8 percent reported being bullied 

through e-mail, chat rooms, instant messaging, Web sites, or 

texting, in 2013. 

Health Services Financing and Utilization

The availability of and access to health care services is important for 

ensuring the health and well-being of U.S. children. Without these services, children are at risk of poor health outcomes.

• In 2013, more than 6.5 million children aged 18 years and under were uninsured, representing 8.9 percent of all children in the 

United States. 

• During the 2013–2014 flu season, 58.9 percent of children aged 

6 months–17 years received the influenza vaccine, which represented a 2.3 percentage point increase in coverage as compared 

to the 2012-2013 flu season. 

• The proportion of children aged 10–71 months receiving a standardized developmental screening increased considerably from 

19.5 percent in 2007 to 30.8 percent in 2011-2012. 

• In 2012, approximately 65 percent of children aged 2–17 years 

received dental care in the past 6 months. The proportion of 

children receiving dental care was highest among children aged 

5–11 years (70.3 percent) and lowest among those aged 2–4 

years (45.3 percent).

• A majority of children under 18 years of age (96.2 percent) had a 

usual source of care, such as a physician’s office or health center, 

in 2012. The percentage of children with a usual source of care 

was highest among privately insured children (98.2 percent) and 

lowest among those who were uninsured (73.2 percent).

Special Features

Several areas of special significance to children’s health are also examined in Child Health USA 2014, as “special features.”

• In 2011, the child mortality rate was 25.7 per 100,000 among 

children aged 1–19, representing a decline of more than 25 percent since 1999. Non-Hispanic American Indian/Alaska Native 

children had the highest mortality rate (47.6 per 100,000) and 

Hispanic children had the lowest mortality rate (21.1 per 100,000).

• In 2011–2012, 22.6 percent of children aged 0–17 years experienced at least two adverse childhood experiences, such as experiencing economic hardship often (25.7 percent) and living with 

a parent who was divorced or separated after the child was born 

(20.1 percent).

• Among children aged 6 months–5 years, 73.2 percent were reported to usually or always exhibit four age-specific behaviors 

associated with flourishing (curiosity, resilience, attachment to 

caregivers, and positive affect). Less than half (47.7 percent) of 

school-aged children were reported to usually or always exhibit 

three age-specific flourishing behaviors (curiosity, resilience, and 

self-regulation).
Child Health USA 2014 Population Characteristics 5

POPULATION CHARACTERISTICS

The increasing diversity of the United States population is reflected 

in the sociodemographic characteristics of children and their families. 

The percentage of children who are Hispanic has more than doubled 

since 1980, while the percentage who are non-Hispanic White has 

declined. The percentage of children who are Black has remained relatively stable. This reflects the changes in the racial and ethnic makeup of the population as a whole.

At the national, state, and local levels, policymakers use population information to address health-related issues that affect mothers, 

children, and families. By carefully analyzing and comparing available 

data, public health professionals can often identify high-risk populations that could benefit from specific interventions.

This section presents data on selected population characteristics 

that can influence maternal and child health program development 

and evaluation. Included are data on the age and racial and ethnic 

distribution of the U.S. population, as well as data on children and their 

families, covering topics such as poverty, child care arrangements, 

education, and geographic location.

This section also presents the latest estimate of the proportion of 

U.S. children with special health care needs. Children are considered 

to have a special health care need if, in addition to a chronic medical, 

behavioral, or developmental condition that has lasted or is expected 

to last 12 months or longer, they experience either service-related or 

functional consequences, including the need for or use of prescription 

medications and/or specialized therapies.
Child Health USA 2014 Population Characteristics 6

POPULATION OF CHILDREN

In 2013, there were nearly 74 million children under 18 years of 

age in the United States, representing 23.3 percent of the population. 

Adults aged 18–64 years comprised 62.6 percent of the population, 

while 14.1 percent of Americans were aged 65 years or older. Approximately 6 million Americans were 85 and older.

The age distribution of the population has shifted significantly in the 

past several decades. The percentage of the population that is under 

18 fell from 28.1 percent in 1980 to 23.3 percent in 2013. The representation of adolescents and young adults (aged 15–19 and 20–24 

years) has also fallen, from 9.3 and 9.4 percent to 6.7 and 7.2 percent, 

respectively (figure 1). During this period, the percentage of the population aged 25–64 years increased from 47.3 to 52.6 percent, and 

the percentage aged 65 years or older increased from 11.3 to 14.1 

percent. The median age in the United States has increased from 30.0 

years in 1980 to 37.6 years in 2013. 

The distribution of males and females within the U.S. population 

varies with age. In 2013, there were slightly more males than females 

under age 18 in the United States: 37.6 million and 36.0 million, respectively. The trend is reversed among individuals aged 65 years and 

older, however. In 2013, there were 19.6 million males aged 65 years 

and older, comprising 12.6 percent of the overall male population, 

compared to 25.1 million females of the same age, who comprised 

15.6 percent of the overall female population. This distribution has 

remained relatively stable over the past several decades. 

The shifting racial and ethnic makeup of the child population (under 

age 18) reflects the increasing diversity of the population as a whole. 

Hispanic children represented fewer than 9 percent of children in 1980, 

compared to more than 24 percent in 2013 (figure 2). The percentage 

of children who are non-Hispanic Black has remained relatively steady 

over the same period, around 15 percent. However, the percentage 

of children who are non-Hispanic White has fallen significantly, from 

74.2 percent in 1980 to 52.4 percent in 2013. After 2000, changes 

in the way that racial and ethnic data were collected limit comparison 

over time for some groups, including Asians and individuals of more 

than one race.

Figure 1. U.S. Population, by Age Group, 1980 and 2013

Under 5 Years

7.2%

5-9 Years

7.4% 10-14 Years

8.1%

15-19 Years

9.3%

20-24 Years

9.4%

25-44 Years

27.7%

45-64 Years

19.6%

65 Years

and Older

11.3%

1980

Under 5 Years

6.3%

5-9 Years

6.5% 10-14 Years

6.5%

15-19 Years

6.7%

20-24 Years

7.2%

25-44 Years

26.3%

45-64 Years

26.3%

65 Years

and Older

14.1%

2013

Source: [1980] U.S. Census Bureau, Current Population Estimates. Table US-EST90INT-04 : intercensal

estimates of the United States resident population by age groups and sex, 1990–2000: selected months. In:

Statistical Abstract of the United States: 2012.

Available at: http://www.census.gov/prod/2011pubs/12statab/pop.pdf. Accessed July 14, 2014.

[2013] U.S. Census Bureau, Population Division. Annual estimates of the resident population for selected age

groups by sex for the United States, States, counties, and Puerto Rico Commonwealth and municipios: April 1,

2010 to July 1, 2013. Available at: http://www.census.gov/popest/data/national/asrh/2013/index.html.

Accessed July 14, 2014.

Figure 1. U.S. Population, by Age Group, 1980 and 2013

Under 5 Years

7.2%

5-9 Years

7.4% 10-14 Years

8.1%

15-19 Years

9.3%

20-24 Years

9.4%

25-44 Years

27.7%

45-64 Years

19.6%

65 Years

and Older

11.3%

1980

Under 5 Years

6.3%

5-9 Years

6.5% 10-14 Years

6.5%

15-19 Years

6.7%

20-24 Years

7.2%

25-44 Years

26.3%

45-64 Years

26.3%

65 Years

and Older

14.1%

2013

Source: [1980] U.S. Census Bureau, Current Population Estimates. Table US-EST90INT-04 : intercensal

estimates of the United States resident population by age groups and sex, 1990–2000: selected months. In:

Statistical Abstract of the United States: 2012.

Available at: http://www.census.gov/prod/2011pubs/12statab/pop.pdf. Accessed July 14, 2014.

[2013] U.S. Census Bureau, Population Division. Annual estimates of the resident population for selected age

groups by sex for the United States, States, counties, and Puerto Rico Commonwealth and municipios: April 1,

2010 to July 1, 2013. Available at: http://www.census.gov/popest/data/national/asrh/2013/index.html.

Accessed July 14, 2014.

Figure 2. Population of Children Under Age 18, by Race/Ethnicity,*

1980 and 2013

16

32

48

64

80

NonHispanic

Multiple

Races

NonHispanic

Native

Hawaiian/

Other

Pacific Islander

NonHispanic

Asian†

NonHispanic

American

Indian/

Alaska Native**

Non- Hispanic

Hispanic

Black

NonHispanic

White

Percent of Children

52.4

13.8

24.1

0.9 4.6

N/A N/A N/A

4.0

0.4 0.8

8.8

14.5

74.2

1980

2013

*Separate estimates for all race groups not available in 1980. Estimates may not sum to 100 due to rounding.

**Data for 1980 include Hispanics. †

Data for 1980 include Hispanics and Native Hawaiian/Other Pacific Islanders. 

Source: [1980] U.S. Census Bureau. Statistical abstract of the United States 1996. Available at:

https://www.census.gov/prod/2/gen/96statab/pop.pdf. Accessed July 14, 2014. Analyses conducted by the U.S.

Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child

Health Bureau.

[2013] U.S. Census Bureau, Population Division. Annual estimates of the resident population by sex, age, race,

and Hispanic origin for the United States and States: April 1, 2010 to July 1, 2013. Available at:

http://www.census.gov/popest/data/national/asrh/2013/index.html. Accessed July 14, 2014. Analyses conducted

by the U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau.
Child Health USA 2014 Population Characteristics 7

Data Sources

Figure 1. [1980] U.S. Census Bureau, Current Population Estimates. Table US-EST90INT-04 : intercensal estimates of the United States resident population by age 

groups and sex, 1990–2000: selected months. In: Statistical Abstract of the United States: 2012. Available at: http://www.census.gov/prod/2011pubs/12statab/pop.

pdf. Accessed July 14, 2014.

[2013] U.S. Census Bureau, Population Division. Annual estimates of the resident population for selected age groups by sex for the United States, States, counties, and 

Puerto Rico Commonwealth and municipios: April 1, 2010 to July 1, 2013. Available at: http://www.census.gov/popest/data/national/asrh/2013/index.html. Accessed 

July 14, 2014.

Figure 2. [1980] U.S. Census Bureau. Statistical abstract of the United States 1996. Available at: https://www.census.gov/prod/2/gen/96statab/pop.pdf. Accessed 

July 14, 2014. Analyses conducted by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health 

Bureau.

[2013] U.S. Census Bureau, Population Division. Annual estimates of the resident population by sex, age, race, and Hispanic origin for the United States and States: 

April 1, 2010 to July 1, 2013. Available at: http://www.census.gov/popest/data/national/asrh/2013/index.html. Accessed July 14, 2014. Analyses conducted by the 

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Population Characteristics 8

CHILDREN IN POVERTY

In 2013, more than 16.5 million U.S. children under 18 years of 

age lived in households with incomes below the U.S. Census Bureau’s poverty threshold ($23,834 for a family of four in 2013). This 

represents 22.3 percent of all children in the United States. Poverty 

affects many aspects of a child’s life, including living conditions, nutrition, and access to health care. In addition, significant racial and 

ethnic disparities exist. In 2013, nearly 50 percent of non-Hispanic 

American Indian/Alaska Native children, 38.8 percent of non-Hispanic 

Black children, and 34.3 percent of Hispanic children lived in households with incomes below 100 percent of poverty, compared to 12.8 

percent of non-Hispanic White children (figure 1). 

Single-parent families are particularly vulnerable to poverty. In 2013, 

44.7 percent of children living in a mother-headed household experienced poverty, as did 21.3 percent of children living in a father-headed 

household. Only 13.2 percent of children living in two-parent families 

lived in households with incomes below 100 percent of poverty. The 

proportion of children in single- and two-parent families living in poverty also varies by age. In 2013, 52.3 percent of children less than 5 

years of age and 42.1 percent of children aged 5–17 years living in 

mother-only households were living in poverty (figure 2). 

A number of federal programs work to protect the health and 

well-being of children living in low-income families (see page on Federal Programs to Promote Child Health). One of these is the National 

School Lunch Program, administered by the U.S. Department of Agriculture’s Food and Nutrition Service. The program provides nutritionally balanced low-cost or free lunches to children based on household 

poverty level. In 2013, the average daily participation in low-cost or 

free lunches was about 30 million children.1

Data Sources

Figure 1 and 2. U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and Economic Supplement. Analyses conducted by the 

Maternal and Child Health Epidemiology and Statistics Program.

Endnotes

1. U.S. Department of Agriculture, Food and Nutrition Service. Child Nutrition Tables. Available at: http://www.fns.usda.gov/pd/child-nutrition-tables. Accessed February 

16, 2015.

Figure 1. Children Under Age 18 Living in Households with

Incomes Below 100 Percent of Poverty,* by Race/Ethnicity, 2013 Percent of Children

Source: U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and

Economic Supplement. Analyses conducted by the Maternal and Child Health Epidemiology and Statistics

Program.

*The average U.S. Census Bureau poverty threshold for a family of four was $23,834 in 2013.

12

24

36

48

60

NonHispanic

Two or

More

Races

NonHispanic

Native

Hawaiian/

Other

Pacific Islander

NonHispanic

Asian

NonHispanic

American

Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

49.2

34.3

38.8

25.3

12.8

22.3 21.6

13.5

Figure 2. Children Under Age 18 Living in Households with

Incomes Below 100 Percent of Poverty,* by Family Type and Age, 2013

10

20

30

40

50

60

Total Two parents Mother only Father only

Percent of Children

52.3

42.1 44.7

21.3 20.9

11.9 13.2

16.5

25.7

21.0 22.3 23.4

<5 years

Total

5–17 years

*The average U.S. Census Bureau poverty threshold for a family of four was $23,834 in 2013.

Source: U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and

Economic Supplement. Analyses conducted by the Maternal and Child Health Epidemiology and Statistics

Program.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Population Characteristics 9

CHILDREN OF IMMIGRANT PARENTS

The immigrant population in the United States has increased substantially since the 1970s, largely due to immigration from Asia and 

Latin America. In 2013, 25.8 percent of children in the United States 

had at least one immigrant parent. Of all children, 22.5 percent were 

born in the United States with an immigrant parent or parents, and 3.3 

percent were themselves immigrants, with or without an immigrant 

parent. Most children (74.2 percent) were native born with native-born 

parents (figure 1). 

Children’s poverty status varies with nativity. In 2013, immigrant 

children with immigrant parents and native children with immigrant 

parents were most likely to live in poverty, with 30.8 and 28.4 percent 

respectively, living in households with incomes below 100 percent of 

poverty ($23,834 for a family of four in 2013; figure 2). More than a 

quarter of immigrant children with immigrant parents and native children with immigrant parents lived in households with family incomes of 

100–199 percent of poverty. Native-born children with native parents 

were the least likely to experience poverty, with 20.1 percent living in 

households with incomes below 100 percent of poverty and another 

20.1 percent living in households with incomes of 100–199 percent 

of poverty.

A number of other factors vary by the nativity of children and their 

parents. For example, immigrant and native children with immigrant 

parents were more likely to live in two-parent households (77.9 and 

73.3 percent, respectively) compared to children with native parents 

(66.6 percent). Immigrant and native children with immigrant parents 

were also more likely to live in metropolitan areas (93.7 and 94.9 percent, respectively) than children with native parents (82.1 percent).

Data Sources

Figure 1 and 2. U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and Economic Supplement. Analyses conducted by the 

Maternal and Child Health Epidemiology and Statistics Program.

Figure 1. Children Under Age 18, by Nativity of Child and

Parent(s),* 2013

Source: U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and

Economic Supplement. Analyses conducted by the Maternal and Child Health Epidemiology and Statistics

Program.

*“Native parent” indicates that both of the child’s parents were U.S. citizens at birth. “Immigrant parent” indicates

that one or both parents were born outside the United States. Children could be living with one or both parents. 

Native Child

and Parent

74.2% Native Child and

Immigrant Parent

22.5%

Immigrant Child and Parent 3.3%

Figure 2. Children Under Age 18, by Nativity of Child and

Parent(s)* and Poverty Status,** 2013

*“Native parent” indicates that both of the child’s parents were U.S. citizens at birth. “Immigrant parent” indicates

that one or both parents were born outside of the United States. Children could be living with one or both parents.

**The average U.S. Census Bureau poverty threshold for a family of four was $23,834 in 2013.

20 40 60 80 100

Immigrant Child

and Parent

Native Child and

Immigrant Parent

Native Child

and Parent

Less Than

100% of Poverty

100–199% of

Poverty

200% or More of

Poverty

Percent of Children

30.8 25.7 43.5

20.1 20.1 59.9

28.4 27.0 44.5

Source: U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and

Economic Supplement. Analyses conducted by the Maternal and Child Health Epidemiology and Statistics

Program.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Population Characteristics 10

RURAL AND URBAN CHILDREN

Urban and rural children differ in their demographic characteristics, 

which, in combination with geographic factors, can affect their health 

status and access to health care. For instance, children living in rural 

areas are more vulnerable to death from injuries,1 are more likely to 

use tobacco and other substances,2,3 and are more likely to be obese 

than their urban counterparts.4 Rural families may also not have the 

same access to health care because health services are not always 

located nearby.5 Understanding these potential risks can provide program planners and policymakers with information that can be used to 

design and target services. 

In 2011–2012, 84.5 percent of children lived in urban areas, while 

about 15.5 percent lived in rural areas. These areas were classified 

based on ZIP code, the size of the city or town, and the commuting 

pattern in the area. Urban areas include metropolitan areas and surrounding towns with populations of 50,000 and above.

The demographic distribution of the population of children in rural 

areas differs from that of urban children in terms of race, ethnicity, 

and nativity. Among urban children, 49.8 percent were non-Hispanic White, compared to 68.7 percent of children in rural areas (figure 

1). Children living in urban areas were more likely to be non-Hispanic 

Black and Hispanic than those living in rural areas, with more than 

one-quarter (25.4 percent) of urban children being of Hispanic origin 

compared to 13.3 percent of those living in rural communities. In contrast, non-Hispanic American Indian/Alaska Native children accounted 

for a greater proportion of children in rural areas, where they represent 

2.5 percent of the population, compared to less than 1 percent in urban areas. Children living in rural areas were slightly more likely to have 

been born in the United States (98.2 percent) compared to those living 

in urban areas (95.2 percent).

Children in rural areas were more likely than urban children to be 

living in low-income families. More than one-quarter (26.5 percent) of 

children in rural areas had household incomes below 100 percent of 

poverty, compared to 21.6 percent of urban children (figure 2). In contrast, nearly one-third (30.0 percent) of urban children had household 

incomes of 400 percent or more of poverty, compared to 15.9 percent 

of children in rural areas. 

Figure 1. Children Residing in Rural and Urban Areas,* by

Race/Ethnicity, 2011–2012

Urban

Rural

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau and Centers for Disease Control and Prevention, National Center for Health

Statistics. 2011–2012 National Survey of Children’s Health. Analyses conducted by the Maternal and

Child Health Bureau.

*Urban areas include metropolitan areas and surrounding towns from which commuters flow into an urban area,

including suburban and less densely populated areas. Rural areas are composed of all other areas not classified

as urban.

16

32

48

64

80

NonHispanic

Multiple

Races

NonHispanic

Native

Hawaiian/Other

Pacific Islander

NonHispanic

Asian

NonHispanic

American

Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Percent of Children

49.8

68.7

9.3

2.5 0.7 0.4 0.4

4.5 4.9 5.0

0.8

13.3 14.3

25.4
Child Health USA 2014 Population Characteristics 11

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau and Centers for 

Disease Control and Prevention, National Center for Health Statistics. 2011–2012 National Survey of Children’s Health. Analyses conducted by the Maternal and Child 

Health Bureau.

Endnotes

1. Cherry DC, Huggins B, Gilmore K. Children’s health in the rural environment. Pediatric Clinics of North America. 2007; 54:121–133.

2. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the future: national survey results on drug use, 1975–2008. NIH Publication No. 09-7402. 

Bethesda, MD: National Institutes of Health, National Institute on Drug Abuse; 2009.

3. Maine Rural Health Research Center. Research and policy brief. Substance abuse among rural youth: a little meth and a lot of booze. Available at: http://muskie.usm.

maine.edu/. Accessed September 9, 2012.

4. South Carolina Rural Health Research Center. Key facts and rural health: diet, physical activity, and sedentary behaviors as risk factors for childhood obesity: an urban 

and rural comparison. Available at: http://rhr.sph.sc.edu/. Accessed September 9, 2012.

5. Probst JC, Laditka SH, Wang J-Y, Johnson AO. Effects of residence and race on burden of travel for care: cross-sectional analysis of the 2001 U.S. National Household Travel Survey. BMC Health Services Research. March 9, 2007;7:40.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/

Figure 2. Children Residing in Rural and Urban Areas,* by Poverty

Status,** 2011–2012

Percent of Children

20.7

*Urban areas include metropolitan areas and surrounding towns from which commuters flow into an urban area,

including suburban and less densely populated areas. Rural areas are composed of all other areas not classified

as urban. **Based on the U.S. Department of Health and Human Services poverty guidelines, poverty was

$23,050 for a family of four in 2012.

20 40 60 80 100

Rural

Urban

Less Than 100%

of Poverty

100-199%

of Poverty

200-399%

of Poverty

400% or More

of Poverty

26.5

21.6 20.7

27.1

27.8

30.5

30.0

15.9

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau and Centers for Disease Control and Prevention, National Center for Health

Statistics. 2011–2012 National Survey of Children’s Health. Analyses conducted by the Maternal and

Child Health Bureau.
Child Health USA 2014 Population Characteristics 12

FAMILY STRUCTURE

The number of parents in the household plays an important role 

in the growth and development of children. Previous studies found 

that two-parent households were generally associated with better 

health outcomes than single-parent households. For example, children in two-parent, married households were less likely than children 

in single-parent households to be in fair or poor health. Children in 

single-parent households were more likely to have a learning disability 

or attention deficit hyperactivity disorder (ADHD) and certain chronic 

health conditions than children in two-parent, biological households.1

In 2013, more than two-thirds of all U.S. children less than 18 

years of age lived in households with two parents (includes biological, adopted, or stepparents), nearly a quarter lived in a mother-only 

household, and 4.1 percent lived in a father-only household (figure 1). 

A small proportion of children (1.9 percent) lived with a grandparent. 

Between 2000 and 2013, the percentages of children under 18 years 

of age living in two-parent and single-parent households remained relatively stable.

Family structure differs with race and ethnicity. In 2013, less than 

half of non-Hispanic Black and non-Hispanic American Indian/Alaska 

Native children lived in two-parent households, compared to 77.4 percent of non-Hispanic White children (figure 2). The majority of non-Hispanic Asian (86.0 percent), non-Hispanic Native Hawaiian/other Pacific Islander (70.0 percent), non-Hispanic White (77.4 percent), and 

Hispanic (65.0 percent) children lived in two-parent households. 

Household income as a percent of poverty is also related to family 

structure. In 2013, children in single-parent households were most 

likely to live in poverty, with 41.2 percent living in households with incomes below 100 percent of poverty ($23,834 for a family of four in 

2013), compared to 13.2 percent of two-parent households.

Figure 2. Family Structure of Children Under Age 18 Residing with at

Least One Parent, by Race/Ethnicity, 2013 Percent of Children

Source: U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and

Economic Supplement. Analyses conducted by the Maternal and Child Health Epidemiology and Statistics

Program.

20

40

60

80

100

NonHispanic

Multiple

Races

NonHispanic

Native

Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Two Parents

Mother Only

Father Only

27.9

65.0

3.2

22.7

70.0

5.3

29.9

61.3

5.1

39.6

45.0

5.4

15.3

51.0

38.1

77.4

4.4

9.6

86.0

2.5 4.5

5

10

15

20

25

2000 2002 2004 2006 2008 2010 2012 2013

1.9

1.0

4.1

23.7

Grandparent Other Relative

Mother Only

Father Only

Two Parents

*A small percentage of children less than 18 years of age (less than 1 percent) lived with only nonrelatives in

2008, 2010, 2012, and 2013; none of the children were living with only nonrelatives in 2000, 2002, 2004,

and 2006.

Source: U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and

Economic Supplement. Analyses conducted by the Maternal and Child Health Epidemiology and Statistics

Program. Percent of Children

Figure 1. Family Structure* of Children Under Age 18, 2000–2013

64

80

68.5
Child Health USA 2014 Population Characteristics 13

Data Sources

Figure 1 and 2. U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and Economic Supplement. Analyses conducted by the 

Maternal and Child Health Epidemiology and Statistics Program.

Endnotes

1. Blackwell DL. Family structure and children’s health in the United States: findings from the National Health Interview Survey, 2001–2007. National Center for Health 

Statistics. Vital Health Statistics. 2010;10(246).

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Population Characteristics 14

PARENTAL EMPLOYMENT AND CHILD 

CARE

In 2013, 69.9 percent of women with children under 18 years of 

age were in the labor force (either employed or looking for work), and 

64.8 percent of all women were employed. Among men with children, 

92.8 percent were in the labor force and 88.2 percent were employed. 

Labor force participation and employment among women with children varied by the age of their youngest child (figure 1). Of mothers 

with children from birth through age 5, 63.9 percent were in the labor 

force and 58.2 percent were employed. In comparison, 74.7 percent 

of women whose youngest child was aged 6–17 years were in the 

labor force and 70.1 percent were employed. Mothers of infants less 

than 1 year of age were least likely to be employed (51.9 percent); this 

rate increased to 55.0 percent at 1 year and 59.9 percent at 3 years. 

Employed mothers with children aged 0–5 years were more likely to 

be employed part-time than mothers with older children (27.8 versus 

23.6 percent, respectively). 

The proportion of mothers with children under the age of 18 who 

were employed was similar regardless of marital status: 64.5 percent 

of married women with a spouse present versus 65.3 percent of those 

who were never married, separated, widowed, or divorced. 

Unemployment — calculated as the proportion of adults in the labor force who are not employed — among mothers who were married 

with a spouse present was lower than among mothers of other marital 

statuses (4.8 versus 12.0 percent, respectively). This is partly due to 

the significantly higher proportion of mothers of other marital statuses 

in the labor force. Among mothers, unemployment rates were highest among those who were never married, separated, widowed, or 

divorced and with children under 3 years of age: Nearly one-fifth (19.0 

percent) of these mothers who had a child under the age of 1 year 

were unemployed, while the same was true of 17.5 percent of those 

with a 1-year-old child and 14.5 percent of those with a 2-year-old 

child (data not shown).

In 2011, 12.5 million or 61.3 percent of pre-school aged children 

(less than 5 years of age) were in some form of child care for at least 1 

day each week on a regular basis (figure 2). The most common source 

of care was a parent or relative. More than 40 percent of children 

(42.1 percent) were cared for by their mother, father, grandparent, or 

other relative, with grandparents providing care to nearly one-quarter 

of children (23.7 percent). Approximately one-third of children in this 

age group (32.9 percent) received care from a nonrelative, including 

23.5 percent who received care in a center-based setting (e.g., dayFigure 1. Parent’s Labor Force* Participation Rate, by Age of

Youngest Child,** 2013 Percent of Parents

*Includes people who are employed and those who are actively seeking work. **Children include sons,

daughters, stepchildren, and adopted children.

Source: U.S. Department of Labor, Bureau of Labor Statistics. Employment characteristics of families, 2013.

Available at: http://www.bls.gov/news.release/famee.nr0.htm. Accessed July 17, 2014.

20

40

60

80

100

Children Under 18 Years Children Aged 0–5 Years Children Aged 6–17 Years

Fathers Mothers

69.9

93.9 91.9

74.7

92.8

63.9
Child Health USA 2014 Population Characteristics 15

care center, nursery school) and 11.2 percent who were cared for by 

a nonrelative in a home-based setting (e.g., family daycare provider, 

nanny). Nearly 40 percent of preschool aged children had no regular 

child care arrangement.

Child care arrangements for pre-school aged children living with 

their mother varied primarily by maternal employment status. Only 

12.3 percent of children of employed mothers did not have a regular 

child care arrangement compared to 71.8 percent of those whose 

mother was unemployed. Children of employed mothers were more 

likely to have multiple arrangements, however, compared to unemployed mothers (26.7 versus 8.0 percent, respectively.) One-third of 

children of employed mothers received care in an organized facility 

such as a daycare center. The same was true for 12.4 percent of 

children of unemployed mothers. Grandparents were a key source of 

care for employed mothers, as well, providing regular care for nearly 

one-third of preschoolers. Among children of unemployed mothers, 

grandparents provided care for 13.3 percent of children.

Data Sources

Figure 1. U.S. Department of Labor, Bureau of Labor Statistics. Employment characteristics of families, 2013. Available at: http://www.bls.gov/news.release/famee.nr0.

htm. Accessed July 17, 2014.

Figure 2. U.S. Census Bureau. Who’s minding the kids? Child care arrangements: spring 2011. Available at: http://www.census.gov/prod/2013pubs/p70-135.pdf. 

Accessed July 17, 2014.

Figure 2. Child Care Arrangements* for Children Aged 0–4 Years, 2011 Percent of Children

32.9

3.5 2.6

17.8

11.2

38.7

42.1

7.4

23.7 23.5

Source: U.S. Census Bureau. Who’s minding the kids? Child care arrangements: spring 2011. Available at:

http://www.census.gov/prod/2013pubs/p70-135.pdf. Accessed July 17, 2014.

*The arrangement used for care at least 1 day a week on a regular basis; no regular arrangement indicates that

the reference parent provides care. Estimates for specific types of care may not equal totals as children may

have more than one type of regular care. **Only asked for the time during which the reference parent was

working or in school. †

Includes daycare centers, nurseries, and preschools. ‡Includes care provided by a

nonrelative in a home-based setting, such as a family daycare provider or nanny.

10

20

30

40

50

Other

Nonrelative

Care‡

Organized

Facility†

Other Total

Relative

GrandparentTotal Total Mother** Father** Sibling

No

Regular

Arrangements Relative Care Nonrelative Care

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Population Characteristics 16

CHILDREN WITH SPECIAL HEALTH 

CARE NEEDS

Children are considered to have a special health care need if, in 

addition to a chronic medical, behavioral, or developmental condition 

that has lasted or is expected to last 12 months or longer, they experience either service-related or functional consequences, including the 

need for or use of prescription medications and/or specialized therapies.1 In 2011–2012, 19.8 percent of U.S. children under the age of 

18 had a special health care need, representing 14.6 million children.2

Previous research indicates that among households with children under the age of 18 years, nearly one-quarter (23.0 percent) include at 

least one child with special health care needs.3

The prevalence of special health care needs in 2011–2012 varied 

by sociodemographic characteristics. Significantly more males than 

females were reported to have such needs (22.5 versus 17.0 percent, 

respectively), as were school-aged children compared to children 

aged 0–5 years: Approximately one-quarter of children aged 6–11 

and 12–17 years were reported to have a special health care need 

(22.7 and 25.1 percent, respectively) compared to 11.4 percent of 

those aged 0–5 years (figure 1).

The proportion of children with reported special health care needs 

also varied by race and ethnicity, and primary language spoken in the 

home. Non-Hispanic Black children had the highest rate (24.2 percent), followed by non-Hispanic White children (21.6 percent), while 

Hispanic children had the lowest rate of special health care needs 

(14.7 percent). The prevalence of special health care needs was higher among children living in households where the primary language 

spoken was English (21.9 percent) compared to households where 

the primary language spoken was something else (8.7 percent). 

Although the presence of special health care needs did not vary by 

economic status, children living in households where at least one adult 

had a high school diploma or higher were more likely to have such 

needs reported (approximately 20.5 percent) than those that lived in a 

household where no adult had completed high school (15.9 percent). 

The proportion of children with special health care needs was also 

lower for those living in a household with two biological or adoptive 

parents (16.4 percent) compared to children in other types of family 

arrangements (approximately 26 percent).

The complexity and severity of health impacts among children with 

special health care needs can vary greatly.4 Among children with such 

a need in 2011–2012, more than one-third (34.7 percent) had a condition that was managed with prescription medication only, while 16.6 

percent had conditions that resulted in above-routine use of medical, 

mental health, or other services (figure 2). Approximately one-quarter 

of this population needed or used both prescription medication(s) and 

greater levels of health services. Another 24.0 percent were the most 

severely affected children that had conditions resulting in functional 

limitations.

Figure 1. Children Under Age 18 with Special Health Care Needs, by

Age and Sex, 2011–2012 

5

10

15

20

25

30

Total 0–5 Years 6–11 Years 12–17 Years

Percent of Children

13.2

9.5

27.2

17.8

11.4

17.0

19.8

22.5 23.4

25.1

26.8

22.7

Total Male Female

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau and Centers for Disease Control and Prevention, National Center for Health

Statistics, National Survey of Children’s Health. Unpublished data. Analyzed by the Maternal and Child Health

Bureau. Figure 2. Children Under Age 18 With Special Health Care Needs, by

Type of Impact, 2011–2012* 

*Estimates do not sum to 100 percent due to rounding.

Need or use of

prescription

medication only

34.7%

Functional limitations

with a health care impact

24.0%

Need or use of both

prescription medication

and above-routine

use of services

24.6% Need or use of

above-routine

use of services only

16.6%

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau and Centers for Disease Control and Prevention, National Center for Health

Statistics, National Survey of Children’s Health. Unpublished data. Analyzed by the Maternal and Child Health

Bureau.
Child Health USA 2014 Population Characteristics 17

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau and Centers for Disease Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health. Unpublished data. Analyzed by the Maternal and Child Health 

Bureau.

Endnotes

1. McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needs. Pediatrics. 1998;102(1):137–139. 

2. Note: Published estimates of the prevalence of special health care needs may vary depending by data source. The 2009–2010 National Survey of Children With Special Health Care Needs found the prevalence of such needs to be 15.1 percent among U.S. children.

3. Child and Adolescent Measurement Initiative. Data Resource Center. Available at: http://www.childhealthdata.org/browse/survey/results?q=1813&r=1. Accessed July 

21, 2014.

4. Bramlett MD, Read D, Bethell C, Blumberg SJ. Differentiating subgroups of children with special health care needs by health status and complexity of health care 

needs. Maternal Child Health J. 2009 Mar;13(2):151-63.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors 18

HEALTH STATUS AND BEHAVIORS

Monitoring the health status of infants, children, and adolescents 

allows health professionals, program planners, and policymakers to 

assess the impact of past and current health interventions and prevention programs and identify areas of need within the child population. 

Although indicators of child health and well-being are often assessed 

on an annual basis, some surveillance systems collect data at regular 

intervals, such as every 2, 4, or 5 years. Trends can be identified by 

examining and comparing data from one data collection period to the 

next when multiple years of data are available.

In the following section, mortality, disease, and health behavior indicators are presented by age group: infants, children, and adolescents. 

The health status indicators in this section are based on vital statistics and national surveys and surveillance systems. Population-based 

samples are designed to yield information that is representative of the 

maternal and child populations that are affected by, or in need of, 

specific health services or interventions.
Child Health USA 2014 Health Status and Behaviors - Infants 19

FETAL MORTALITY

Fetal mortality is defined as the death of a fetus before birth, regardless of gestational age. Based on survey data, more than a million fetal 

losses are estimated to occur annually in the United States, most of 

which are early fetal losses, which are also called miscarriages.1 Only 

fetal deaths at 20 or more weeks’ gestation—often called stillbirths—

are generally reported by states in the National Vital Statistics System.2

 In 2012, there were 24,073 fetal deaths at 20 or more weeks’ 

gestation, for a rate of 6.05 fetal deaths per 1,000 live births plus fetal 

deaths. The number of fetal deaths is as high as the number of infant 

deaths (24,001 in 2011), which doubles the health and emotional toll 

when fetal and infant mortality are considered together. Causes of fetal 

death are similar to causes of infant death in the first month of life, including placental problems and preterm labor, birth defects, infection, 

umbilical cord accidents, and chronic conditions such as hypertension and diabetes.3,4

Fetal mortality rates at 20 weeks or more have declined from 7.49 

to 6.05 per 1,000 between 1990 and 2006 (figure 1). Most of this 

decline is attributed to reductions in fetal mortality at 28 weeks or 

more gestation, which declined from 4.30 to 2.97 per 1,000 between 1990 and 2006. However, there has been no change in fetal 

mortality from 2006 to 2012, a period during which infant mortality 

declined (see page on infant mortality).

As with infant mortality, there are large differences in fetal mortality 

rates by race and ethnicity. In 2012, fetal mortality rates at 20 or more 

weeks’ gestation were more than twice as high among non-Hispanic 

Black women as among non-Hispanic White women (10.67 versus 

4.91 per 1,000; figure 2). Relative to non-Hispanic Whites, fetal mortality rates were also higher for American Indian/Alaska Native and 

Puerto Rican women (6.64 and 6.62 per 1,000, respectively). 

Fetal mortality also varies by maternal age, with higher rates observed among younger and older women. In 2012, fetal mortality was 

highest among women aged 35 years and older (7.65 per 1,000), 

followed by those under 20 years of age (6.90 per 1,000). Women 

aged 25–34 years had the lowest fetal mortality rates, at about 5.50 

per 1,000.

Prevention opportunities that may reduce the risk of stillbirth include avoiding smoking, substance use, and certain prescription and 

over-the-counter medications; maintaining a healthy weight; and preventing and managing chronic conditions before and during pregnancy through preconception and prenatal care.4

 Careful clinical monitoring for women with high-risk conditions or vaginal bleeding may also 

avert fetal deaths, as early cesarean delivery can be lifesaving when 

medically necessary.

Figure 1. Fetal Mortality Rates per 1,000 Live Births and Fetal Deaths,*

1990–2012 Rate per 1,000 Live Births and Fetal Deaths

3.11

2.96

6.05

Source: MacDorman MF, Kirmeyer SE, Wilson EC. Fetal and perinatal mortality, United States, 2006. National

Vital Statistics Reports, vol. 60, no. 8. Hyattsville, MD: National Center for Health Statistics; 2012.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center

for Health Statistics. User Guide to the 2012 Fetal Death Public Use File. Available at:

http://www.cdc.gov/nchs/data_access/VitalStatsOnline.htm. Accessed October 7, 2014.

Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. National Vital Statistics Reports, vol. 62,

no. 9. Hyattsville, MD: National Center for Health Statistics; 2013.

*Fetal deaths with a stated or presumed period of gestation of 20 weeks or more. Cases of unknown gestational

age are proportionally assigned according to the known gestational age distribution. Rates do not sum to the

total due to slight differences in the denominator.

2

4

6

8

10

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

20–27 Weeks’ Gestation 

28 Weeks’ or More Gestation 

Total
Child Health USA 2014 Health Status and Behaviors - Infants 20

Data Sources

Figure 1. MacDorman MF, Kirmeyer SE, Wilson EC. Fetal and perinatal mortality, United States, 2006. National Vital Statistics Reports, vol. 60, no. 8. Hyattsville, MD: 

National Center for Health Statistics; 2012.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. User Guide to the 2012 Fetal Death 

Public Use File. Available at: http://www.cdc.gov/nchs/data_access/VitalStatsOnline.htm. Accessed October 7, 2014.

Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. National Vital Statistics Reports, vol. 62, no. 9. Hyattsville, MD: National Center for Health Statistics; 2013.

Figure 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. User Guide to the 2012 

Fetal Death Public Use File. Available at: http://www.cdc.gov/nchs/data_access/VitalStatsOnline.htm. Accessed October 7, 2014.

Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. National Vital Statistics Reports, vol. 62, no. 9. Hyattsville, MD: National Center for Health Statistics; 2013.

Endnotes

1. Ventura SJ, Curtin SC, Abma JC, Henshaw SK. Estimated pregnancy rates and rates of pregnancy outcomes for the United States, 1990–2008. National Vital Statistics Reports, vol. 60, no. 7. Hyattsville, MD: National Center for Health Statistics; 2012.

2. MacDorman MF, Kirmeyer SE, Wilson EC. Fetal and perinatal mortality, United States, 2006. National Vital Statistics Reports, vol. 60, no. 8. Hyattsville, MD: National 

Center for Health Statistics; 2012.

3. Stillbirth Collaborative Research Network Writing Group. Causes of death among stillbirths. Journal of the American Medical Association. December 14, 

2011;306(22):2459–2468.

4. March of Dimes Foundation. Stillbirth. Available at: http://www.marchofdimes.com/loss/stillbirth.aspx. Accessed September 24, 2014.

Figure 2. Fetal Mortality Rates per 1,000 Live Births and Fetal Deaths,*

by Maternal Race/Ethnicity, 2012 Rate per 1,000 Live Births and Fetal Deaths

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. User Guide to the 2012 Fetal Death Public Use File. Available at:

http://www.cdc.gov/nchs/data_access/VitalStatsOnline.htm. Accessed October 7, 2014.

Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. National Vital Statistics Reports, vol. 62,

no. 9. Hyattsville, MD: National Center for Health Statistics; 2013.

*Fetal deaths with a stated or presumed period of gestation of 20 weeks or more. Cases of unknown gestational

age are proportionally assigned according to the known gestational age distribution. **May include Hispanics.

†

Separate data for Asians, Native Hawaiians, and other Pacific Islanders are not available.

3

6

9

12

15

 Central and South

American

 Puerto Cuban RicanHispanic Mexican (total)Asian/

Pacific

Islander**†

American

Indian/

Alaska

Native**

NonHispanic

Black

NonHispanic

White

Total

4.67

6.64

10.67

5.33 4.63 5.16 4.91

6.05 6.62

5.03

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Infants 21

INFANT MORTALITY

Infant mortality, or the death of a child within the first year of life, 

is a sentinel measure of population health that reflects the underlying 

well-being of mothers and families, as well as the broader community 

and social environment that cultivate health and access to health-promoting resources. In 2011, 24,001 infants died before their first birthday in the United States, representing an infant mortality rate of 6.07 

deaths per 1,000 live births (table 1). Among grouped summary causes of death, preterm-related conditions accounted for 35.4 percent of 

all infant deaths, followed by congenital anomalies (20.9 percent; see 

page on birth defects), other perinatal conditions not directly related 

to prematurity (14.5 percent), and sudden unexpected infant death 

(SUID, 14.2 percent; see page on sleep-related SUID). About twothirds of infant deaths occur in the neonatal period or within the first 

month of life (4.06 per 1,000 live births), with the remaining third occurring in the postneonatal period from 1 month to less than 1 year 

(2.01 per 1,000 live births). Neonatal mortality is predominantly related to prematurity, congenital anomalies, and other perinatal conditions; postneonatal mortality is mostly attributable to SUID, congenital 

anomalies, infection, and injury.

With the exception of 2000–2005, the U.S. infant mortality rate 

had been consistently declining at least every few years since it was 

first assessed in 1915 (figure 1). The substantial infant mortality decline over the 20th century has been attributed to economic growth, 

improved nutrition, new sanitary measures, and advances in clinical 

medicine and access to care.1,2 Infant mortality declines in the 1990s 

were aided particularly by the approval of synthetic surfactants to 

reduce the severity of respiratory distress syndrome (a common 

affliction of preterm infants) and the recommendation that infants 

be placed on their backs to sleep to prevent sudden infant death 

syndrome. The lack of progress between 2000 and 2005 has been 

attributed to increases in preterm birth and obstetric interventions 

such as inductions and cesareans,3 which have begun to decline in 

the last several years along with the infant mortality rate.4,5

Table 1: Infant, Neonatal, and Postneonatal Mortality Rates per 1,000 Live Births,* by Summary Cause of Death,** 2011

Summary Cause of Death

Infant Mortality Neonatal Mortality Postneonatal Mortality

Number Rate per 1,000

Live Births

Percent of

Deaths

Number Rate per 1,000

Live Births

Percent of

Deaths

Number Rate per 1,000

Live Births

Percent of

Deaths

All causes 24,001 6.07 100.0% 16,065 4.06 100.0% 7,936 2.01 100.0%

Preterm-related conditions 8,500 2.15 35.4% 8,188 2.07 51.0% 312 0.08 3.9%

Congenital anomalies 5,016 1.27 20.9% 3,569 0.90 22.2% 1,447 0.05 18.2%

Other perinatal conditions 3,478 0.88 14.5% 3,292 0.83 20.5% 186 0.37 2.3%

SUID 3,399 0.86 14.2% 398 0.10 2.5% 3,001 0.76 37.8%

Infection 906 0.23 3.8% 64 0.02 0.4% 842 0.21 10.6%

Injury 904 0.23 3.8% 85 0.02 0.5% 819 0.21 10.3%

All other causes 1,797 0.45 7.5% 468 0.12 2.9% 1,329 0.34 16.7%

*Infant deaths are of those less than 1 year old; neonatal deaths are of those less than 28 days old; postneonatal deaths are of those at least 28 days old and less than 1 year old. **Preterm-related conditions: infant born preterm (<37 weeks) and an ICD-10 underlying cause-of-death code of K550, P000, P010, P011, P015, P020, P021, P027, P070–P073, P102, P220–229, 

P250–279, P280, P281, P360–369, P520–523, or P77. Developed by: Callaghan WM, MacDorman MF, Rasmussen SA, Qin C, Lackritz EM. The contribution of preterm birth to infant mortality 

rates in the United States. Pediatrics. October 2006;118(4):1566–1573. Other perinatal conditions: All other codes in P00–P96, regardless of prematurity. Congenital anomalies: Q00–Q99. 

SUID: R95–R99 and W75. Infections: A00–B99, G00, G03, I30, I33, I40, and J00–J42. Injury: J69, U01, V01–W74, and W76–Y36. 

Figure 1. Infant, Neonatal, and Postneonatal Mortality Rates per

1,000 Live Births,* 1915–2011** Rate per 1,000 live births

4.06

2.01

6.07

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. Natality. Vital Statistics of the United States, 1993, vol. I. Hyattsville, MD: National

Center for Health Statistics; 1999.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center

for Health Statistics. Mortality, part A. Vital Statistics of the United States, 1993, vol. II. Hyattsville, MD: National

Center for Health Statistics; 2002.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center

for Health Statistics. Compressed mortality file 1979–1998. CDC WONDER Online Database. 2003. Available at:

*Infant deaths are of those less than 1 year old; neonatal deaths are of those less than 28 days old; postneonatal

deaths are of those at least 28 days old and less than 1 year old. **Data from 1915–1932 are a subset from

states with birth registration, which became 100 percent by 1933.

20

40

60

80

100

1915 1925 1935 1945 1955 1965 1975 1985 1995 2005 2011

Neonatal Mortality 

Postneonatal Mortality

Infant Mortality
Child Health USA 2014 Health Status and Behaviors - Infants 22

In 2011, the U.S. infant mortality rate ranked 27th among industrialized nations, behind most European countries, Australia, Canada, 

Israel, and South Korea (table 2). Sweden had the lowest infant mortality rate, 2.1 per 1,000 live births, followed by Japan and Finland 

with infant mortality rates of 2.3 and 2.4 deaths per 1,000 live births, 

respectively. The United States did not always rank this low; in 1960, 

it ranked 11th, with Norway, the Netherlands, and Sweden reporting 

the three lowest rates among industrialized nations that year. Differences in infant mortality rates among industrialized nations may reflect 

variation in the definition, measurement, and reporting of fetal and infant deaths. However, analyses by gestational age indicate that this 

disparity is most likely related to the high rate of preterm birth in the 

United States.6 Although the United States compares favorably with 

European countries with respect to the survival of preterm infants, the 

higher rate of preterm birth in the United States significantly affects the 

infant mortality rate. Mortality among infants born at term (37 or more 

weeks’ gestation) is also higher in the United States.

Large and persistent disparities by race and ethnicity and educational attainment may also contribute to higher rates of infant mortality 

in the United States relative to other countries. With respect to maternal education, infant mortality decreases with increasing levels of 

education. In 2011, among the 33 states and the District of Columbia 

that had implemented the 2003 U.S. Standard Certificate of Live Birth 

as of January 1, 2010, infants born to mothers with less than a high 

school degree were more than twice as likely to die in their first year 

of life than infants born to mothers with a bachelor’s degree or higher 

(7.54 versus 3.63 per 1,000). Educational disparities in both neonatal 

and postneonatal mortality were present; however, the postneonatal disparity was higher, with infants of mothers with less than a high 

school diploma 1.69 times as likely to die in the first month of life and 

3.26 times as likely to die between 1 month and 1 year of life as infants 

of mothers with a college degree or higher. If all infants in the United 

States had the same risk of death as those born to mothers with a 

college degree or higher, the United States would climb from 27th 

to 16th in international infant mortality rankings and tie with Austria, 

Germany, and the Netherlands. 

Table 2: International Infant Mortality Rates and Rankings,* 

Selected Countries,** 1960 and 2011

Country

1960 2011

Rate per 1,000

Live Births

Rank Rate per 1,000

Live Births

Rank

Australia 20.2 5 3.8 19

Austria 37.5 19 3.6 16

Belgium 31.4 17 3.4 10

Canada 27.3 12 4.8 23

Chile 120.3 27 7.7 28

Czech Republic 20.0 4 2.7 5

Denmark 21.5 8 3.5 12

Finland 21.0 6 2.4 3

France 27.7 13 3.5 12

Germany 35.0 18 3.6 16

Greece 40.1 20 3.4 10

Hungary 47.6 23 4.9 24

Ireland 29.3 15 3.5 12

Israel NA NA 3.5 12

Italy 43.9 22 2.9 6

Japan 30.7 16 2.3 2

South Korea NA NA 3.0 7

Mexico 92.3 26 13.7 30

Netherlands 16.5 2 3.6 16

New Zealand 22.6 10 5.2 26

Norway 16.0 1 2.4 3

Poland 56.1 24 4.7 22

Portugal 77.5 25 3.1 8

Slovak Republic 28.6 14 4.9 24

Spain 43.7 21 3.2 9

Sweden 16.6 3 2.1 1

Switzerland 21.1 7 3.8 19

Turkey 189.5 28 7.7 28

United Kingdom 22.5 9 4.3 21

United States 26.0 11 6.1 27

*Rankings are from lowest to highest infant mortality rates (IMRs). Countries with the same IMR 

receive the same rank. Relative rankings may be affected if not all counties have reported data. 

**Countries with at least 2.5 million people and listed in the Organisation for Economic Co-operation and Development database. NA = data not available.
Child Health USA 2014 Health Status and Behaviors - Infants 23

Figure 2. Infant, Neonatal, and Postneonatal Mortality Rates,* by

Maternal Race/Ethnicity, 2011

Source: U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, National

Center for Health Statistics. 2011 Linked Birth/Infant Death File. Analyzed by the U.S. Department of Health and

Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

*Infant deaths are of those less than 1 year old; neonatal deaths are of those less than 28 days old; postneonatal

deaths are of those at least 28 days old and less than 1 year old. **May include Hispanics. †

Separate data for

Asians, Native Hawaiians, and other Pacific Islanders are not available.

Total

Neonatal Mortality Postneonatal Mortality

Rate per 1,000 Live Births

3 6 9 12 15

 Central and

South American

 Cuban

 Puerto Rican

 Mexican

Hispanic

(total)

Asian/Pacific Islander**†

American Indian/

Alaska Native**

Non-Hispanic

Black

Non-Hispanic White

Total 6.07

5.07

11.45

8.21

4.36

5.15

4.99

7.84

4.34

4.35

3.84

3.51

1.26

1.52

1.48

2.55

0.88

1.12

7.62

4.70

3.10

3.63

3.51

5.29

3.46

3.24

2.01

1.76

4.06

3.31

In 2011, the infant mortality rate was highest for infants of non-Hispanic Black mothers (11.45 per 1,000 live births)—a rate 2.3 times 

that of non-Hispanic Whites (5.07 per 1,000; figure 2). Infant mortality 

was also higher among infants born to American Indian/Alaska Native 

and Puerto Rican mothers (8.21 and 7.84 per 1,000, respectively). 

Infant mortality was lowest among Cubans, Central and South Americans, and Asian/Pacific Islanders (~4.35 per 1,000); however, there 

is considerable variability within the Asian/Pacific Islander population, 

and higher infant mortality has been shown among Native Hawaiians.7

Excess prematurity and SUID tend to be the largest proximate causes of racial and ethnic disparities in infant mortality.8

 If all U.S. infants 

had the same risk of dying as non-Hispanic Whites, the U.S. ranking 

among industrialized countries would move from 27th to 26th.

Infant mortality prevention strategies include clinical and population-based efforts to promote the health of women before and between pregnancies to prevent and manage chronic conditions and 

risk factors, such as diabetes, hypertension, smoking, unintended 

pregnancy, and short birth intervals, which may lead to prematurity, low birth weight, and congenital anomalies.9

 Improving access 

to risk-appropriate prenatal and newborn care, such as progesterone therapy, antenatal steroids, and regionalized perinatal systems, 

can also reduce prematurity or morbidity among preterm infants.10 In 

addition, efforts to promote positive postpartum behaviors, such as 

breastfeeding, smoking cessation, and safe sleep practices, can help 

reduce the risk of SUID.11 Finally, programmatic and policy interventions to address the fundamental social determinants of health, such 

as education and housing, would reduce virtually all causes of infant 

death.12 Many of these prevention opportunities are being addressed 

through various state and community-based initiatives such as the 

Collaborative Improvement and Innovation Network (CoIIN) to reduce 

infant mortality, the Healthy Babies Initiative, the Strong Start Initiative, 

Healthy Start,12 Best Babies Zones,13 and the Institute for Equity in 

Birth Outcomes,14 with support from multiple prevention components 

of the Affordable Care Act.15
Child Health USA 2014 Health Status and Behaviors - Infants 24

Data Sources

Table 1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. 2011 Linked Birth/Infant 

Death File. Analyzed by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Figure 1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Natality. Vital Statistics of 

the United States, 1993, vol. I. Hyattsville, MD: National Center for Health Statistics; 1999.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Mortality, part A. Vital Statistics of 

the United States, 1993, vol. II. Hyattsville, MD: National Center for Health Statistics; 2002.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed mortality file 1979–

1998. CDC WONDER Online Database. 2003. Available at: http://wonder.cdc.gov/cmf-icd9.html. Accessed August 11, 2014.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed mortality file 1999–

2011. CDC WONDER Online Database. July 2014. Available at: http://wonder.cdc.gov/cmf-icd10.html. Accessed August 11, 2014.

Table 2. Organisation for Economic Co-operation and Development. OECD.StatExtracts: Maternal and Infant Mortality. Available at: http://stats.oecd.org/index.aspx?-

DataSetCode=HEALTH_STAT. Accessed August 11, 2014.

Figure 2. U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, National Center for Health Statistics. 2011 Linked Birth/Infant

Death File. Analyzed by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Endnotes

1. Guyer B, Freedman MA, Strobino DM, and Sondik EJ. Annual summary of vital statistics: trends in the health of Americans during the 20th century. Pediatrics. 

2000;106:1307–1317.

2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Advancements in public health, 1900–1999: healthier mothers and 

babies. Morbidity and Mortality Weekly Report. 1999;48:849–858.

3. MacDorman MF, Mathews TJ. Recent Trends in Infant Mortality in the United States. NCHS data brief, no 9. Hyattsville, MD: National Center for Health Statistics; 2008.

4. Hamilton BE, Martin JA, Osterman MJK, Curtin SC. Births: preliminary data for 2013. National Vital Statistics Reports, vol. 63, no. 2. Hyattsville, MD: National Center 

for Health Statistics; 2014.

5. Osterman MJK, Martin JA. Recent Declines in Induction of Labor by Gestational Age. NCHS data brief, no. 155. Hyattsville, MD: National Center for Health Statistics; 

2014.

6. MacDorman MF, Mathews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, 2010. National Vital 

Statistics Reports, vol. 63, no. 5. Hyattsville, MD: National Center for Health Statistics; 2014. 

7. Mathews TJ, Menacker F, MacDorman MF. Infant mortality statistics from the 2002 period linked birth/infant death data set. National Vital Statistics Reports, vol. 53, 

no. 10. Hyattsville, Maryland: National Center for Health Statistics; 2004.

8. MacDorman MF, Mathews TJ. Understanding Racial and Ethnic Disparities in U.S. Infant Mortality Rates. NCHS data brief, no. 74. Hyattsville, MD: National Center for 

Health Statistics; 2011.

9. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care—United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recommendations and Reports: Morbidity and Mortality Weekly Report. April 21, 

2006;55(RR-6):1–23.

10. Berns S, Kott A, eds. Toward Improving the Outcome of Pregnancy III. White Plains, NY: March of Dimes Foundation; December 2010. 

11. Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. November 2011;128(5):1030–1039.

12. Lu MC, Johnson KA. Toward a national strategy on infant mortality. American Journal of Public Health. February 2014;104(Suppl 1):S13–S16.

13. W.K. Kellogg Foundation. Best Babies Zone: A holistic, Neighborhood-Based Approach to Improving Birth Outcomes. Available at: http://www.wkkf.org/what-we-do/

featured-work/best-babies-zone-a-holistic-neighborhood-based-approach-to-improving-birth-outcomes. Accessed September 22, 2014.

14. CityMatCH. Institute for Equity in Birth Outcomes. Available at: http://www.citymatch.org/projects/institute-equity-birth-outcomes-0. Accessed September 22, 2014.

15. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. New England Journal of Medicine. September 30, 2010;363(14):1296–1299.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Infants 25

PRETERM BIRTH AND LOW BIRTH 

WEIGHT

Babies born preterm (before 37 completed weeks of gestation) 

or at low birth weight (less than 2,500 grams or 5.5 pounds) are at 

increased risk of immediate life-threatening health problems as well 

as long-term complications and developmental delays. Complications 

that can occur during the newborn period include respiratory distress, 

jaundice, anemia, and infection. Long-term complications can include 

learning and behavioral problems, cerebral palsy, lung problems, and 

vision and hearing loss.1,2

As a result of these risks, preterm birth and low birth weight are 

leading causes of infant death and childhood disability. Babies who 

are born the earliest and smallest have the highest risks of morbidity and mortality. For example, infants born very preterm (less than 

32 weeks’ gestation) or at a very low birth weight (less than 1,500 

grams) have 89 and 110 times the risk of dying in the first year of life 

as their full-term and non-low birth weight counterparts, respectively 

(see page on infant mortality). In other words, more than half of all 

infant deaths occur among the less than 2 percent of infants born 

very preterm or at low birth weight. However, even babies born “late 

preterm” (34–36 weeks’ gestation) or at moderately low birth weight 

(1,500–2,499 grams) are more likely than full-term and normal birth 

weight babies to experience morbidity and mortality. Preterm birth and 

low birth weight exact a heavy societal toll with the annual economic 

burden related to preterm birth estimated to exceed $26 billion, including costs for medical care and early intervention as well as lost 

productivity due to disabling conditions.3

The causes of preterm birth are not well understood but are linked 

to infection and vascular disease as well as medical conditions, such 

as diabetes and hypertension, which may necessitate labor induction 

or cesarean delivery.3,4 The majority of very low birth weight infants are 

born prematurely, whereas those born at moderately low birth weight 

include a mix of prematurity as well as fetal growth restriction that may 

be related to factors such as maternal hypertension, tobacco smoke 

exposure, and inadequate weight gain during pregnancy.2

In 2012, 11.55 percent of infants were born preterm and 7.99 percent were born at low birth weight. Less than 2 percent were born 

very preterm (1.93 percent) or at very low birth weight (1.42 percent). 

Between 1990 and 2006, the preterm birth rate increased more than 

20 percent, from 10.62 to 12.80 percent; and the rate of very preterm 

birth increased by 6 percent, from 1.92 to 2.04 percent (figure 1). 

Rates of low and very low birth weight also peaked in 2006 at 8.26 

and 1.49 percent, respectively, with 19 and 17 percent respective increases over 1990 levels. Reasons for the rise in preterm birth and 

low birth weight include increases in obstetric interventions, maternal 

age, and fertility treatments, which are more likely to result in multiple 

births.4,5 Since the 2006 peak, preterm birth declined by 10 percent 

and very preterm birth declined by 6 percent, while declines in low and 

very low birth weight were more modest at 3 and 4 percent, respectively. Reasons for these recent declines are not fully known but may 

be associated with declines in nonmarital childbearing6 and obstetric 

interventions, such as “elective” or non-medically indicated deliveries 

at less than 39 weeks.7

Preterm birth and low birth weight vary by race and ethnicity, with 

rates typically highest among infants born to non-Hispanic Black 

women. In 2012, 16.53 percent of babies born to non-Hispanic Black 

women were preterm and 13.18 percent were low birth weight, rates 

Figure 1. Very Preterm, Preterm, Very Low Birth Weight, and Low Birth

Weight Rates, 1990–2012 Percent of Live Births

1.93

7.99

1.42

11.55

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. VitalStats. Available at: http://www.cdc.gov/nchs/vitalstats.htm. Accessed September

19, 2014.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center

for Health Statistics, Division of Vital Statistics. Natality public use data 1995–2002. CDC WONDER Online

Database; November 2005. Available at: http://wonder.cdc.gov/natality-v2002.html. Accessed August 25, 2014. 

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center

for Health Statistics, Division of Vital Statistics. Natality public use data 2003–2006. CDC WONDER Online

Database; March 2009. Available at: http://wonder.cdc.gov/natality-v2006.html. Accessed August 25, 2014.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center

for Health Statistics, Division of Vital Statistics. Natality public use data 2007–2012. CDC WONDER Online

Database; November 2013. Available at: http://wonder.cdc.gov/natality-current.html. Accessed August 25, 2014.

3

6

9

12

15

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Preterm (<37 Weeks)

Very Low Birth Weight (<1500 Grams) Very Preterm (<32 Weeks)

Low Birth Weight (<2500 Grams)
Child Health USA 2014 Health Status and Behaviors - Infants 26

that were respectively 1.6 and 1.9 times that of non-Hispanic White 

infants (10.29 and 6.97 percent, respectively; figures 2 and 3). The 

disparity in very preterm and very low birth weight is even greater, 

with non-Hispanic Black infants being 2.4 and 2.6 times more likely 

than non-Hispanic White infants to be born very preterm (3.71 versus 1.55 percent, respectively) and very low birth weight (2.94 versus 

1.13 percent, respectively). Compared to non-Hispanic White infants, 

Puerto Rican infants also had higher rates of preterm birth and low 

birth weight (13.23 and 9.40 percent, respectively), while Asian/Pacific 

Islander infants had a higher rate of low birth weight (8.21 percent). 

Racial and ethnic disparities in birth outcomes may be explained by 

differences in a variety of socioeconomic, psychosocial, behavioral, 

and medical risk factors.8

Rates of adverse birth outcomes also vary by maternal age. In 

2012, very preterm, preterm, very low birth weight, and low birth 

weight rates were all highest among mothers less than 20 years of 

Figure 2. Very Preterm and Preterm Birth Rates, by Maternal

Race/Ethnicity, 2012

Source: Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. National Vital Statistics Reports.

2013;62(9).

*May include Hispanics. †

Separate data for Asians, Native Hawaiians, and other Pacific Islanders not available.

Percent of Live Births

4 8 12 16 20

Central and

South American

Cuban

Puerto Rican

Mexican

Hispanic (total)

Asian/Pacific

Islander*†

American Indian/

Alaska Native*

Non-Hispanic

Black

Non-Hispanic White

Total

Very Preterm

(<32 weeks)

Preterm

(<37 weeks)

1.93

1.55

3.71

2.13

1.45

1.77

1.67

2.37

1.89

1.74

11.55

10.29

16.53

13.25

10.15

11.58

11.10

13.23

14.53

11.78

Figure 3. Very Low and Low Birth Weight Rates, by Maternal

Race/Ethnicity, 2012

Percent of Live Births

3 6 9 12 15

Central and South American

Cuban

Puerto Rican

Mexican

Hispanic (total)

Asian/Pacific

Islander*†

American Indian/ Alaska Native*

Non-Hispanic

Black

Non-Hispanic White

Total 1.42

1.13

2.94

1.33

1.13

1.22

1.13

1.77

1.55

1.13

7.99

6.97

13.18

7.61

8.21

6.97

6.48

9.40

7.43

6.64

Very Low Birth

Weight

(<1,500 grams)

Low Birth

Weight

(<2,500 grams)

Source: Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. National Vital Statistics Reports.

2013;62(9).

*May include Hispanics. †

Separate data for Asians, Native Hawaiians, and other Pacific Islanders not available.
Child Health USA 2014 Health Status and Behaviors - Infants 27

age and aged 35 years or older (figures 4 and 5). For example, very 

preterm birth rates were 2.59 percent among teenaged mothers and 

2.22 percent among those aged 35 years and older, compared to 

1.72 among 25- to 29-year-olds and 1.75 percent among 30- to 

34-year-olds. The higher rates of adverse birth outcomes among 

teens may be partly explained by socioeconomic disadvantage, while 

the higher rates among women aged 35 years and older tends to be 

a function of obstetric and medical complications and a greater probability of multiple births, both naturally and through fertility treatments, 

which have a substantially higher likelihood of preterm birth and low 

birth weight.8

Preventive interventions to reduce prematurity and low birth weight 

include screening and counseling to reduce smoking, alcohol, and 

substance use in pregnancy; comprehensive care before, during, and 

between pregnancies to identify and address chronic health conditions and to prevent unintended and rapid repeat pregnancies; placebased initiatives and care models that address social determinants 

such as housing and employment; and progesterone therapy to help 

sustain pregnancies among women with prior spontaneous preterm 

birth or with short cervical lengths.8 Other tertiary prevention efforts 

can reduce morbidity and mortality among infants born prematurely, 

such as improving access to risk-appropriate neonatal intensive care 

at delivery and antenatal corticosteroids that can promote fetal lung 

development prior to imminent premature delivery.8

Figure 4. Very Preterm and Preterm Birth Rates, by Maternal Age, 2012

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. 2012 Natality File. Analyzed by the Maternal and Child Health Bureau.

Percent of Live Births

3 6 9 12 15

35 Years

and Older

30–34

Years

25–29

Years

20–24

Years

Less than

20 Years

Total

Very Preterm

(<32 weeks)

Preterm

(<37 weeks)

1.93

2.59

2.13

1.97

1.72

1.75

1.89

2.22

11.55

13.29

11.48

10.55

10.97

13.61

Figure 5. Very Low and Low Birth Weight Rates, by Maternal Age, 2012

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. 2012 Natality File. Analyzed by the Maternal and Child Health Bureau.

Percent of Live Births

3 6 9 12 15

35 Years

and Older

30–34 Years

25–29 Years

20–24 Years

Less than

20 Years

Total 1.42

1.69

2.13

1.43

1.28

1.33

1.89

1.71

7.99

9.37

8.24

7.27

7.47

9.18

Very Low Birth

Weight

(<1,500 grams)

Low Birth

Weight

(<2,500 grams)
Child Health USA 2014 Health Status and Behaviors - Infants 28

Data Sources

Figure 1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. VitalStats. Available at: 

http://www.cdc.gov/nchs/vitalstats.htm. Accessed September 19, 2014.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Vital Statistics. Natality 

public use data 1995–2002. CDC WONDER Online Database; November 2005. Available at: http://wonder.cdc.gov/natality-v2002.html. Accessed August 25, 2014. 

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Vital Statistics. Natality 

public use data 2003–2006. CDC WONDER Online Database; March 2009. Available at: http://wonder.cdc.gov/natality-v2006.html. Accessed August 25, 2014.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Vital Statistics. Natality 

public use data 2007–2012. CDC WONDER Online Database; November 2013. Available at: http://wonder.cdc.gov/natality-current.html. Accessed August 25, 2014.

Figure 2 and 3. Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. National Vital Statistics Reports. 2013;62(9).

Figure 4 and 5. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. 2012 Natality File. 

Analyzed by the Maternal and Child Health Bureau.

Endnotes

1. March of Dimes. Premature babies. Available at: http://www.marchofdimes.org/baby/premature-babies.aspx. Accessed September 12, 2014.

2. March of Dimes. Low birth weight. Available at: http://www.marchofdimes.org/baby/low-birthweight.aspx. Accessed September 12, 2014.

3. Behrman R, Stith Butler A, eds. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: National Academies Press; 2007.

4. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet. January 5, 2008;371(9606):75–84.

5. Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. National Vital Statistics Reports. 2013;62(9).

6. Curtin SC, Ventura SJ, Martinez GM. Recent Declines in Nonmarital Childbearing in the United States. NCHS data brief no. 162. Hyattsville, MD: National Center for 

Health Statistics; 2014.

7. Osterman MJK, Martin JA. Recent Declines in Induction of Labor by Gestational Age. NCHS data brief no. 155. Hyattsville, MD: National Center for Health Statistics; 

2014.

8. Berns S, Kott A eds. Toward Improving the Outcome of Pregnancy III. White Plains, NY: March of Dimes; December 2010. 

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Infants 29

BIRTH DEFECTS

Birth defects, also known as congenital anomalies, occur in approximately 3 percent of all live births1

 and are the second leading 

cause of infant mortality behind prematurity, accounting for 20.9 percent of all infant deaths in the United States in 2011 (see page on 

infant mortality). Birth defects are conditions present at birth that most 

often occur during the first trimester of pregnancy and cause structural changes in one or more parts of the body.2

 Although most birth 

defects have unknown causes, they are thought to be caused by a 

combination of genetic, behavioral, and environmental factors. Some 

factors that have been linked to birth defects include tobacco, alcohol, 

and illicit drug use during pregnancy; obesity and uncontrolled diabetes; use of certain medications during pregnancy; a maternal age of 

more than 34 years; and a family history of birth defects.2

Congenital heart defects are the most common type of birth defect 

in the United States, affecting nearly 1 percent of—or about 40,000—

births per year.3 Atrioventricular septal defects, in which there is a hole 

in the wall of the heart chambers and valves, are a common type of 

congenital heart defect, with about 2,000 cases annually (table 1). 

Among the chromosomal abnormalities, trisomy 21, or Down syndrome, is the most common, with about 6,000 annual cases. Orofacial defects, including cleft lip and cleft palate, are another common 

type of birth defect, with approximately 7,000 cases annually. 

In 2011, congenital heart defects and chromosomal abnormalities were the leading categories of infant death due to birth defects, 

accounting for 23.6 and 19.5 percent of deaths attributable to birth 

defects, respectively. Central nervous system defects, also known as 

neural tube defects, were the third leading category at 13.6 percent. 

Infant mortality rates due to birth defects vary by several demographic characteristics, including maternal age, race/ethnicity, educational attainment, and rural/urban residence. For example, infant mortality due to birth defects generally increased with rurality, ranging from 

11.21 per 10,000 live births among residents of large fringe metro 

Table 1. National Prevalence Estimates of Selected Major

Birth Defects,* 2004–2006

Estimated Annual 

Number of Cases

Prevalence per 10,000 

Live Births

Congenital heart defects**

Atrioventricular septal defect 1,966 4.71

Common truncus 301 0.72

Hypoplastic left heart syndrome 960 2.30

Tetralogy of Fallot 1,657 3.97

Transposition of great arteries 1,252 3.00

Chromosomal abnormalities†

Trisomy 13 528 1.26

Trisomy 18 1,109 2.66

Trisomy 21 (Down syndrome) 6,037 14.47

Orofacial defects**

Cleft palate without cleft lip 2,651 6.35

Cleft lip with or without cleft palate 4,437 10.63

Central nervous system defects**

Anencephaly 859 2.06

Encephalocele 341 0.82

Spina bifida without anencephaly 1,460 3.50

*Fourteen programs contributed data: Arkansas, Arizona, California (eight-county Central 

Valley), Colorado, Georgia (five-county metropolitan Atlanta), Illinois, Iowa, Kentucky, Massachusetts, North Carolina, Oklahoma, Puerto Rico, Texas, and Utah. The number of live 

births represented by these 14 programs from 2004 to 2006 was 4,038,506. **Estimates 

are adjusted for maternal race/ethnicity. †Estimates are adjusted for maternal age.
Child Health USA 2014 Health Status and Behaviors - Infants 30

Figure 1. Infant Mortality Rates due to Birth Defects per 10,000 Live

Births,* by Urban/Rural Residence,** 2011 Rate per 10,000 Live Births

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. Underlying cause of death 1999–2011. CDC WONDER Online Database. 2014.

Available at: http://wonder.cdc.gov/ucd-icd10.html. Accessed October 1, 2014. 

*Infant deaths at less than 1 year of age with an underlying cause-of-death ICD-10 code of Q00–Q99. **Based

on: Ingram DD, Franco SJ. 2013 NCHS urban–rural classification scheme for counties. National Vital Health

Statistics. 2014;2(166). Available at: http://www.cdc.gov/nchs/data_access/urban_rural.htm.

Accessed October 7, 2014.

4

8

12

16

20

All Micropolitan Noncore

Nonmetro

Small

Metro

Medium

Metro

Large

Fringe

Metro

Large

Central

Metro

Total All Metro

13.58 13.69

15.59

11.21 11.68 12.23 12.69

16.25

15.15

counties (suburban) to 16.25 per 10,000 live births among residents 

of noncore or completely rural counties (figure 1). Demographic differences in mortality rates attributable to birth defects may be due to 

differential exposures and the prevalence of birth defects, as well as 

differential access to screening and risk-appropriate care.

Certain birth defects can be prevented by maintaining a healthy 

weight before and during pregnancy, controlling diabetes, abstaining 

from substance use, talking to a doctor about which medications are 

safe to take during pregnancy, getting appropriate vaccinations to 

avoid infection, and taking a daily prenatal vitamin prior to and during 

pregnancy.2

 In particular, taking folic acid before becoming pregnant 

has been shown to reduce the risk for neural tube defects by 50–70 

percent.4

 Screening tests that can identify some birth defects can be 

administered during both the first and second trimesters of pregnancy and may include blood tests, ultrasounds, and/or testing of the 

placenta or amniotic fluid.2

 Screening healthy newborns using pulse 

oximetry can be a useful, cost-effective way to identify babies born 

with critical congenital heart defects before they are discharged from 

the birth hospital.5

Data Sources

Table 1. Parker SE, Mai CT, Canfield MA, et al. Updated national birth prevalence estimates for selected birth defects in the United States, 2004–2006. Birth Defects 

Research, Part A: Clinical and Molecular Teratology. December 2010;88(12):1008–1016.

Figure 1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying cause of death 

1999–2011. CDC WONDER Online Database. 2014. Available at: http://wonder.cdc.gov/ucd-icd10.html. Accessed October 1, 2014. 

Endnotes

1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Update on overall prevalence of major birth defects—Atlanta, Georgia, 

1978–2005. Morbidity and Mortality Weekly Report. 2008;57(1):1–5.

2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Birth Defects. Available at: http://www.cdc.gov/ncbddd/birthdefects/

index.html. Accessed October 3, 2014. 

3. Reller MD, Strickland MJ, Riehle-Colarusso T, Mahle WT, Correa A. Prevalence of congenital heart defects in Atlanta, 1998–2005. Journal of Pediatrics. 2008;153:807–

813. 

4. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR Recommendations and Reports: 

Morbidity and Mortality Weekly Report. September 11, 1992;41(RR-14):1–7.

5. Peterson, C, Grosse SD, Oster ME, Olney RS, Cassell CH. Cost-effectiveness of routine screening for critical congenital heart disease in U.S. newborns. Pediatrics. 

September 2013;132(3):e595–e603.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Infants 31

SLEEP-RELATED SUDDEN 

UNEXPECTED INFANT DEATH

Sleep-related sudden unexpected infant death (SUID) accounts for 

the most deaths in infants between 1 month and 1 year of age at 38 

percent in 2011 (see page on infant mortality). SUID is defined by a 

Healthy People 2020 objective to include deaths due to sudden infant 

death syndrome (SIDS), unknown causes, and accidental suffocation 

and strangulation in bed.1 These causes of death have been grouped 

due to evidence that some deaths previously classified as SIDS are 

now being assigned to other sleep-related causes of death.2 For example, SIDS rates declined from 1998 to 2001, while death rates due 

to other unknown causes and accidental suffocation and strangulation in bed were rising. SUID is generally believed to result from the 

intersection of three risks: a biological vulnerability (e.g., a dysfunctional arousal system); a critical period of development (1–6 months 

of age); and an environmental cofactor such as stomach or side sleep 

position, soft bedding, or overheating.2

In 2011, there were a total of 3,403 cases of SUID, occurring at a 

rate of 0.86 per 1,000 live births (figure 1). The SUID rate generally declined from 1990 to 1998, which has been attributed to the American 

Academy of Pediatrics (AAP) recommendation that infants be placed 

to sleep on their backs, with an accompanying public awareness 

campaign known as “Back to Sleep.”2 The SUID rate generally plateaued from 1998 to 2009 but then declined for 2 consecutive years 

reaching a historic low in 2011. 

Despite recent progress, SUID rates vary greatly by race and ethnicity. In 2011, SUID rates were highest for infants born to American 

Indian/Alaska Native and non-Hispanic Black mothers (2.01 and 1.62 

per 1,000 live births, respectively); these rates were twice or more 

the rate among infants born to non-Hispanic Whites (0.84 per 1,000; 

figure 2). Compared with non-Hispanic Whites, the higher rate of SUID 

was the leading contributor to the higher overall infant mortality rate 

for American Indians/Alaska Natives, accounting for 37 percent of the 

disparity. SUID was the second leading cause of the higher non-Hispanic Black infant mortality rate, accounting for 12 percent of the 

disparity. SUID rates were generally lowest for infants born to Asian/

Pacific Islander mothers (0.38 per 1,000) and Hispanic mothers (0.50 

per 1,000), except for Puerto Ricans (1.19 per 1,000). However, SUID 

rates have been shown to be higher among infants born to Native Hawaiian mothers.3

 Racial and ethnic differences in safe sleep practices 

may contribute to SUID disparities (see page on safe sleep behavior). 

In 2011, the American Academy of Pediatrics released expanded recommendations to promote safe sleep environments and other protective factors that can reduce the risk of sleep-related infant 

deaths.4 These form the basis of the new “Safe to Sleep” campaign5

and include recommendations beyond the back sleep position, such 

as sleeping in a safety-approved crib or bassinet, removing loose bedding and soft objects from the sleep surface, room sharing without 

bed sharing, breastfeeding, and avoiding exposure to tobacco smoke 

and other drugs. In addition, a new classification system developed 

by the Centers for Disease Control and Prevention may help improve 

SUID investigation and prioritize prevention opportunities at state and 

local levels.6

Figure 1. Sleep-Related SUID* Mortality Rates per 1,000 Live Births,

by Listed Cause of Death, 1990–2011 Rate per 1,000 Live Births

0.22

0.16

0.48

0.86

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. Compressed mortality file 1979–1998. CDC WONDER Online Database. 2003.

Available at: http://wonder.cdc.gov/cmf-icd9.html. Accessed August 8, 2014.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center

for Health Statistics. Compressed mortality file 1999–2011. CDC WONDER Online Database. July 2014.

Available at: http://wonder.cdc.gov/cmf-icd10.html. Accessed August 8, 2014.

*Sudden unexpected infant deaths (SUID) include sudden infant death syndrome (SIDS; ICD-10 code of R95),

unknown cause (R99), and accidental suffocation or strangulation in bed (W75).

0.4

0.8

1.2

1.6

2.0

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2011

Accidental Suffocation and Strangulation in Bed

All Sleep-Related SUID

Unknown Cause

SIDS
Child Health USA 2014 Health Status and Behaviors - Infants 32

Data Sources

Figure 1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed mortality file 

1979–1998. CDC WONDER Online Database. 2003. Available at: http://wonder.cdc.gov/cmf-icd9.html. Accessed August 8, 2014.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed mortality file 1999–

2011. CDC WONDER Online Database. July 2014. Available at: http://wonder.cdc.gov/cmf-icd10.html. Accessed August 8, 2014.

Figure 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. 2011 Linked Birth/Infant 

Death File. Analyzed by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Endnotes

1. U.S. Department of Health and Human Services. Healthy People 2020 Topics & Objectives: Maternal, Infant, and Child Health. Available at: http://www.healthypeople.

gov/2020/topicsobjectives2020. Accessed September 26, 2014. 

2. American Academy of Pediatrics. Technical report—SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleep environment.

Pediatrics. November 2011;128(5):e1341–e1367. 

3. U.S. Department of Health and Human Services, Centers of Disease Control and Prevention, National Center for Health Statistics, Division of Vital Statistics. Linked 

birth/infant death records, 1999–2002. CDC WONDER Online Database. Available at: http://wonder.cdc.gov/lbd-v2002.html. Accessed September 26, 2014.

4. American Academy of Pediatrics. Policy statement—SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleep environment.

Pediatrics. November 2011;128(5):1030–1039. 

5. U.S. Department of Health and Human Services, National Institutes of Health, National Institutes of Child Health and Human Development. Safe to Sleep® Public 

Education Campaign. Available at: http://www.nichd.nih.gov/sts/Pages/default.aspx. Accessed September 26, 2014. 

6. Shapiro-Mendoza CK, Camperlengo L, Ludvigsen R, et al. Classification system for the Sudden Unexpected Infant Death Case Registry and its application. Pediatrics.

July 2014;134(1):e210–e219.

Figure 2. Sleep-Related SUID* Mortality Rates per 1,000 Live Births,

by Maternal Race/Ethnicity, 2011

Rate per 1,000 Live Births

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. 2011 Linked Birth/Infant Death File. Analyzed by the U.S. Department of Health and

Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

*Sudden unexpected infant deaths (SUID) include sudden infant death syndrome (SIDS; ICD-10 code of R95),

unknown cause (R99), and accidental suffocation or strangulation in bed (W75). **May include Hispanics.

†

Fewer than 20 deaths. Data did not meet standards of reliability or precision.

0.5 1.0 1.5 2.0 2.5

Central and South American

Cuban

Puerto Rican

Mexican

Hispanic (Total)

Asian/

Pacific Islander**

American Indian/

Alaska Native** 

Non-Hispanic Black

Non-Hispanic White

Total 0.86

0.84

0.45

1.62

0.38

1.19

†

0.33

2.01

0.50

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Infants 33

SAFE SLEEP BEHAVIORS

Safe sleep behaviors are practices that reduce the risk of sleep-related sudden unexpected infant death (SUID), which accounts for the 

most deaths among infants aged 1 month to 1 year. SUID includes 

sudden infant death syndrome (SIDS), unknown causes, and accidental suffocation and strangulation in bed (see page on sleep-related 

SUID). Safe sleep practices recommended by the American Academy of Pediatrics (AAP) include placing an infant on his or her back 

in a separate crib or bassinet without soft bedding both at night and 

during naps.1 Additional practices with strong evidence for reducing 

the risk of SUID include breastfeeding, offering a pacifier before naptime or bedtime, and avoiding smoke and alcohol exposure during 

and after pregnancy.1 

In 2011, 74.0 percent of recent mothers in 23 states and New York 

City reported that their infant was laid down to sleep on his or her 

back most of the time (figure 1). The proportion of mothers reporting 

this safe sleep behavior was between 75.8 and 80.0 percent among 

non-Hispanic White, non-Hispanic American Indian/Alaska Native, 

non-Hispanic Asian, and non-Hispanic Native Hawaiian/other Pacific 

Islander mothers. Use of the back sleep position was lowest among 

non-Hispanic Black mothers (53.9 percent), followed by Hispanic 

mothers (66.0 percent). 

The AAP recommends room sharing without bed sharing, in which 

infants may be brought into bed for breastfeeding or comfort but returned to a separate in-room crib or bassinet for sleep.1

 Sharing a 

bed with an infant during sleep increases the risk of SUID, particularly 

with soft bedding and blankets, soft sleep surfaces like couches and 

armchairs, and parental smoking or substance use.1 In 2011, 43.3 

percent of recent mothers in 13 states reported that their infants never 

slept in the same bed with an adult (figure 2). The proportion of mothers who reported no infant and adult bed sharing was highest among 

non-Hispanic White mothers (50.6 percent), followed by Hispanic 

mothers (38.3 percent). About one-quarter or fewer mothers from 

most other racial and ethnic groups reported never bed sharing. Conversely, mothers who reported always or often bed sharing ranged 

from 13.8 percent of non-Hispanic White mothers to 43.2 percent of 

non-Hispanic Asian mothers.

Back sleep position and never bed sharing increase with maternal 

age and education. For example, usual practice of back sleep position 

ranged from 64.4 percent among mothers with less than 12 years of 

education to 82.4 percent among those with 16 or more years of education. Similarly, never bed sharing ranged from 27.5 percent among 

mothers less than 20 years old to nearly 50 percent among mothers 

aged 30 years and older.

Figure 1. Infants Usually Placed to Sleep on Their Backs, by Maternal

Race/Ethnicity, 2011* Percent of Women Delivering Live Births

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC).

Pregnancy Risk Assessment Monitoring System, 2011. Analysis conducted by the CDC Division of Reproductive

Health, National Center for Chronic Disease Prevention and Health Promotion.

*Includes data from 23 states (AR, CO, GA, HI, ME, MD, MI, MN, MO, NE, NJ, NM, NY, OK, OR, PA, RI, UT, VT,

WA, WV, WI, WY) and New York City. Mothers completed surveys between 2 and 9 months postpartum.

Responses that included sleep positions other than the back (e.g., stomach, side) alone or in combination with

the back are not counted as usually put to sleep on back. Multiple race data were not reported by 5 of 23 states

(AR, HI, ME, NJ, WV); therefore, specific race categories may include multiple race mothers.

18

36

54

72

90

NonHispanic

Multiple

Races

NonHispanic

Native

Hawaiian/

Other

Pacific Islander

NonHispanic

Asian

NonHispanic

American

Indian/Alaska

Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

66.0

53.9

80.0 78.4

72.5 74.0 76.6 75.8
Child Health USA 2014 Health Status and Behaviors - Infants 34

To reduce the risk of sleep-related SUID, the AAP also recommends 

removing soft bedding from infant sleep areas, such as blankets, 

quilts, and pillows.1 A recent national study found that 54.7 percent 

of U.S. infants are placed to sleep underneath or on top of potentially 

hazardous bedding.4 Resources to educate parents, caregivers, and 

health care providers regarding ways to reduce the risk for SIDS and 

other sleep-related causes of infant death are provided by the “Safe 

to Sleep” campaign (previously known as the “Back to Sleep” campaign).2

 This collaborative effort at the federal, state, and local levels 

was renamed and expanded in 2012 to reflect the AAP’s broader recommendations and to address all sleep-related infant deaths. Crib 

distribution programs may also be effective in providing safe sleep 

education and cribs to mothers and families who may not be able to 

afford them.3

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). Pregnancy Risk Assessment Monitoring System, 

2011. Analysis conducted by the CDC Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion.

Endnotes

1. American Academy of Pediatrics. SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleep environment. Pediatrics. November 

2011;128(5):1030–1039. 

2. U.S. Department of Health and Human Services, National Institutes of Health, National Institutes of Child Health and Human Development. Safe to Sleep® Public 

Education Campaign. Available at: http://www.nichd.nih.gov/sts/Pages/default.aspx. Accessed September 26, 2014. 

3. Carlins EM, Collins KS. Cribs for kids: risk and reduction of sudden infant death syndrome and accidental suffocation. Health & Social Work. August 2007;32(3):225–

229.

4. Shapiro-Mendoza CK, Colson ER, Willinger M, Rybin DV, Camperlengo L, Corwin MJ. Trends in Infant Bedding Use: National Infant Sleep Position Study, 1993-2010. 

Pediatrics. Dec 1, 2014.

Figure 2. Infant and Adult Bed Sharing, by Maternal Race/Ethnicity,

2011*

*Includes data from 13 states (GA, HI, MD, MN, MO, NE, NJ, NY without NY City, PA, VT, WA, WV, WI).

Mothers completed surveys between 2 and 9 months postpartum. The question reflects whether the infant slept

in the same bed with the mother or another adult. Percentages may not sum to 100 due to rounding. Multiple

race data were not reported by 3 of 13 states (HI, NJ, WV); therefore, specific race categories may include

multiple race mothers.

20 40 60 80 100

Non-Hispanic

Multiple Races

Non-Hispanic

Native Hawaiian/

Other Pacific Islander

Non-Hispanic Asian

Non-Hispanic American Indian/Alaska Native

Hispanic

Non-Hispanic Black

Non-Hispanic White

Total

43.0

40.5

40.8

19.5

13.8

29.4

23.8

31.3

43.2

35.9

27.2

35.2

37.2

35.7

38.0

46.6

27.7

32.3

27.9

21.6

43.3

50.6

38.3

17.6

Percent of Women Delivering Live Births

Always/Often Sometimes/Rarely Never

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC).

Pregnancy Risk Assessment Monitoring System, 2011. Analysis conducted by the CDC Division of Reproductive

Health, National Center for Chronic Disease Prevention and Health Promotion.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Infants 35

SMOKING BEFORE AND DURING 

PREGNANCY

After alcohol, tobacco is the most prevalent substance consumed 

by women of child-bearing age.1 Smoking among nonpregnant women contributes to reduced fertility. Fetal effects of smoking during 

pregnancy include premature birth, fetal growth restriction/low birth 

weight, orofacial clefts, and heightened risk of sudden infant death 

syndrome.2,3 Notable maternal complications of smoking are placental 

abruption, premature rupture of membranes, and placenta previa. In 

addition, there is evidence of a causal relationship between maternal 

smoking and ectopic pregnancy.2

In 2011, 22.7 percent of recent mothers in 23 states and New York 

City reported smoking in the 3 months before pregnancy. The proportion of mothers who smoked dropped by approximately half by the 

last 3 months of pregnancy (10.2 percent). Smoking during both preconception and prenatal periods varied by race and ethnicity. Smoking 

in the 3 months prior to pregnancy ranged from 6.1 percent among 

non-Hispanic Asian mothers to 41.6 percent among non-Hispanic 

American Indian-Alaska Native mothers (figure 1). Similarly, smoking 

in the last 3 months of pregnancy ranged from 2.0 percent among 

non-Hispanic Asian mothers to 16.9 percent among non-Hispanic 

American Indian/Alaska Native mothers. Preconception and prenatal 

smoking rates were also relatively low among Hispanic mothers (12.1 

and 3.7 percent, respectively). Rates of smoking cessation, defined 

as not smoking in the last 3 months of pregnancy among those who 

smoked prior to pregnancy, were highest for Hispanic mothers (69.5 

percent) and non-Hispanic Asian mothers (66.6 percent) compared to 

55.3 percent overall.

The proportion of mothers who reported smoking before and 

during pregnancy also varied by maternal age. Compared to older 

mothers, preconception and prenatal smoking were more prevalent 

among mothers aged 20–24 years (33.1 and 16.0 percent, respectively) and under 20 years of age (32.4 and 15.5 percent, respectively; 

figure 2). Mothers aged 35 years or older were the least likely to smoke 

before conception (12.8 percent), while mothers aged 30–34 years 

and 35 years or older were least likely to smoke during the prenatal 

period (6.7 and 5.6 percent, respectively). 

Smoking before and during pregnancy also varied by maternal education and marital status. Smoking before pregnancy was at least 

3 times greater among mothers with 12 years of education or less 

(29.3 to 33.3 percent) than among those with 16 or more years of 

education (8.9 percent). Prenatal smoking was about 12 times greater among mothers with 12 years of education or less (17.0 to 17.2 

Figure 1. Cigarette Smoking Before and During Pregnancy, by

Maternal Race/Ethnicity, 2011*

10

20

30

40

50

NonHispanic

Multiple Race

NonHispanic

Native

Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American

Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Percent of Women Delivering Live Births

41.6

19.5

25.2 27.1

12.8 10.6

2.0

22.7

10.2 8.2 6.1 3.7

31.9

15.4

12.1

16.9

Prepregnancy Smoking**

Prenatal Smoking†

*Includes data from 23 states (AR, CO, GA, HI, ME, MD, MI, MN, MO, NE, NJ, NM, NY, OK, OR, PA, RI,

UT, VT, WA, WV, WI, WY) and New York City. Mothers completed surveys between 2 and 9 months

postpartum. Multiple race data were not reported by 5 of 23 states (AR, HI, ME, NJ, WV); therefore, specific race

categories may include multiple race mothers.**Defined as the proportion of mothers who reported smoking in

the 3 months before pregnancy. †

Defined as the proportion of mothers who reported smoking in the last

3 months of pregnancy. 

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC),

Pregnancy Risk Assessment Monitoring System, 2011–2012. Analysis conducted by the CDC Division of

Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion.
Child Health USA 2014 Health Status and Behaviors - Infants 36

percent) than among those with 16 or more years of education (1.4 

percent). This reflects a considerably higher cessation rate for mothers 

with at least 16 years of education (85.0 percent) than for those with 

12 years of education or less (42.0 to 48.3 percent). Unmarried mothers were more than twice as likely as married mothers to smoke in the 

3 months before pregnancy (36.3 versus 14.4 percent, respectively) 

and three times more likely to smoke during pregnancy (18.5 versus 

5.1 percent, respectively).

In order to avoid early pregnancy complications, it is recommended that women quit smoking before they become pregnant.4 Due to 

awareness of the neonatal health consequences of smoking, pregnancy may be a time of heightened motivation to quit. The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians 

ask all pregnant women about tobacco use and provide augmented, 

pregnancy-tailored counseling for those who smoke.5

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), Pregnancy Risk Assessment Monitoring System, 

2011–2012. Analysis conducted by the CDC Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion.

Endnotes

1. Floyd RL, Jack BW, Cefalo R, et al. The clinical content of preconception care: alcohol, tobacco, and illicit drug exposures. American Journal of Obstetrics and Gynecology. 2008;199(6 Suppl 2):S333–S339.

2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of 

Health and Human Services; 2014.

3. Minnes S, Lang A, Singer L. Prenatal tobacco, marijuana, stimulant, and opiate exposure: outcomes and practice implications. Addiction Science & Clinical Practice. 

2011;6:57–70. 

4. Gregory KD, Niebyl JR, Johnson TRB. Preconception and prenatal care: part of the continuum. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics: Normal and 

Problem Pregnancies, 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2012.

5. U.S. Preventive Services Task Force. Counseling to prevent tobacco use and tobacco-caused disease in adults and pregnant women: reaffirmation recommenda¬tion 

statement. American Family Physician. 2010;82(10):1266–1268. 

Figure 2. Cigarette Smoking Before and During Pregnancy, by

Maternal Age, 2011*

8

16

24

32

40

35 Years

and Older 

30–34

Years 

25–29

Years 

20–24

Years 

Under

20 Years 

Percent of Women Delivering Live Births

33.1

12.8

15.5

10.0

32.4

16.0 16.8

6.7 5.6

22.6

Prepregnancy Smoking†

Prenatal Smoking‡

*Includes data from 23 states (AR, CO, GA, HI, ME, MD, MI, MN, MO, NE, NJ, NM, NY, OK, OR, PA,

RI, UT, VT, WA, WV, WI, WY) and New York City. Mothers completed surveys between 2 and 9 months

postpartum. †

Defined as the proportion of mothers who reported smoking in the 3 months before pregnancy. ‡

Defined as the proportion of mothers who reported smoking in the last 3 months of pregnancy. 

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC),

Pregnancy Risk Assessment Monitoring System, 2011–2012. Analysis conducted by the CDC Division of

Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Infants 37

BINGE DRINKING BEFORE AND 

DURING PREGNANCY

Both preconception and prenatal alcohol consumption are associated with significant maternal and fetal health risks, particularly 

when that drinking is excessive. Binge drinking for women is defined 

as consuming four or more alcohol drinks (beer, wine, or liquor) on 

an occasion.1 Among non-pregnant women, binge drinking is more 

likely to lead to unprotected sex and multiple sex partners which in 

turn increases the risks of unintended pregnancy.2 Women who become pregnant without realizing it may continue alcohol use during 

the early first trimester when fetal organ systems are being formed, 

posing serious risk to fetal development throughout gestation.3 Prenatal drinking is associated with spontaneous abortion, prenatal and 

postnatal growth restriction, sudden infant death syndrome (SIDS), 

birth defects, and neurodevelopmental deficits such as Fetal Alcohol 

Syndrome (FAS).4,5

In 2011, approximately one quarter (23.0 percent) of recent mothers in 23 states and New York City reported binge drinking in the 3 

months prior to pregnancy (figure 1). The overwhelming majority of 

mothers discontinued binge drinking by the last 3 months of pregnancy (97.4 percent) and less than 1 percent (0.77 percent) reported 

binge drinking during the final 3 months of pregnancy. Binge drinking 

varied by maternal age prior to pregnancy but not during pregnancy. Pre-pregnancy binge drinking was most common among women 

aged 20–29 years (25–26 percent) and least common among women 

age 19 years or less (17.0 percent) and those age 35 years or older 

(17.8 percent). Quit rates for binge drinking did not vary by maternal 

age. 

Both pre-pregnancy and prenatal binge drinking varied by race and 

ethnicity. Pre-pregnancy binge drinking was most common among 

non-Hispanic American Indian/Alaska Native, non-Hispanic White, 

non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic mothers of multiple races (25–30 percent; figure 2). These 

women were approximately 2.5 to 3.0 times more likely to binge 

drink during the 3 months before pregnancy as non-Hispanic Asian 

mothers (9.1 percent). Prenatal binge drinking varied across race and 

ethnicity: compared to non-Hispanic White mothers (0.5 percent), 

binge drinking in the last 3 months of pregnancy was higher among 

Hispanic, non-Hispanic American Indian/Alaska Native, and non-Hispanic Black mothers (1.5, 1.4, and 0.9 percent, respectively). Binge 

drinking cessation rates were lower for non-Hispanic Asian, Hispanic, 

non-Hispanic Black, and non-Hispanic American Indian/Alaska Native 

mothers (89.8, 90.7, 95.1, and 95.7 percent, respectively) compared 

with non-Hispanic White mothers (98.7 percent).

Binge drinking before and during pregnancy also varied by maternal education and marital status. Pre-pregnancy binge drinking 

was lowest among those with less than a high school education 

Figure 1. Binge Drinking Before and During Pregnancy, by Maternal

Age, 2011*

8

16

24

32

40

35 Years

or More 

30-34

Years 

25-29

Years 

20-24

Years 

19 Years

or Less 

Total

Percent of Women Delivering Live Births

26.1 25.3

17.8 17.0

0.76 0.87

23.0

0.77 0.91 0.64 0.60

22.6

Prepregnancy Binge Drinking†

Prenatal Binge Drinking‡

*Includes data from 23 states (AR, CO, GA, HI, ME, MD, MI, MN, MO, NE, NJ, NM, NY, OK, OR, PA, RI, UT, VT,

WA, WV, WI, WY) and New York City. Mothers completed surveys between 2 and 9 months postpartum.

†

Reported binge drinking (> 4 drinks on an occasion) in the 3 months before pregnancy. ‡

Reported binge drinking (> 4 drinks on an occasion) in the last 3 months of pregnancy.

Source: Centers for Disease Control and Prevention, Pregnancy Risk Assessment Monitoring System, 2011.

Analysis conducted by the Division of Reproductive Health, National Center for Chronic Disease Prevention and

Health Promotion.
Child Health USA 2014 Health Status and Behaviors - Infants 38

(12.5 percent) and above 20 percent for women with higher levels 

of education. The highest rate of pre-pregnancy binge drinking was 

among women with some college education (28.0 percent). However, binge drinking during the last 3 months of pregnancy was lowest 

among women with a college degree (0.49 percent) compared with 

0.89-0.95 percent of women with less education. Binge drinking was 

greater among unmarried mothers versus married mothers both before pregnancy (26.2 versus 21.1 percent, respectively) and during the 

last 3 months of pregnancy (1.1 versus 0.58 percent, respectively). 

Drinking before and during pregnancy continues to be an important public health concern. Screening for alcohol problems is recommended for adults by the U.S. Preventive Services Task Force and is 

recommended for adolescents by the American Academy of Pediatrics. Screening coupled with brief intervention strategies such as 

physician advice or counseling have proved effective in decreasing 

alcohol abuse and binge drinking in primary care settings in general 

and among women of childbearing age in particular.6,7

Data Sources

Figure 1 and 2. Centers for Disease Control and Prevention, Pregnancy Risk Assessment Monitoring System, 2011. Analysis conducted by the Division of Reproductive 

Health, National Center for Chronic Disease Prevention and Health Promotion.

Endnotes

1. CDC Vital Signs. Binge drinking. A serious, under-recognized problem among women and girls. National Center for Chronic Disease Prevention and Health Promotion. 

Division of Population Health. 2013.

2. Naimi TS, Lipscomb LE, Brewer RD, Gilbert BC. Binge drinking in the preconception period and the risk of unintended pregnancy: Implications for women and their 

children. Pediatrics. 2003;111(5):1136–1141.

3. Streissguth AP, O’Malley K. Neuropsychiatric implications and long-term consequences of fetal alcohol spectrum disorders. Semin Clin Neuropsychiatry. 2000;5:177-

90.

4. Kesmodel U, Wisbong K, Olsen SF et al. Moderate alcohol intake in pregnancy and the risk of spontaneous abortion. Alcohol Alcohol. 2002;37:87-92.

5. Mattson SN, Schoenfeld REP. Teratogenic effects of alcohol on brain and behavior. Alcohol Clin Exp Res. 2001;25:185-91. 

6. Fleming MF, Barry KL, Manwell LB et al. Brief physician advice for problem drinkers. JAMA. 1997;277:1039–1045.

7. Manwell LB, Fleming MF, Mundt MP et al. Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial. Alcohol Clin Exp Res. 

2000;24:1517–1524.

Figure 2. Binge Drinking Before and During Pregnancy, by Maternal

Race/Ethnicity, 2011*

8

16

24

32

40

NonHispanic

Multiple

Race

NonHispanic Native Hawaiian/ Other Pacific IslanderNonHispanic

Asian

NonHispanic American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

9.1

14.2

25.2

14.8

0.88 1.01 0.70

28.2

0.49 1.53 1.44

26.9

2.27

30.5

Prepregnancy Binge Drinking†

Prenatal Binge Drinking‡

*Includes data from 23 states (AR, CO, GA, HI, ME, MD, MI, MN, MO, NE, NJ, NM, NY, OK, OR, PA, RI, UT, VT,

WA, WV, WI, WY) and New York City. Mothers completed surveys between 2 and 9 months postpartum. Multiple

race data were not reported by 5 of 23 states (AR, HI, ME, NJ, WV); therefore, specific race categories may

include multiple race mothers. †

Reported binge drinking (> 4 drinks on an occasion) in the 3 months before

pregnancy. ‡Reported binge drinking (> 4 drinks on an occasion) in the last 3 months of pregnancy.

Source: Centers for Disease Control and Prevention, Pregnancy Risk Assessment Monitoring System, 2011.

Analysis conducted by the Division of Reproductive Health, National Center for Chronic Disease Prevention and

Health Promotion. Percent of Women Delivering Live Births

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Infants 39

BREASTFEEDING

Breastfeeding has been shown to promote the health and development of infants, as well as their immunity to disease. It also confers 

a number of maternal health benefits, such as a decreased risk of 

breast and ovarian cancers and other chronic conditions, including 

cardiovascular disease.1,2 The American Academy of Pediatrics Section on Breastfeeding recommends exclusive breastfeeding—with no 

supplemental food or liquids—through the first 6 months of life and 

continued breastfeeding through at least the first year.3 One study indicated that suboptimal breastfeeding rates in the United States add an 

estimated $2.2 billion dollars annually to direct medical costs.4

While three-quarters of infants born in 2010 were ever breastfed 

(76.5 percent), slightly less than half (49.0 percent) were fed breast 

milk for the first 6 months of life, and 16.4 percent were exclusively 

breastfed for that duration. Breastfeeding practices vary considerably 

by maternal race and ethnicity, age, and education. With respect to 

race and ethnicity, the proportion of infants to have ever been breastfed was higher among Asian, Hispanic, and non-Hispanic White infants (84.8, 77.9, and 78.8 percent, respectively) than non-Hispanic 

Black infants (61.9 percent; figure 1).

Infants born to mothers aged 30 years or older were most likely to 

have been breastfed (80.9 percent), while children born to mothers 

under 20 years of age were least likely to have ever been breastfed 

(51.3 percent; figure 2). Similarly, 17.9 percent of infants born to mothers aged 30 years or older breastfed exclusively at 6 months, compared to 5.8 percent of infants born to mothers younger than age 20.

With regard to maternal education, the proportion of infants to 

have ever been breastfed and to have been breastfed exclusively at 

6 months was highest among those born to mothers with at least 

a college education (88.7 and 21.8 percent, respectively). Common 

barriers to exclusive breastfeeding include maternal employment, 

pain related to breastfeeding, and unsupportive hospital policies.5 The 

Affordable Care Act requires most health insurance plans to provide 

breastfeeding support, counseling, and equipment to pregnant and 

nursing women.6

Figure 1. Infants* Who Are Breastfed, by Race/Ethnicity and Duration,

2010 Percent of Infants

*Includes only infants born in 2010; data are provisional. **Reported that the child was ever breastfed or fed

human breast milk. †

Exclusive breastfeeding is defined as only human breast milk—no solids, water, or other

liquids. ‡Includes Hispanics. 

20

40

60

80

100

Multiple

Races‡

Native

Hawaiian/

Other

Pacific Islander‡

American

Indian/Alaska

Native‡

Asian Non- Hispanic ‡

Hispanic

Black

NonHispanic

White

Total

Ever Breastfed**

Any at 6 Months

Exclusively at 6 Months†

49.0

76.5

16.4

48.3

77.9

16.0

57.2

74.6

8.3

48.3

74.9

19.1

58.2

84.8

12.4

51.8

35.9

61.9

78.8

18.6

50.7

94.0

10.1 9.2

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. National

Immunization Survey (NIS). Unpublished data. The 2010 provisional rates are based on the landline telephone

sample in NIS to maintain comparability with previous years in the decade when only a landline sample

was available.
Child Health USA 2014 Health Status and Behaviors - Infants 40

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. National Immunization Survey (NIS). Unpublished data. 

The 2010 provisional rates are based on the landline telephone sample in NIS to maintain comparability with previous years in the decade when only a landline sample 

was available.

Endnotes

1. Ip S, Chung M, Raman G, Chew P, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment.

April 2007;153:1–186.

2. Schwarz EB, Ray RM, Steube AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics and Gynecology. 2009;113(5):974–982.

3. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496–506.

4. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125(5):e1048–e1056.

5. Office of the Surgeon General; U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; U.S. Department of Health and Human 

Services, Office on Women’s Health. Barriers to breastfeeding in the United States. The Surgeon General’s Call to Action to Support Breastfeeding. Rockville (MD): 

Office of the Surgeon General; 2011. Available at: http://www.ncbi.nlm.nih.gov/books/NBK52688/. Accessed August 20, 2014. 

6. U.S. Department of Health and Human Services, Health Resources and Services Administration. Women’s Preventive Services Guidelines.

Available at: http://www.hrsa.gov/womensguidelines/. Accessed August 20, 2014.

Figure 2. Infants* Who Are Breastfed, by Maternal Age and Duration,

2010 Percent of Infants

*Includes only infants born in 2010; data are provisional. **Reported that the child was ever breastfed or fed

human breast milk. †

Exclusive breastfeeding is defined as only human breast milk—no solids, water, or

other liquids. 

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. National

Immunization Survey (NIS). Unpublished data. The 2010 provisional rates are based on the landline telephone

sample in NIS to maintain comparability with previous years in the decade when only a landline sample

was available.

20

40

60

80

100

Total Under 20 Years 20–29 Years 30 Years and Older

Ever Breastfed**

Any at 6 Months

Exclusively at 6 Months†

76.5

16.7

5.8

37.9

14.3

56.2

49.0 51.3

16.4

80.9

70.0

17.9

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Children 41

CHILD OVERWEIGHT AND OBESITY

Childhood overweight and obesity is a significant public health issue, affecting nearly a third of all children in the United States.1

 Obese 

children are at increased risk of several adverse health outcomes, including high blood pressure and cholesterol, asthma, and many other 

chronic physiologic and psychosocial health conditions.2 Childhood 

obesity is also associated with obesity in adulthood and children who 

are overweight are more likely to have severe obesity in adulthood.5

Body mass index (BMI) is the ratio of weight to height squared that 

is used to define overweight and obesity. In children, BMI is categorized as a function of age and sex, since both of these factors affect 

body composition. Children below the 5th percentile of BMI for age 

are considered underweight, those between the 5th and 84th percentiles are considered to have a normal weight, those between the 85th 

and 94th percentiles are considered overweight, and those in the 95th 

percentile or above are considered obese. In 2011−2012, nearly 30 

percent of children aged 2−11 years were overweight or obese, 66.9 

percent were of normal weight, and 3.4 percent were underweight 

based on measured height and weight.

Children’s weight status varies by a number of factors, including 

age, sex, and race and ethnicity. For example, school-aged children 

are more likely to be obese than preschool-aged children. In 2011–

2012, 17.7 percent of children aged 6–11 years were obese, compared to 8.4 percent of children aged 2−5 years (figure 1). The percent 

of children who were overweight was similar by age: 14.5 percent of 

2- to 5-year-olds and 16.5 percent of 6- to 11-year-olds.

With regard to race and ethnicity, nearly 40 percent of Hispanic 

children and 31.4 percent of non-Hispanic Black children aged 6–11 

years were overweight or obese overall. By comparison, 26.1 percent of non-Hispanic White children and 15.5 percent of non-Hispanic

Asian children were overweight or obese. Racial and ethnic differences in obesity were particularly pronounced among males: 18.6 percent of non-Hispanic Black males and 24.2 percent of Hispanic males 

were obese, compared to 7.9 percent of their non-Hispanic White

counterparts (figure 2).

Several strategies may prevent childhood obesity, such as increasing physical activity, eating right, and reducing screen time. Dietary 

strategies for preventing childhood obesity include limiting access 

calories from fats and sugars, consuming smaller portions, and increasing intake of whole grains, vegetables, and fruits.6

 The 2008 

Physical Activity Guidelines for Americans recommend that children 

aged 6−11 years participate in 60 minutes or more per day of aerobic activity.3

 The recommended amount of fruits and vegetables is 

1−1.5 cups of each for children aged 2–8 years.4 Recommendations 

for children aged 9 years and older vary depending on their age, sex, 

and activity level. The Community Preventive Services Task Force also 

recommends behavioral interventions for reducing screen time (e.g., 

time spent watching television, playing computer games, or browsing the Internet) to improve physical activity, diet, and weight-related 

outcomes.7

Figure 1. Weight Status* of Children Aged 2–11 Years, by Sex and Age,

2011–2012

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Health and Nutrition Examination Survey, 2011–2012. Unpublished estimates. Analyses conducted by the

National Center for Health Statistics.

*Based on Body Mass Index (BMI, ratio of height to weight squared) growth charts for age and sex from

measured height and weight: underweight is a BMI under the 5th percentile, normal weight is a BMI between

the 5th and 84th percentile, overweight is a BMI between the 85th and 94th percentile, and obesity is a BMI in

the 95th percentile or above. **Estimate is not reliable; relative standard error > 30 percent. 

Underweight Normal-Weight Overweight Obese

Percent of Children

68.6

76.1

86.1

58.5

20 40 60 80 100

6–11 Years

2–5 Years

Male

6–11 Years

2–5 Years

Female

6–11 Years

2–5 Years

Total

3.2

3.6

3.4

3.7

3.0**

3.5**

8.4

9.5

19.1

17.7

7.2

16.4

14.5

14.4

16.2

16.5

14.6

16.8

74.0

73.1

61.1

62.2

74.9

63.3
Child Health USA 2014 Health Status and Behaviors - Children 42

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, 

2011–2012. Unpublished estimates. Analyses conducted by the National Center for Health Statistics.

Endnotes

1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. Journal of the American Medical Association. 

2014;311(8):806–814.

2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Childhood Overweight and Obesity. 2012. Available at:

http://www.cdc.gov/obesity/childhood/basics.html. Accessed September 5, 2014.

3. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. 2008. Available at: http://www.health.gov/PAGUidelines/guidelines/

default.aspx. Accessed September 5, 2014.

4. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Strategies To Prevent Obesity and Other Chronic Diseases: The CDC 

Guide to Strategies To Increase the Consumption of Fruits and Vegetables. Atlanta: U.S. Department of Health and Human Services; 2011.

5. Centers for Disease Control and Prevention. 2012. Basics about childhood obesity. Available at: http://www.cdc.gov/obesity/childhood/basics.html. Accessed February 17, 2015.

6. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans 2010. 2010. Available at: http://www.health.

gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf. Accessed February 12, 2015.

7. Guide to Community Preventive Services. Obesity prevention and control: behavioral interventions that aim to reduce recreational sedentary screen time among children. Available at: www.thecommunityguide.org/obesity/behavorial.html. Accessed September 5, 2014.

Figure 2. Weight Status* of Children Aged 2–11 Years, by Sex and

Race/Ethnicity, 2011–2012

*Based on Body Mass Index (BMI, ratio of height to weight squared) growth charts for age and sex from

measured height and weight: underweight is a BMI under the 5th percentile, normal weight is a BMI between

the 5th and 84th percentile, overweight is a BMI between the 85th and 94th percentile, and obesity is a BMI in

the 95th percentile or above. **Estimate is not reliable; relative standard error > 30 percent.

Total

Total

Percent of Children

24.7

31.9

41.5

18.1

27.6

30.8

37.5

12.7

10 20 30 40 50

Non-Hispanic

Asian

Hispanic 

Non-Hispanic

Black

Non-Hispanic

White

Male

Non-Hispanic

Asian

Hispanic 

Non-Hispanic

Black

Non-Hispanic

White

Female

24.2

18.6

4.1**

8.8

17.3

16.6

12.2

8.6

13.3

16.8

17.3

9.3

11.0

7.9

18.6

20.2

Overweight Obese

Overweight Obese

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Health and Nutrition Examination Survey, 2011–2012. Unpublished estimates. Analyses conducted by the

National Center for Health Statistics.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Children 43

CHILD NUTRITION

Healthy eating habits begin in childhood and can affect a person’s 

health throughout their lifetime. Poor dietary habits adopted during 

childhood may have lifelong consequences, as children and adolescents who are overweight and obese are at substantially increased 

risk of being overweight and obese as adults. Additionally, poor diet 

quality is associated with an increased risk of osteoporosis, hypertension, type 2 diabetes, cardiovascular disease, and dental caries.1

The Healthy Eating Index-2010 (HEI-2010) is designed to measure 

dietary quality2

 and can be used to assess how well a population eats 

on average, compared to the recommendations outlined in the 2010 

Dietary Guidelines for Americans. Nine of the 12 HEI-2010 components address adequate consumption of healthy foods. The remaining 

three components assess intake of foods that should be consumed 

in moderation: refined grains, sodium, and empty calories. In the table 

below, the HEI-2010 total and component scores are averages across 

all children, based on a 24-hour dietary recall. 

In 2009–2010, the overall composite score for the HEI-2010 

among children aged 2–11 years was 53 out of 100 points, where 

100 points indicates a diet that aligns with the 2010 Dietary Guidelines for Americans. With regard to the nine components of dietary 

adequacy, children received 100 percent of the possible points for 

whole fruit intake and 96 percent for dairy. Children were least likely to 

consume adequate amounts of greens and beans and whole grains 

with 18 and 22 percent, respectively, of possible points obtained (table 

1). However, consumption of greens and beans was higher among 

female than male children (on average 20 versus 16 percent of points, 

respectively). 

With regard to race and ethnicity, scores for individual HEI-2010 

components varied, although the total HEI scores varied little between 

groups. Non-Hispanic White children were less likely than all other racial and ethnic groups to consume adequate amounts of greens and 

beans, meeting only 13 percent of possible points on average compared to about 25 percent for all other children (table 1). Conversely, 

non-Hispanic White and non-Hispanic children of other races were 

closer to consuming adequate amounts of seafood and plant proteins 

(48 and 62 percent of possible points, respectively) than non-Hispanic 

Black and Hispanic children (37 and 41 percent, respectively). 

Similar differences in the consumption of seafood and plant proteins exist with regard to household income. Children in households 

with incomes of 200 percent or more of poverty consumed 55 percent 

of possible points, compared to 39 percent among children in households with incomes of less than 100 percent of poverty. 

The overconsumption of refined grains, sodium, and empty calories was present across all racial and ethnic groups. Overall, the diet 

quality of children would be improved by increasing the consumption 

of whole grains, vegetables, seafood, and plant proteins; decreasing 

the consumption of sodium and empty calories; and increasing the 

relative proportions of mono- and poly-unsaturated to saturated fatty 

acids. 

Table 1. Diet Quality Among Children Aged 2–11 as Measured by Healthy Eating Index

(HEI-2010) Scores,* by Dietary Component and Race/Ethnicity, 2009–2010

Dietary Component Overall Average Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic Other Race

Total HEI-2010 53 52 52 54 53

Adequacy (higher score indicates higher consumption)

Total fruit 91 86 88 98 97

Whole fruit 100 99 90 100 100

Total vegetables 40 38 38 44 41

Greens and beans 18 13 25 25 26

Whole grains 22 24 22 18 19

Dairy 96 100 74 94 89

Total protein foods 81 75 90 86 85

Seafood and plant proteins 46 48 37 41 62

Fatty acids 28 24 38 29 33

Moderation (higher score indicates lower consumption)

Refined grains 44 45 47 40 35

Sodium 49 50 48 52 35

Empty calories 51 48 51 57 56

*In this table, all scores are shown as a percentage of possible points. Total HEI-2010 scores reflect overall dietary quality. For the adequacy components, higher scores reflect higher intakes and a score corresponding to 100 indicates that the standard was met or exceeded on average. For the 

moderation components, higher scores reflect lower intakes because lower intakes are more desirable and a score corresponding to 100 indicates 

that the standard was met. For all components, a higher score indicates a higher quality diet.

Data Sources

Table 1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Health and Nutrition Examination Survey, 2009-2010. Data analyzed 

by the Maternal and Child Health Epidemiology and Statistics Program.

Endnotes

1. U.S. Department of Agriculture; U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 7th edition. Washington, DC: Government Printing 

Office; 2010. Available at: http://health.gov/dietaryguidelines/dga2010/dietaryguidelines2010.pdf. Accessed September 30, 2014.

2. Guenther PM, Casavale KO, Reedy J, et al. Update of the Healthy Eating Index: HEI-2010. Journal of the Academy of Nutrition and Dietetics. April 2013;113(4):569–

580.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Children 44

CHILD ABUSE AND NEGLECT

Child abuse and neglect has been defined as “any recent act or 

failure to act on the part of a parent or caretaker which results in death, 

serious physical or emotional harm, sexual abuse or exploitation; or an 

act or failure to act, which presents an imminent risk of serious harm.”1

In 2012, state child protective services agencies received approximately 3.4 million referrals, involving an estimated 6.3 million children, 

alleging abuse or neglect. Based on investigation, states reported that 

an estimated 678,810 unique children were victims of abuse or neglect in 2012, resulting in a national victimization rate of 9.2 per 1,000 

children in the population. 

Neglect was the most common type of maltreatment (experienced 

by 78.3 percent of victims), followed by physical abuse (18.3 percent), 

sexual abuse (9.3 percent), psychological maltreatment (8.5 percent), 

and medical neglect (2.3 percent; figure 1). About 10 percent of victims experienced other types of maltreatment including abandonment, 

threats of harm, or congenital drug addiction. Children may have experienced more than one type of maltreatment. In 2012, an estimated 

1,640 children died as a result of abuse or neglect.

In 2012, children aged 0–3 years accounted for 33.6 percent of all 

victims, with 12.8 percent younger than 1 year of age. About one-quarter of victims were between the ages of 4 and 7 years, 18.7 percent 

were aged 8–11 years, 16.8 percent were aged 12–15 years, and 5.8 

percent were aged 16–17 years (figure 2). With the exception of sexual abuse, children aged 0–2 years represented the largest proportion 

of victims in each maltreatment category. For example, 33.2 percent 

of those who experienced medical neglect were in this age group, as 

were 24.6 percent of those who experienced physical abuse.

Although the percentage of child victims by sex was similar for boys 

and girls (48.7 and 50.9 percent, respectively) the rate of abuse was 

higher among girls: 9.5 per 1,000 girls compared to 8.7 per 1,000 

boys. Similarly, although 44.0 percent of victims were non-Hispanic White, rates of victimization were highest among non-Hispanic 

Black and American Indian and Alaska Native children: 14.2 and 12.4 

per 1,000 children, respectively, compared to 8.0 per 1,000 among 

non-Hispanic White children.

Overall, 81.5 percent of perpetrators of abuse or neglect were parents of the victim (either alone or in conjunction with another person). 

Male relatives and male partners of the child’s parent were the perpetrators in another 3.0 and 2.3 percent of victimizations, respectively. 

Other types of perpetrators included foster parents, friends and neighbors, and legal guardians.

A variety of risk factors have been associated with child maltreatment, including child health and disability status, caregiver substance 

abuse, intimate partner or domestic violence, and poverty.2 The effects of child maltreatment can be serious and long lasting, ranging 

from increased risk of chronic emotional, behavioral, and physical illness3

 to delinquency and criminality4 to lower levels of socioeconomic 

achievement.5 Taken together, the lifetime cost per victim of nonfatal 

child maltreatment has been estimated at $210,012, while the lifetime cost associated with one year of all confirmed cases has been 

estimated at $124 billion.6 Early childhood home visitation programs, 

where trained personnel visit the home during the child’s first two 

years of life, are recommended as an evidence-based way to prevent 

child maltreatment.7

Figure 1. Reported Abuse and Neglect Among Children Under Age 18,

by Type of Maltreatment, 2012* Percent of Victims

*Estimates do not total 100 percent, as children may experience more than one type of maltreatment.

**Includes other types of maltreatment not mentioned above such as threats of abuse or congenital

drug addiction.

18

36

54

72

90

Medical Other** Neglect Psychological

Maltreatment 

Sexual

Abuse 

Neglect Physical Abuse 

78.3

18.3

10.6 9.3

2.3

8.5

Source: U.S. Department of Health and Human Services, Administration for Children and Families,

Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2012. Available at:

http://www.acf.hhs.gov/sites/default/files/cb/cm2012.pdf#page=31. Accessed July 24, 2014.
Child Health USA 2014 Health Status and Behaviors - Children 45

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s 

Bureau. Child maltreatment 2012. Available at: http://www.acf.hhs.gov/sites/default/files/cb/cm2012.pdf#page=31. Accessed July 24, 2014.

Endnotes

1. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau.

Child Maltreatment 2012. Available at: http://www.acf.hhs.gov/sites/default/files/cb/cm2012.pdf#page=31. Accessed May 17, 2012.

2. U.S. Department of Health and Human Services, Administration for Children and Families. Child welfare information gateway: child abuse and neglect, risk and protective factors. Available at: https://www.childwelfare.gov/can/factors/. Accessed July 24, 2014.

3. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of 

the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998;14(4):245–258.

4. Widom CS, Maxfield MG. An update on the “cycle of violence” research in brief. Available at: https://www.ncjrs.gov/pdffiles1/nij/184894.pdf. Accessed July 24, 2014.

5. Currie J, Widom CS. Long-term consequences of child abuse and neglect on adult economic well-being. Child Maltreatment. 2010;15(2):111–120.

6. Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect. 

2012;36(2):156–165.

7. The Community Guide. Violence Prevention: Early Childhood Home Visitation. Available at: http://www.thecommunityguide.org/violence/home/index.html. Accessed 

March 2, 2015.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/

Figure 2. Reported Abuse and Neglect Among Children Under Age 18,

by Age, 2012

Source: U.S. Department of Health and Human Services, Administration for Children and Families,

Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2012. Available at:

http://www.acf.hhs.gov/sites/default/files/cb/cm2012.pdf#page=31. Accessed July 24, 2014.

4–7 Years

24.7%

8–11 Years

18.7%

12–15 Years

16.8%

3 Years

6.8%

2 Years

7.0%

1 Year

7.0%

Under 1 Year

12.8%

Unknown

16–17 Years 0.4%

5.8%
Child Health USA 2014 Health Status and Behaviors - Children 46

SCHOOL READINESS

Early childhood is a critical period for learning and development. 

From birth to 5 years of age, children acquire language, develop learning and problem-solving skills, and obtain knowledge that is essential for helping them succeed in school and life. Children who begin 

kindergarten with early skills, such as early math, literacy, and attention-related skills, are more likely to have later academic achievement,1

while those with fewer or less developed skills are more likely to attain 

lower levels of education and be unemployed as adults.2

School readiness can be defined as when a child possesses the 

skills, knowledge, and attitudes necessary for school and for later 

learning and life. It is suggested that school readiness is composed 

of five dimensions: physical well-being and motor development, social 

and emotional development, approaches to learning, language development and early literacy, and cognition and general knowledge.3

Although there is no standard measure of school readiness, there are 

several skills that can be assessed to indicate a child’s readiness for 

school. For example, skills pertaining to early literacy and cognitive 

development include a child’s ability to recognize the beginning sound 

of a word, recognize letters of the alphabet, clearly explain things that 

he or she has seen or done, write his or her first name, count to 20, 

recognize basic shapes, and use a pencil or crayon. 

In 2007, the latest year for which data are available, approximately 

93 percent of children aged 3–6 years not yet enrolled in kindergarten 

were reportedly understandable to strangers when speaking to them; 

87 percent used their fingers when holding a pencil; 63 percent counted to 20 or higher; 60 percent could write their first name; 32 percent 

recognized all letters; and 8 percent could read the words written in 

books (figure 1).

School readiness varied widely by children’s race and ethnicity. 

Among children aged 3–6 years, a lower percentage of Hispanics 

demonstrated each of the six skills compared to their non-Hispanic 

counterparts. For example, in 2007, a lower percentage of Hispanic 

children could read written words in a book (3 percent) compared to 

non-Hispanic White (8 percent), non-Hispanic Black (16 percent), and 

non-Hispanic Asian or Pacific Islander children (8 percent; figure 2). 

School readiness also varied by household income as a percent 

of poverty. Children living in households with incomes below 100 percent of poverty were less likely than those in households with higher 

incomes to recognize all letters (21 versus 35 percent, respectively), 

count to 20 or higher (49 versus 67 percent, respectively), and write 

his or her first name (46 versus 64 percent, respectively). The percentage of children who could hold a pencil with his or her fingers, read 

written words in books, and speak understandably to strangers did 

not vary as widely by poverty status.

A number of federal programs work to ensure that children are 

ready for school. Two of these are the Head Start and Early Head 

Start programs, administered by the Administration on Children and 

Families in the U.S. Department of Health and Human Services. These 

programs provide early education, health, nutrition, and social services to low-income children and families.4

Figure 1. School Readiness Skills Among Children Aged 3–6 Years

Not Yet Enrolled in Kindergarten, 2007 Percent of Children

*Sometimes, often, or very often understandable to a stranger when speaking to them. †Use their fingers when

holding a pencil as opposed to those who grip a pencil in their fists or cannot hold a pencil. ††Can write their first

name, even if some letters are not quite right (e.g., backwards). ‡Children who read the words written in books as

opposed to pretending to read.

20

40

60

80

100

Reads written words

in books‡

Recognizes

all letters

Writes first

name††

Counts

to 20

or higher

Holds

a pencil

with fingers†

Speech is understandable

to strangers*

93

87

8

63

32

60

Source: O’Donnell K. Parents’ Reports of the School Readiness of Young Children from the National Household

Education Surveys Program of 2007. Washington, DC: National Center for Education Statistics; August 2008.

Available at: http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2008051. Accessed October 6, 2014.
Child Health USA 2014 Health Status and Behaviors - Children 47

Data Sources

Figure 1 and 2. O’Donnell K. Parents’ Reports of the School Readiness of Young Children from the National Household Education Surveys Program of 2007. Washington, DC: National Center for Education Statistics; August 2008. Available at: http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2008051. Accessed October 6, 2014.

Endnotes

1. Duncan GJ, Dowsett CJ, Claessens A, et al. School readiness and later achievement. Developmental Psychology. 2007;43(6):1428–1446.

2. Rouse C, Brooks-Gunn J, McLanahan S. School readiness: closing racial and ethnic gaps: introducing the issue. Future of Children. 2005;15(1).

Available at: http://www.princeton.edu/futureofchildren/publications/docs/15_01_FullJournal.pdf. Accessed October 6, 2014.

3. National Education Goals Panel. Achieving the Goals: Goal 1—All Children in America Will Start School Ready to Learn. Available at:

http://www2.ed.gov/pubs/AchGoal1/goal1.html. Accessed September 20, 2014.

4. Administration for Children and Families. Head Start: An Office of the Administration for Children and Families Early Childhood Learning & Knowledge Center

(ECKLC)—About Head Start. Available at: http://eclkc.ohs.acf.hhs.gov/hslc/hs/about. Accessed September 22, 2014.

Figure 2. School Readiness Skills Among Children Aged 3–6 Years

Not Yet Enrolled in Kindergarten, by Race/Ethnicity, 2007

Percent of Children

Source: O’Donnell K. Parents’ Reports of the School Readiness of Young Children from the National Household

Education Surveys Program of 2007. Washington, DC: National Center for Education Statistics; August 2008.

Available at: http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2008051. Accessed October 6, 2014.

*Includes non-Hispanic American Indian or Alaska Natives, other races not specified, and children of two or more

races. **Sometimes, often, or very often understandable to a stranger when speaking to them. †

Use their fingers

when holding a pencil as opposed to those who grip a pencil in their fists or cannot hold a pencil. ††Can write

their first name, even if some letters are not quite right (e.g., backwards). ‡Children who read the words written in

books as opposed to pretending to read.

88

90

69

88

8

86

36

64

69

20 40 60 80 100

Non- Hispanic

Other*

NonHispanic

Asian/

Pacific

Islander

Hispanic

NonHispanic

Black

Non- Hispanic White

Speech is understandable

to strangers**

Holds a pencil with fingers†

Counts to 20 or higher

Writes first name††

Recognizes all letters

Reads written words in books‡

97

84

87

50

42

3

15

6

35

38

16

85

92

92

66

64

56

58

76

8

43

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Children 48

MATH AND READING ACHIEVEMENT

Students’ achievement scores across school subjects are important indicators of their overall academic performance. The National 

Assessment of Educational Progress (NAEP) conducts periodic assessments to measures students’ knowledge and skills and provides 

results on subject matter achievement.1 For mathematics, the NAEP 

assessment measures students’ knowledge in number properties and 

operations, measurement, geometry, data analysis and statistics, and 

algebra. The NAEP reading assessment measures students’ comprehension of both literary and informational texts. For all subjects, 

the National Assessment Governing Board sets three achievement 

levels—basic, proficient, and advanced—based on what students 

should know and be able to do at each grade assessed.2

In 2013, 42 percent of fourth-graders and 36 percent of 

eighth-graders were at or above proficiency in mathematics. Math 

achievement levels varied widely by students’ race and ethnicity. 

Among fourth-graders, the highest percentage of students performing 

at the advanced level were non-Hispanic Asians (23 percent), followed 

by non-Hispanic Whites (10 percent) and non-Hispanics of multiple 

races (10 percent; figure 1). Less than 6 percent of students from 

each of the other racial and ethnic groups performed at the advanced 

level. The highest percentage of fourth-grade students performing below the basic proficiency level were non-Hispanic Black students (34 

percent), followed by non-Hispanic American Indians/Alaska Natives 

(32 percent) and Hispanics (27 percent). Fewer than 10 percent of 

non-Hispanic White and non-Hispanic Asian students performed below the basic proficiency level. Overall, similar patterns were observed 

among eighth-graders.

Reading achievement varies by grade level and sex. In 2013, 35 

percent of fourth-graders and 36 percent of eighth-graders were at or 

above proficiency in reading. Among both fourth- and eighth-graders, 

a higher percentage of females performed at the proficient (29 and 36 

percent, respectively) and advanced (10 and 6 percent, respectively) 

levels compared to their male counterparts (proficient: 25 and 28 percent, respectively; advanced: 7 and 3 percent, respectively). At both 

grade levels, a higher percentage of males performed below the basic 

proficiency level (figure 2). 

Figure 1. Proficiency* in NAEP Mathematics Among Students in

Grade 4, by Race/Ethnicity,** 2013

Percent of Students

Below Basic Basic Proficient Advanced

*Performance standards are set by the National Assessment Governing Board. Basic, proficient, and advanced

levels measure what students should know and be able to do at each grade assessed. “Basic” denotes partial

mastery of prerequisite knowledge and skills. “Proficient” reflects solid academic performance. “Advanced”

denotes superior performance. Examples of knowledge and skills demonstrated by students at each

achievement level are available in the Nation’s Report Cards in Mathematics and Reading at

http://nces.ed.gov/nationsreportcard/subjectareas.asp. **Black includes African American, and Hispanic includes

Latino. Race categories exclude Hispanic origin.

20 40 60 80 100

Non-Hispanic

Multiple Race

Non-Hispanic Native Hawaiian/ Other Pacific Islander

Non-Hispanic

American

Indian/Alaska Native

Non-Hispanic Asian

Hispanic

Non-Hispanic Black

Non-Hispanic White

Total 17

9

34

8

32

15

37

41

27 47

43

44

40

48

43 10

34 8

24 3

23

2

27

21

23 44 28 5

36 10

17 1

Source: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics,

National Assessment of Educational Progress.
Child Health USA 2014 Health Status and Behaviors - Children 49

Data Sources 

Figure 1 and 2. U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, National Assessment of Educational Progress.

Endnotes

1. National Center for Education Statistics. NAEP Overview. Washington, DC: U.S. Department of Education, Institute of Education Sciences. Available at: http://nces.

ed.gov/nationsreportcard/about/. Accessed September 11, 2014.

2. National Center for Education Statistics. The Nation’s Report Card. Washington, DC: U.S. Department of Education, Institute of Education Sciences. Available at: 

http://www.nationsreportcard.gov/. Accessed September 11, 2014.

Figure 2. Proficiency* in NAEP Reading Among Students, by Grade

Level and Sex, 2013

Percent of Students

Below Basic Basic Proficient Advanced

*Performance standards are set by the National Assessment Governing Board. Basic, proficient, and advanced

levels measure what students should know and be able to do at each grade assessed. “Basic” denotes partial

mastery of prerequisite knowledge and skills. “Proficient” reflects solid academic performance. “Advanced”

denotes superior performance. Examples of knowledge and skills demonstrated by students at each

achievement level are available in the Nation’s Report Cards in Mathematics and Reading at

http://nces.ed.gov/nationsreportcard/subjectareas.asp.

Source: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics,

National Assessment of Educational Progress.

20 40 60 80 100

Grade 8, Female

Grade 8, Male

Grade 4, Female

Grade 4, Male 35

28

26

18

33

3

40

29

25 7

6

43 28

36

33 10

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 50

SEXUAL ACTIVITY AND 

CONTRACEPTIVE USE

In 2013, 46.8 percent of students in grades 9–12 reported having had sexual intercourse at least once during their lifetime. While 

this self-reported prevalence among high school students has not 

changed significantly from 2011 (47.4 percent), there has been a sustained decrease since 1991, when 54.1 percent of high school students reported ever having had sexual intercourse.1

Among all students, a similar number of male and female high 

school students reported having ever had sex (47.5 and 46.0 percent, respectively). With respect to race and ethnicity, 60.6 percent 

of non-Hispanic Black high school students reported having ever had 

sexual intercourse, compared to 49.2 percent of Hispanic, 43.7 percent of non-Hispanic White, and 22.6 percent of non-Hispanic Asian 

high school students (figure 1). The proportion of students who reported having had sexual intercourse increased with grade level: 30.0 

percent of 9th-grade students had done so, compared to 41.4 percent of 10th-graders, 54.1 percent of 11th-graders, and 64.1 percent 

of 12th-graders.

Overall, 34.0 percent of students reported current sexual activity, defined as sexual intercourse with at least one person during the 

past 3 months. Among those students who reported current sexual 

activity, 40.9 percent reported not using a condom (whether they or 

their partner wore it) during their last intercourse (figure 2). With regard 

to sex, 46.9 percent of females reported not using a condom, compared to 34.2 percent of males. Additionally, female students were 

more likely than male students to report that no method to prevent 

pregnancy had been used (by themselves or partners) during their last 

intercourse (15.7 and 11.5 percent, respectively). With regard to grade 

level, the proportion of sexually active students to report not using a 

condom was highest among 12th-graders (47.0 percent). 

Contraceptive use is a key component to reducing unintended 

pregnancies,2 and the majority of pregnancies occurring to adolescents are unintended.3

 The U.S. Department of Health and Human 

Services Healthy People 2020 campaign includes national goals to increase the proportion of adolescents aged 17 years and younger who 

have never had sexual intercourse, reduce the number of pregnancies 

among adolescent females, increase the proportion of births that are 

intended, and increase contraceptive use among females who are at 

risk of unintended pregnancy.4

Figure 1. High School Students Who Have Ever Had Sexual

Intercourse, by Race/Ethnicity, 2013 Percent of Students 14

28

42

56

70

NonHispanic

Multiple

Races

NonHispanic

American

Indian/

Alaska

Native

NonHispanic

Native 

Hawaiian/

Other Pacific

Islander

NonHispanic

Asian

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

46.8 43.7 41.1

48.5

60.6

49.2

22.6

43.8

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High

School Youth Risk Behavior Survey. Available at: http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014. Figure 2. Lack of Contraceptive Use* During Last Sexual Intercourse

Among Sexually Active** High School Students, by Sex, 2013 Percent of Students

*By themselves or partners. **Defined as having had sexual intercourse with at least one person during the

past 3 months.

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High

School Youth Risk Behavior Survey. Available at: http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014.

20

40

60

80

100

Did Not Use

Any

Contraceptive

Did Not Use Both

a Condom and

Hormonal

Contraceptive

Did Not Use

Hormonal

Contraceptive

Did Not Use

Condom

Total Male Female

40.9

91.2

70.2

92.8

13.7

89.8

11.5

46.9

79.9

74.7

34.2

15.7
Child Health USA 2014 Health Status and Behaviors - Adolescents 51

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High School Youth Risk Behavior Survey. Available at: 

http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014.

Endnotes

1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2013. Morbidity and 

Mortal Weekly Report. June 13, 2014;63(4). Available at: http://www.cdc.gov/mmwr/pdf/ss/ss6304.pdf. Accessed September 20, 2014.

2. Guttmacher Institute. Preventing unintended pregnancy: the need and the means. The Guttmacher Report on Public Policy. December 2003;6(5). Available at: http://

www.guttmacher.org/pubs/tgr/06/5/gr060507.html. Accessed September 20, 2014.

3. Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the United States, 2001–2008. American Journal of Public Health. 2014;104(S1):S44–S48. 

Available at: http://www.guttmacher.org/pubs/journals/ajph.2013.301416.pdf. Accessed September 20, 2014.

4. U.S. Department of Health and Human Services. Healthy People 2020 Topics & Objectives: Maternal, Infant, and Child Health. Available at: http://www.healthypeople.

gov/. Accessed September 20, 2014.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 52

STIs AND HIV/AIDS

Sexually transmitted infections (STIs), such as chlamydia and 

gonorrhea, can pose serious, long-term health complications for adolescents and young adults.1

 Although young people aged 15–24 

years represent only one-quarter of the sexually experienced population, they acquire nearly half of all new STIs.2

 Among adolescents 

and young adults, chlamydia continues to be the most common of all 

the STIs reported to the Centers for Disease Control and Prevention 

(CDC). Overall, there were 2,001.7 reported cases of chlamydia per 

100,000 adolescents aged 15–19 years in 2012 (figure 1). Rates of 

chlamydia vary by sex, with 3,291.5 cases of chlamydia per 100,000 

female adolescents and 774.8 cases per 100,000 male adolescents. 

Gonorrhea was less common, with rates of 376.8 per 100,000 among 

all adolescents, 521.2 per 100,000 female adolescents, and 239.0 

per 100,000 male adolescents (figure 2). 

Human immunodeficiency virus (HIV) is a disease that destroys 

cells that are critical to a healthy immune system. Acquired immunodeficiency syndrome (AIDS) is diagnosed when HIV has weakened the 

immune system enough that the body has difficulty fighting disease 

and infections. Early age at sexual initiation, unprotected sex, drug 

use, older sex partners, and lack of awareness place adolescents at 

an increased risk of contracting HIV.3 By the end of 2010, an estimated 7,272 adolescents between 15 and 19 years of age were 

living with a diagnosed HIV infection. With regard to race and ethnicity, 148.2 per 100,000 non-Hispanic Black adolescents and 7.1 per 

100,000 non-Hispanic White adolescents were living with HIV.

Abstaining from sex and drug use is the most effective way to avoid 

HIV. Adolescents and young adults can also reduce their risk by knowing where to get tested for HIV, how to negotiate safer sex, and how 

to use a condom correctly. CDC has developed interventions that can 

be carried out locally to help reduce the risk to adolescents. One such 

program, Choosing Life: Empowerment! Action! Results!, is targeted 

to adolescents older than 16 and living with HIV/AIDS or at high risk 

for HIV.4

Figure 1. Reported Chlamydia Infection Rates per 100,000

Adolescents Aged 15–19 Years, by Race/Ethnicity* and Sex, 2012

Rate per 100,000 Adolescents

1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000

Non-Hispanic

Multiple Races

Non-Hispanic

American Indian/

Alaska Native

Non-Hispanic Native Hawaiian/ Other Pacific Islander

Non-Hispanic

Asian

Hispanic

Non-Hispanic

Black

Non-Hispanic White

Total

Total

Male

Female

774.8

830.1

1,448.3

4,977.7

7,719.1

236.4

421.4

313.0

86.3

548.9

326.2

101.7

552.2

2,013.6

2,333.5

1,190.0

512.5

3,219.8

1,841.9

863.2

4,235.1

2,509.8

2,001.7

3,291.5

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Sexually

Transmitted Disease Surveillance, 2012. Atlanta, GA: U.S. Department of Health and Human Services; 2014.

*Rates by race/ethnicity should be interpreted with caution: 25.8% of case reports were missing race/ethnicity.
Child Health USA 2014 Health Status and Behaviors - Adolescents 53

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2012. Atlanta, 

GA: U.S. Department of Health and Human Services; 2014.

Endnotes

1. Centers for Disease Control and Prevention. Sexually Transmitted Diseases (STD). CDC Fact Sheets. Available at: http://www.cdc.gov/std/healthcomm/fact_sheets.

htm. Accessed September 20, 2014.

2. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual and 

Reproductive Health. 2004:36(1):6–10.

3. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Who’s at Risk for HIV?. Available at: http://www.cdc.gov/hiv/risk/. Accessed September 21, 2014. 

4. Centers for Disease Control and Prevention. HIV Surveillance Report: Diagnoses of HIV Infection and AIDS in the United States and Dependent Areas, 2010. Available 

at: http://www.cdc.gov/hiv/pdf/statistics_surveillance_report_vol_22.pdf. Accessed May 20, 2012.

Figure 2. Reported Gonorrhea Infection Rates per 100,000

Adolescents Aged 15–19 Years, by Race/Ethnicity* and Sex, 2012

Rate per 100,000 Adolescents

*Rates by race/ethnicity should be interpreted with caution: 25.8% of case reports were missing race/ethnicity.

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Sexually

Transmitted Disease Surveillance, 2012. Atlanta, GA: U.S. Department of Health and Human Services; 2014.

440 880 1,320 1,760 2,200

Non-Hispanic

Multiple Races

Non-Hispanic

American Indian/

Alaska Native

Non-Hispanic Native Hawaiian/

Other

Pacific Islander

Non-Hispanic Asian

Hispanic

Non-Hispanic

Black

Non-Hispanic

White

Total

Total

Male

Female

239.0

85.3

134.5

1,513.5

2,032.2

38.7

97.6

36.5

22.0

51.4

68.9

27.4

110.7

184.6

1,012.3

139.7

139.3

279.5

208.0

155.9

501.9

324.6

376.8

521.2

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 54

ADOLESCENT CHILDBEARING

Teen pregnancy is generally unintended and has long-term negative effects on future physical, behavioral, educational, and economic 

development of both mothers and children.1,2 Adolescent mothers are 

less likely than older mothers to finish high school or go on to college.3

Compared with babies of mothers in their 20s and early 30s, children 

born to teen mothers are more likely to be premature, have a low birth 

weight, or die as infants.4,5 Children of adolescent mothers generally 

have poorer educational and behavioral outcomes than children born 

to older mothers and are more likely to initiate sex at an early age or to 

have a teen birth themselves.6,7

According to preliminary data for 2013, the overall birth rate for 

adolescents aged 15–19 years was 26.6 births per 1,000 females, 

representing an 11 percent decline from 2012 (29.4 per 1,000) and 

a historic low for the nation (figure 1). Birth rates for younger adolescents 15–17 years of age (12.3 per 1,000) declined by 13 percent 

while the rates for older adolescents, aged 18–19 years, declined by 8 

percent to 47.4 per 1,000. Record lows were reached for both younger (15–17 years) and older teens (18–19 years). The teen birth rate 

has fallen by more than 55 percent since 1991 (61.8 per 1,000), when 

the long-term decline began.8 The rate for teens aged 15–17 years 

has fallen 67 percent and the rate for those aged 18–19 years has 

declined by 47 percent. 

Overall, birth rates for teenagers aged 15–19 years decreased for 

all racial and ethnic groups from 2011 to 2012, with declines ranging 

from 3 percent for American Indian/Alaska Native teens to 5 percent 

for Asian/Pacific Islander teens and 6–7 percent for non-Hispanic 

White, non-Hispanic Black, and Hispanic teens (figure 2). Birth rates 

for younger teens aged 15–17 years decreased for all race and ethnic 

groups in 2012, while rates for older teens aged 18–19 years decreased for all but American Indian/Alaska Native and Asian/Pacific 

Islander adolescents.

Despite observed decreases, profound disparities continue to persist in adolescent childbearing rates across racial and ethnic groups. 

Among teens aged 15–19 years, birth rates ranged from a low of 9.7 

per 1,000 females for Asian/Pacific Islander teens to a high of 46.3 per 

1,000 females for Hispanic teens, an approximately fivefold difference. 

The birth rate among non-Hispanic White 15- to 19-year-olds was 

more than twice as low as those of both Hispanic and non-Hispanic 

Black teens of the same age. 

The Community Preventive Services Task Force recommends both 

group-based and youth development behavioral interventions to protect against the risk of HIV/AIDS, other sexually transmitted diseases, 

and teen pregnancy.9 Group-based interventions, referred to as Comprehensive Risk Reduction Interventions for Adolescents, have shown 

results in reducing sexual activity, unprotected sex, and sexually transmitted infections and are applicable across a variety of populations 

and settings. Youth development behavioral interventions in these 

programs are coordinated with community service. Social, emotional, or cognitive competence training promotes prosocial norms, improved decisionmaking, self-determination, and positive peer or role 

model bonding, while community service provides opportunities to 

gain membership in groups with explicit rules and responsibilities.9

Figure 1. Birth Rates Among Adolescent Females Aged 15–19 Years,

by Age, 1990–2013*

Source: Martin JA, Hamilton BE, Osterman MJK, et al. Births: final data for 2012. National Vital Statistics

Reports. 2013;62(9). Hamilton BE, Martin JA, Osterman MJK, et al. Births: Preliminary data for 2013. National

Vital Statistics Reports. 2014;63(2).

*Data for 2013 are preliminary.

20

40

60

80

100

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2013

Rate per 1,000 Females

Total

(15–19 Years)

15–17 Years

18–19 Years

47.4

26.6

12.3
Child Health USA 2014 Health Status and Behaviors - Adolescents 55

Data Sources

Figure 1. Martin JA, Hamilton BE, Osterman MJK, et al. Births: final data for 2012. National Vital Statistics Reports. 2013;62(9). Hamilton BE, Martin JA, Osterman 

MJK, et al. Births: Preliminary data for 2013. National Vital Statistics Reports. 2014;63(2).

Figure 2. Martin JA, Hamilton BE, Osterman MJK, et al. Births: final data for 2012. National Vital Statistics Reports. 2013;62(9).

Endnotes

1. Finer LB, Henshaw S. Disparities in rates of unintended pregnancy in the United States. Perspectives on Sexual and Reproductive Health. 2006;38(2):90–96.

2. Pogarsky G, Thornberry TP, Lizotte AJ. Developmental outcomes for children of young mothers. Journal of Marriage and Family. 2006;68:332–344.

3. Hofferth SL, Reid L, Mott FL. The effects of early childbearing on schooling over time. Family Planning Perspectives. 2001;33(6):259–267.

4. Chen X-K, Wen SW, Fleming N, Demissie K, Rhoads GG, Walker M. Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort 

study. International Journal of Epidemiology. 2007;36:368–373.

5. Mathews TJ, MacDorman MF. Infant mortality statistics from the 2004 period linked birth/infant death data set. National Vital Statistics Report. 2007;55(14).

6. Lipman EL, Georgiades K, Boyle MH. Young adult outcomes of children born to teen mothers: effects of being born during their teen or later years. Journal of the 

American Academy of Child and Adolescent Psychiatry. 2011;50(3):232–241.

7. Levine JA, Pollack H, Comfort ME. Academic and behavioral outcomes among the children of young mothers. Journal of Marriage and Family. 2001;63(2):355–369.

8. Hamilton BE, Mathews TJ, Ventura SJ. Declines in state teen birth rates by race and Hispanic origin. NCHS data brief, no 123. Hyattsville, MD: National Center for 

Health Statistics. 2013

9. The Community Guide. Preventing HIV/AIDS, other STIs, and teen pregnancy: comprehensive risk reduction interventions—task force finding and rationale statement. 

Available at: http://www.thecommunityguide.org/hiv/RRriskreduction.html. Accessed September 18, 2014.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/

Figure 2. Birth Rates Among Adolescent Females Aged 15–19 Years,

by Age and Race/Ethnicity, 2011 and 2012

Rate per 1,000 Females

2011

2012

Source: Martin JA, Hamilton BE, Osterman MJK, et al. Births: final data for 2012. National Vital Statistics

Reports. 2013;62(9).

*May include individuals of Hispanic origin. †

Separate estimates for Asians, Native Hawaiians, and other Pacific

Islanders were not available.

18 36 54 72 90

 Asian/Pacific Islander*†

 American Indian/ Alaska Native*

 Hispanic

 Non-Hispanic

Black

 Non-Hispanic

White 

Total

18–19 Years

 Asian/Pacific

Islander*†

 American Indian/

Alaska Native*

 Hispanic

 Non-Hispanic Black

 Non-Hispanic White 

Total

15–17 Years

 Asian/Pacific

Islander*†

 American Indian/ Alaska Native*

 Hispanic

 Non-Hispanic Black

 Non-Hispanic

White 

Total

15–19 Years

29.4

31.3

43.9

47.3

46.3

49.6

20.5

21.7

9.7

10.2

14.1

15.4

17.0

18.2

17.7

18.1

21.9

24.6

25.5

28.0

37.9

39.9

74.1

78.8

77.2

81.5

51.4

54.1

60.5

61.6

8.4

9.0

4.1

4.6

34.9

36.1
Child Health USA 2014 Health Status and Behaviors - Adolescents 56

ADOLESCENT OVERWEIGHT AND 

OBESITY 

Over the past 30 years, the prevalence of obesity has quadrupled 

among adolescents in the United States.1 In 2011−2012, 20.5 percent of youth aged 12−19 years were obese, 14.0 percent were overweight, 61.9 percent were of normal weight, and 3.6 percent were 

underweight. Overweight and obesity in adolescence is associated 

with overweight and obesity in adulthood, putting obese adolescents 

at increased risk of several adverse health conditions, including overweight and obesity later in life, high cholesterol and blood pressure, 

prediabetes, bone and joint problems, cancer, and other social and 

psychological health outcomes.2

Adolescent weight status varies by several factors, including sex, 

race and ethnicity, and poverty status. In 2011−2012, nearly 40 percent of non-Hispanic Black and Hispanic youth were reportedly overweight or obese, compared to 31.2 percent of non-Hispanic White 

youth. Racial and ethnic differences varied by sex and were particularly pronounced among males, such that 21.4 percent of non-Hispanic 

Black males and 23.9 percent of Hispanic males were obese, compared to 18.3 percent of non-Hispanic White males (figure 1).

The prevalence of overweight and obesity also varies by poverty status. In 2011–2012, nearly 41 percent of youth living in households with incomes below 100 percent of poverty were overweight or 

obese. By comparison, 28.2 percent of youth living in households with 

incomes of 300 percent or more of poverty were overweight or obese. 

These differences were only notable among females: 17.1 and 25.9 

percent of females living in households with incomes below 100 percent of poverty were overweight and obese, respectively, compared to 

9.0 and 10.8 percent of their female counterparts living in households 

with incomes of 300 percent or more of poverty (figure 2).

The Community Preventive Services Task Force recommends several strategies for preventing obesity in community settings. For example, behavioral interventions for reducing screen time (e.g., time 

spent watching television, playing computer games, or browsing the 

Internet) have improved weight-related outcomes among children and 

adolescents.

Figure 1. Weight Status* of Children Aged 12–19 Years, by

Race/Ethnicity and Sex, 2011–2012

*Based on Body Mass Index (BMI, ratio of height to weight squared) growth charts for age and sex from

measured height and weight: underweight is a BMI under the 5th percentile, normal weight is a BMI between

the 5th and 84th percentile, overweight is a BMI between the 85th and 94th percentile, and obesity is a BMI in

the 95th percentile or above." **Estimate is not reliable; based on fewer than 10 cases or relative standard error

> 30 percent.

Underweight Normal-Weight Overweight Obese

Percent of Children

20 40 60 80 100

 Hispanic

 NonHispanic

Asian

 NonHispanic

Black

 NonHispanic

White

Males

 Hispanic

 Non- Hispanic Asian

 Non- Hispanic

Black

 Non- Hispanic White

Females

1.9**

2.1**

20.9

22.7

10.1

19.7

67.1

55.4

1.2** 62.3 15.2 21.3

3.8** 81.2 7.7** 7.3**

8.6**

4.1**

14.8

23.9

19.1

15.7

57.5

3.7** 59.0 15.9 21.4

56.3

6.2** 62.3 13.2 18.3

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Health and Nutrition Examination Survey, 2011–2012. Unpublished estimates. Analyses conducted by the

National Center for Health Statistics.
Child Health USA 2014 Health Status and Behaviors - Adolescents 57

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, 

2011–2012. Unpublished estimates. Analyses conducted by the National Center for Health Statistics.

Endnotes

1. U.S. Department of Health and Human Services, National Center for Health Statistics. Health, United States, 2011: With Special Features on Socioeconomic Status 

and Health. Hyattsville, MD: U.S. Department of Health and Human Services; 2012.

2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Adolescent and School Health: Childhood Obesity Facts. 2012. Available 

at: http://www.cdc.gov/healthyyouth/obesity/facts.htm. Accessed September 5, 2014.

Figure 2. Overweight and Obese Children Aged 12–19 Years, by

Sex and Poverty Status,** 2011–2012

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Health and Nutrition Examination Survey, 2011–2012. Unpublished estimates. Analyses conducted by the

National Center for Health Statistics.

*Based on Body Mass Index (BMI, ratio of height to weight squared) growth charts for age and sex from

measured height and weight: underweight is a BMI under the 5th percentile, normal weight is a BMI between

the 5th and 84th percentile, overweight is a BMI between the 85th and 94th percentile, and obesity is a BMI in

the 95th percentile or above. **The U.S. Census Bureau weighted average poverty threshold for a family of

four was $23,492 in 2012.

Overweight

Obese

Total

Percent of Children 10

20

30

40

50

18.9

25.9

43.0 41.0

15.9

28.2

10.8

19.8

21.7

40.6

11.4

21.3

32.7

13.7

23.3

37.0

35.0

12.3

15.0 15.8

9.0

20.8

17.1

20.0

17.5

38.3 25.2

Less Than 100 Percent of Poverty

Total Male Female

100–299 Percent of Poverty

300 Percent or More of Poverty

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 58

PHYSICAL ACTIVITY AND SEDENTARY 

BEHAVIOR

The U.S. Department of Health and Human Services recommends 

that children and adolescents get 1 hour or more of physical activity 

every day, most of which should be moderate- to vigorous-intensity 

aerobic activity.1 Data from the 2013 Youth Risk Behavior Surveillance 

System showed that 27.1 percent of high school students were physically active for at least 60 minutes on each of the 7 previous days 

(figure 1). 

Achievement of recommended levels of physical activity varied by 

both sex and grade level. Among high school students in all grades, a 

smaller proportion of females reported 60 minutes of physical activity 

on each of the previous 7 days than males (17.7 versus 36.6 percent, 

respectively). Students in the 9th grade were more likely to achieve 

the recommended level of physical activity than those in the 12th 

grade (30.4 versus 24.3 percent, respectively). With regard to race 

and ethnicity, 21.8 percent of non-Hispanic Asian students reported 

recommended levels of physical activity, compared to 28.2 percent of 

non-Hispanic Whites.

In conjunction with physical activity, experts recommend limiting 

sedentary behaviors. Specifically, the American Academy of Pediatrics recommends that parents limit children’s media time to 1–2 hours 

per day.2 This includes time spent watching TV or videos as well as 

time spent playing video or computer games. In 2013, 32.5 percent of 

high school students reported watching 3 or more hours of television 

per day on an average school day. There was no difference in the 

proportion of males and females who reported this level of television 

watching. However, students in 9th grade were slightly more likely to 

watch 3 or more hours of television than students in 12th grade (34.9 

versus 31.3 percent, respectively).

The proportion of students who reported 3 or more hours of television watching varied significantly by race and ethnicity (figure 2). 

More than half of non-Hispanic Black students (53.7 percent) reported this level of television viewing, while the same was true for about 

one-quarter of non-Hispanic White and Asian students (25.0 and 24.5 

percent, respectively) and more than one-third of Hispanic students 

(37.8 percent). 

In the same year, 41.3 percent of high school students reported 

playing video games or using computers for something other than 

school work, such as computer games, for 3 or more hours per day 

on an average school day. The proportion varied by grade level, as 

9th-grade students were more likely to engage in this behavior than 

those in 12th grade (44.8 versus 36.9 percent, respectively). These 

activities varied by race and ethnicity, with non-Hispanic Asian (51.5 

percent) and non-Hispanic Black students (49.1 percent) more likely 

to report this level of video game and computer use than non-Hispanic White students (37.4 percent).

Figure 1. Physical Activity* Among High School Students, by Grade,

2013 Percent of Students

*Defined as physical activity that increased their heart rate and made them breathe hard some of the time for a

total of at least 60 minutes on each of the last 7 days.

8

16

24

32

40

Total 9th Grade 10th Grade 11th Grade 12th Grade

27.6

24.3

30.4

25.5 27.1

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High

School Youth Risk Behavior Survey. Available at: http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014.
Child Health USA 2014 Health Status and Behaviors - Adolescents 59

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High School Youth Risk Behavior Survey. Available at: 

http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014.

Endnotes

1. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Available at: http://www.health.gov/paguidelines/guidelines/. Accessed September 2, 2014.

2. Committee on Public Education. Children, adolescents, and television. Pediatrics. 2001;107(2):423–426.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/

Figure 2. Sedentary Behavior in the Past Week Among High School

Students, by Race/Ethnicity, 2013

Watched 3 or More Hours of Television per Day

Played Video Games or Used a Computer for 3 or More

Hours per Day for Something Other Than School Work

14

28

42

56

70

NonHispanic

Multiple

Races

NonHispanic

American

Indian/

Alaska Native

NonHispanic

Native

Hawaiian/

Other

Pacific Islander

NonHispanic

Asian

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High

School Youth Risk Behavior Survey. Available at: http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014. Percent of Students

25.0

41.3

37.4

49.1 51.5

24.5

42.3

46.1

35.1

38.3

46.3

51.4

43.4

53.7

37.8

32.5
Child Health USA 2014 Health Status and Behaviors - Adolescents 60

ADOLESCENT NUTRITION

Adolescents face unique challenges to healthy eating as they become more independent from their families. Improving diet quality 

among this population is a key public health concern, as approximately one out of every five adolescents aged 12–19 years was obese in 

2011–2012.1

 Inadequate consumption of essential nutrients can have 

a negative impact on adult health. Adequate calcium intake in adolescence is essential to attainment of peak bone mass.4

 In addition, poor 

diet quality can increase the risk of chronic diseases such as cardiovascular disease, cancer, and type 2 diabetes.2

The Healthy Eating Index-2010 (HEI-2010) is designed to measure 

dietary quality3

 and can be used to assess how well a population eats 

on average compared to the recommendations outlined in the 2010 

Dietary Guidelines for Americans. Nine of the 12 HEI-2010 components address dietary adequacy of healthy foods. The remaining three 

components assess intake of foods that should be consumed in moderation: refined grains, sodium, and empty calories. In the table below, 

the HEI-2010 total and component scores are averages across all 

children, based on a 24-hour dietary recall. 

In 2009–2010, the overall composite score for the HEI-2010 

among adolescents aged 12–19 years was 46 out of 100 possible 

points, where 100 points indicates a diet that aligns with the 2010 

Dietary Guidelines for Americans. With regard to the nine components 

of dietary adequacy, adolescents received 96 percent of the possible points for protein intake and 63 percent of the possible points for 

whole fruit intake. Adolescents were least likely to consume adequate 

amounts of greens and beans and whole grains, with 17 and 14 percent, respectively, of possible points obtained (table 1). 

HEI-2010 scores for individual components varied with sex. Female adolescents consumed 50 percent of the possible points for 

vegetables compared to 43 percent for males. Female adolescents 

were also more likely to consume recommended levels of sodium than 

were male adolescents, with 42 and 38 percent, respectively, consuming moderate levels. Non-Hispanic White adolescents were closer 

to meeting recommended levels of dairy consumption (78 percent) 

than non-Hispanic Black and Hispanic adolescents (59 and 64 percent, respectively). Overconsumption of refined grains, sodium, and 

empty calories was prevalent across all racial and ethnic groups.

Overall composite scores for diet quality did not vary by household 

poverty level; however, these scores mask differences in consumption 

of individual components (table 1). With regard to seafood and plant 

proteins, adolescents in households with incomes of 200 percent 

or more of poverty consumed about 57 percent of possible points 

compared to 36 percent among those in households with incomes 

of less than 100 percent of poverty. Conversely, adolescents living in 

households with incomes of 200 percent or more of poverty had lower 

scores for optimal consumption of sodium compared to adolescents 

in households with incomes less than 100 percent of poverty (35 versus 43 percent, respectively). 

Table 1. Diet Quality Among Adolescents Aged 12–19 as Measured by Healthy Eating 

Index (HEI-2010) Scores,* by Poverty Status,** 2009–2010

Dietary Component Overall Average Less Than 100% of Poverty 100–199% of Poverty 200% or More of Poverty

Total HEI-2010 46 45 45 46

Adequacy (higher score indicates higher consumption)

Total fruit 56 59 52 56

Whole fruit 63 60 46 72

Total vegetables 46 42 42 49

Greens and beans 17 19 19 16

Whole grains 14 12 17 14

Dairy 71 71 67 73

Total protein foods 96 94 93 97

Seafood and plant proteins 50 36 48 57

Fatty acids 36 39 40 34

Moderation (higher score indicates lower consumption)

Refined grains 39 41 44 35

Sodium 39 43 44 35

Empty calories 47 46 43 49

*In this table, all scores are shown as a percentage of possible points. Total HEI-2010 scores reflect overall dietary quality. For the adequacy 

components, higher scores reflect higher intakes and a score corresponding to 100 indicates that the standard was met or exceeded on 

average. For the moderation components, higher scores reflect lower intakes because lower intakes are more desirable and a score 

corresponding to 100 indicates that the standard was met. For all components, a higher score indicates a higher quality diet. “Empty calories” 

refers to calories from solid fats (i.e., sources of saturated fats and trans fats) and added sugars (i.e., sugars not naturally occurring). Total 

fruit includes 100 percent fruit juice. **The U.S. Census Bureau weighted average poverty threshold for a family of four was $23,492 in 2012.

Data Sources

Table 1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Health and Nutrition Examination Survey, 2009–2010. Data analyzed 

by the Maternal and Child Health Epidemiology and Statistics Program.

Endnotes

1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. Journal of the American Medical Association. 

2014;311(8):806–814.

2. U.S. Department of Agriculture; U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 7th edition. Washington, DC: Government Printing 

Office; 2010. Available at: http://www.cnpp.usda.gov/dietaryguidelines.htm. Accessed September 30, 2014.

3. Guenther PM, Casavale KO, Reedy J, et al. Update of the Healthy Eating Index: HEI-2010. Journal of the Academy of Nutrition and Dietetics. April 2013;113(4):569–580.

4. American Academy of Pediatrics. Calcium requirements of infants, children, and adolescents. Pediatrics 1999;104(5):1152-1157.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 61

MENTAL HEALTH

An individual is considered to have a mental disorder when he or 

she experiences changes in thinking, mood, or behavior as a result 

of distress or impairment.1 Approximately one in five adolescents has 

a mental disorder, of which mood disorders such as depression are 

among the most common.2 The American Psychiatric Association 

defines major depressive disorder as severe symptoms that interfere with an individual’s ability to work, sleep, study, eat, and enjoy 

life.3 Individuals who experience a major depressive episode (MDE) 

report at least 2 weeks of a depressed or irritated mood or loss of 

interest or pleasure in daily activities and have at least four of seven 

additional symptoms, such as altered sleeping patterns, fatigue, and 

feelings of worthlessness.4,5 Mental disorders in adolescents may lead 

to struggles with school, drugs and alcohol, and family. Mental disorders, especially depression, are also a risk factor for suicide and have 

also been shown to be associated with the development of mood 

disorders in adulthood as well as chronic illnesses, such as diabetes, 

hypertension, stroke, cardiovascular disease, and cancer.6,7,8

According the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2012, 2.2 million adolescents aged 12–17 

years (9.1 percent) had an MDE in the past year. Adolescent females 

were nearly three times as likely as adolescent males to have experienced a past-year MDE (13.7 versus 4.7 percent, respectively; figure 

1). The occurrence of past-year MDEs was greater among older adolescents of both sexes. For example, among female adolescents, 5.4 

percent of those aged 12 years and more than 15 percent of those 

aged 15–17 years experienced past-year MDE. Substance dependence or abuse commonly co-occurs with an MDE. Among youth 

who experienced a past-year MDE, 16.0 percent had a substance 

use disorder compared to 5.1 percent of adolescents without a pastyear MDE (figure 2).

The occurrence of an MDE in the past year among adolescents 

was higher among those who reported being in poor health. Among 

adolescents in fair or poor health, nearly one-fifth (17.8 percent) reported experiencing a past-year MDE compared to 12.4 percent of 

those in good health, 9.2 percent of those in very good health, and 6.2 

percent of those in excellent health. With respect to race and ethnicity, past-year occurrence of an MDE ranged from 4.2 percent among 

non-Hispanic Asian youth to 11.3 percent of non-Hispanic adolescents of multiple races. 

Risk factors for depression include stress, experiencing a significant loss, and having an existing emotional or behavioral disorder.9 

Primary care providers can screen for depression in adolescents when 

Figure 1. Occurrence of Major Depressive Episode (MDE)* in the Past

Year Among Adolescents Aged 12–17 Years, by Age and Sex, 2012 Percent of Adolescents

4

8

12

16

20

Total 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years

*MDE is defined as a period of at least two weeks when a person experienced a depressed mood or loss of

pleasure in daily activities and had a majority of specific depression symptoms. 

TotalMale

Female

9.1

3.7

13.7

7.1

11.8 13.1

17.4

11.8

5.4 4.7

8.6

2.1

4.4

15.4

10.9

6.4

2.5

6.6

18.3

11.8

5.7

Source: Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on

Drug Use and Health: detailed tables, NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD:

Substance Abuse and Mental Health Services Administration; 2013. Available at:

http://www.samhsa.gov/data/nsduh/2k12mh_findingsanddettables/mhdt/nsduh-mhdettabstoc2012.htm.

Accessed March 14, 2014. Figure 2. Past Year Substance Dependence or Abuse Among

Adolescents Aged 12–17 Years, by Past Year Major Depressive

Episode (MDE)*, 2012

*MDE is defined as a period of at least two weeks when a person experienced a depressed mood or loss of

pleasure in daily activities and had a majority of specific depression symptoms. **Illicit Drugs include

marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type

psychotherapeutics used non-medically.

Source: Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on

Drug Use and Health: detailed tables, NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD:

Substance Abuse and Mental Health Services Administration; 2013. Available at:

http://www.samhsa.gov/data/nsduh/2k12mh_findingsanddettables/mhdt/nsduh-mhdettabstoc2012.htm.

Accessed March 14, 2014. Percent of Adolescents

4

8

12

16

20

Illicit Drugs** Alcohol Illicit Drugs** or Alcohol

Past Year MDE

No Past Year MDE

11.1

2.9

9.3

16.0

5.1

3.3
Child Health USA 2014 Health Status and Behaviors - Adolescents 62

systems following a collaborative care model are in place. By connecting primary care providers, case managers, and mental health 

specialists to each other and patients, systems can efficiently improve 

symptoms, adherence and response to treatment, remission, and recovery.10,11 Other mental health interventions can be found at SAMHSA’s National Registry of Evidence-based Programs and Practices 

(NREPP), which is a database of interventions that have met minimum 

requirements for review and have been independently assessed and 

rated for quality and readiness for dissemination. NREPP is available 

to help the public learn more about evidence-based programs and 

practices to help determine which may best meet their needs.12

Data Sources

Figure 1 and 2. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: detailed tables, NSDUH 

Series H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. Available at: http://www.samhsa.

gov/data/nsduh/2k12mh_findingsanddettables/mhdt/nsduh-mhdettabstoc2012.htm. Accessed March 14, 2014.

Endnotes

1. U.S. Department of Health and Human Services. Healthy People 2020 topics & objectives: mental health and mental disorders. Available at: http://healthypeople.

gov/2020/topicsobjectives2020/default.aspx. Accessed April 1, 2014. 

2. Kessler RC, Berglund R, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry. 2005;65(6):593–602. 

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

4. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: mental health findings, NSDUH Series 

H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. Available at: http://www.samhsa.gov/

data/nsduh/2k12mh_findingsanddettables/2k12mhf/nsduhmhfr2012.htm. Accessed March 28, 2014.

5. Substance Abuse and Mental Health Services Administration. Mental disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. 

Available at: http://www.samhsa.gov/disorders/mental. Accessed February 17, 2015.

6. Rushton JL, Forcier M, Schectman RM. Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. Journal of the American Academy of Child & Adolescent Psychiatry. 2002;41(2):199–205.

7. Centers for Disease Control and Prevention. Suicide prevention: youth suicide. Available at: http://www.cdc.gov/violenceprevention/pub/youth_suicide.html. Accessed 

April 4, 2014. 

8. U.S. Department of Health and Human Services. Healthy People 2020 leading health indicators: mental health. Available at: http://healthypeople.gov/2020/LHI/mentalHealth.aspx. Accessed April 4, 2014. 

9. Cash RE. Depression in children and adolescents: information for parents and educators. Bethesda, MD: National Association of School Psychologists; 2004. 

10. Guide to Community Preventive Services. Improving mental health and addressing mental illness: collaborative care for the management of depressive disorders. 

Available at: http://www.thecommunityguide.org/mentalhealth/collab-care.html. Accessed April 15, 2014. 

11. Richardson LP, Ludman E, McCauley E, Lindenbaum J, Larison C, Zhou C, Clarke G, Brent D, & Katon W. Collaborative care for adolescents with depression in primary care: a randomized clinical trial. Journal of the American Medical Association. 2014 Aug 27;312(8):809-16.

12. National Registry of Evidence-based Programs and Practices . About NREPP. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. Available at: http://www.nrepp.samhsa.gov/AboutNREPP.aspx. Accessed February 17, 2015.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 63

VIOLENCE

Violence among adolescents occurs in multiple forms and is a critical public health issue in the United States. Instances of violence include physical fighting, dating violence, and homicide, which was the 

third leading cause of death among all persons aged 10–24 years in 

2010 (the latest year for which data are available).1

Data from the Youth Risk Behavior Surveillance System show that 

in 2013, 8.1 percent of high school students reported being in a physical fight on school property during the preceding 12 months. This 

represents a decrease since 2011, when 12.0 percent of students 

reported such violence. The proportion of students to report fighting 

at school also varied by grade level, with 10.9 percent of 9th-graders 

reporting fighting compared to 4.9 percent of 12th-graders (figure 1). 

In 2013, male students were more than twice as likely to report 

having been in a fight as female students (10.7 versus 5.6 percent, 

respectively). With regard to race and ethnicity, 12.8 percent of all 

non-Hispanic Black students reported fighting at school, compared 

to 9.4 percent of Hispanic students and 6.4 percent of non-Hispanic 

White students. 

In addition to a physical fight, high school students may experience 

dating violence in the form of either physical violence or unwanted 

sexual advances. Approximately 1 of every 10 high school students 

who had been in a relationship during the past 12 months reported 

that they were hit, slapped, or otherwise physically hurt on purpose by 

their boyfriend or girlfriend at least once. The proportion of students 

who reported that they had experienced physical dating violence was 

higher among 12th-graders compared to 9th-graders (11.7 versus 

8.8 percent, respectively) and higher among female students than 

male students (13.0 versus 7.4 percent, respectively). 

Sexual dating violence is any unwanted kissing, unwanted touching, or being forced to have sexual intercourse by the person they are 

dating. In 2013, approximately 1 of every 10 high school students who 

had been in a relationship during the past 12 months reported this 

form of violence. Females were more than twice as likely as males to 

experience sexual dating violence (14.4 versus 6.2 percent, respecFigure 1. High School Students in a Physical Fight on School Property

in the Past 12 Months, by Grade, 2013 Percent of Students

10.9

7.5

4.9

8.1

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High

School Youth Risk Behavior Survey. Available at: http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014.

8.3

4

8

12

16

20

Total 9th Grade 10th Grade 11th Grade 12th Grade
Child Health USA 2014 Health Status and Behaviors - Adolescents 64

tively). With regard to race and ethnicity, non-Hispanic Asian students 

(17.0 percent) were more likely to experience sexual dating violence 

than non-Hispanic White students (9.8 percent) and non-Hispanic 

Black students (8.9 percent; figure 2). School-based programs where 

Figure 2. High School Students* Experiencing Dating Violence in the

Past 12 Months, by Race/Ethnicity,** 2013 Percent of Students

17.0

10.3 10.4

Experienced Physical Dating Violence†

Experienced Sexual Dating Violence‡

*Includes students who dated someone during the 12 months before the survey. **Data for Native Hawaiians,

Other Pacific Islanders, American Indians, and Alaska Natives do not meet standards for reliability or precision.

†

Defined as being hit, slammed into something, or injured with an object or weapon on purpose by someone

whom they were dating. ‡

Defined as unwanted kissing, unwanted touching, or being physically forced to have

sexual intercourse by someone whom they were dating. 

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High

School Youth Risk Behavior Survey. Available at: http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014.

9.7 9.8 10.3

4

8

12

16

20

NonHispanic

Multiple

Races

NonHispanic

Asian

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

8.9

10.4

11.5 11.8 12.6

10.6

students are taught about violence prevention are recommended as 

an evidence-based way to reduce youth violence. Both individual and 

group cognitive-behavioral therapy are also recommended.2,3

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High School Youth Risk Behavior Survey. Available at: 

http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014.

Endnotes

1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Youth Violence: National Statistics. Available at: http://www.cdc.gov/

violenceprevention/youthviolence/stats_at-a_glance/lcd_10-24.html. Accessed September 21, 2014.

2. The Community Guide. Violence Prevention: School-Based Programs. Available at: http://www.thecommunityguide.org/violence/school.html. Accessed March 2, 

2015.

3. The Community Guide. Violence Prevention: Reducing Psychological Harm From Traumatic Events Among Children and Adolescents. Available at: http://www.thecommunityguide.org/violence/traumaticevents/index.html. Accessed March 2, 2015.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 65

BULLYING

Bullying is defined as unwanted, aggressive behavior that may be 

repeated and involves a real or perceived imbalance of power. Making 

threats, spreading rumors, attacking someone physically or verbally, 

and excluding someone from a group on purpose are all examples of 

bullying. Cyberbullying, or bullying that uses electronic technology, is 

different from other types of bullying in that it can happen at any time, 

messages and images can be posted anonymously and distributed 

quickly via the Internet, and they can be very difficult to delete after 

posting.1

There is no specific factor that puts children at risk of being bullied or bullying others, although some groups, such as lesbian, gay, 

bisexual, or transgendered youth; youth with disabilities; and socially 

isolated youth may be at higher risk.2 Being bullied has been associated with a wide range of short- and long-term emotional, physical, and 

developmental consequences, including depression, anxiety, headaches, sleeping problems, stomach ailments, and decreased academic achievement. Children who bully are also more likely to engage 

in violent and risky behaviors, such as drug and alcohol use and early 

sexual activity. Even children who witness bullying can be negatively 

affected.3

In 2013, 19.6 percent of high school students reported that they 

had been bullied on school property in the past year and approximately one in six high school students (14.8 percent) reported having been 

electronically bullied through e-mail, chat rooms, instant messaging, 

Web sites, or texting (figure 1). The likelihood of being bullied varied by 

a number of factors, including sex, grade level, and race and ethnicity. 

Females were more likely than males to have been bullied on school 

property (23.7 versus 15.6 percent, respectively) and more than twice 

as likely as males to have been electronically bullied (21.0 versus 8.5 

percent, respectively).

Younger high school students were also more likely to report being 

bullied than older students: 25.0 percent of 9th-graders reported being bullied at school compared to 13.3 percent of 12th-graders (figure 

1). Similarly, 9th-graders were slightly more likely than 12th-graders to 

report being bullied electronically (16.1 versus 13.5 percent, respectively).

Non-Hispanic Black students were less likely to report being bullied on school property or bullied electronically (12.7 and 8.7 percent, 

respectively) than all other racial and ethnic groups (figure 2). In comparison, non-Hispanic White students were significantly more likely 

Figure 1. High School Students Who Were Bullied in the Past Year, by

Grade and Location of Bullying, 2013 Percent of Students

6

12

18

24

30

Total 9th grade 10th grade 11th grade 12th grade

Bullied on School Property

Bullied Electronically

19.6

14.5

22.2

16.8

14.9 13.3 13.5 14.8

25.0

16.1

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High

School Youth Risk Behavior Survey. Available at: http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014.

Figure 2. High School Students Who Were Bullied in the Past Year, by

Race/Ethnicity and Location of Bullying, 2013

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High

School Youth Risk Behavior Survey. Available at: http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014. Percent of Students

6

12

18

24

30

NonHispanic

Multiple

Races

NonHispanic

American

Indian/

Alaska

Native

NonHispanic

Native

Hawaiian/

Other

Pacific

Islander

NonHispanic

Asian

Non- Hispanic

Hispanic

Black

NonHispanic

White

Bullied on School Property

Bullied Electronically

8.7

12.7

17.8

12.8

21.7

12.9

15.7

22.9 21.4

18.0

24.4

18.9

21.8

16.9
Child Health USA 2014 Health Status and Behaviors - Adolescents 66

to report electronic bullying (16.9 percent) than non-Hispanic Asian, 

Hispanic, and non-Hispanic Black high school students (12.9, 12.8, 

and 8.7 percent, respectively). Evidence-based recommendations to 

reduce bullying and its associated risks include both school-based 

programs that teach students about violence prevention and individual and group cognitive-behavioral therapy interventions for students 

exposed to violence.4,5

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. High School Youth Risk Behavior Survey. Available at: 

http://nccd.cdc.gov/YouthOnline. Accessed September 20, 2014.

Endnotes

1. Gladden R. M., Vivolo-Kantor, A.M., Hamburger, M., & Lumpkin, C. (2014). Bullying surveillance: Uniform definitions and recommended data elements, Version 1.0. 

Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Available at: http://www.cdc.gov/violenceprevention/pdf/

bullying-definitions-final-a.pdf

2. U.S. Department of Health and Human Services. Stop Bullying: Risk Factors. Available at: http://www.stopbullying.gov/at-risk/factors/index.html. Accessed September 

20, 2014.

3. U.S. Department of Health and Human Services. Stop Bullying: Effects of Bullying. Available at: http://www.stopbullying.gov/at-risk/effects/index.html. Accessed 

February 16, 2015.

4. The Community Guide. Violence Prevention: School-Based Programs. Available at: http://www.thecommunityguide.org/violence/school.html. Accessed March 2, 

2015.

5. The Community Guide. Violence Prevention: Reducing Psychological Harm From Traumatic Events Among Children and Adolescents. Available at: http://www.thecommunityguide.org/violence/traumaticevents/index.html. Accessed March 2, 2015.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 67

CIGARETTE SMOKING

The use of tobacco products, such as cigarettes, can lead to a variety of illnesses and conditions, including cancer, heart disease, and 

lung disease.1 Smoking is the leading preventable cause of death and 

disease in the United States, accounting for more than 1,200 deaths 

each day. Cigarette smoking among adolescents can result in both 

immediate and long-term damage. Adolescents who smoke face 

reduced lung function and slowed lung growth, which may increase 

their risk for chronic obstructive pulmonary disease. The earlier the 

age of initiation, the more likely individuals will develop nicotine addiction, which prolongs cigarette use. Almost 9 out of 10 cigarette users 

started smoking by age 18.2

The rate of past month cigarette use among adolescents aged 12–

17 years declined by nearly half, from 13.0 to 6.6 percent, between 

2002 and 2012 (figure 1). Current cigarette use in 2012 varied by age, 

with rates of 13.6 percent among youth aged 16–17 years, compared 

to 4.6 percent of youth aged 14–15 years and 1.2 percent of youth 

aged 12–13 years. 

While cigarette use rates were similar for adolescent males and 

females (6.8 and 6.3 percent, respectively), past-month use varied by 

race and ethnicity. Rates were highest among non-Hispanic American 

Indian/Alaska Native (11.8 percent), non-Hispanic White (8.2 percent), 

and non-Hispanic youth of multiple races (7.5 percent) while lowest 

among non-Hispanic Asian youth (1.7 percent). 

The rate of past-month cigarette use was greater in nonmetro 

counties (9.0 percent) than in both large metro (5.6 percent) and small 

metro counties (7.1 percent; figure 2).

The rate of past year initiation of cigarette use among adolescents 

was 4.1 percent. Rates of past year initiation have only recently started 

to decline, with rates falling from 4.9 percent in 2010 to 4.1 percent 

in 2012. 

Prevention strategies must focus on reducing initiation and continuation of cigarette use as well as promoting cessation. More than 

80 percent of smokers under 18 years of age used cigarettes from 

the top three most advertised brands.3 Health communication interventions have been shown to effectively decrease tobacco use initiation and prevalence as well as increase cessation, especially as part 

of a set of comprehensive tobacco control measures.2 Successful 

messages used emotional appeal through personal testimonials or 

graphic images of harms caused by tobacco and also provided cessation services information.6

 Smoke-free policies have been shown to 

effectively reduce tobacco-related morbidity and mortality,7 in addition to reducing tobacco use initiation and prevalence and increasing 

Figure 1. Past Month Cigarette Use Among Adolescents Aged 12–17

Years, 2002–2012 Percent of Adolescents

4

8

12

16

20

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

6.6

Source: Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on

Drug Use and Health: detailed tables, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD:

Substance Abuse and Mental Health Services Administration; 2013. Available at:

http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUH-DetTabsTOC2012.htm.

Accessed March 7, 2014.
Child Health USA 2014 Health Status and Behaviors - Adolescents 68

*Urban/rural residence is determined based on metropolitan statistical area (MSA), which is defined by having at

least one urbanized area of 50,000 or more population, plus adjacent territory that has a high degree of social

and economic integration with the core as measured by commuting ties. Large Metro includes persons living in

an MSA of 1 million or more population; Small Metro areas have a population of less than 1 million. Nonmetro

consists of persons not living in an MSA.

Source: Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on

Drug Use and Health: detailed tables, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD:

Substance Abuse and Mental Health Services Administration; 2013. Available at:

http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUH-DetTabsTOC2012.htm.

Accessed March 7, 2014.

6.6

5.6

7.1

9.0

Figure 2. Past Month Cigarette Use Among Adolescents Aged

12─17 Years, by Urban/Rural Residence,* 2012 Percent of Adolescents 2

4

6

8

10

Total Large Metro Small Metro Nonmetro

cessation. Smoking may be restricted to designated outdoor locations or even completely banned. Initiation, prevalence, and intensity 

of cigarette smoking can be reduced by increasing tobacco prices.4

In addition, clinicians can play a role in promoting cessation as part 

of comprehensive pediatric care. Adolescents should be screened 

for tobacco use at every clinical encounter, and receive appropriate 

guidance regarding the risks of tobacco use and benefits of tobacco 

cessation.5

Data Sources

Figure 1 and 2. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: detailed tables, NSDUH 

Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. Available at: http://www.samhsa.

gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUH-DetTabsTOC2012.htm. Accessed March 7, 2014.

Endnotes

1. U.S. Department of Health and Human Services. Healthy People 2020 topics & objectives: tobacco use. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid. Accessed March 7, 2014. 

2. U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the Surgeon General, 2012. Fact sheet. Available 

at: http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/factsheet.html. Accessed March 14, 2014.

3. Centers for Disease Control and Prevention. Youth and tobacco use. CDC fact sheets. Available at: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_

data/tobacco_use/. Accessed March 14, 2014. 

4. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure. Available at: http://www.thecommunityguide.org/tobacco/index.

html. Accessed March 18, 2014. 

5. American Academy of Pediatrics. Tobacco as a Substance of Abuse. Available at: http://pediatrics.aappublications.org/content/124/5/e1045.full. Accessed February 

16, 2015.

6. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: Mass-reach health communication interventions. Available at: 

http://www.thecommunityguide.org/tobacco/massreach.html. Accessed February 16, 2015.

7. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: Smoke-free policies. Available at: http://www.thecommunityguide.

org/tobacco/smokefreepolicies.html. Accessed February 16, 2015.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 69

SUBSTANCE USE

Drugs alter brain functioning, and early substance use is especially dangerous, as it increases an individual’s risk for drug abuse and 

addiction as well as teenage pregnancy, HIV/AIDS, other sexually 

transmitted diseases, motor vehicle accidents, crime, homicide, and 

suicide.1,2 Substance use includes the use of alcohol, as well as the 

use of illicit drugs including cocaine, hallucinogens, heroin, inhalants, 

marijuana, and nonmedical use of prescription-type psychotherapeutic drugs, such as pain relievers and stimulants.

Alcohol continues to be the most commonly used substance 

among adolescents aged 12–17 years, with 12.9 percent reporting 

past-month use in 2012 (figure 1). This reflects a decrease from 17.6 

percent in 2002. Alcohol use varied greatly by age, with only 2.2 percent of youth aged 12–13 years reporting past-month use, compared 

to 11.1 percent of youth aged 14–15 years and 24.8 percent of youth 

aged 16–17 years. Past-month alcohol use also varied by race and 

ethnicity, with rates ranging from 4.9 percent among non-Hispanic 

Asian youth to 14.6 percent of non-Hispanic White youth (figure 1). 

In 2012, 9.5 percent of adolescents reported using illicit drugs in the 

past month compared to 11.5 percent in 2002. In contrast to alcohol 

use, illicit drug use among adolescents has not consistently declined 

over the past decade and has remained between 9 and 10 percent 

since 2005. The rate of current illicit drug use was greater among older 

adolescents, ranging from 3.5 percent of those aged 12–13 years to 

16.6 percent of those aged 16–17 years (figure 2).

Non-Hispanic Asian youth reported the lowest rates of past month 

illicit drug use (2.6 percent), while the highest rates were among 

non-Hispanic youth of multiple races (14.7 percent). Rates of pastmonth illicit drug use among non-Hispanic White, Hispanic, non-Hispanic Black, and non-Hispanic American Indian/Alaska Native youth 

were 9.6, 9.7, 10.2, and 12.1 percent, respectively.

Marijuana is consistently the most commonly used illicit drug 

among adolescents, with 7.2 percent reporting past-month use in 

2012. This was followed by nonmedical use of prescription-type psychotherapeutics (2.8 percent; figure 2). There were no differences in 

past-month alcohol or illicit drug use between male and female adolescents.

Adolescence is an especially critical time for substance use prevention.2

 Evidence-based prevention programs that focus on increasing 

protective factors and reducing risk factors for drug use can significantly reduce substance use among adolescents. Some risk factors include early aggressive behavior, lack of parental supervision, 

drug availability, and poverty. Protective factors include self-control, 

parental monitoring, academic competence, anti-drug use policies, 

and strong neighborhood attachment.3,4 The Community Preventive 

Services Task Force also recommends several school and community-based strategies to reduce underage drinking and alcohol-impaired 

driving.5,6

Figure 1. Past Month Alcohol Use Among Adolescents Aged 12–17

Years, by Race/Ethnicity,* 2012 Percent of Adolescents

*Estimates for non-Hispanic Native Hawaiian/Other Pacific Islanders did not meet standards of reliability.

4

8

12

16

20

NonHispanic

Multiple Races 

NonHispanic

Asian 

NonHispanic

American Indian/

Alaska Native

Non- Hispanic 

Hispanic

Black

NonHispanic

White

Total

12.9

14.6

12.8

11.7

9.3

4.9

10.0

Source: Substance Abuse and Mental Health Services Administration. Results From the 2012 National Survey on

Drug Use and Health: detailed tables, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD:

Substance Abuse and Mental Health Services Administration; 2013. Available at:

http://www.samhsa.gov/data/nsduh/2012summnatfinddettables/dettabs/nsduh-dettabstoc2012.htm.

Accessed February 25, 2014.
Child Health USA 2014 Health Status and Behaviors - Adolescents 70

Data Sources

Figure 1 and 2. Substance Abuse and Mental Health Services Administration. Results From the 2012 National Survey on Drug Use and Health: detailed tables, NSDUH 

Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. Available at: http://www.samhsa.

gov/data/nsduh/2012summnatfinddettables/dettabs/nsduh-dettabstoc2012.htm. Accessed February 25, 2014.

Endnotes

1. National Institutes of Health. National Institute on Drug Abuse. Preventing drug abuse: the best strategy. Available at: http://www.drugabuse.gov/publications/

drugs-brains-behavior-science-addiction/preventing-drug-abuse-best-strategy. Accessed March 4, 2014.

2. U.S. Department of Health and Human Services. Healthy People 2020 topics & objectives: substance abuse. Available at: http://www.healthypeople.gov/2020/topics-objectives/topic/substance-abuse. Accessed February 28, 2014. 

3. National Institutes of Health, National Institute on Drug Abuse. Preventing drug use among children and adolescents (in brief). Available at: http://www.drugabuse.gov/

publications/preventing-drug-use-among-children-adolescents. Accessed March 4, 2014. 

4. National Registry of Evidence-based Programs and Practices . About NREPP. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. Available at: http://www.nrepp.samhsa.gov/AboutNREPP.aspx. Accessed February 17, 2015.

5. Guide to Community Preventive Services. Preventing excessive alcohol consumption. Available at: www.thecommunityguide.org/alcohol/index.html. Accessed March 

4, 2014.

6. Guide to Community Preventive Services. Motor vehicle-related injury prevention: reducing alcohol-impaired driving. Available at: www.thecommunityguide.org/mvoi/

AID/index.html. Accessed March 4, 2014.

Figure 2. Past Month Substance Use Among Adolescents Aged 12−17

Years, by Drug Type and Age, 2012

Percent of Adolescents

Source: Substance Abuse and Mental Health Services Administration. Results From the 2012 National Survey on

Drug Use and Health: detailed tables, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD:

Substance Abuse and Mental Health Services Administration; 2013. Available at:

http://www.samhsa.gov/data/nsduh/2012summnatfinddettables/dettabs/nsduh-dettabstoc2012.htm.

Accessed February 25, 2014.

*Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or

prescription-type psychotherapeutics used non-medically. **Includes nonmedical use of pain relievers, sedatives,

stimulants, and tranquilizers; does not include over-the-counter substances. †

Includes LSD, PCP, and ecstasy. 

5 10 15 20 25

Cocaine

Hallucinogens†

Inhalants

Non-Medical

Use of

Psychotherapeutics**

Marijuana

Any

Illicit Drug*

Alcohol

12.9

1.2

1.2

1.7

0.9

0.2

0.1

0.5

0.6

0.0

11.1

8.2

6.1

2.5

2.2

0.8

0.1

7.2

2.8

9.5

3.5

16−17 Years

14−15 Years

12–13 Years

Total

0.2

0.7

0.7

24.8

16.6

14.0

4.0

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Status and Behaviors - Adolescents 71

HIGH SCHOOL COMPLETION

Education plays a critical role in the health and well-being of young 

adults in the United States. Previous studies have found that education is associated with better health outcomes. For example, those 

who graduate from high school have lower death rates and an average life expectancy 6–9 years greater than those who do not graduate 

from high school.1,2 Individuals who do not complete high school have 

higher rates of illness and earlier deaths. 

In 2013, more than 90 percent of 18- to 24-year-olds not enrolled in 

high school had received a high school diploma or equivalent credential (e.g., General Educational Development certificate). High school 

completion was highest among non-Hispanic Asians (95.8 percent), 

non-Hispanic Native Hawaiians and other Pacific Islanders (95.3 percent), and non-Hispanic Whites (93.7 percent; figure 1). High school 

completion was lower among other racial and ethnic groups, including 

non-Hispanic persons of multiple races (92.5 percent), non-Hispanic 

Blacks (89.3 percent), non-Hispanic American Indians and Alaska Natives (86.2 percent), and Hispanics (81.8 percent). 

High school completion also varies by age and sex. In 2013, a 

higher percentage of females had a high school degree or equivalent 

than their male counterparts (91.9 versus 89.4 percent, respectively; 

figure 2). These differences were also evident at specific ages. High 

school completion was highest among females who were 23 years 

of age (94.5 percent), and lowest among 18-year-old males and females (76.5 and 83.6 percent, respectively). High school completion 

programs for students at high risk of non-completion show strong 

evidence of effectiveness for all students and for the subset of students at risk for non-completion because they are pregnant or have 

children.3

Figure 1. Young Adults Aged 18–24 Years Not Currently Enrolled in

High School With a High School Degree or Equivalent, by

Race/Ethnicity, 2013 Percent of Young Adults

20

40

60

80

100

NonHispanic

Multiple

Races

NonHispanic

Native

Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American

Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

86.2 81.8

89.3

95.8 93.7 90.6 92.5 95.3

Source: U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and

Economic Supplement. Analysis conducted by the Maternal and Child Health Epidemiology and Statistics

Program.

Figure 2. Young Adults Aged 18–24 Years Not Currently Enrolled in

High School With a High School Degree or Equivalent, by Age and

Sex, 2013 Percent of Young Adults

Source: U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and

Economic Supplement. Analysis conducted by the Maternal and Child Health Epidemiology and Statistics

Program.

20

40

60

80

100

Total 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years

90.6 93.4 91.2 92.9 89.0 91.4 90.0 91.0

83.6

76.5

89.4 91.9 90.3 91.5 90.1 94.5

MaleFemale
Child Health USA 2014 Health Status and Behaviors - Adolescents 72

Data Sources

Figure 1 and 2. U.S. Census Bureau and Bureau of Labor Statistics, Current Population Survey, Annual Social and Economic Supplement. Analysis conducted by the 

Maternal and Child Health Epidemiology and Statistics Program.

Endnotes

1. Allensworth D, Lewallen TC, Stevenson B, Katz S. Addressing the needs of the whole child: what public health can do to answer the education sector’s call for a stronger partnership. Preventing Chronic Disease. 2011;8(2):A44. Available at: http://www.cdc.gov/pcd/issues/2011/mar/10_0014.htm. Accessed September 5, 2014.

2. Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of major diseases to disparities in mortality. New England Journal of Medicine. 2002;347(20):1585–

1592.

3. The Community Guide. Promoting Health Equity Through Education Programs and Policies: High School Completion Programs. Available at: http://www.thecommunityguide.org/healthequity/education/highschoolcompletion.html. Accessed March 2, 2015.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 73

HEALTH SERVICES FINANCING 

AND UTILIZATION

The availability of and access to quality health care 

directly affects the health of the population. This is espe-

cially true of those at high risk due to low socioeconomic 

status or chronic medical conditions.

Children may receive health coverage through a 

number of sources, including private insurance, either 

through employers or purchased directly, or through 

public programs, such as Medicaid or the Children’s 

Health Insurance Program (CHIP). Eligibility for public 

programs is based on a family’s income, size and other 

requirements, such as citizenship or immigrant status. 

Every state has a CHIP program that helps to expand 

coverage to children who would otherwise be uninsured. 

Despite the progress achieved through public programs, 

approximately 6.5 million children remain uninsured in 

the United States.

This section presents data on the health insurance 

status and utilization of health services within the ma-

ternal and child population including prenatal care, wellchild visits and developmental screening for young children, and mental health care for adolescents. Data are 

summarized by source of payment, type of care, and 

place of service delivery where appropriate and feasible. 
Child Health USA 2014 Health Services Financing and Utilization 74

HEALTH INSURANCE

Health insurance is critical for ensuring the health and well-being 

of children in the United States. Without health insurance coverage, 

children are less likely to receive medical care and more likely to have 

poor health status.1 In 2013, more than 4.8 million children under age 

18 did not have health insurance. This represents 6.6 percent of all 

children in the United States. More than half of children (53.2 percent) 

were covered by private insurance, and 37.7 percent were covered by 

public insurance (e.g., Medicaid or other state-sponsored health plans 

including Children’s Health Insurance Program [CHIP]). 

Children’s health insurance status varies by several factors, including race, ethnicity, and income. In 2013, nearly 70 percent of non-Hispanic White and non-Hispanic Asian children and more than half of 

non-Hispanic children of multiple races had private coverage (figure 1). 

In comparison, less than half of non-Hispanic Native Hawaiian/Pacific 

Islander (40.3 percent), non-Hispanic Black (33.6 percent), Hispanic 

(28.2 percent), and non-Hispanic American Indian/Alaska Native (36.3 

percent) children had private coverage. Children with the highest percentage of public insurance were non-Hispanic Blacks (58.8 percent), 

Hispanics (58.2 percent), non-Hispanic Native Hawaiians/other Pacific 

Islanders (52.8 percent), and non-Hispanic American Indians/Alaska 

Natives (49.2 percent). The highest proportions of uninsured children 

were among non-Hispanic American Indians/Alaska Natives (11.9 

percent) and Hispanics (11.8 percent).

In 2013, households with incomes below 100 percent of poverty 

had the highest percentage of children with public health insurance 

(82.3 percent) and the lowest percentage of children with private 

health insurance (8.4 percent). The highest percent of children who 

were uninsured in 2013 were children living in households with incomes of 100–199 percent of poverty (11.1 percent), followed by children from households with incomes below 100 percent of poverty 

(8.2 percent). Children in households with incomes of 200 percent 

or more of poverty were more likely to have private coverage (81.7 

percent) and less likely to have public coverage (11.1 percent) or to 

be uninsured (4.2 percent), as compared to those in households with 

lower incomes. 

16 32 48 64 80

Non-Hispanic

Multiple Race

Non-Hispanic Native Hawaiian/

Pacific Islander

Non-Hispanic

Asian

Non-Hispanic

American Indian/

Alaska Native

Hispanic

Non-Hispanic

Black

Non-Hispanic

White

Figure 1. Health Insurance Coverage* Among Children Under Age 18,

by Race/Ethnicity, 2013

*Private coverage includes children with any private insurance; Public includes children who do not have private

coverage, but who have Medicaid or other state-sponsored health plans, including CHIP; A child was 

considered uninsured if he or she did not have any private health insurance, Medicare, Medicaid, Children's

Health Insurance Program (CHIP), state-sponsored or other government-sponsored health plan, or military plan.

A child was also defined as uninsured if he or she had only Indian Health Service coverage or had only a private

plan that paid for one type of service such as accidents or dental care. Estimates do not sum to 100 because

children who are covered by military plans, Medicare, or other government-sponsored health plans are not

shown. †

Estimates are considered unreliable. Data followed by a dagger have a relative standard error (RSE)

greater than 30% and less than or equal to 50% and should be used with caution. Data not shown have an RSE

greater than 50%.

58.2

49.2

66.1

51.6

23.7

58.8

33.6

68.8

28.2

Percent of Children

4.7

5.1

11.8

36.3†

25.6

11.9†

40.3†

5.9

52.8†

†

38.5

5.6

Private Insurance

Public Insurance

Uninsured

Source: Centers for Disease Control and Prevention, National Center for Health Statistics. National Health

Interview Survey. Analyses conducted by the National Center for Health Statistics.
Child Health USA 2014 Health Services Financing and Utilization 75

Between 2000 and 2013 there were shifts in the proportion of children in each of the three types of insurance categories (private insurance, public insurance and uninsured). Private health insurance coverage for children is lower in 2013 (53.2 percent) than it was in 2000 

(67.0 percent; figure 2). A larger difference is seen in public health 

insurance coverage for children which is higher in 2013 (37.7 percent) than it was in 2000 (18.4 percent). The percentage of children 

who were uninsured in 2013 is nearly half as much as it was in 2000 

(6.6 versus 12.4 percent, respectively). Implementation of the Affordable Care Act may further support reductions in uninsurance among 

children through new electronic data systems that will streamline the 

eligibility and application process for programs such as Medicaid and 

CHIP, and by increasing insurance coverage among adults.2

 Research 

has shown that children’s Medicaid and CHIP coverage increases 

when their parents applied for Medicaid.3

Data Source

Figure 1 and 2. Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey. Analyses conducted by the National 

Center for Health Statistics.

Endnotes

1. Szilagyi PG, Schuster MA, Cheng TL. The scientific evidence for child health insurance. Acad Pediatr. 2009 Jan-Feb;9(1):4-6.

2. Urban Health Institute: Health Policy Center. A first look at children’s health insurance coverage under the ACA in 2014. September 9, 2014. Available at: http://hrms.

urban.org/briefs/childrens-health-insurance-coverage-under-the-aca-in-2014.html. Accessed March 2, 2015.

3. DeVoe JE, Marino M, Angier H, et al. Effect of expanding Medicaid for parents on children’s health insurance coverage. JAMA Pediatr. 2015;169(1):e143145. Available 

at: http://archpedi.jamanetwork.com/article.aspx?articleid=2086457. Accessed March 2, 2015.

Figure 2. Health Insurance Coverage* Among Children Under Age 18,

by Year, 2000–2013

*Private coverage includes children with any private insurance; Public includes children who do not have private

coverage, but who have Medicaid or other state-sponsored health plans, including CHIP; Children were

considered uninsured if he or she did not have any private health insurance, Medicare, Medicaid, Children's

Health Insurance Program (CHIP), state-sponsored or other government-sponsored health plan, or military plan.

A child was also defined as uninsured if he or she had only Indian Health Service coverage or had only a private

plan that paid for one type of service such as accidents or dental care. Estimates do not sum to 100 because

children who are covered by military plans, Medicare, or other government-sponsored health plans are

not shown.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics. National Health

Interview Survey. Analyses conducted by the National Center for Health Statistics.

53.2

37.7

6.6

16

32

48

64

80

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Public Insurance

Uninsured

Private Insurance

Percent of Children

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 76

PRENATAL CARE

Early and adequate prenatal care helps to promote healthy pregnancies through screening and management of a woman’s risk factors 

and health conditions as well as education and counseling on healthy 

behaviors during and after pregnancy, including nutrition, physical activity, and breastfeeding.1

 Women should schedule a prenatal visit as 

soon as they know or suspect that they are pregnant, ideally within 

the first trimester of pregnancy (12 weeks).2 Monthly visits are recommended thereafter that increase to biweekly visits at 28 weeks and 

weekly visits after 36 weeks.1,3 More frequent care may be necessary 

for women with certain conditions and risk factors.1

In 2012, in the District of Columbia and the 38 states that had 

implemented the 2003 revision to the standard birth certificate as of 

January 1 and collected prenatal care information in the same format, 

74.1 percent of women giving birth were determined to have received 

early prenatal care in the first trimester, while 6.0 percent of women 

began prenatal care in the third trimester or did not receive any prenatal care. Rates of first-trimester prenatal care increased greatly with 

educational attainment, from 58.5 percent of mothers with less than a 

high school diploma to 86.1 percent of mothers with a bachelor’s degree or higher (figure 1). Conversely, late or no prenatal care declined 

sharply with educational attainment, from 11.4 percent of mothers 

with less than a high school diploma to 2.7 percent of mothers with a 

bachelor’s degree or higher.

Timing of prenatal care entry also varied greatly by race and ethnicity and delivery payment source. First trimester prenatal care initiation 

was highest for non-Hispanic White and non-Hispanic Asian women 

(79.0 and 78.0 percent, respectively), followed by non-Hispanic multiple race and Hispanic women (70.7 and 69.0 percent, respectively), 

and was lowest for non-Hispanic Black, non-Hispanic American Indian/Alaska Native, and non-Hispanic Native Hawaiian/other Pacific 

Islander women (63.6, 59.4, and 54.7 percent, respectively). With respect to delivery payment source, privately insured women had the 

highest rate of early prenatal care entry (85.0 percent), followed by 

women with Medicaid insurance (65.2 percent), while uninsured women were least likely to receive early prenatal care (51.4 percent).

In 2012, 84.9 percent of women in the District of Columbia and 

the 38-state reporting area received adequate prenatal care, defined 

as receiving 80 percent or more of expected visits given the timing 

of prenatal care entry and gestational age at delivery. Regardless of 

when care was initiated, privately insured women were most likely to 

Figure 1. Timing of Prenatal Care Initiation,* by Maternal Education,

2012

*Data are from the District of Columbia and 38 states that implemented the 2003 revision of the birth certificate

as of January 1, 2012, representing 86 percent of all U.S. births. Percentages may not total 100 due to rounding.

20 40 60 80 100

Bachelor’s Degree

or Higher

Some College or

Associate’s Degree

High School

Diploma or GED 

Less than High

School Diploma

Total

First Trimester Second Trimester

Third Trimester

or No Care

Percent of Mothers

68.6

4.9

2.7

76.1

86.1

74.1 19.9 6.0

58.5

24.2

19.0

11.2

30.1 11.4

7.2

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. 2012 Natality File. Analysis conducted by the U.S. Department of Health and Human

Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
Child Health USA 2014 Health Services Financing and Utilization 77

have received adequate care (88.0 percent), followed by those with 

Medicaid (83.3 percent) and other forms of insurance (80.1 percent; 

figure 2). Uninsured women were least likely to receive adequate care 

(72.2 percent). Receipt of adequate care by race and ethnicity and 

education were similar to those for timing of prenatal care entry.

The Affordable Care Act improves access to early and adequate 

prenatal care by expanding health insurance and requiring Medicaid 

expansions and Marketplace plans (and other small and individual 

group plans) to cover pregnancy and maternity care as part of essential health benefits.4

 The Affordable Care Act also requires new 

private plans to cover, without cost sharing, prenatal visits and many 

preventive services routinely provided in prenatal care, such as vaccinations; screening for gestational diabetes, anemia, sexually transmitted infections, and depression; screening and counseling for obesity, 

tobacco and alcohol use, and interpersonal and domestic violence; 

and breastfeeding counseling and support.4

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. 2012 Natality File. 

Analysis conducted by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Endnotes

1. U.S. Department of Health and Human Services Office on Women’s Health. Pregnancy: prenatal care and tests. Available at:

http://www.womenshealth.gov/pregnancy/you-are-pregnant/prenatal-care-tests.html. Accessed September 8, 2014.

2. National Committee for Quality Assurance. Prenatal and postpartum care. Available at: http://www.ncqa.org/portals/0/Prenatal%20Postpartum%20Care.pdf. Accessed September 8, 2014.

3. National Committee for Quality Assurance. Frequency of ongoing prenatal care. Available at: http://www.ncqa.org/portals/0/Frequency%20of%20Ongoing%20Prenatal%20Care.pdf. Accessed September 8, 2014.

4. Kaiser Family Foundation. Health reform: implications for women’s access to coverage and care. August 2013. Available at: http://kff.org/womens-health-policy/issue-brief/health-reform-implications-for-womens-access-to/ Accessed September 8, 2014.

Figure 2. Adequacy of Prenatal Care Utilization Upon Initiation,*

by Delivery Payment Source, 2012

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. 2012 Natality File. Analysis conducted by the U.S. Department of Health and Human

Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

*Based on a ratio of observed to expected prenatal care visits given the timing of prenatal care entry and

gestational age at delivery (Kotelchuck Index), adequate prenatal care is defined as receiving 80 percent or

more of expected visits, intermediate is receipt of 50–79.9 percent of expected visits, and inadequate is receipt

of less than 50 percent of expected visits. Data are from the District of Columbia and 38 states that implemented

the 2003 revision of the birth certificate as of January 1, 2012, representing 86 percent of all U.S. births.

Percentages may not total to 100 due to rounding. **Includes CHAMPUS/TRICARE; the Indian Health Service;

and other federal, state, or local government payment sources.

20 40 60 80 100

Other**

Self-Pay

(Uninsured)

Private Insurance

Medicaid

Total

Adequate Intermediate Inadequate

Percent of Mothers

88.0

11.3

4.0

72.2

80.1

84.9 11.9 3.3

83.3

10.4

16.4

15.9

12.5 4.2

1.5

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 78

IMMUNIZATIONS: EARLY CHILDHOOD

Vaccination is one of the greatest public health achievements of the 

20th century, resulting in dramatic declines in morbidity and mortality 

for many infectious diseases.1 Childhood vaccination in particular is 

considered among the most cost-effective preventive services available, as it averts a potential lifetime lost to death and disability.2 Healthy 

People 2020 has set a target of 80 percent coverage for a full vaccine 

series to be received by young children aged 19–35 months: four doses of diphtheria, tetanus, and acellular pertussis vaccine (DTaP/DT/

DTP); three doses of poliovirus vaccine; one dose of measles-containing vaccine (MMR); three (or four, depending on vaccine type) doses 

of Haemophilus influenzae type b (Hib); three doses of the hepatitis B 

vaccine (HepB); one dose of the varicella (chicken pox) vaccine; and 

four doses of the pneumococcal conjugate vaccine (PCV).3

In 2013, 70.4 percent of children aged 19–35 months received the 

full recommended series, which was similar to the 2012 rate of 68.4 

percent. Non-Hispanic Black 19- to 35-month-olds were less likely 

than non-Hispanic White children to receive the full recommended series (65.0 and 72.1 percent, respectively; figure 1). Similarly, the vaccination rate was lower for those with household incomes below 100 

percent of poverty compared to their counterparts living at or above 

the poverty level (64.4 versus 73.8 percent, respectively). Differences in vaccination rates by race and ethnicity vary within categorical 

poverty levels. Among children in households with incomes below 

100 percent of poverty, Hispanic children were more likely to be fully 

vaccinated than non-Hispanic White children (68.6 versus 61.3 percent, respectively), however, within this income category there was no 

difference between rates of vaccination between non-Hispanic White 

and non-Hispanic Black children (61.3 and 60.4 percent, respectively). Among children with household incomes of 100 percent or more 

of poverty, Hispanic and non-Hispanic Black children had lower rates 

of vaccination than non-Hispanic White children (70.2 and 69.1 versus 

74.9 percent, respectively).

The proportion of children receiving the full series of recommended 

vaccinations also varied by provider facility type (figure 2). Compared 

to private provider facilities (e.g., private clinics, health maintenance 

organizations, group practices), lower rates of full series coverage 

were reported by public provider facilities (e.g., public health clinics, 

community health centers) and other (e.g., hospitals, military facilities) 

types of provider facilities (72.2, 63.3, and 67.4 percent, respectively). 

The vaccination rate at mixed provider facilities (76.0 percent) was 

similar to the private provider facility rate. 

Children who never participated in WIC, but were eligible, had the 

lowest vaccination coverage. Current WIC participants had vaccination coverage comparable to more affluent children, and higher coverage than previous WIC participants.6

 Finally, the vaccination rate 

among 19- to 35-month-olds living in metropolitan statistical area 

Figure 1. Receipt of Recommended Vaccinations* Among Children

Aged 19–35 Months, by Race/Ethnicity,†

 2013

Percent of Children

*Recommended Full Series: ≥4 DTaP, ≥3 Polio, ≥1 MMR, 3 (4) Hib, ≥3 HepB, ≥1 Varicella, ≥4 PCV. †Estimates

for Native Hawaiian/other Pacific Islander children were not available.

18

36

54

72

90

NonHispanic

Multiple Races

NonHispanic

Asian

NonHispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

69.3 70.1

65.0

72.1 72.7 70.4 71.8

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Immunization Survey. Retrieved from:

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/child/data/tables-2013.html 

Accessed September 4, 2014.
Child Health USA 2014 Health Services Financing and Utilization 79

(MSA) noncentral cities (72.5 percent) was greater than for those living 

in MSA central cities (68.8 percent) and non-MSA central cities (69.1 

percent).

Immunization levels for the recommended full series of vaccinations for 19- to 35-month-olds in the United States remained at similar 

levels from 2012 to 2013, and disparities in vulnerable populations 

continue to exist. A variety of strategies can be used to help address 

coverage gaps. These include the Vaccine for Children (VFC) program, 

an important and effective way to help increase immunization rates 

in children who might otherwise have difficulty in paying for vaccines 

by providing vaccines at no cost to qualifying children.7

 Some proven strategies (e.g., reducing costs, linking immunization to WIC services, home visiting) are well suited to increasing rates among specific 

populations, such as infants living in low-income families and families 

with limited access to immunization services.4

 State and local health 

department use of Immunization Information Systems can aid in identifying pockets of undervaccinated children to ensure that they are 

adequately protected.5

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Immunization Survey. Retrieved from: http://

www.cdc.gov/vaccines/imz-managers/coverage/nis/child/data/tables-2013.html. Accessed September 4, 2014.

Endnotes

1. Centers for Disease Control and Prevention (CDC). Achievements in public health, 1900–1999: Control of infectious diseases. Morbidity and Mortality Weekly Report. 

1999 Jul 30;48(29):621-9.

2. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review 

and analysis. Am J Prev Med. 2006 Jul;31(1):52-61.

3. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Immunization Schedules. Available at: http://www.cdc.gov/vaccines/

schedules/index.html. Accessed August 2, 2013.

4. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. The Guide to Community Preventive Services. Universally Recommended Vaccinations: Enhancing Access to Vaccination Services. Available at: http://www.thecommunityguide.org/about/conclusionreport.html. Accessed September 22, 

2014.

5. Elam-Evans LD, Yankey D, Singleton JA, Kolasa M. National, State, and selected local area vaccination coverage among children aged 19–35 months—United States, 

2013. Morbidity and Mortality Weekly Report. 2014;63:741–748.

6. Thomas, TN, Kolasa, MS, Zhang, F, & Shefer, AM. Assessing Immunization Interventions in the Women, Infants, and Children (WIC) Program. American Journal Of 

Preventive Medicine. 2014 Nov;47(5):624-628.

7. Centers for Disease Control and Prevention. Vaccines for Children Program. Available at: http://www.cdc.gov/vaccines/programs/vfc/index.html. Accessed February 

16, 2015.

Figure 2. Receipt of Recommended Vaccinations* Among Children

Aged 19–35 Months, by Provider Facility Type,** 2013 Percent of Children

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Immunization Survey. Retrieved from:

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/child/data/tables-2013.html 

Accessed September 4, 2014.

*Recommended Full Series: ≥4 DTaP, ≥3 Polio, ≥1 MMR, 3 (4) Hib, ≥3 HepB, ≥1 Varicella, ≥4 PCV.

**Self-reported by provider. Public provider includes public health clinics and community health centers. Private

provider includes private clinics, HMOs, and group practices. Mixed provider includes more than one type of

provider. Other provider includes all other types of providers such as hospitals, military facilities, and

unknown responses.

18

36

54

72

90

Private Public Mixed Other

76.0

63.3

72.2 67.4

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 80

IMMUNIZATIONS: INFLUENZA

Influenza is a contagious respiratory illness that can have mild to 

severe effects. Older people, young children, pregnant women, and 

people with certain health conditions are at higher risk for serious flu 

complications, possibly resulting in hospitalization or death. To avoid 

potentially serious complications, the Advisory Committee on Immunization Practices (ACIP) recommends seasonal flu vaccination for 

everyone 6 months of age and older.1 In 2014, ACIP voted to recommend a preference for using the nasal spray flu vaccine instead of 

the flu shot in healthy children 2–8 years of age when it is available.5

The Healthy People 2020 target vaccination rate for children aged 6 

months through 17 years is 70 percent.2

The overall proportion of children aged 6 months to 17 years who 

were vaccinated during the 2013–2014 flu season was 58.9 percent, 

which represented a 2.3 percentage point increase in coverage over 

the previous year. Vaccination rates held steady at around 75 percent 

during this timeframe, however, for children aged 6 to 23 months, 

representing a successful achievement of the Healthy People 2020

goal for that age group. In contrast, children aged 2–17 years did 

not meet the Healthy People 2020 goal. The proportion of children 

vaccinated for seasonal influenza decreased with age, falling to 46.4 

percent among children aged 13–17 years (figure 1).

During the 2013–2014 flu season, the proportion of children aged 

6 months to 17 years who received influenza vaccination varied by 

race and ethnicity, ranging from 55.2 percent of non-Hispanic White 

children to 70.6 percent of non-Hispanic Asian children (figure 2). The 

proportion of children vaccinated was higher among all races and ethnicities compared to non-Hispanic White children, with the exception 

of non-Hispanic Black children (57.2 percent). In the 2013–2014 flu 

season, non-Hispanic American Indian/Alaska Native, Hispanic, and 

non-Hispanic White children showed increases in vaccination rates 

compared to the previous flu season.

Children in families with household incomes above 100 percent of 

poverty but below $75,000 had the lowest rate of vaccination (54.0 

percent) in the 2013–2014 flu season. Children in families with incomes less than 100 percent of poverty or above $75,000 had similar 

rates of vaccination (62.8 and 60.8 percent, respectively). 

The 2013–2014 vaccination rates among children living in nonmetropolitan statistical areas (MSA) were lower (52.6 percent) than those 

in MSAs (62.6 and 58.9 percent for central city and non-central city, 

respectively). Children living in MSAs showed an increase in vaccination rates over the previous flu season, while children in non-MSAs 

did not. 

Flu vaccination is the most effective strategy against the flu and 

serious flu-related complications. Multifaceted strategies are required 

to increase vaccination rates: (1) use of evidence-based practices 

(e.g., reducing client costs for vaccination; provision of immunizations 

at schools and Women, Infants, and Children programs; home visits; client reminder/recall; standing orders; provider reminders),3

 (2) 

nontraditional settings for vaccination (e.g., pharmacy, workplace, 

school venues),4 and (3) utilizing immunization information systems at 

the point of clinical care and to guide clinical/public health vaccination 

decisions.4

Figure 1. Seasonal Flu Vaccinations Among Children Aged

6 Months–17 Years, by Selected Age Group, 2012–2014

Percent of Children

68.1

61.0

46.4

42.5

58.9

56.6

10 20 30 40 50 60 70 80 90 100

13–17 years

5–12 years

2–4 years

6–23 months

Total 2013–2014

2012–2013

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Immunization Survey - Flu. Retrieved from: http://www.cdc.gov/flu/fluvaxview/coverage-1314estimates.htm

Accessed September 18, 2014.

74.3

76.9

65.8

58.6
Child Health USA 2014 Health Services Financing and Utilization 81

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Immunization Survey - Flu. Retrieved from: http://

www.cdc.gov/flu/fluvaxview/coverage-1314estimates.htm Accessed September 18, 2014.

Endnotes

1. Centers for Disease Control and Prevention. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization 

Practices, 2010. MMWR. August 6, 2010;59(RR08):1–62. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5908a1.htm?s_cid=rr5908a1_w. Accessed 

September 23, 2013.

2. U.S. Department of Health and Human Services. Healthy People 2020: Immunization and Infectious Diseases. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/default. Accessed August 20, 2013.

3. The Community Guide. Increasing Appropriate Vaccination. Available at: http://www.thecommunityguide.org/vaccines/universally/index.html. Accessed August 12, 

2013.

4. Murphy PA, Frazee SG, Cantlin JP, Cohen E, Rosan JR, Harshburger DE. Pharmacy provision of influenza vaccinations in medically underserved communities. Journal 

of the American Pharmaceutical Association. 2012;52(1):67–70.

5. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) recommends a preference for using the nasal spray flu vaccine. 

Available at: http://www.cdc.gov/media/releases/2014/s0625-acip.html. Accessed February 16, 2015.

Figure 2. Seasonal Flu Vaccinations Among Children Aged

6 Months–17 Years, by Race/Ethnicity, 2012–2014 Percent of Children †

Includes Native Hawaiian or other Pacific Islanders, and children of multiple and other races.

70.6

58.5 59.2 57.2 60.9

55.2 56.7

66.0 65.5 65.8

53.8 52.5

2013-2014

2012–2013

10

20

30

40

50

60

70

80

90

100

NonHispanic

Other or Multiple Race†

NonHispanic

Asian

NonHispanic American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Immunization Survey - Flu. Retrieved from: http://www.cdc.gov/flu/fluvaxview/coverage-1314estimates.htm

Accessed September 18, 2014.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 82

IMMUNIZATIONS: ADOLESCENTS

The U.S. immunization program, with its strong emphasis on infant 

and early childhood immunizations, has been a remarkable success. 

However, past-year preventive care doctor visits decline from infancy 

and early childhood to middle childhood and adolescence,1 providing 

fewer opportunities for older children and teens to receive immunizations. The Healthy People 2020 (HP2020) targets for vaccination 

coverage among adolescents aged 13–15 years are 80 percent coverage for one dose of tetanus toxoid, reduced diphtheria toxoid, and 

acellular pertussis (Tdap) vaccine; one dose of meningococcal conjugate (MenACWY) vaccine; and for females, three doses of human 

papilloma virus (HPV) vaccine.2 Tdap and MenACWY vaccines protect 

against bacterial infections that can cause breathing problems, paralysis, brain damage, and death, while the HPV vaccine protects against 

several viral strains that can cause cervical and anal cancer and genital 

warts.3

From 2012 to 2013, coverage increased from 84.6 to 86.0 percent 

for Tdap vaccination dose and from 74.0 to 77.8 percent for at least 

one MenACWY vaccination targets (figure 1). HPV vaccination coverage for adolescents was substantially lower with 37.6 percent of female adolescents and only 13.9 percent of male adolescents receiving 

the recommended 3 doses (figure 2). The HPV vaccine is the newest 

routinely recommended vaccine for adolescents, having been recommended in 2006 for females aged 11–12 years and in 2010 for males 

of the same age with catch-up vaccination at later ages for females 

(13–26 years) and males (13–21 years) who have not completed the 

3-dose series.3 Despite lower coverage, HPV vaccination has generally increased annually for both female and male adolescents for ≥1, 

≥2, and ≥3 doses.

Adolescent HPV vaccination varied by age among females only, 

with ≥1, ≥2, and ≥3 HPV-dose coverage being higher among 15- to 

17-year-old females compared with 13-year-old females in 2013. 

There were no differences by age or sex for Tdap or MenACWY vaccination.

In 2013, there were no racial and ethnic differences in Tdap vaccination coverage; however, MenACWY coverage was higher among 

Hispanic and non-Hispanic Asian adolescents compared with 

non-Hispanic Whites (83.4 and 83.8 percent, respectively, versus 75.6 

percent). HPV vaccination also varied by race/ethnicity. For example, 

receipt of ≥1 dose of HPV vaccine was higher among Hispanic and 

non-Hispanic American Indian/Alaska Native females than non-Hispanic White females (67.5 and 73.3 percent, respectively, versus 53.1 

percent) and higher among non-Hispanic Black and Hispanic males 

Figure 1. Selected Vaccination Coverage* for Adolescents Aged

13–17 Years,** 2012 and 2013 Percent of Adolescents

*The Advisory Committee on Immunization Practices recommends that adolescents routinely receive one dose

of Tdap and two doses of MenACWY. **Adolescents (N = 18,264) in the 2013 National Immunization

Survey–Teen were born January 11, 1995–February 13, 2001. †

Includes percentages receiving Tdap vaccine at

or after 10 years. ‡Includes percentages receiving MenACWY or meningococcal-unknown-type vaccine.

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Immunization Survey - Teen. Retrieved from:

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/teen/index.html Accessed September 18, 2014.

77.8 74.0

84.6

80.0

86.0

2012 2013

20

40

60

80

100

Tdap† ≥ 1 dose MenACWY‡ ≥ 1 dose
Child Health USA 2014 Health Services Financing and Utilization 83

Figure 2. HPV Vaccination Coverage* for Adolescents Aged 13–17

Years, by Sex and Doses Received, 2007–2013 Percent of Adolescents

*The Advisory Committee on Immunization Practices recommends that adolescents routinely receive three

doses of human papilloma virus vaccine. 

57.3

47.7

37.6

34.6

23.5

13.9 12

24

36

48

60

2007 2008 2009 2010 2011 2012 2013

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Immunization Survey - Teen. Retrieved from:

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/teen/index.html Accessed September 18, 2014.

versus non-Hispanic White males (42.2 and 49.6 percent, respectively, versus 26.7 percent). 

High Tdap coverage levels among adolescents aged 13–17 years 

indicate that similar coverage levels are attainable for other vaccines 

recommended for adolescents. Improved adherence of clinicians and 

parents to the Advisory Committee on Immunization Practices (ACIP) 

recommendation to administer all age-appropriate vaccines during a 

single visit could substantially increase lagging vaccination coverage 

levels for HPV vaccination.4

 Use of patient reminder and recall systems, immunization information systems, coverage assessment and 

feedback to clinicians, clinician reminders, standing orders, and other 

interventions can also help make use of every health care visit to ensure that adolescents are fully protected from vaccine-preventable infections and cancers, especially when such interventions are coupled 

with clinicians’ vaccination recommendations.5

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Immunization Survey - Teen. Retrieved from: 

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/teen/index.html Accessed September 18, 2014.

Endnotes

1. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau; U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. National Survey of Children’s Health 2011–2012.

Available at: http://www.childhealthdata.org/. Accessed September 2, 2014. 

2. U.S. Department of Health and Human Services. Healthy People 2020. Available at: http://www.healthypeople.gov. Accessed September 2, 2014.

3. Centers for Disease Control and Prevention. Vaccines Recommended for Preteens and Teens. Retrieved from:

http://www.cdc.gov/vaccines/who/teens/vaccines/index.html Accessed on September 4, 2014.

4. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases. ACIP Recommendations. Available at: http://www.cdc.gov/vaccines/acip/. Accessed September 2, 2014.

5. Community Preventive Services Task Force. Increasing Appropriate Vaccination. Atlanta, GA: Community Preventive Services Task Force; 2014.

Available at: http://www.thecommunityguide.org/vaccines/index.html. Accessed September 2, 2014.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 84

WELL-CHILD VISITS

In 2012, 79.5 percent of children under 18 years of age were reported by their parents to have had a preventive or “well-child” medical 

visit in the past year, when they were not sick or injured. The American 

Academy of Pediatrics recommends that children have eight preventive health care visits in their first year, three in their second year, and at 

least one per year from age 3 through adolescence.1 Well-child visits 

offer an opportunity not only to monitor children’s health and provide 

immunizations but also to assess a child’s behavior and development, 

discuss nutrition, and answer parents’ questions.

The proportion of children receiving well-child visits declines with 

age. In 2012, 89.1 percent of children aged 4 and younger had received a preventive visit in the past year, compared to 79.2 percent 

of children 5–11 years of age and 72.0 percent of those aged 12–17 

years (figure 1). There was no significant difference between males 

and females in the proportion of children who received a well-child 

visit in the past year.

Receipt of preventive medical care also varies by several other factors, including health insurance status and type of insurance, parental 

education, race and ethnicity, and nativity. In 2012, only 54.2 percent 

of uninsured children had received a well-child visit in the past year, 

compared to more than 80 percent of those with public or private insurance (figure 2). Children with at least one parent who had attained 

more than a high-school level education were more likely to have received a past-year preventive medical visit (82.0 percent) compared 

to those for whom the highest level of parental education was a high 

school degree (76.0 percent) or less (72.3 percent).

With respect to race and ethnicity, non-Hispanic Black children 

were more likely to have received a well-child visit in the past year 

(85.1 percent) compared to non-Hispanic White children (79.9 percent) and Hispanic children (75.9 percent). Finally, children who were 

born in the United States were more likely than those born outside the 

United States to have had a well-child visit in the past year: 79.9 and 

71.2 percent, respectively.

Data Sources

Figure 1 and 2. Centers for Disease Control and Prevention, National Center for Health Statistics. 2012 National Health Interview Survey. Unpublished estimates.

Analyzed by the National Center for Health Statistics.

Endnotes

1. American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. Available at: http://www.aap.org/en-us/professional-resources/practice-support/periodicity/periodicity%20schedule_final.pdf. Accessed August 10, 2014.

Figure 1. Children Under Age 18 Who Received a Well-Child Visit* in

the Past Year, by Age, 2012 Percent of Children

*Based on the question, "During the past 12 months did [child's name] receive a well-child checkup – that is, a

general checkup when [he/she] was not sick or injured?"

Source: Centers for Disease Control and Prevention, National Center for Health Statistics. 2012 National Health

Interview Survey. Unpublished estimates. Analyzed by the National Center for Health Statistics.

79.5 79.2

72.0

89.1

20

40

60

80

100

Total 0–4 Years 5–11 Years 12–17 Years

Figure 2. Children Under Age 18 Who Received a Well-Child Visit* in

the Past Year, by Health Insurance, 2012 Percent of Children

Source: Centers for Disease Control and Prevention, National Center for Health Statistics. 2012 National Health

Interview Survey. Unpublished estimates. Analyzed by the National Center for Health Statistics.

79.5 81.0

54.2

81.8

20

40

60

80

100

Total Private Public Uninsured

*Based on the question, "During the past 12 months did [child's name] receive a well-child checkup – that is, a

general checkup when [he/she] was not sick or injured?"

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 85

DEVELOPMENTAL SCREENING

Since 2006, the American Academy of Pediatrics (AAP) has recommended that assessment for developmental problems among 

young children be incorporated into every preventive health visit and 

that formal screening occur at regular intervals, including the 9-, 18-, 

and either 24- or 30-month well-child visits.1 Developmental screening is critical to the early identification of developmental delays and 

the provision of early intervention services and treatments that have 

the capacity to change both short- and long-term developmental trajectories of children who may be experiencing such delays or have 

a developmental disability. The importance of timely developmental 

screening is underscored by its inclusion as a national objective for 

Maternal, Infant, and Child Health in Healthy People 2020.

2

In 2007, 1 year after the AAP recommendation, approximately onefifth (19.5 percent) of U.S. children aged 10–71 months were reported 

to have received a standardized developmental screening.3 Data from 

the latest National Survey of Children’s Health, however, show that 

this proportion has risen dramatically since then: In 2011–2012, nearly 

one-third (30.8 percent) of children aged 10–71 months had received 

such a screening in the previous 12 months (figure 1).

In 2011–2012, few significant differences were observed among 

children with respect to receipt of developmental screening and their 

demographic or household characteristics. Children living in households with two biological or adoptive parents were more likely than 

those in “other” family structures (i.e., those not living with two parents 

or a single mother) to have received a standardized developmental 

screening (31.2 versus 24.9 percent, respectively). 

No differences, however, were observed with respect to the child’s 

race and ethnicity, poverty, or health insurance status or type, as was 

observed in 2007. At that time, non-Hispanic Black children (24.4 percent) were more likely than non-Hispanic White and Hispanic children 

(18.6 and 19.1 percent, respectively) to have been assessed for developmental delay through a parent-reported standardized screening 

tool. Also in 2007, parents of poor children, or those living in households with incomes of less than 100 percent of poverty, were more 

likely to report having completed this kind of evaluation compared 

to those living in households with incomes of 400 percent or more 

of poverty (21.5 versus 17.2 percent, respectively). Finally, children 

with public health insurance coverage were significantly more likely to 

Figure 1. Receipt of Developmental Screening* in the Past 12 Months

Among Children Aged 10–71 Months, 2007 and 2011–2012

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau; and U.S. Department of Health and Human Services, Centers for Disease

Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health. Analyzed by

the Health Resources and Services Administration’s Maternal and Child Health Bureau.

*Among children who had a preventive health visit in the past 12 months. Parents reported whether they

completed a questionnaire about their child’s development, communication, or social behaviors during the

previous 12 months and, if so, whether the questionnaire included age-appropriate follow-up items on language

or social development.

2007 2011–2012

Yes

19.5%

Yes

30.8%

No

80.5%

No

69.2%
Child Health USA 2014 Health Services Financing and Utilization 86

have been screened for developmental delay in 2007 (23.7 percent) 

than either those with private coverage (17.8 percent) or no coverage 

(14.8 percent); no significant difference in the rate of screening was 

observed at that time between those with private coverage and those 

without any coverage at the time of the survey (figure 2).

The overall increase in the rate of developmental screening and 

the reduction in some disparities in the receipt of this type of evaluation suggests that efforts such as those by the AAP and Healthy 

People may be raising awareness of the importance of developmental 

screening. Additional analyses of data from the 2007 National Survey 

of Children’s Health indicates that health care providers may also be 

using informal means to inquire about parents’ and caregivers’ concerns regarding their children’s development. Such approaches, while 

potentially important to parent-provider relationships, should not be 

viewed as a substitute for screening using a standardized tool.4

 Much 

work remains to be done, with less than one-third of children receiving 

this important preventive service in 2011–2012.

Data Sources 

Figure 1 and 2. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau; and U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health. Analyzed 

by the Health Resources and Services Administration’s Maternal and Child Health Bureau.

Endnotes

1. American Academy of Pediatrics, Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics, Bright Futures Steering Committee and 

Medical Home Initiatives for Children With Special Needs. Identifying infants and young children with developmental disorders in the medical home: an algorithm for 

developmental surveillance and screening. Pediatrics. 2006;118(1):405–420. Correction in Pediatrics. 2006;118(4):1808–1809.

2. U.S. Department of Health and Human Services. Health People 2020 Maternal, Infant, and Child Health Objective 20.1: Increase the proportion of children (aged 

10–35 months) who have been screened for an Autism Spectrum Disorder (ASD) and other developmental delays. Available at: http://www.healthypeople.gov/2020/

topics-objectives/topic/maternal-infant-and-child-health/objectives?topicId=26. Accessed September 12, 2014.

3. Bethell C, Reuland C, Schor E, Abrahms M, Halfon N. Rates of parent-centered developmental screening: disparities and links to services access. Pediatrics. July 

2011;128(1):146–155.

4. Rice CE, Naarden Braun KV, Kogan MD, et al. Screening for developmental delays among young children—National Survey of Children’s Health, United States, 2007. 

MMWR Surveillance Summaries: Morbidity and Mortality Weekly Report. September 12, 2014;63:27–35.

Figure 2. Receipt of Developmental Screening* in the Past 12 Months

Among Children Aged 10–71 Months, by Health Insurance, 2007 and

2011–12

8

16

24

32

40

Private Public Uninsured

Percent of Children

24.5

14.8

30.7

17.8

23.7

31.5

2007 2011–2012

*Among children who had a preventive health visit in the past 12 months. Parents reported whether they

completed a questionnaire about their child’s development, communication, or social behaviors during the

previous 12 months and, if so, whether the questionnaire included age-appropriate follow-up items on language

or social development.

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau; and U.S. Department of Health and Human Services, Centers for Disease

Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health. Analyzed by

the Health Resources and Services Administration’s Maternal and Child Health Bureau.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 87

MENTAL HEALTH TREATMENT

Mental disorders are the most common cause of disability and are 

responsible for 25 percent of all years of life lost to disability and premature mortality.1

 Besides disability, untreated mental disorders may 

lead to unemployment, substance abuse, homelessness, incarceration, and suicide, and cost the U.S. economy $100 billion a year. Early 

implementation of treatment accelerates recovery and reduces the 

impacts of mental disorders. Treatment can reduce symptoms and 

improve the quality of life.2

In 2012, 3.1 million (12.7 percent) of adolescents aged 12–17 received past-year treatment or counseling for problems with emotions 

or behavior (not related to drug or alcohol use) in a specialty mental 

health setting, including both outpatient and inpatient care (11.5 and 

2.4 percent, respectively). A similar proportion of adolescents received 

mental health services in an educational setting (12.9 percent), 2.5 

percent received services in a medical setting, and 5.5 percent received services in both a specialty mental health setting as well as 

either an educational or medical setting (figure 1). 

The most commonly reported reason for past year receipt of mental health services was feeling depressed, reported by 44.3 percent 

of adolescents who accessed mental health services. Other reasons 

include feeling afraid and tense (16.2 percent), having thoughts of 

or attempting suicide (14.8 percent), breaking rules and “acting out” 

(14.8 percent), having problems at school (14.8 percent), and having 

problems with home or family (14.2 percent). 

Increasing the proportion of people with mental disorders who receive treatment is a national Healthy People 2020 objective.1

 Among 

adolescents who experienced a past-year major depressive episode 

(MDE – see definition on mental health page), 37.0 percent received 

treatment for their depression. Treatment included seeing or talking to 

a professional or using prescription medication for depression. 

The rate of treatment varied by sex, race, ethnicity, geographic region, and insurance coverage. Females were more likely to receive 

treatment for depression than males (40.1 versus 28.3 percent, respectively; figure 2). Non-Hispanic White youth were more likely to 

receive treatment than Hispanic youth (40.7 versus 30.8 percent, respectively); 33.5 percent of non-Hispanic Black youth received treatment for depression. 

With regard to geographic region, adolescents who experienced 

a past-year MDE from the Northeast and Midwest (42.2 and 41.2 

percent, respectively) were more likely to receive treatment than those 

Figure 1. Past Year Mental Health Service* Use Among Adolescents

Aged 12–17 Years, by Service Source, 2012 Percent of Adolescents

*Respondents could indicate multiple service sources; thus, response categories are not mutually exclusive.

**Respondents who did not report their school enrollment status or reported being home-schooled were not

asked about receipt of mental health treatment or counseling in an educational setting; however, respondents

who reported not being enrolled in school in the past 12 months were classified as not having received treatment

or counseling from this source. †

Because of revisions to the Source of Youth Mental Health Education Services

questions in 2009, these estimates are not comparable with estimates presented before 2009. ‡Includes receipt

of any specialty mental health services and receipt of services from either education or medical sources.

Source: Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on

Drug Use and Health: detailed tables, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD:

Substance Abuse and Mental Health Services Administration; 2013. Available at:

http://www.samhsa.gov/data/nsduh/2012summnatfinddettables/dettabs/nsduh-dettabstoc2012.htm.

Accessed April 18, 2014.

4

8

12

16

20

Multiple

Settings†,‡

Medical

Setting

Educational

Setting**,†

Specialty

Mental

Health –

Inpatient 

Specialty

Mental

Health –

Outpatient 

Any Specialty

Mental Health

Setting

11.5

12.9

5.5

2.4

12.7

2.5
Child Health USA 2014 Health Services Financing and Utilization 88

Figure 2. Receipt of Past Year Treatment* for Depression Among

Adolescents Aged 12–17 Years with Major Depressive Disorder

(MDE)**, by Sex, 2012 Percent of Adolescents

*Treatment is defined as seeing or talking to a professional or using prescription medication for depression in the

past year. Respondents with unknown treatment data were excluded. **An MDE is defined as a period of at least

2 weeks when a person experienced a depressed mood or loss of pleasure in daily activities and had a majority

of specific depression symptoms.

Source: Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on

Drug Use and Health: detailed tables, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD:

Substance Abuse and Mental Health Services Administration; 2013. Available at:

http://www.samhsa.gov/data/nsduh/2012summnatfinddettables/dettabs/nsduh-dettabstoc2012.htm.

Accessed April 18, 2014.

40.1

28.3

37.0

10

20

30

40

50

Total Males Females 

from the South and West (34.1 and 34.9 percent, respectively). Adolescents with no insurance coverage (23.0 percent) were less likely to 

receive treatment for their depression compared to adolescents with 

Medicaid/Children’s Health Insurance Program or private coverage 

(36.9 and 38.1 percent, respectively). 

Some barriers to treatment for mental disorders include discrimination and prejudice and accessibility. Discrimination and prejudice may 

cause individuals to avoid talking about their illness with friends and 

family and inhibit receipt of care.3

 Individuals may fear that symptoms 

will not be taken seriously, especially those of adolescents that may be 

mistaken for puberty instead of a mental disorder.4

 The Mental Health 

Parity Act under the Affordable Care Act requires health insurance to 

cover mental and physical health equally.5

 The expansion of coverage includes preventive services, such as behavioral assessments for 

children, free of charge and insurance companies no longer being allowed to deny coverage or charge more for mental disorders.6

Data Sources

Figure 1 and 2. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: detailed tables, NSDUH 

Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. Available at: http://www.samhsa.gov/data/nsduh/2012summnatfinddettables/dettabs/nsduh-dettabstoc2012.htm. Accessed April 18, 2014.

Endnotes

1. U.S. Department of Health and Human Services. Healthy People 2020 topics & objectives: mental health and mental disorders. Available at: http://healthypeople.

gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=28. Accessed April 22, 2014. 

2. National Alliance on Mental Illness. What is mental illness: mental illness facts. Available at: http://www.nami.org/template.cfm?section=about_mental_illness. Accessed April 22, 2014. 

3. U.S. Department of Health and Human Services, Office of Adolescent Health. Adolescent health topics: mental health. Available at: http://www.hhs.gov/ash/oah/adolescent-health-topics/mental-health/home.html. Accessed April 22, 2014. 

4. National Institutes of Health, National Institute of Mental Health. Depression. Available at: http://www.nimh.nih.gov/health/topics/depression/index.shtml. Accessed 

April 22, 2014.

5. American Psychological Association. Mental Health Parity and Addiction Equity Act. Available at: http://www.apa.org/helpcenter/parity-law.aspx. Accessed April 22, 

2014.

6. U.S. Department of Health and Human Services. MentalHealth.gov. Available at: http://www.mentalhealth.gov/get-help/health-insurance/. Accessed April 22, 2014.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 89

DENTAL CARE

Tooth decay (dental caries) is a bacterial infection of the tooth and 

is estimated to be the most common chronic infectious disease in 

children in the United States.1,2 The Centers for Disease Control and 

Prevention estimates that more than one-quarter of children aged 2–5 

years and half of youth aged 12–15 years are affected by tooth decay.3

Untreated tooth decay causes pain and infection, which may affect a 

child’s ability to eat, speak, play, and learn. Tooth decay is preventable 

with proper dental care, including cleaning, brushing, and flossing, 

sealant application, and fluoride treatment. The American Academy 

of Pediatric Dentistry recommends that children have their first dental 

visit shortly after the eruption of their first tooth and no later than their 

first birthday, with two dental checkups per year thereafter.2

Approximately 65 percent of children aged 2–17 years received 

dental care in the past 6 months in 2012, as determined from parental report. Receipt of dental care at recommended intervals varied 

by age, race and ethnicity, poverty status, and insurance status and 

type. Children aged 5–11 years and 12–17 years were more likely to 

have received dental care in the past 6 months than those aged 2–4 

years (70.3 and 68.0 percent compared to 45.3 percent, respectively). With respect to race and ethnicity, non-Hispanic American Indian/

Alaska Native children were most likely to have had a dental visit in the 

past 6 months (78.0 percent) compared to 61–68 percent of children 

from other racial and ethnic groups. Children living in households with 

incomes of less than 100 percent and 100–199 percent of poverty 

were less likely than children living in households with incomes of 200 

percent or more of poverty to have received dental care in the past 

6 months (56.9 and 59.1 percent, respectively, versus 70.1 percent; 

figure 1). Uninsured children were about half as likely to have received 

a dental visit in the past 6 months (34.9 percent) as those with public 

or private insurance (62.5 and 70.2 percent, respectively). 

In 2012, parents of 5.5 percent or 4 million children reported that 

their child did not receive needed dental care due to cost. The rates 

of unmet dental need due to cost increased with age and were lowest 

among children aged 2–4 years (2.8 percent), but rose substantially 

for those aged 5–11 years and 12–17 years (4.9 and 7.6 percent, 

respectively). Similar to receipt of dental care, children living in households with incomes of less than 100 percent and 100–199 percent of 

poverty were approximately twice as likely to have unmet needs as 

Figure 1. Time Since Last Dental Visit* Among Children Aged 2–17

Years, by Poverty Status,** 2012

Percent of Children

Less Than

6 Months

Between

6 Months

and 1 Year

Between

1 and

2 Years

Between

2 and

5 Years

More

Than

5 Years

*All estimates are age adjusted and may not total 100 due to rounding. **The U.S. Census Bureau weighted

average poverty threshold for a family of four was $23,492 in 2012.

Source: Bloom B, Jones LI, Freeman G. Summary health statistics for U.S. children: National Health Interview

Survey, 2012. National Center for Health Statistics. Vital Health Statistics. 2013;10(258).

20 40 60 80 100

200%

or More of Poverty 

100–199%

of Poverty 

Less Than 100%

of Poverty 

Total 9.1

10.0

10.5

8.4

2.1

3.1

2.5

1.6

6.3

10.0

8.2

4.3

17.5

20.0

19.7

15.5

64.9

56.9

59.1

70.1
Child Health USA 2014 Health Services Financing and Utilization 90

Figure 2. Unmet Dental Need* in the Past Year Among Children Aged

2–17 Years, by Type of Health Insurance,** 2012 Percent of Children

5.5

3.8

5.4

21.1

*Based on parent report that services were needed but not affordable; all estimates are age adjusted. **Refers to

general health insurance and not single service coverage, such as dental insurance. Private coverage includes

persons with any private insurance, either alone or in combination with public coverage; Public includes those

covered only by government programs such as Medicaid, Medicare, military plans, and state-sponsored

health plans.

Source: Bloom B, Jones LI, Freeman G. Summary health statistics for U.S. children: National Health Interview

Survey, 2012. National Center for Health Statistics. Vital Health Statistics. 2013;10(258).

5

10

15

20

25

Total Private Public Uninsured

children living in households with higher incomes (7.2 and 8.4 percent 

compared to 3.8 percent, respectively). The proportion of children with 

unmet needs was much higher among those who were uninsured 

(21.1 percent) compared to those with either public (5.4 percent) or 

private (3.8 percent) health insurance (figure 2). 

Limited access to oral health care and dental insurance coverage 

contribute to poor oral health.4

 The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program and Federally Qualified Health 

Centers (FQHCs) work to address such barriers. The EPSDT Program 

is the section of Medicaid that addresses child health, requiring dental 

services including appropriate screening, diagnostic, and treatment.5

Additionally, the Affordable Care Act will expand coverage and include 

child oral health care as a required health benefit.6 Healthy People 

2020 oral health objectives aim to “increase the proportion of [FQHCs] 

that have an oral health care program” and “increase the proportion 

of patients who receive oral health services at [FQHCs] each year.”7

All FQHCs must provide preventive services, regardless of the ability 

to pay. Community programs such as school based sealant programs 

and community water fluoridation are another way to deliver effective 

preventive interventions to children who may lack access to dental 

care.8

Data Sources

Figure 1 and 2. Bloom B, Jones LI, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2012. National Center for Health Statistics. 

Vital Health Statistics. 2013;10(258).

Endnotes

1. Centers for Disease Control and Prevention, Division of Oral Health. Children’s oral health. Available at: http://www.cdc.gov/oralhealth/children_adults/child.htm. 

Accessed April 29, 2014. 

2. American Academy of Pediatric Dentistry. Health care providers brochures: the pediatric dentist. Available at: http://www.aapd.org/publications/brochures/. Accessed 

April 29, 2014. 

3. Centers for Disease Control and Prevention, Division of Oral Health. Oral health: preventing cavities, gum disease, tooth loss, and oral cancers at a glance 2011. Available at: http://www.cdc.gov/chronicdisease/resources/publications/aag/doh.htm. Accessed April 29, 2014. 

4. Institute of Medicine. Advancing oral health in America. Report brief. 2011. Available at: http://www.iom.edu/reports/2011/advancing-oral-health-in-america.aspx. 

Accessed May 2, 2014. 

5. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. EPSDT overview. Available at: 

http://mchb.hrsa.gov/epsdt/overview.html. Accessed May 2, 2014. 

6. Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured. Children and oral health: accessing needs, coverage, and access. Available at: 

http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7681-04.pdf. Accessed May 6, 2014. 

7. U.S. Department of Health and Human Services. Healthy People 2020 topics & objectives: oral health. Available at: http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=32. Accessed April 29, 2014. 

8. Jones E, Shi L, Hayashi AS, Sharma R, Daly C, Metzger QN. Access to oral health care: the role of Federally Qualified Health Centers in addressing disparities and 

expanding access. American Journal of Public Health. 2013;103(3):488–493.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 91

USUAL SOURCE OF CARE

An indicator of access to health care is having a usual source of 

care.1 A usual source of care is “a place where [children go] when sick, 

such as a physician’s office or health center but not an emergency 

department.”2 A Healthy People 2020 objective for access to health 

services is to “increase the proportion of children and youth aged 17 

years and under who have a specific source of ongoing care.”3 People 

with a usual source of care are more likely to receive preventive health 

services, have better health outcomes, and have fewer disparities and 

costs than those without a usual source of care.1,3,4

A majority of children under 18 years of age (96.2 percent) had a 

usual source of care in 2012. Having a usual source of care varied by 

age, poverty status, and insurance type. The proportion of children 

who had a usual source of care decreased with age: 97.9 percent 

of children aged 0–4 years, 96.6 percent of those aged 5–11 years, 

and 94.4 percent of children aged 12–17 years. The percentage of 

children with a usual source of care was greater for those living in 

households with incomes of 200 percent or more of poverty (97.3 percent) than for children living in households with incomes less than 100 

percent and 100–199 percent of poverty (94.8 and 95.2 percent, respectively). Uninsured children were less likely to have a usual source 

of care, compared to children with public or private health insurance 

(73.2 versus 97.5 and 98.2 percent, respectively; figure 1). 

Among children with a usual source of care in 2012, 74.2 percent 

of children used a doctor’s office; 23.9 percent used a clinic; and 1.9 

percent used the hospital and other places, including emergency 

rooms and hospital outpatient departments. Usual source of care 

location varied by race and ethnicity, poverty status, and insurance 

type. American Indian/Alaska Native and Hispanic children (46.9 and 

38.4, respectively) were more likely to use clinics as a usual source 

of care than multiple-race, non-Hispanic Black, and Asian children 

(24.4, 24.4, and 22.4 percent, respectively). Non-Hispanic White 

children (17.2 percent) were the least likely to use clinics as a usual 

source of care. 

Figure 1. Usual Source of Care* Among Children Under Age 18, by

Health Insurance Type, 2012

Percent of Children

*Has a place where the child is usually taken when sick or in need of health advice. All estimates are age

adjusted and may not total 100 due to rounding.

Source: Bloom B, Jones Li, Freeman G. Summary health statistics for U.S. children: National Health Interview

Survey, 2012. National Center for Health Statistics. Vital Health Statistics. 2013;10(258). Available at:

http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf. Accessed May 2, 2014.

Usual Source of Care No Usual Source of Care

20 40 60 80 100

Uninsured 

Public 

Private

Total 96.2

98.2

97.5

73.2

3.8

1.8

2.5

26.8
Child Health USA 2014 Health Services Financing and Utilization 92

Figure 2. Location of Usual Source of Care* Among Children Under

Age 18, by Poverty Status,** 2012

20

40

60

80

100

200% or More

of Poverty

100–199%

of Poverty

Less Than

100% of Poverty

Total 

Percent of Children

36.9

2.7 2.4

30.5

60.3

1.9

74.2

23.9

1.2

83.1

15.6

67.2

Doctor’s Office 

Clinic 

Hospital or Other Place†

Source: Bloom B, Jones Li, Freeman G. Summary health statistics for U.S. children: National Health Interview

Survey, 2012. National Center for Health Statistics. Vital Health Statistics. 2013;10(258). Available at:

http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf. Accessed May 2, 2014.

*Has a place where the child is usually taken when sick or in need of health advice. All estimates are age

adjusted and may not total 100 due to rounding. **The U.S. Census Bureau weighted average poverty threshold

for a family of four was $23,492 in 2012. †

Includes “emergency room,” “hospital outpatient department,”

“some other place,” and “not using one place most often.”

Children with household incomes of less than 100 percent and 

100–199 percent of poverty (36.9 and 30.5 percent, respectively) were 

approximately twice as likely to use a clinic as a usual source of care 

than children with household incomes of 200 percent or more of poverty (15.6 percent; figure 2). Conversely, 83.1 percent of children with 

household incomes of 200 percent or more of poverty used a doctor’s 

office as a usual source of care, compared to 67.2 percent of those 

with incomes of 100–199 percent of poverty and 60.3 percent of 

those with incomes below 100 percent of poverty. Uninsured children 

and children with public insurance (38.6 and 35.1 percent, respectively) were more than two times as likely to use a clinic as a usual source 

of care than children with private insurance (14.1 percent). 

Problems with affordability and insurance are common barriers to 

having a usual source of care.1

 The Affordable Care Act increases 

access to health benefits, expands insurance, and focuses on preventive health. Through the expansion of health center operations, 

including construction of new sites and expansion of preventive and 

primary services, having a usual source of care will be more accessible 

for individuals and families with lower incomes and with public or no 

insurance.5,6

Data Sources

Figure 1 and 2. Bloom B, Jones Li, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2012. National Center for Health Statistics. 

Vital Health Statistics. 2013;10(258). Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf. Accessed May 2, 2014.

Endnotes

1. Pancholi M. Statistical brief #32: reasons for lacking a usual source of care: 2001 estimates for the U.S. civilian noninstitutionalized population. Medical Expenditure 

Panel Survey. Rockville, MD: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality; 2001. 

2. U.S. Department of Health and Human Services, Health Resources and Services Administration. Women’s Health USA 2013 health services utilization: usual source of 

care. Available at: http://www.mchb.hrsa.gov/whusa13/health-services-utilization/p/usual-source-care.html. Accessed May 9, 2014.

3. U.S. Department of Health and Human Services. Healthy People 2020 topics & objectives: access to health services. Available at: http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=1. Accessed May 9, 2014. 

4. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Access to health care. In: National Healthcare Disparities Report. Available at: http://www.ahrq.gov/research/findings/nhqrdr/nhdr10/pdf/nhdr10ch9.pdf. Accessed May 9, 2014.

5. Pilkey D, Skopec L, Gee E, Finegold K, Amaya K, Robinson W, Office of Adolescent Health. ASPE research brief: the Affordable Care Act and adolescents. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; August 2013. 

6. Kirby JB. Statistical brief #308: main reason for not having a usual source of care: differences by race/ethnicity, income, and insurance status, 2007. Medical Expenditure Panel Survey. Rockville, MD: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality; 2007.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 93

MEDICAL HOME

The National Center for Medical Home Implementation defines a 

medical home as “an approach to providing comprehensive primary care” rather than a physical space or service.1

 According to the 

American Academy of Pediatrics, primary care should be accessible, 

continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. The Maternal and Child Health Bureau 

has operationalized this concept for children using five criteria: (1) having a personal doctor or nurse, (2) having a usual source for sick and 

well care, (3) receipt of family-centered care, (4) no problems getting 

needed referrals, and (5) receipt of effective care coordination when 

needed.2 Individuals with a medical home may experience “improved 

health outcomes, reduced emergency room visits, and better communication [with pediatric health providers].”3

In 2011–2012, the care received by 54.4 percent of children under the age of 18 met medical home criteria. Receipt of care from 

a medical home varied by age, race/ethnicity, and primary household language. Receipt of care in a medical home decreased with 

age: 58.2 percent of children aged 0–5 years had a medical home, 

while 53.7 and 51.4 percent of children aged 6–11 and 12–17 years, 

respectively, had a medical home. Hispanic children (37.2 percent) 

were least likely to have a medical home, followed by non-Hispanic Black, non-Hispanic American Indian/Alaska Native, non-Hispanic 

Asian, and non-Hispanic Native Hawaiian/Pacific Islander children, all 

of which had fewer than 45 percent of children with a medical home 

(figure 1). Over half of non-Hispanic White and non-Hispanic children 

of multiple races received care meeting the criteria for a medical home 

(65.7 and 58.3 percent, respectively). Children living in a household 

with English as the primary language were more than twice as likely to 

have a medical home as children living in a household with a primary 

language other than English (59.3 versus 26.5 percent, respectively). 

Children living in a household with two parents (biological or adoptive) were more likely to have a medical home than those with two 

parents where at least one was a stepparent, those with only a mother, and those with all other family structures (58.6 compared to 49.6, 

45.3, and 47.4 percent, respectively). 

Medical home access also varied by socioeconomic status. Children of parents whose highest level of education was less than a high 

school diploma were nearly half as likely to have a medical home as 

children with at least one parent with more than a high school education (31.1 versus 61.6 percent, respectively). Similarly, receipt of 

care in a medical home also increased with household income: 36.5 

percent of children living in households with incomes less than 100 

Figure 1. Children with a Medical Home, by Race/Ethnicity, 2011–2012 Percent of Children 14

28

42

56

70

NonHispanic

Other

Races

NonHispanic

Multiple

Races

NonHispanic

Native

Hawaiian/

Pacific Islander 

NonHispanic

Asian 

NonHispanic

American

Indian/

Alaska Native 

Non- Hispanic 

Hispanic

Black 

NonHispanic

White 

44.7 43.5 41.4

37.2

65.7

58.3

47.9

43.1

Source: Health Resources and Services Administration, Maternal and Child Health Bureau and Centers for

Disease Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health.

Analyzed by the Health Resources and Services Administration’s Maternal and Child Health Bureau.
Child Health USA 2014 Health Services Financing and Utilization 94

Figure 2. Children with a Medical Home, by Health Insurance Status

and Type, 2011–2012 Percent of Children

Source: Health Resources and Services Administration, Maternal and Child Health Bureau and Centers for

Disease Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health.

Analyzed by the Health Resources and Services Administration’s Maternal and Child Health Bureau.

27.8

43.9

64.0

14

28

42

56

70

Public Uninsured

Insurance

Private

Insurance

percent of poverty had a medical home compared to 67.8 percent 

of children living in households with incomes of 400 percent or more 

of poverty. Uninsured children were less likely to receive care from a 

medical home than children with public and private insurance (27.8 

versus 43.9 and 64.0 percent, respectively; figure 2). 

Barriers to having a medical home include personnel constraints, 

clinical practice patterns, and economic or social forces.2

 As an increasing number of community health centers seek recognition as 

patient-centered medical homes, the National Association of Community Health Centers predicts that an additional 20 million Americans 

will have medical homes. Primary care practices are also increasingly 

seeking accreditation as medical homes. The Affordable Care Act authorized funding to establish community-based health teams to support these practices.4,5

Data Sources

Figure 1 and 2. Health Resources and Services Administration, Maternal and Child Health Bureau and Centers for Disease Control and Prevention, National Center for 

Health Statistics, National Survey of Children’s Health. Analyzed by the Health Resources and Services Administration’s Maternal and Child Health Bureau.

Endnotes

1. American Academy of Pediatrics, National Center for Medical Home Implementation. What is a family-centered medical home?. Available at: http://www.medicalhomeinfo.org/. Accessed May 20, 2014. 

2. Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110(1):184–186. 

3. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Implementation of the Medical 

Home Program. Available at: http://www.mchb.hrsa.gov/programs/medicalhome/index.html. Accessed May 20, 2014. 

4. Association of Maternal and Child Health Programs. Health reform: what’s in it to promote the medical home?. Available at: http://www.amchp.org/policy-advocacy/

health-reform/documents/medical-homes-aca-fact-sheet.pdf. Accessed May 20, 2014. 

5. National Conference of State Legislature. The medical home model of care. Available at: http://www.ncsl.org/research/health/the-medical-home-model-of-care.aspx. 

Accessed May 20, 2014.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Health Services Financing and Utilization 95

QUALITY OF CARE

Quality health care can be defined as the degree to which health 

services increase the likelihood of desired health outcomes for individuals and populations and which are consistent with current professional knowledge.1

 Quality is reflected in numerous program aspects, 

including access to services, clinical effectiveness, comprehensiveness, and integration of services. High quality care can play a significant role in improving health care outcomes and decreasing overall 

health care costs, while impacting consumer information and choice.1

Quality of care can be measured in a number of ways, including receipt of appropriate treatment for infections and weight counseling.2

An upper respiratory infection (URI), also referred to as the common 

cold, is a type of acute respiratory tract infection (ARTI)—an infection 

of the lining in the nose and throat that can cause symptoms including 

coughing, congestion, and fever that last for 1–2 weeks. Though most 

URIs are viral in nature, antibiotics are often inappropriately prescribed 

for children despite no evidence that they are helpful against viral infections.3

In 2012, children had 12.7 million outpatient visits for URIs, 4.7 

million of which involved children under the age of 2 years, and 8.1 

million for children aged 2–17 years. None of the children presenting at 

these visits were expected to have a bacterial pathogen; however, 3.1 

million children were prescribed a “potentially preventable” antibiotic. 

Of these prescriptions, 871,000 were for children under the age of 

2, and more than 2.2 million were for children aged 2–17 years (figure 1). This is equivalent to 11.4 million potentially avoidable antibiotic 

prescriptions for all ARTIs in children. This number has not decreased 

notably in the past decade.4

While the number of infection-related hospitalizations from antibiotic resistance have increased in all age groups, the greatest increase 

has been in children under 18 years of age (395 percent between 

1997 and 2006). Antibiotic-resistant infections often lead to prolonged 

treatments or hospital stays and greater rates of disability and death. 

The use of antibiotics is the most important element leading to antibiotic resistance.5

 Greater awareness of the dangers of antibiotic-resistant bacteria and better communication between patients and providers could improve treatment and reduce unnecessary antibiotic use.3

Since the 1980s, childhood obesity has increased more than twofold in children and threefold in adolescents (see pages on childhood 

and adolescent overweight and obesity). Obesity has negative effects 

on children’s health including high blood pressure and cholesterol, insulin resistance, type 2 diabetes, and breathing problems, although 

early intervention and nutrition counseling can improve children’s 

overall health and lifestyle. For the second consecutive year, clinical 

assessments of childhood weight status have improved. 

In 2012, 51.6 percent of children aged 3–17 years in commercial 

health maintenance organizations (HMOs), 31.2 percent of children 

in commercial preferred provider organizations (PPOs), and 51.8 

percent of children in Medicaid HMOs had an outpatient visit with a 

Figure 1. Number of Annual Visits and Visits With Potentially

Preventable Antibiotic Prescriptions for Children With Upper

Respiratory Infections, by Age Group, 2012

Source: Kronman MP, Zhou C, Mangione-Smith R. Bacterial prevalence and antimicrobial prescribing trends for

acute respiratory tract infections. Pediatrics. September 15, 2014;134(4):e956–e965. Number of Visits in Thousands 2,600

5,200

7,800

10,400

13,000

Total Under 2 Years 2–17 Years

Annual Visits

Visits with “Potentially Preventable”

Antibiotic Prescriptions

12,715

871

8,072

2,242

3,108

4,656
Child Health USA 2014 Health Services Financing and Utilization 96

primary care practitioner during the year when BMI percentile was 

documented (figure 2). This translates to increases from 2011 of 15.4 

percent in commercial HMOs, 26.8 percent in commercial PPOs, and 

12.6 percent in Medicaid HMOs. 

The percentage of providers counseling children on proper nutrition and/or physical activity also showed improvement. From 2011 to 

2012, rates for counseling children on nutrition increased in commercial HMOs from 46.4 to 54.3 percent, in commercial PPOs from 28.4 

to 35.4 percent, and in Medicaid HMOs from 50.1 to 55.0 percent. 

For the same period, rates for counseling children on physical activity 

increased in commercial HMOs from 43.0 to 50.4 percent, in commercial PPOs from 25.7 to 32.6 percent, and in Medicaid HMOs from 

40.6 to 44.2 percent.3

Figure 2. Receipt of Body Mass Index (BMI) Assessment and

Counseling for Nutrition and Physical Activity Among Children

Aged 3–17 Years, 2012

Source: National Committee for Quality Assurance. Improving Quality and Patient Experience: The State of

Health Care Quality 2013. Available at:

http://www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf.

Accessed September 15, 2014. Percent of Children 14

28

42

56

70

Commercial HMO Commercial PPO Medical HMO

BMI Assessment

Nutrition Counseling

Physical Activity Counseling

51.6

31.2 35.4 32.6

51.8

44.2

54.3 55.0

50.4

Data Sources

Figure 1. Kronman MP, Zhou C, Mangione-Smith R. Bacterial prevalence and antimicrobial prescribing trends for acute respiratory tract infections. Pediatrics.

September 15, 2014;134(4):e956–e965.

Figure 2. National Committee for Quality Assurance. Improving Quality and Patient Experience: The State of Health Care Quality 2013. Available at:

http://www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf. Accessed September 15, 2014. 

Endnotes

1. U.S. Department of Health and Human Services. Public Health Quality. Available at: http://www.hhs.gov/ash/initiatives/quality/quality/. Accessed September 15, 2014.

2. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Quality Measures. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html?redirect=/QUALITYMEASURES/. Accessed September 22, 2014. 

3. National Committee for Quality Assurance. Improving Quality and Patient Experience: The State of Health Care Quality 2013. Available at:

http://www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf. Accessed September 15, 2014. 

4. Kronman MP, Zhou C, Mangione-Smith R. Bacterial prevalence and antimicrobial prescribing trends for acute respiratory tract infections. Pediatrics. September 15, 

2014;134(4):e956–e965. Available at: http://pediatrics.aappublications.org/content/early/2014/09/09/peds.2014-0605.abstract. Accessed September 16, 2014.

5. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. Available at: 

http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Accessed September 15, 2014. 

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Special Features 97

SPECIAL FEATURES

This section provides information on factors associated with child 

health and well-being which can impact children and adolescents 

across the life course. Topics include adverse childhood experiences, 

flourishing and resiliency among youth and adolescents, and mortality 

and nonfatal injury. Additional information is provided on a wide range 

of federal policies and programs that support women’s and children’s 

health throughout the lifespan. 
Child Health USA 2014 Special Features 98

CHILD MORTALITY

The death of a child is a tragedy for family and friends and a loss 

to the community. Along with the direct impact of a child’s death to 

a family, the child mortality rate in a community can be an important indicator for researchers or policymakers.1

 A high rate can point 

to underlying problems, such as poor access to health care, violent 

neighborhoods, high levels of risk-taking behaviors, or inadequate 

child supervision.2 It can also point to inequities, for example, in access to behavioral health services, safe places to play, or exposure to 

environmental toxins. 

Since 1999, the overall mortality rate for children aged 1–19 years 

declined by more than 25 percent to a low of 25.7 per 100,000 in 

2011 (figure 1). The decline was fairly uniform, ranging from 23 to 30 

percent across age groups. 

According to 2011 data, racial and ethnic disparities persisted in 

mortality among children. Mortality rates were highest for non-Hispanic American Indian/Alaska Native (47.6 per 100,000) and non-Hispanic Black (37.3 per 100,000) children, while the rates for Hispanic 

(21.1 per 100,000) and non-Hispanic Asian/Pacific Islander (13.4 per 

100,000) children were lowest (figure 2). 

According to 2011 data, the “All Cause” mortality rate for children 

aged 1–9 years was 18.3 per 100,000. Most deaths to children in 

that age group (10.8 per 100,000) were classified as noninjury (i.e., 

natural causes) followed by unintentional injury (5.9 per 100,000), 

homicide (1.5 per 100,000), and deaths of undetermined nature (0.2 

per 100,000). For adolescents aged 10–19 years, the “All Cause” 

mortality rate was 75 percent greater (32.0 per 100,000) than that of 

children 1–9 years of age. Most of the difference could be attributed 

to the higher mortality rates among 15- to 19-year-old males (68.5 

per 100,000) resulting from higher rates of unintentional injury (27.4 

per 100,000), homicide (13.0 per 100,000), and suicide (12.9 per 

100,000) relative to younger males. The mortality rates for females in 

all age groups were lower than the rates for males. 

Leading causes of death due specifically to intentional and unintentional injury varied by age group. Drowning, homicide, and motor 

vehicle accidents were predominant in the 1- to 9-year-olds, though 

their rank order frequency was different for 1- to 4-year-olds (drowning, homicide, and motor vehicle traffic accident) compared to 5- to 

9-year-olds (motor vehicle traffic accident, homicide, and drowning). 

Motor vehicle traffic accidents, suicide, and homicide were the highest 

ranked leading causes of deaths due to injury for adolescents aged 

10–19 years; however, the rates were higher for 15- to 19-year-olds 

(12.9, 8.3, and 7.8 per 100,000, respectively) compared to 10- to 

14-year-olds (2.1, 1.4, and 0.7 per 100,000, respectively). 

General societal improvements, advances in medical care, and 

the introduction of Medicaid have been cited as factors in the longterm decline in child mortality.3

 Despite these advances, many states 

have disproportionately high child and adolescent mortality, and rates 

among some racial and ethnic groups fall far short of the Healthy People 2020 goals.4

 Continued research on mechanisms underlying racial 

and ethnic disparities and expansion of child fatality review to inform 

state and local prevention strategies have been suggested.5,6

Figure 1. Mortality Among Children Aged 1–19 Years, by Year and

Age, 1999–2011 Rate per 100,000 Children

12.1

26.3

25.7

14.2

48.9

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. Underlying cause of death 1999–2011. CDC WONDER Online Database, released

2014. Data are from the Multiple Cause of Death Files, 1999–2011.

Aged 10–14 Years

Aged 1–4 Years

Aged 15–19 Years

Total

Aged 5–9 Years

16

32

48

64

80

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Child Health USA 2014 Special Features 99

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying cause of 

death 1999–2011. CDC WONDER Online Database, released 2014. Data are from the Multiple Cause of Death Files, 1999–2011.

Endnotes

1. Institute of Medicine. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: National Academies Press; 1999.

2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. National Action Plan for 

Child Injury Prevention. Atlanta, GA: Centers for Disease Control and Prevention; 2012.

3. Howell E, Decker S, Hogan S, Yemane A, Foster J. Declining child mortality and continuing racial disparities in the era of the Medicaid and SCHIP insurance coverage 

expansions. American Journal of Public Health. 2010;100(12):2500–2506.

4. Singh GK, Kogan MD. Widening socioeconomic disparities in U.S. childhood mortality, 1969–2000. American Journal of Public Health. 2007;97(9):1658–1665.

5. Brown RL. Epidemiology of injury and the impact of health disparities. Current Opinion in Pediatrics. 2010;22:321–325.

6. Christian CW; Sege RD; Committee on Child Abuse and Neglect; Committee on Injury, Violence, and Poison Prevention; Council on Community Pediatrics. Child 

fatality review. Pediatrics. 2010;126;592–596.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/

Figure 2. Mortality Among Children Aged 1–19 Years, by Age and

Race/Ethnicity, 2011 Rate per 100,000 Children

37.3 40.1

26.4

47.6

40.8

25.0 24.1 21.1 23.5

8.5

48.2

9.3

21.7

46.4

95.9

68.4

Total

1–4 Years

5–9 Years 

10–14 Years 

15–19 Years 

*Separate estimates for Asians, Native Hawaiians, and other Pacific Islanders were not available.

20

40

60

80

100

Non-Hispanic

Asian/Pacific

Islander*

Non-Hispanic

American Indian/

Alaska Native

Non-Hispanic Hispanic

Black

Non-Hispanic

White

17.5 13.8 12.1 13.4 14.4

19.8

10.0 11.7

18.0

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Health Statistics. Underlying cause of death 1999–2011. CDC WONDER Online Database, released

2014. Data are from the Multiple Cause of Death Files, 1999–2011.
Child Health USA 2014 Special Features 100

NONFATAL INJURY

Each year, millions of children are injured and live with the consequences of those injuries. For some children, injury causes temporary 

pain and functional limitation; for others, injury can lead to permanent 

disability, traumatic stress, depression, chronic pain, and a decreased 

ability to perform age-appropriate activities.1 In addition, family members must often care for the injured child, which can cause stress, 

time away from work, and lost income.2 Communities, states, and the 

Nation feel the economic burden of child injuries, including medical 

care for the injured child and lost productivity for caregivers.3

The U.S. nonfatal injury rate among children aged 0–19 years was 

11,548 per 100,000 children in 2012. While injuries were higher among 

children aged 0–4 years compared to 5- to 9-year-olds (12,280 and 

9,087 per 100,000, respectively), those aged 15–19 years had the 

highest nonfatal injury rates (13,579 per 100,000; figure 1). In all age 

groups, rates of injuries were higher for males than for females.

In general, nonfatal injuries trended downward for all age groups 

from approximately 2001 to 2007 (figure 2). After 2009, however, 

overall rates began trending upward. A particularly pronounced upward trend is noted for 0- to 4-year-olds beginning in 2007–2008. 

Although overall a 10 percent decrease in nonfatal injuries occurred 

between 2001 and 2012 for children: 3 percent for those aged 0–4 

years, 14 percent for children aged 5–9, 13 percent for 10- to 14-yearolds, and 10 percent for 15- to 19-year-olds. 

Falls were the leading cause of nonfatal injury among 0- to 4-yearolds (43.7 percent) and 5- to 9-year-olds (36.7 percent), followed by 

being struck by or against an object (17.0 and 23.0 percent, respectively). For children aged 10–14 years, the most frequent causes of 

nonfatal injuries were also falls and being struck by or against an object (26.0 and 26.5 percent, respectively), followed by overexertion 

(13.8 percent). Among 15- to 19-year-olds, being struck by or against 

an object was ranked highest (20.8 percent), followed by falls (15.7 

percent) and overexertion (13.3 percent).

In 2012, more than 60 stakeholders and the Centers for Disease 

Control and Prevention collaborated to produce a National Action 

Plan for Child Injury Prevention. The focus of the group was to increase awareness of child injury, highlight prevention solutions through 

stakeholder action, and mobilize a coordinated national effort to reduce child injury. The plan is structured across six domains relevant 

to child injury prevention, each containing goals and specific actions: 

data and surveillance for planning, implementing, and evaluating injury prevention efforts; research on gaps and priorities in risk factor 

identification, interventions, program evaluation, and dissemination 

strategies; communications or messaging to promote prevention; education and training toward behavior change conducive to preventing 

injuries; health systems and health care for clinical and community 

preventive services; and policy that includes laws, regulations, incentives, administrative actions, and voluntary practices that enable safer 

environments and decisionmaking.4

Figure 1. Nonfatal Injury* Among Children Aged 0–19 Years, by Age

and Sex, 2012

Rate per 100,000 Children

7,875

11,548

9,988

9,087

11,057

9,428

11,562

13,579

15,492

12,852

10,248

11,179

12,280

Total

Male

Female

*Nonfatal injuries (all intents, all causes) resulting in an emergency department visit.

3,600 7,200 10,800 14,400 18,000

15–19 Years 

10–14 Years 

5–9 Years 

0–4 Years 

Total 13,037

13,449

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Injury Prevention & Control. National Electronic Injury Surveillance System—All Injury Program.
Child Health USA 2014 Special Features 101

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention & Control. National 

Electronic Injury Surveillance System—All Injury Program.

Endnotes

1. National Research Council and Institute of Medicine. Children’s Health, the Nation’s Wealth: Assessing and Improving Child Health. Washington, DC: National Academies Press; 2004.

2. Shudy M, de Almeida ML, Ly S, Landon C, Groft S, Jenkins TL, Nicholson CE. Impact of pediatric critical illness and injury on families: A systematic literature review. 

Pediatrics. 2006;118:S203–S218.

3. Children’s Safety Network. Injury prevention: What works? A summary of cost-outcome analysis for injury prevention programs: 2012 update. Available at: http://www.

childrenssafetynetwork.org/sites/childrenssafetynetwork.org/files/InjuryPreventionWhatWorks2012.pdf. Accessed September 11, 2014.

4. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. National Action Plan for 

Child Injury Prevention. Atlanta, GA: U.S. Department of Health and Human Services; 2012.

Figure 2. Rates of Nonfatal Injury* per 100,000 Among Children Aged

0–19 Years, by Year and Age, 2001–2012 Rate per 100,000 Children

9,087

13,579

11,548

11,179

12,280

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National

Center for Injury Prevention & Control. National Electronic Injury Surveillance System—All Injury Program.

*Nonfatal injuries (all intents, all causes) resulting in an emergency department visit.

6,400

8,320

10,240

12,160

14,080

16,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Total

5–9 Years

15–19 Years

0–4 Years

10–14 Years

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Special Features 102

ADVERSE CHILDHOOD EXPERIENCES

Adverse childhood experiences (ACEs), such as living with someone who had problems with drugs or alcohol or witnessing violence 

in the home, can have significant effects on long-term health and 

well-being.1 Early exposure to these types of life events has been 

linked to a wide range of chronic health conditions and health risk behaviors later in life.2

 The National Survey of Children’s Health (NSCH) 

asks parents and caregivers about children’s exposure to nine such 

experiences, including

• Economic hardship (defined as living in a household that often 

had difficulty affording basics like housing or food); 

• Living with a parent who was divorced or separated since the 

child’s birth;

• Living with a parent who died; 

• Living with a parent who served time in jail after the child was 

born; 

• Witnessing intimate partner violence; 

• Witnessing or was the victim of violence in their neighborhood; 

• Living with someone who was mentally ill, suicidal, or severely 

depressed for more than a couple of weeks; 

• Living with someone who had a problem with alcohol or drugs; 

and

• Having been discriminated against because of race/ethnicity.

In 2011–2012, nearly one-quarter (22.6 percent) of children aged 

0–17 were reported to have experienced two or more of these nine 

ACEs. Economic hardship was the most commonly reported ACE 

(25.7 percent), followed by living with a parent who was divorced or 

separated after the child’s birth (20.1 percent), living with someone 

who had a substance use or abuse problem (10.7 percent), and being 

a victim of or witness to neighborhood violence and living with someone who was mentally ill or suicidal for more than a couple of weeks 

(both 8.6 percent; figure 1).

Exposure to ACEs among children varied by sociodemographic 

characteristics, including race and ethnicity, parental education, and 

poverty. The proportion of children who had experienced two or more 

Figure 1. Adverse Childhood Experiences (ACEs) Among Children

Aged 0–17 Years, 2011–2012

Percent of Children

*Reported that it was somewhat or very often hard to get by on the family’s income; i.e., it was hard to cover the

basics like food or housing.

25.7

20.1

3.1

7.3

10.7

8.6

6.9

4.1

8.6

22.6

6 12 18 24 30

Experienced two or more ACEs

Lived with a

parent who died

Was ever treated or

judged unfairly because

of his or her race

or ethnic group

Lived with a parent who

served time in jail after the child was born

Saw parents or any other

adults in the home slap,

hit, kick, punch, or beat

each other up

Lived with someone

who was mentally ill,

suicidal, or severely

depressed for more than

a couple of weeks

Was a victim of violence or witnessed violence

in the neighborhood

Lived with someone who

had a problem with

alcohol or drugs

Lived with a parent

who was divorced or

separated after the child was born

Experienced economic

hardship often*

Source: Health Resources and Services Administration, Maternal and Child Health Bureau; and Centers for

Disease Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health.

Analyzed by the Health Resources and Services Administration’s Maternal and Child Health Bureau.
Child Health USA 2014 Special Features 103

ACEs was highest among non-Hispanic American Indian/Alaska Native children, of whom two-fifths (40.3 percent) had experienced two 

or more of these nine life events; followed by non-Hispanic Black children and non-Hispanic children of multiple races, of whom approximately one-third had experienced such events (31.1 and 32.7 percent, respectively). About one-fifth of non-Hispanic Whites, Hispanics, 

and non-Hispanic Native Hawaiians/other Pacific Islanders reported 

experiencing two or more ACEs. Only 5.3 percent of non-Hispanic 

Asian children had experienced two or more ACEs since birth.

Exposure to two or more ACEs was more common among children living in poor and nearly poor families as well as those living in 

households where neither parent had completed college. More than 

one-third of children living in households with incomes less than 100 

percent of poverty (34.9 percent) had experienced two or more ACES 

since birth, compared to 28.7 percent of those in households with incomes of 100–199 percent of poverty (figure 2). Less than 10 percent 

of children living in households with incomes of 400 percent or more of 

poverty had experienced two or more of these life events. 

Similarly, while approximately 30 percent of children living in households where neither parent had completed college were reported to 

have experienced two or more ACEs, 13.1 percent of those living in 

households where at least one parent had completed college were 

reported to have done so.

Data Sources

Figure 1 and 2. Health Resources and Services Administration, Maternal and Child Health Bureau; and Centers for Disease Control and Prevention, National Center for 

Health Statistics, National Survey of Children’s Health. Analyzed by the Health Resources and Services Administration’s Maternal and Child Health Bureau.

Endnotes

1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse 

Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998;14(4):245–258.

2. Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE) Study: major findings by publication year. Available at:

http://www.cdc.gov/violenceprevention/acestudy/. Accessed September 9, 2014.

Figure 2. Children Aged 0–17 Years Experiencing Two or More ACEs,

by Poverty Status,* 2011–2012

*Based on the U.S. Department of Health and Human Services poverty guidelines, poverty was $23,050 for a

family of four in 2012.

Source: Health Resources and Services Administration, Maternal and Child Health Bureau; and Centers for

Disease Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health.

Analyzed by the Health Resources and Services Administration’s Maternal and Child Health Bureau. Percent of Children

8

16

24

32

40

400% or More

of Poverty

200 to 399%

of Poverty

100 to 199%

of Poverty

Less Than 100%

of Poverty

34.9

9.7

28.7

20.9

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Special Features 104

FLOURISHING AND RESILIENCE

In addition to traditional measures of health status and risk factors, 

positive health indicators can be used to help create a more complete picture of child health and well-being.1

 The 2011–2012 National 

Survey of Children’s Health (NSCH) included several such items to 

contribute to a better understanding of whether U.S. children were 

“flourishing” or “thriving.” The concept of flourishing is comprised of 

multiple dimensions of physical health, mental and emotional health, 

caring, empathy, and resilience.2 Two sets of flourishing items were 

included in the NSCH: one for children aged 6 months to 5 years and 

a separate set for children aged 6–17 years based on developmentally 

relevant milestones and experiences. Four questions were included 

for younger children focused on curiosity, resilience, attachment to 

caregivers, and positive affect.2 For parents and caregivers of schoolaged children, three items were asked that focused on curiosity, resilience, and self-regulation.2

In 2011–2012, the proportion of children who were reported by 

their parents and caregivers to usually or always exhibit all age-specific behaviors associated with flourishing varied by age group. Among 

children aged 6 months to 5 years, 73.2 percent were reported to 

usually or always exhibit all four flourishing behaviors, while less than 

half (47.7 percent) of school-aged children were reported to usually or 

always exhibit the three flourishing behaviors (figure 1). 

Among younger children, the most common behaviors reported 

were smiling and laughing a lot followed by showing interest and curiosity in new things; more than 80 percent of children aged 6 months 

to 5 years were reported to always exhibit these behaviors (figure 2). 

About one-fifth of children in this age group were reported to never, 

rarely, or only sometimes bounce back quickly when things did not 

go their way.

Difficulties facing challenging situations were common among 

school-aged children, among whom more than one-third (35.3 percent) were reported to never, rarely, or only sometimes stay calm and 

in control when faced with a challenge. More than a third (34.8 percent) of this population also exhibited difficulties in finishing tasks and 

following through with what they said that they would do. The most 

commonly reported behavior among children in this age group was 

showing interest and curiosity in learning new things, with 85.0 percent reported to usually or always exhibit this characteristic.

The prevalence of parent-reported flourishing behaviors and characteristics varied by both child and family characteristics. Greater 

proportions of children living in households with higher incomes and 

greater parental educational attainment were reported to usually or 

always exhibit all age-relevant behaviors and characteristics. For example, among children aged 6–17 years, 37.6 percent of those living 

in a household where neither parent had completed high school usually or always exhibited all three related behaviors compared to 54.9 

percent among those living in a household where at least one parent 

or caregiver had completed college. Among children of all ages, girls 

were more likely than boys to be reported as meeting all age-specific measures of flourishing: 75.1 versus 71.3 percent, respectively, 

among younger children and 51.4 versus 44.1 percent, respectively, 

among school-aged children. 

Figure 1. Overall Flourishing Behaviors and Characteristics Among

Children Aged 6 months to 17 years, by Age, 2011–2012 

6 Months to 5 Years* 6–17 Years**

*Parent or caregiver reported that the child usually or always exhibited: being affectionate and tender with the

parent or caregiver, bouncing back quickly when things did not go their way, showing interest and curiosity in

learning new things, and smiling and laughing a lot. **Parent or caregiver reported that the child usually or

always exhibited: finishing tasks and following through, staying calm when faced with a challenge, and showing

interest and curiosity in learning new things.

3 Flourishing

Behaviors and

Characteristics

20.8%

4 Flourishing

Behaviors and

Characteristics

73.2%

0–2 Flourishing

Behaviors and

Characteristics 6.1%

2 Flourishing

Behaviors and

Characteristics 26.8%

3 Flourishing

Behaviors and

Characteristics 47.7%

0–1 Flourishing

Behaviors and

Characteristics 25.6%

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau; U.S. Department of Health and Human Services, Centers for Disease Control

and Prevention, National Center for Health Statistics, National Survey of Children’s Health, 2011–2012.
Child Health USA 2014 Special Features 105

Data Sources

Figure 1 and 2. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau; U.S. Department of 

Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health, 2011–2012.

Endnotes

1. Child Trends. Positive Indicators Project. Available at: http://www.childtrends.org/our-research/positive-indicators/positive-indicators-project/. Accessed September 10, 

2014.

2. Child and Adolescent Health Measurement Initiative. National Survey of Children’s Health, 2011–2012 Data Resource Center. Available at:

http://www.childhealthdata.org. Accessed September 10, 2014.

Figure 2. Detailed Flourishing Behaviors and Characteristics Among

Children Aged 6 Months to 17 Years, by Age, 2011–2012

Percent of Children

Never, Rarely,

or Sometimes Usually Always

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau; U.S. Department of Health and Human Services, Centers for Disease Control

and Prevention, National Center for Health Statistics, National Survey of Children’s Health, 2011–2012.

20 40 60 80 100

Child shows interest

and curiosity in

learning new things

Child stays calm and

in control when

faced with challenge

Child finishes tasks and

follows through with

what he or she says

that he or she will do

6 – 17 Years

Child smiles and

laughs a lot

Child shows interest

and curiosity in

learning new things

Child bounces back quickly when things do

not go his or her way

Child is

affectionate and

tender with parent

6 Months–5 Years

6.6

21.3

4.4

2.1

34.8

21.3

34.6

33.4

72.1

13.4

15.0 80.6

84.4

30.7

35.3 39.2 25.5

15.0 27.2 57.8

45.3

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Special Features 106

AFFORDABLE CARE ACT

The Affordable Care Act, enacted on March 23, 2010, contains 

provisions to expand access to health insurance coverage, control 

health care costs, and improve health care quality for U.S. citizens 

and legal residents.1 These comprehensive insurance reforms were 

implemented with the goal of all Americans having access to affordable health insurance options. 

For children, a key provision of the Affordable Care Act is the extension of dependent coverage, allowing them to remain on their parents’ 

insurance through age 26.2 In 2011, an estimated 3.1 million young 

adults gained health insurance coverage as a result of this law.3 The 

Affordable Care Act also prevents health insurance plans from denying coverage for children aged 19 years and younger with preexisting 

medical conditions. In 2008, approximately 24 percent of children had 

a preexisting health condition that would prevent them from receiving 

coverage without the health reform law.4

The Affordable Care Act includes coverage without family co-pays 

for preventive health services for children (table 1).5 For example, preventive services for infants include screening for hearing, development, sickle cell disease, phenylketonuria, and several other health 

conditions. These services are particularly important, as early detection of medical conditions during infancy can help prevent long-term 

disability and improve children’s health and well-being. In 2007, before 

the enactment of the Affordable Care Act, an estimated 80 percent of 

children aged 10–47 months were not administered a screening test 

for developmental delays.7 In addition, 50 percent of newborns who 

did not pass hearing screenings did not receive further testing for the 

diagnosis of hearing loss between 2009 and 2010.6

Preventive services that are covered for adolescents include 

screening for sexually transmitted infections, obesity screening and 

counseling, immunizations, and alcohol and drug use assessments. 

These services are especially important for lessening the potential 

for adverse consequences from risky behaviors during adolescence. 

Before the enactment of the Affordable Care Act, more than half of 

sexually active females aged 15–21 years had not been screened for 

chlamydia between 2006 and 2010.6 In addition, tobacco use was not 

documented for 31 percent of outpatient visits among young adults 

aged 11–21 years during the 6-year period from 2004 to 2010.6

Table 1. Covered Preventive Services for Children Under the Affordable Care Act

Alcohol and drug use assessments for adolescents

Autism screening for children at 18 and 24 months

Behavioral assessments for children of all ages

Blood pressure screening for children

Cervical dysplasia screening for sexually active females

Congenital hypothyroidism screening for newborns

Depression screening for adolescents

Developmental screening for children under age 3 and surveillance throughout childhood

Dyslipidemia screening for children at higher risk of lipid disorders

Fluoride chemoprevention supplements for children without fluoride in their water source

Gonorrhea preventive medication for the eyes of all newborns

Hearing screening for all newborns

Height, weight, and body mass index measurements for children 

Hematocrit or hemoglobin screening for children

Hemoglobinopathies or sickle cell screening for newborns

HIV screening for adolescents at higher risk

Immunization vaccines for children from birth to age 18

Iron supplements for children aged 6–12 months at risk for anemia 

Lead screening for children at risk of exposure 

Medical history for all children throughout development

Obesity screening and counseling

Oral health risk assessment for young children

Phenylketonuria screening for this genetic disorder in newborns 

Sexually transmitted infection prevention counseling and screening for adolescents at higher risk

Tuberculin testing for children at higher risk of tuberculosis

Vision screening for all children
Child Health USA 2014 Special Features 107

Data Sources

Table 1. U.S. Department of Health and Human Services. Preventive Services Covered Under the Affordable Care Act. Available at: http://www.hhs.gov/healthcare/

facts/factsheets/2010/07/preventive-services-list.html. Accessed October 6, 2014.

Endnotes

1. Henry J. Kaiser Family Foundation. Summary of the Affordable Care Act. Available at: http://www.kff.org/healthreform/8061.cfm. Accessed September 19, 2014.

2. U.S. Department of Health and Human Services. Key Features of the Affordable Care Act. Available at: http://www.hhs.gov/healthcare/facts/timeline/index.html. 

Accessed September 19, 2014.

3. U.S. Department of Health and Human Services. State-Level Estimates of Gains in Insurance Coverage Among Young Adults. Available at: http://www.hhs.gov/healthcare/facts/factsheets/2012/06/young-adults06192012a.html. Accessed September 19, 2014.

4. U.S. Department of Health and Human Services. At Risk: Pre-existing Conditions Could Affect 1 in 2 Americans: 129 Million People Could Be Denied Affordable Coverage Without Health Reform. Washington, DC: U.S. Department of Health and Human Services; 2011. Available at: http://aspe.hhs.gov/health/reports/2012/pre-existing. Accessed September 19, 2014.

5. U.S. Department of Health and Human Services. Preventive Services Covered Under the Affordable Care Act. Available at: http://www.hhs.gov/healthcare/facts/factsheets/2010/07/preventive-services-list.html. Accessed September 19, 2014.

6. Yeung LF, Coates RJ, Seeff L, Monroe JA, Lu MC, Boyle CA. Conclusions and future directions for periodic reporting on the use of selected clinical preventive services 

to improve the health of infants, children, and adolescents—United States. MMWR Surveillance Summaries: Morbidity and Mortality Weekly Review. September 12, 

2014; 63:99–107.

7. Child and Adolescent Health Measurement Initiative. National Survey of Children’s Health, 2011–2012 Data Resource Center. Available at:

http://www.childhealthdata.org. Accessed September 10, 2014.

Suggested Citation

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2015. Online at http://mchb.hrsa.gov/chusa14/
Child Health USA 2014 Special Features 108

FEDERAL PROGRAMS TO PROMOTE 

CHILD HEALTH

The U.S. Department of Health and Human Services’ (HHS) 

Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB) works to improve the 

physical and mental health, safety, and well-being of the maternal and 

child population, which includes all of the nation’s women, infants, children, adolescents, and their families through a variety of programs.1

Enacted in 1935, the Title V Maternal and Child Health Block 

Grant Program is the Nation’s oldest federal-state partnership. State 

maternal and child health agencies apply for and receive formula grants 

each year that support programs designed to improve the health of 

women, infants, children and youth through population-based public 

health and preventive health care services. Some goals of the Title V 

program include ensuring access to quality care, especially for those 

households with limited incomes or limited care availability; increasing 

the number of children receiving health assessments and follow-up 

diagnostic and treatment services; providing and ensuring access to 

preventive and child care services and rehabilitative services for certain children; and implementing family-centered, community-based 

systems of coordinated care for children with special health care 

needs. A total of 59 states and jurisdictions receive Title V Maternal 

and Child Health Block Grant funding administered by MCHB. In fiscal year 2013, Title V programs served nearly 42 million individuals, 

including 2.3 million pregnant women, 4.0 million infants, 27.6 million 

children, and 2.7 million children with special health care needs.2,3

The Healthy Start Program, also administered by MCHB, works 

to reduce the rate of infant mortality and improve perinatal outcomes 

through grants to communities with high infant mortality rates. In 2013, 

105 Healthy Start projects were providing services in 39 states, the 

District of Columbia, and Puerto Rico, serving 196 different communities. These projects provide core services: direct outreach and client 

recruitment, health education, case management, depression screening and referral, and services between pregnancies.4

 The life course 

perspective posits that birth outcomes can have long-term impacts 

on a child’s health. Healthy Start aims to improve birth outcomes and 

thereby reduce the likelihood of adverse childhood health outcomes. 

Adverse consequences of being born preterm or with low birth weight 

include developmental problems, poorer health and social/emotional 

functioning throughout young adulthood, poorer educational achievement, lower college attendance, and higher incidence of health issues 

in adulthood such as high blood pressure and respiratory disorders.5–8

HRSA’s Maternal, Infant, and Early Childhood Home Visiting 

Program facilitates collaboration and partnership at the federal, state, 

and community levels to improve health and developmental outcomes 

for at-risk children through evidence-based home visiting programs. 

The program provides grants to support programs to improve maternal and newborn health, promote school readiness and achievement, 

prevent family violence and child injury, and develop family economic 

self-sufficiency. In 2013, HRSA awarded $109.5 million to the 52 eligible states and territories. In addition, approximately $69.6 million was 

awarded to 13 states to expand existing programs.9 There is also a 

Tribal Maternal, Infant, and Early Childhood Home Visiting program for American Indian and Alaska Native communities.10

The Maternal, Infant, and Early Childhood Home Visiting Program is part of a portfolio of early learning initiatives that work together to support access to high-quality early education for all children. 

These initiatives focus on the early years in a child’s life, since research 

has shown that the early years are a window of opportunity to develop 

a child’s potential and shape academic, social, and cognitive skills that 

determine a child’s success in school and life. This agenda includes 

the Preschool for All initiative to improve quality and expand access 

to preschool; the Child Care Development Fund initiative to subsidize the cost of child care for low-income households and increase the 

availability and quality of that care; Race to the Top: Early Learning 

Challenge, which challenges states to compete and deliver better 

training and education for early educators; and the reformation and 

expansion of Head Start. Through the American Recovery and Reinvestment Act, $2.1 billion is invested in Head Start and Early Head 

Start. Efforts are underway to raise Head Start standards, promote 

accountability, focus on school readiness, and utilize a process to ensure only the highest quality programs receive Head Start grants.11

Text messaging is a means of improving health knowledge, behaviors, and clinical outcomes, especially among hard-to-reach populations. Text4Baby is a free mobile health education service that 

provides evidence-based health messages regarding issues such as 

breastfeeding, immunizations, safe sleep, and nutrition. These text 

messages are intended for pregnant mothers and parents and caregivers of infants less than 1 year of age. Text4baby is a campaign 

of the National Healthy Mothers, Healthy Babies Coalition. TXT4Tots

distributes short, evidence-based messages regarding nutrition and 

physical activity. These text messages are intended for parents and 

caregivers of children aged 1–5 years. Content for messages is derived from the American Academy of Pediatrics (AAP) Bright Futures 

recommendations. A 2012 environmental scan found that research 

has shown that health text messaging programs can bring about 

behavior change and improve treatment compliance to improve outcomes.12

Injuries are the leading public health threat facing those aged 1–44 

years. More children die from injuries and violence than all diseases 

combined. Injuries are also the leading cause of disability and medical spending for children. Funded by MCHB, the Children’s Safety 

Network aids states in planning, implementing, strengthening, and 

evaluating injury and violence prevention programs. The National 

Center for the Review and Prevention of Child Death strengthens state capacity to perform Child Death Reviews (CDR), develops 

prevention-oriented recommendations, and translates those recommendations into local policies and programs. CDR is a community-based action process intended to guide communities in identifying 

and solving problems that contribute to poor child and adolescent 

health outcomes.13 The CDC supports the Essentials for Childhood 

Framework, with evidence-based strategies for communities to promote relationships and environments that help children grow up to be 

healthy and productive, as well as the national Striving To Reduce 

Youth Violence Everywhere (STRYVE) initiative which focuses on 

preventing youth violence before it starts.14,15

HRSA’s Adolescent and Young Adult Health Program provides 

information and resources to assist health professionals, program ad-
Child Health USA 2014 Special Features 109

ministrators, and policymakers in the development of programs and 

policies at the community, state, and national levels that will help adolescents and young adults thrive. This program supports the National Adolescent Health Information and Innovation Center, which 

collects and disseminates relevant information on the health, safety, 

development, and social and economic well-being of school-aged 

children in transition to adolescence.16

HRSA’s Stop Bullying Now! (SBN!) campaign serves children and 

adolescents. Bullying is intentionally aggressive behavior that involves 

an imbalance of power. It can take many forms, and studies show 

that 15–25 percent of U.S. students are bullied. Bullying can affect 

educational success and have social and emotional consequences. 

The SBN! campaign connects with its audience through the Web at 

http://www.stopbullying.gov. When SBN! began in 2001, only nine 

states had legislation regarding bullying; today 45 states have such 

legislation. The SBN! campaign has more than 80 active partners, and 

six federal departments are working together to coordinate bullying 

prevention activities.17

Part of HHS, the Administration for Children & Families (ACF)

promotes the economic and social well-being of families, children, individuals, and communities.18 Programs for children include adolescent pregnancy prevention, adoption, child abuse and neglect prevention and intervention, child care, child and family services reviews, 

child support, child welfare, early childhood development, foster care, 

Head Start, and runaway and homeless youth and unaccompanied 

children’s services.19 The ACF Office of Head Start administers 

the Head Start program, which aims to improve school readiness of 

young children from low-income households through local community agencies. Head Start and Early Head Start programs provide 

comprehensive services to support emotional, social, and mental 

development for children aged 0–5 years. The program provides education, health, nutrition, social, and other services. Programs also 

support positive parent-child relationships and family well-being. Head 

Start services are delivered by 1,700 public and private nonprofit and 

for-profit agencies. More than 80 percent of the children served by 

Head Start in 2013 were 3–4 years old. Early Head Start serves pregnant women, infants, and toddlers and is available to families until 

their child turns 3 years old. More than 1 million children are served by 

Head Start programs annually. In 2013, with a budget of $7.6 billion, 

Head Start programs served 932,164 children and their families, and 

Early Head Start served 150,100 children. 20,21

The HHS Centers for Medicare and Medicaid Services’ 

(CMS) Children’s Health Insurance Program (CHIP) was enacted in 1997. This program provides health care coverage to children 

in households whose incomes are too high to qualify for Medicaid 

but who cannot afford private coverage. CHIP is administered by the 

states and funded by both the federal government and states.22 From 

1997 to 2012, the rate of uninsured children was halved, from 14 to 7 

percent.23 For 2013, $19.1 billion was set aside for CHIP allotments, 

and 8.5 million children received insurance through CHIP at some time 

during the year.24 The Affordable Care Act of 2010 extends CHIP and 

enhances federal funding for the program by maintaining CHIP eligibility standards through 2019 and extending funding through October 1, 

2015. The CHIP federal matching rate will be increased by 23 percent, 

resulting in an average federal matching rate for CHIP of 93 percent. 

The Affordable Care Act provided $40 million to continue efforts to 

promote Medicaid and CHIP enrollment.22

Launched by the First Lady, the Let’s Move! program is a comprehensive initiative intended to address the challenge of childhood 

obesity within a generation. The program involves parents, elected 

officials, schools, health care professionals, community-based organizations, and private-sector companies. Components of the program 

include providing information for parents to foster environments that 

support healthy choices; providing healthier foods in schools; ensuring that all families have access to healthy, affordable food; and 

helping kids become more physically active.25 As part of this effort, 

the President established the first-ever White House Task Force on 

Childhood Obesity to develop and implement an interagency plan to 

end childhood obesity.25 The Let’s Move! program is supported by the 

U.S. Department of Education, the U.S. Department of the Interior, the 

U.S. Department of Agriculture (USDA), HHS, the White House, and 

numerous other organizations.26,27

The USDA Food and Nutrition Service administers the Supplemental Nutrition Assistance Program (SNAP), which helped more 

than 47 million low-income Americans put food on the table in 2013. 

SNAP primarily serves vulnerable populations, especially households 

with children, elders, and disabled members. About 44 percent of all 

SNAP participants are children.28,29 Nutrition educators teach SNAP 

participants the importance of a healthy diet and how to prepare 

healthy foods and make healthy choices.30 In 2013, the SNAP budget 

was $79.9 billion, resulting in an average monthly benefit of $133.07 

per person.29

The USDA Special Supplemental Nutrition Program for 

Women, Infants and Children (WIC) serves low-income pregnant, 

postpartum and breastfeeding women, and infants and children up 

to age 5 who are at risk for poor nutrition. Foods provided through 

the WIC program are designed to supplement recipients’ diets with 

specific nutrients. Some WIC foods include iron-fortified adult cereal, 

vitamin C-rich fruit or vegetable juice, eggs, milk, cheese, and peanut 

butter. WIC served approximately 4.6 million children, 2 million infants, 

and 2 million women in 2013.31

The Food and Nutrition Service administers other programs that 

provide healthy food to children, including the National School 

Lunch Program, the School Breakfast Program, the Child and 

Adult Care Food Program, the Summer Food Service Program, 

the Fresh Fruit and Vegetable Program, and the Special Milk 

Program. These programs are administered by state agencies and 

help fight hunger and obesity by reimbursing organizations such as 

schools, child care centers, and afterschool programs for providing 

healthy meals to children.32 The National School Lunch Program operates in about 100,000 schools and child care institutions. It provided nutritionally balanced low-cost or free lunches to about 30 million 

children each school day in 2012.33 The School Breakfast Program 

also operates in schools and child care institutions. Breakfasts served 

meet federal requirements, and eligible children are offered free or 

reduced-price breakfasts. In 2012, nearly 13 million children participated daily; of those, more than 10 million received their meals at a 

reduced price or for free.34
Child Health USA 2014 Special Features 110

Endnotes

1. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. About Us. Available 

at: http://mchb.hrsa.gov/about/index.html. Accessed September 16, 2014. 

2. U.S. Department of Health and Human Services, Health Resources and 

Services Administration, Maternal and Child Health. Title V Maternal and Child 

Health Services Block Grant Program. Available at: http://mchb.hrsa.gov/

programs/titlevgrants/index.html. Accessed September 16, 2014. 

3. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health. Title V Information System: 

Data Summary Report for Number of Individuals Served by Title V by Class 

of Individuals. Available at: https://mchdata.hrsa.gov/tvisreports/special/special_prgsch04_result.aspx. Accessed September 16, 2014. 

4. U.S. Department of Health and Human Services, Health Resources and 

Services Administration, Maternal and Child Health Bureau. Healthy Start. 

Available at: http://mchb.hrsa.gov/programs/healthystart/. Accessed September 22, 2014. 

5. Morse SB, Zheng H, Tang Y, Roth J. Early school-age outcomes of late 

preterm infants. Pediatrics. April 1, 2009;123(4):e622–e629. Available at: 

http://pediatrics.aappublications.org.ezproxyhhs.nihlibrary.nih.gov/content/123/4/e622.long. Accessed September 22, 2014. 

6. Zwicker JG, Harris SR. Quality of life of formerly preterm and very low 

birth weight infants from preschool age to adulthood: a systematic review. 

Pediatrics. February 2008;121(2): e366–e376. Available at: http://pediatrics.

aappublications.org.ezproxyhhs.nihlibrary.nih.gov/content/121/2/e366.long. 

Accessed: September 22, 2014. 

7. Ment LR, Kesler S, Vohr B, et al. Longitudinal brain volume changes in 

preterm and term control subjects during late childhood and adolescence. 

Pediatrics. February 2009;123(2):503–511. Available at: http://pediatrics.

aappublications.org.ezproxyhhs.nihlibrary.nih.gov/content/123/2/503.long. 

Accessed September 22, 2014.

8. Hack M. Young adult outcomes of very-low-birth-weight children. Seminars 

in Fetal & Neonatal Medicine. April 2006;11(2):127–137. Available at: http://

www.sciencedirect.com.ezproxyhhs.nihlibrary.nih.gov/science/article/pii/

S1744165X05001010. Accessed September 22, 2014.

9. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Home Visiting Grants 

and Grantees. Available at: http://mchb.hrsa.gov/programs/homevisiting/

grants.html. Accessed September 22, 2014. 

10. U.S. Department of Health and Human Services, Office of the Administration 

for Children & Families. Tribal Maternal, Infant, and Early Childhood Home 

Visiting. Available at: http://www.acf.hhs.gov/programs/ecd/home-visiting/

tribal-home-visiting. Accessed February 16, 2015.

11. The White House. Early Learning. Available at: http://www.whitehouse.gov/

issues/education/early-childhood. Accessed September 16, 2014.

12. U.S. Department of Health and Human Services, Health Resources and Services Administration, Health Information Technology. Text 4 Health. Available 

at: http://www.hrsa.gov/healthit/txt4tots/. Accessed September 16, 2014. 

13. U.S. Department of Health and Human Services, Health Resources and 

Services Administration, Maternal and Child Health. Injury and Violence Prevention and Safety Promotion. Available at: http://mchb.hrsa.gov/programs/

injuryprevention/index.html. Accessed September 16, 2014. 

14. Centers for Disease Control and Prevention. Essentials for Childhood Framework: Steps to Create Safe, Stable, and Nurturing Relationships and Environments for all Children. Available at: http://www.cdc.gov/violenceprevention/

childmaltreatment/essentials.html/ Accessed March 2, 2015.

15. Centers for Disease Control and Prevention. Striving to Reduce Youth Violence Everywhere (STRYVE). Available at: http://vetoviolence.cdc.gov/apps/

stryve/. Access March 2, 2015.

16. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health. Adolescent and Young Adult 

Health Program. Available at: http://mchb.hrsa.gov/programs/adolescents/

index.html. Accessed September 16, 2014. 

17. U.S. Department of Health and Human Services, Health Resources and 

Services Administration, Maternal and Child Health. Bullying Prevention 

Campaign. Available at: http://mchb.hrsa.gov/programs/bullying/index.html. 

Accessed September 16, 2014. 

18. U.S. Department of Health and Human Services, Health Resources and Services Administration, Administration for Children and Families. What We Do. 

Available at: http://www.acf.hhs.gov/about/what-we-do. Accessed September 16, 2014.

19. U.S. Department of Health and Human Services, Health Resources and 

Services Administration, Administration for Children and Families. Programs. 

Available at: http://www.acf.hhs.gov/programs. Accessed September 16, 

2014.

20. U.S. Department of Health and Human Services, Health Resources and Services Administration, Administration for Children and Families. Office of Head 

Start: Head Start Services. Available at: http://www.acf.hhs.gov/programs/

ohs/about/head-start. Accessed September 16, 2014.

21. U.S. Department of Health and Human Services, Health Resources and Services Administration, Administration for Children and Families. Office of Head 

Start: What We Do. Available at: http://www.acf.hhs.gov/programs/ohs/about/

what-we-do. Accessed September 16, 2014. 

22. U.S. Department of Health and Human Services. Children’s Health Insurance 

Program (CHIP). Available at: http://www.medicaid.gov/chip/chip-program-information.html. Accessed September 16, 2014. 

23. Rudowitz R, Artiga S, Arguello R. Children’s Health Coverage: Medicaid, 

CHIP, and the ACA. March 26, 2014. Available at: http://kff.org/health-reform/

issue-brief/childrens-health-coverage-medicaid-chip-and-the-aca/. Accessed 

September 16, 2014.

24. U.S. Department of Health and Human Services, Centers for Medicare & 

Medicaid Services. HHS FY2015 Budget in Brief: Children’s Health Insurance 

Program. Available at: http://www.hhs.gov/budget/fy2015-hhs-budget-inbrief/hhs-fy2015budget-in-brief-cms-chip.html. Accessed September 16, 

2014. 

25. Let’s Move. Learn the Facts. Available at: http://www.letsmove.gov/learnfacts/epidemic-childhood-obesity. Accessed September 16, 2014.

26. Let’s Move. White House Task Force on Childhood Obesity Report to the 

President. Available at: http://www.letsmove.gov/white-house-task-forcechildhood-obesity-report-president. Accessed September 16, 2014.

27. Let’s Move. Initiatives. Available at: http://www.letsmove.gov/initiatives. Accessed September 16, 2014.

28. U.S. Department of Agriculture, Food and Nutrition Service. Characteristics 

of Supplemental Nutrition Assistance Program Households: Fiscal Year 2012. 

Nutrition Assistance Report Services, Report No. SNAP-14-CHAR. Available at: http://www.fns.usda.gov/sites/default/files/2012Characteristics.pdf. 

Accessed February 16, 2015.

29. U.S. Department of Agriculture. Supplemental Nutrition Assistance Program 

Participation and Cost. Available at: http://www.fns.usda.gov/sites/default/ 

files/pd/SNAPsummary.pdf. Accessed February 16, 2015.

30. U.S. Department of Agriculture. The Benefits of the Supplemental Nutrition Assistance Program (SNAP). Available at: http://www.fns.usda.gov/sites/default/

files/bc_benefits.pdf. Accessed September 16, 2014.

31. U.S. Department of Agriculture, Food and Nutrition Service. Nutrition Program 

Facts: WIC—The Special Supplemental Nutrition Program for Women, Infants 

and Children. Available at: http://www.fns.usda.gov/sites/default/files/WICFact-Sheet.pdf. Accessed September 16, 2014.

32. U.S. Department of Agriculture, Food and Nutrition Service. School Meals: 

Child Nutrition Programs. Available at: http://www.fns.usda.gov/school-meals/

child-nutrition-programs. Accessed September 16, 2014.

33. U.S. Department of Agriculture. National School Lunch Program. Available at: 

http://www.fns.usda.gov/sites/default/files/NSLPFactSheet.pdf. Accessed 

September 16, 2014.

34. U.S. Department of Agriculture. The School Breakfast Program. Available 

at: http://www.fns.usda.gov/sites/default/files/SBPFactSheet.pdf. Accessed 

September 16, 2014.
Child Health USA 2014 Contributors 111

CONTRIBUTORS

This publication was prepared by the U.S. Department of Health 

and Human Services, Health Resources and Services Administration, 

Maternal and Child Health Bureau.

Federal Contributors within the U.S. Department of

Health and Human Services 

• Administration for Children and Families

• Agency for Healthcare Quality and Research

• Centers for Disease Control and Prevention

• Centers for Medicare and Medicaid Services

Other Federal and Non-Governmental Contributors 

• National Birth Defects Prevention Network 

• The Henry J. Kaiser Family Foundation

• U.S. Census Bureau

• U.S. Department of Agriculture

• U.S. Department of Education

• Institutes of Medicine