Child

Health

USA

2012

January 2013

U.S. Department of Health and Human Services

Health Resources and Services Administration
Child Health USA 2012 is not copyrighted. Readers are free to duplicate and use all or part of the 

information contained in this publication; however, the photographs are copyrighted and permission may be required to reproduce them. It is 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 2012. 

Rockville, Maryland: U.S. Department of Health and Human Services, 2013.

Single copies of this publication are also available at no cost from:

HRSA Information Center

P.O. Box 2910

Merrifield, VA 22116

1-888-ASK-HRSA or ask@hrsa.gov
 CHILD HEALTH USA 2012 CONTENTS 3

PREFACE AND READER’S GUIDE 4

INTRODUCTION 5

POPULATION CHARACTERISTICS 7

Population of Children 8

Children in Poverty 9

Children of Foreign-Born Parents 10

Rural and Urban Children 11

Education 12

Maternal Age 13

Working Mothers and Child Care 14

Children with Special Health Care Needs 15

HEALTH STATUS 16

Health Status - Infants

Low Birth Weight and Very Low Birth Weight 18

Preterm Birth 19

Breastfeeding 20

Pregnancy-Related Mortality 21

Infant Mortality 22

International Infant Mortality 24

Health Status - Children

Vaccine-Preventable Diseases 26

Pediatric HIV and AIDS 27

Hospitalization 28

Abuse and Neglect 29

Child Injury and Mortality 30

Environmental Health 31

Health Status - Adolescents

Sexual Activity and Education 33

Adolescent Childbearing 34

Sexually Transmitted Infections 35

Adolescent and Young Adult HIV and AIDS 36

Physical Activity 37

Sedentary Behaviors 38

Dietary Behaviors 39

Overweight and Obesity 40

Weight Control Behaviors 41

Mental Health 42

Suicide 43

Violence 44

Bullying 45

Cigarette Smoking 46

Substance Abuse 47

Adolescent Mortality 48

Children with Special Health Care Needs 49

HEALTH SERVICES FINANCING AND 

UTILIZATION 50

Health Care Financing 51

Health Care Financing for Children with Special Health 

Care Needs 52

Vaccination Coverage 53

Mental Health Treatment 55

Dental Care 56

Well-Child Visits 57

Health Care Visits 58

Usual Place for Sick Care 59

Emergency Department Utilization 60

Prenatal Care 61

HRSA Serves Children 62

STATE DATA 63

CHIP and Medicaid Enrollment 64

EPDST 65

Health Insurance Status of Children 66

Health Insurance Status Map 67

Birth Outcomes 68

Infant Mortality 69

RURAL AND URBAN DATA 70

Low Birth Weight and Preterm Birth 71

Infant Mortality 72

ENDNOTES 73

REFERENCES 77

CONTRIBUTORS 80
4 CHILD HEALTH USA 2012

PREFACE AND READER’S GUIDE

The Health Resources and Services Administration’s Maternal and Child Health Bureau 

(MCHB) is pleased to present Child Health 

USA 2012, the 22nd annual report on the 

health status and service needs of America’s children. 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 book 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 longterm 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. Data are presented for 

the target population of the Title V Maternal 

and Child Health Block Grant: infants, children, adolescents, children with special health 

care needs, and women of childbearing age. 

Child Health USA 2012 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 book’s succinct format 

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 well-being of children, including poverty, 

education, and child care. The second section, 

entitled Health Status, contains vital statistics 

and health behavior data for the maternal and 

child population. Health Services Financing 

and Utilization, the third section, includes data 

regarding health care financing and utilization 

of selected health services. The final sections, 

State Data and Urban/Rural Data, contain information on selected indicators at those levels. 

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 them. This and 

all editions of Child Health USA since 1999 are 

available online. 

For a complimentary copy of this publication, mail your request to HRSA Information 

Center, P.O. Box 2910, Merrifield, VA 22116. 

You may also call 1-888-ASK-HRSA or email 

ask@hrsa.gov.
 CHILD HEALTH USA 2012 5

INTRODUCTION

The health of the child population is reflective of the overall health of a Nation, and has 

many implications for the Nation’s future as 

these children grow into adults. Physical, mental, 

and emotional health affect virtually every facet 

of life, such as learning, participation in leisure 

activities, and employment. Health habits established in childhood often continue throughout 

the lifespan, and many health problems in childhood, such as obesity and poor oral health, influence health into adulthood. Effective policies 

and programs are important to the establishment 

of healthy habits and the mitigation of risk factors for disease. However, the health and health 

care needs of children change over time, and current data on these issues is critically important 

as policy makers and program planners seek to 

maximize the health of children, now and into 

the future. 

In 2010, nearly one-quarter of the U.S. population was under 18 years of age. The racial and 

ethnic composition of the child population is 

shifting, with a growing population of Hispanics 

and a decline in the representation of non-Hispanic Whites. In addition to race and ethnicity, 

the demographic composition of a population 

can also be characterized by factors such as nativity, poverty, and geographic location. In 2009, 

22.8 percent of children in the United States had 

at least one foreign-born parent. Of all children, 

19.6 percent were U.S.-born with a foreignborn parent or parents, and 3.2 percent were 

themselves foreign-born. In the same year, over 

16 million children under 18 years of age lived 

in households with incomes below 100 percent 

of the U.S. Census Bureau’s poverty threshold 

($22,314 for a family of four in 2010), representing 22.0 percent of all children in the United 

States. Differences in health risks have also been 

observed for children by geographic location. In 

2007, about 82 percent of children lived in urban areas while 18 percent lived in either large 

or small/isolated rural areas. Children in rural areas—particularly those in small or isolated rural 

communities—were more likely to be overweight 

or obese than children living in urban areas.

Using the latest data from the 2009-10 National Survey of Children with Special Health 

Care Needs, Child Health USA also includes 

three pages on the prevalence, health status, and 

health care financing characteristics of 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. In 

2009-10, 15.1 percent of U.S. children aged 18 

and younger had a special health care need, representing 11.2 million children. 

Good health begins before birth. Timely prenatal care is an important preventive strategy that 

can help protect the health of both mother and 

child. In 2010, 73.1 percent of women began 

prenatal care during the first trimester (according to data from areas using the “revised” birth 

certificate). A small proportion of women (6.2 

percent) did not receive prenatal care until the 

third trimester, or did not receive any at all.

Following birth, a variety of preventive or protective factors can affect a child’s health. Vaccination is a preventive health measure that begins 

immediately after birth and protects into adulthood. Currently, there are 12 different vaccines 

recommended by the Centers for Disease Control and Prevention from birth through age 18. 

In 2010, 72.7 percent of children 19-35 months 

of age received each of six vaccines in a modified 

series of recommended vaccines.

Breastfeeding is also an important protective 

factor, and rates have increased steadily since the 

beginning of the last decade. Among those born 

in 2007, 75.0 percent of infants were breastfed 

or fed breastmilk at least once. Although recommended by the American Academy of Pediatrics, 

only 22.4 percent of children were breastfed exclusively (without supplemental food or liquids) 

for the first 6 months of life. Exclusive breastfeeding through the first 6 months of life was more 
6 INTRODUCTION CHILD HEALTH USA 2012

common among older mothers and mothers 

with more than a high-school-level education.

Family characteristics can also play a role in 

the health and well-being of children. In 2010, 

70.8 percent of women with children under 

18 years of age were in the labor force (either 

employed or looking for work). Mothers with 

children under 6 years of age were less likely to 

be in the labor force (63.9 percent) compared 

to those whose youngest child was between the 

ages of 6 and 17 years (76.5 percent). In 2010, 

nearly 50 percent of pre-school aged children 

were cared for by their mother, father, grandparent or some other relative while their mother 

worked. Primary child care arrangements varied 

by poverty status, with 15.4 percent of children 

living in households with incomes below the 

Federal poverty level being cared for in a centerbased setting (e.g., day care) compared to 25.6 

percent of children with household incomes 

above 100 percent of poverty.

Physical activity is another factor that can affect health throughout the lifespan. Results from 

the Youth Risk Behavior Surveillance System 

show that 28.7 percent of high school students 

met currently recommended levels of physical activity in 2011 (1 hour or more of physical activity 

every day, most of which should be moderate- to 

vigorous-intensity aerobic activity). Participation 

in physical activity can be adversely impacted by 

in media use, or “screen time.” The American 

Academy of Pediatrics recommends that parents 

limit children’s daily use of media to 1-2 hours 

per day. Yet, in 2011, 32.4 percent of high school 

students reported watching 3 or more hours of 

television per day on an average school day. 

Child Health USA also presents information 

on risk factors for adverse health outcomes. In 

2010, 11.99 percent of infants were born preterm (or before 37 completed weeks of gestation). Overall, 8.49 percent of babies were born 

at 34 to 36 weeks’ gestation, 1.53 percent were 

born at 32-33 weeks, and 1.96 percent were 

“very preterm” (less than 32 weeks). Babies born 

preterm are at increased risk of immediate and 

long-term complications, as well as mortality.

Violence and neglect are also risk factors for 

poor health, and in 2010, investigations determined that an estimated 695,000 children were 

victims of abuse or neglect, equaling a victimization rate of 9.2 per 1,000 children in the population. Victimization rates were highest among 

young children. Among older children, peer violence is also of concern. In 2011, 12.0 percent of 

high school students reported that they had been 

in a physical fight on school property in the prior 

12 months and 9.4 percent reported that they 

had experienced dating violence — having been 

hit, slapped or physically hurt on purpose—at 

the hands of a boyfriend or girlfriend. 

Obesity is another serious health risk for children—obese children are more likely to have risk 

factors for cardiovascular disease, such as high 

blood pressure, high cholesterol, and Type 2 diabetes. Obese children are also at increased risk of 

obesity in adulthood, which is associated with 

a host of serious health consequences. In 2009-

2010, 14.7 percent of children aged 2-19 years 

were overweight and 16.9 percent were obese.

The health status and health services utilization indicators reported in Child Health USA

can help policymakers and public health officials 

better understand current trends in pediatric 

health and wellness and determine what programs might be needed to further improve the 

public’s health. These indicators can also help 

identify positive health outcomes which may 

allow public health professionals to draw upon 

the experiences of programs that have achieved 

success. The health of our children and adolescents relies on effective public health efforts that 

include providing access to knowledge, skills, and 

tools; providing drug-free alternative activities; 

identifying risk factors and linking people to appropriate services; building community supports; 

and supporting approaches that promote policy 

change, as needed. Such preventive efforts and 

health promotion activities are vital to the continued improvement of the health and well-being 

of America’s children and families.
 CHILD HEALTH USA 2012 POPULATION CHARACTERISTICS 7

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 several 

population characteristics that 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 the poverty 

status of children and their families, child care 

arrangements, and education. 

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 prescription medications and/or 

specialized therapies.
8 POPULATION CHARACTERISTICS CHILD HEALTH USA 2012

POPULATION OF CHILDREN

In 2010, there were more than 74 million 

children under 18 years of age in the United 

States, representing nearly one-quarter of the 

population. Young adults aged 18–24 years 

made up another 9.9 percent of the population, 

while adults aged 25–64 years composed 53.0 

percent of the population, and adults aged 65 

years and older composed 13.0 percent. 

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 28.2 percent in 1980 to 24.0 

percent in 2010. The representation of young 

adults (aged 18–24 years) has also fallen, from 

13.3 percent to 9.9 percent. During this time 

period, the percentage of the population that 

is aged 25–64 years has increased from 47.3 

percent to 53.0 percent, and the percentage that 

is over 65 years has increased from 11.3 percent 

to 13.0 percent. The median age in the United 

States has increased from 30.0 years in 1980 to 

37.2 years in 2010 (data not shown).

The shifting racial/ethnic makeup of the 

child population (under 18 years) 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 23 percent in 2010, while 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 74.3 percent 

in 1980 to 58.3 percent in 2010. After 2000, 

changes in the ways that racial and ethnic data 

were collected limit comparison over time for 

some groups, including Asians and individuals 

of more than one race.

U.S. Population of Children Under Age 18, by Race/Ethnicity, 1980

and 2010

Source (I.2): U.S. Census Bureau

U.S. Population, by Age Group, 1980 and 2010

Source (I.1): U.S. Census Bureau. 

10

20

30

40

50

60

70

80

Two or

More Races**

Native Hawaiian

or Other

Pacific Islander**

American Asian

Indian/

Alaska Native**

Non- Hispanic

Hispanic

Black

NonHispanic

White

Percent of Children

58.3

14.1

23.1

0.9 4.4

* * *

3.6 0.8 0.2

8.8

14.5

74.3

1980

2010

1980 2010

Under 5 Years

7.2% 5-13 Years

13.8% 14-17 Years

7.2%

18-24 Years

13.3%

25-64 Years

47.3%

Under 5 Years

6.5% 5-13 Years

11.9%

25-64 Years

53.0%

14-17 Years

5.5%

18-24

Years

9.9%

65 Years

and Older

11.3%

65 Years

and Older

13.0%

*1980 data not available for this population. **May include Hispanics.
 CHILD HEALTH USA 2012 POPULATION CHARACTERISTICS 9

CHILDREN IN POVERTY

In 2010, more than 16 million children under 18 years of age lived in households with incomes below 100 percent of the U.S. Census 

Bureau’s poverty threshold ($22,314 for a family of four in 2010). This represents 22.0 percent 

of all children in the United States and reflects 

an increase since 2009, when 20.7 percent of 

U.S. children lived in poverty.1 Poverty affects 

many aspects of a child’s life, including living 

conditions, nutrition, and access to health care. 

A number of factors affect poverty status, and 

significant racial/ethnic disparities exist. In 

2010, nearly 40 percent of non-Hispanic Black 

children lived in households with incomes below 100 percent of the poverty threshold, as 

did approximately 35 percent of non-Hispanic 

American Indian/Alaska Native and Hispanic 

children, compared to 12.4 percent of non-Hispanic White children. 

Single-parent families are particularly vulnerable to poverty. In 2010, 46.9 percent of children living in a female-headed household experienced poverty, as did 28.1 percent of children 

living in a male-headed household. Only 11.6 

percent of children living in married-couple 

families lived in poverty (data not shown). The 

proportion of children living in poverty varies by age and family type. In 2010, nearly 60 

percent of children under 5 years of age living 

in female-headed households lived in poverty 

(with incomes below 100 percent of the poverty 

threshold), while the same was true of 41.4 percent of children aged 6–17 years.

A number of Federal programs work to protect the health and well-being of children living in low-income families. 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 2010, the program served free lunch to 17.5 

million children and reduced-price lunch to another 3.0 million children. This represents 65.3 

percent of all lunches served in participating 

schools.2

Children Under Age 18 Living in Households with Incomes Below

100 Percent of the Poverty Threshold,* by Race/Ethnicity, 2010 

Source (I.3): U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement Percent of Children

*The U.S. Census Bureau uses a set of money income thresholds to determine who is in poverty; the poverty threshold

for a family of four was $22,314 in 2010.

Children Under Age 18 Living in Families* with Incomes

Below 100 Percent of the Poverty Threshold,** by Age and

Family Type, 2010

Source (I.3): U.S. Census Bureau, Current Population Survey, Annual Social and

Economic Supplement

*Includes only children who are related to the head of household by birth, marriage, or adoption.

**The U.S. Census Bureau poverty threshold for a family of four was $22,314 in 2010.

10

20

30

40

50

60

Male

Householder

no Wife Present

Female

Householder

no Husband Present

Married-Couple

Families

Total

Percent of Children

25.3

19.6

13.4 10.6

58.2

41.4

31.2

26.3

Under 5 

Years 6-17 

Years

10

20

30

40

50

60

Non-Hispanic

Two or

More Races

NonHispanic

Native Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

22.0

30.9

22.9

12.4 14.1

39.2

35.0 34.9
10 POPULATION CHARACTERISTICS CHILD HEALTH USA 2012

CHILDREN OF FOREIGN-BORN 

PARENTS

The foreign-born population in the United 

States has increased substantially since the 

1970s, largely due to immigration from Asia 

and Latin America. In 2010, 22.8 percent of 

children in the United States had at least one 

foreign-born parent. Of all children, 19.6 percent were U.S.-born with a foreign-born parent 

or parents, and 3.2 percent were themselves foreign-born, with or without a foreign-born parent. Most children (72.9 percent) were nativeborn with native-born parents. 

Children’s poverty status varies with their 

nativity. In 2010, foreign-born children with 

foreign-born parents were most likely to live in 

poverty, with 32.8 percent living in households 

with incomes below 100 percent of the U.S. 

Census Bureau’s poverty threshold ($22,314 

for a family of four in 2010). Another 30.1 percent of these children lived in households with 

family incomes of 100–199 percent of the poverty threshold. Native-born children with native parents were the least likely to experience 

poverty, with 18.1 percent living in households 

with incomes below 100 percent of the poverty 

threshold, and another 19.4 percent living in 

households with incomes of 100–199 percent 

of the poverty threshold. 

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

parents. For instance, native-born children with 

native parents were most likely to have health 

insurance in 2010 (92.4 percent), while foreignborn children with foreign-born parents were 

least likely (71.3 percent). Almost 87 percent of 

native-born children with foreign-born parents 

had health insurance in 2010 (data not shown).

Children Under Age 18, by Nativity of Child and Parent(s)* and

Poverty,** 2010

Source (I.4): U.S. Census Bureau, Current Population Survey, Annual Social and Economic

Supplement

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

indicates that one or both parents were born outside of the United States. **The U.S. Census Bureau

poverty threshold for a family of four was $22,314 in 2010.

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

indicates that one or both parents were born outside of the United States; children could be living with one

or both parents. “Other” includes children with parents whose native status is unknown and foreign-born

children with native parents.

Children Under Age 18, by Nativity of Child and Parent(s),* 2010 

Source (I.4): U.S. Census Bureau, Current Population Survey, Annual Social and Economic

Supplement

32.8 30.1 37.0

18.1 19.4 62.5

26.3 27.0 46.7

20 40 60 80 100

Foreign-Born

Child and Parent

Native Child,

Foreign-Born Parent

Native Child

and Parent

Below 100%

of Poverty

100–199%

of Poverty

200% of Poverty 

and Above

Percent of Children

Native Child,

Foreign-Born Parent

19.6%

Foreign-Born Child

and Parent

3.2%

Other 4.3%

Native Child and Parent

72.9%
 CHILD HEALTH USA 2012 POPULATION CHARACTERISTICS 11

RURAL AND URBAN CHILDREN

Urban and rural children differ in their demographic characteristics, which, in combination with geographic factors, can affect their 

health and access to health care. For instance, 

children living in rural areas are more vulnerable to death from injuries,3

 are more likely to 

use tobacco and other substances,4,5 and are 

more likely to be obese than their urban counterparts.6

 Rural families may also not have the 

same access to health care because health services are not always located nearby.7

 Understanding these potential risks can provide program 

planners and policymakers information that can 

be used to design and target services.

In 2007, 81.7 percent of children lived in urban areas, while about 9 percent lived in either 

large or small/isolated rural areas, respectively 

(data not shown). 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, large rural areas include towns with 

populations of 10,000 to 49,999 persons and 

their surrounding areas, and small/isolated rural 

areas include towns with populations of 2,500 

to 9,999 persons and their surrounding areas.

The demographic distribution of the population of children in small and large rural areas differs from that of urban children in terms of both 

race/ethnicity and family income. Among urban 

children, 53.0 percent were White, compared to 

67.1 percent of children in large rural areas and 

73.8 percent of those in small rural areas. Children living in urban areas were more likely to be 

Non-Hispanic Black and Hispanic than those 

living in both small and large rural areas. American Indian/Alaska Native children were most 

likely to reside in small rural areas, where they 

represent 3.3 percent of the population. 

Children in rural areas were more likely 

than urban children to be living in low-income 

families. Nearly one-quarter of children in both 

small and large rural areas had household incomes below the Federal poverty level (FPL), 

compared to 17.4 percent of urban children. In 

contrast, nearly one-third of urban children had 

household incomes of 400 percent of the FPL 

or more, compared to 17.3 percent of children 

in large rural areas and 14.1 percent of those in 

small rural areas.

Poverty Among Children, by Location, 2007

Source (I.5): 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

Percent of Children

22.3

15.5

9.4

Race/Ethnicity Among Children, by Location, 2007

Source (I.5): 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

Percent of Children 16

32

48

64

80

400% or greater

Federal Poverty Level 

200-399% Federal

Poverty Level

100-199% Federal

Poverty Level

< 100% Federal

Poverty Level

23.7 23.4

17.4 19.8

29.1 25.2

33.5 30.5 33.9

14.1

32.4

17.3 15.3

9.1

67.1

73.8

9.8

53.0

1.3 1.0 4.6 0.5 1.6 3.3 4.4 4.8 3.5

16

32

48

64

80

American Indian/ Multiracial Other

Alaskan Native

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Urban

Large Rural

Small/Isolated Rural

*Federal poverty level was $20,650 for a family of four in 2007

Urban

Large Rural

Small/Isolated Rural
12 POPULATION CHARACTERISTICS CHILD HEALTH USA 2012

EDUCATION

In 2009, nearly 90 percent of 18- to 24-yearolds not enrolled in high school had received a 

high school diploma or alternative credential in 

the United States. Status completion rates8 were 

highest among non-Hispanic Asians and Other 

Pacific Islanders (95.9 percent) and non-Hispanic Whites (93.8 percent). These rates were lower 

in other racial/ethnic groups, including nonHispanic persons of two or more races (89.2 percent), non-Hispanic Blacks (87.1 percent), nonHispanic American Indians/Alaska Natives (82.4 

percent), and Hispanics (76.8 percent). 

Differences are also observed between males 

and females within racial/ethnic groups. Overall, 

females had a higher status completion rate in 

2009 (91.2 percent) than their male counterparts 

(88.3 percent). Among non-Hispanic Whites 

and Blacks, females aged 18-24 who were not enrolled in high school had higher status completion rates than males (data not shown).

The National Assessment Governing Board 

sets three achievement levels – Basic, Proficient, 

and Advanced – for children based on what students should know and be able to do at each grade 

assessed.9 In 2011, 82.5 percent of 4th graders 

and 73.4 percent of 8th graders, respectively, 

were at or above basic proficiency in mathematics, while 67.5 percent of 4th graders and 76.0 

percent of either grade students had achieved at 

or above basic proficiency in reading. 

Among eighth-graders, there was no significant difference in the proportion of students 

achieving at least basic proficiency in mathematics by sex; however, a slightly larger proportion 

of males than females were ranked as proficient 

or advanced in this subject. Larger differences 

were evident in reading: a significantly higher 

proportion of females were ranked as proficient 

and advanced than males (data not shown).

Proficiency* in Mathematics and Reading among Students, by

Grade Level, 2011

Source (I.7): U.S. Department of Education, Institute of Education Sciences, National

Center for Education Statistics, National Assessment of Educational Progress 

School Status Completion* Rates Among Persons Aged 18–24

Years Not Currently Enrolled in High School, by Race/Ethnicity, 2009

 Source (I.6): US Department of Commerce, Census Bureau, Current Population Survey Percent of Population

93.8

76.8

87.1 89.2

82.4

95.9 89.8

*Performance standards are set by the National Assessment Governing Board. Basic, Proficient, and

Advanced Levels each 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, and 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 are available at: http://nces.ed.gov/nationsreportcard/subjectareas.asp. 

*Status completion rates include individuals who are not enrolled in high school and who have earned a high

school diploma or an alternative credential, including a GED certificate.

**Separate estimates were not available for non-Hispanic Asians and Pacific Islanders.

20

40

60

80

100

NonHispanic

Two or

More Races

NonHispanic

American Indian/

Alaska Native

NonHispanic

Asian/Other

Pacific Islander**

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Grade 4

Mathematics

At or Above Proficient Advanced

17.5 82.5

Below Basic 40.5 6.7 At or Above Basic

Grade 4

Reading

At or Above Proficient Advanced

32.5 67.5

Below Basic 33.7 8.0 At or Above Basic

Grade 8

Mathematics

At or Above Proficient Advanced

26.6 73.4

Below Basic 34.7 8.3 At or Above Basic

20 40 60 80 100

Grade 8

Reading

At or Above Proficient Advanced

24.0 76.0

33.5 3.4 Below Basic At or Above Basic

Level of Proficiency
 CHILD HEALTH USA 2012 POPULATION CHARACTERISTICS 13

MATERNAL AGE

In 2010, the birth rate among women aged 

15–44 years was 64.1 births per 1,000—a decrease of 3 percent from 2009 and the lowest 

rate reported in over a decade.10 Although births 

and birth rates declined for women of all race 

and ethnic groups, Hispanic women continued 

to have the highest birth rate, followed by nonHispanic Black women (80.2 and 66.6 births 

per 1,000 women aged 15–44 years, respectively). American Indian/Alaska Native women had 

the lowest birth rate (48.6 per 1,000 women 

aged 15–44 years). Between 2009 and 2010, the 

birth rate also declined in every age group except for 40–44 years, which increased 2 percent 

to the highest level since 1967 (10.2 births per 

1,000 women).10 The birth rates among teenagers aged 15-19 years and young women aged 

20–24 years reached historic lows in 2010 (34.2 

and 90.0 births per 1,000 women, respectively). 

Overall, birth rates were highest among 

women aged 25–29 years (108.3 births per 

1,000 women), followed by those aged 30–34 

years (96.5 births per 1,000 women). However, 

age patterns vary by race/ethnicity. For Hispanic, non-Hispanic Black, and American Indian/

Alaska Native women, birth rates were highest 

among 20- to 24-year-olds (126.1, 119.4, 91.0 

births per 1,000 women, respectively), whereas 

birth rates were highest among 25- to 29-yearolds for non-Hispanic Whites (105.8 per 1,000) 

and among 30- to 34-year-olds for Asian/Pacific 

Islanders (113.6 per 1,000).

Demonstrating the trend toward delayed 

childbearing, average age at first birth rose 3.8 

years between 1970 and 2010 to 25.4 years (data 

not shown).10,11 The proportion of first births to 

women aged 35 and older increased from just 1 

percent in 1970 to 8.2 percent in 2010. Meanwhile, the proportion of first births to teenagers 

(under 20 years) dropped in half between 1970 

and 2010, from 35.6 to 18.9 percent.

Live Births per 1,000 Women by Age and Race/Ethnicity,* 2010 

Source (I.8): Centers for Disease Control and Prevention, National Center for Health Statistics,

National Vital Statistics System

Percent of First Births* by Mother’s Age, 1970-2010

Source (I.8, I.9): Centers for Disease Control and Prevention, National Center for

Health Statistics, National Vital Statistics System

*Percentages may not add up to 100 due to rounding.

18

36

54

72

90

1970 1980 1990 2000 2010*

Percent of First Births

35.6

63.4

70.5

28.2 23.8

71.7

23.1

69.5

Under 20 

Years 20-34 

Years

35 Years

and Older

1.0 1.3 4.5 7.4

18.9

73.0

8.2

Age Group Total Non-Hispanic 

White

Non-Hispanic 

Black

Hispanic American Indian/

Alaska Native*

Asian/Pacific 

Islander*

Total 64.1 58.7 66.6 80.2 48.6 59.2

15-19 Years 34.2 23.5 51.5 55.7 38.7 10.9

20-24 Years 90.0 74.9 119.4 126.1 91.0 42.6

25-29 Years 108.3 105.8 102.5 125.3 74.4 91.5

30-34 Years 96.5 99.9 73.6 96.6 48.4 113.6

35-39 Years 45.9 44.1 36.4 51.7 22.3 62.8

40-44 Years 10.2 9.2 9.2 13.0 5.2 15.1

*Includes Hispanics.
14 POPULATION CHARACTERISTICS CHILD HEALTH USA 2012

WORKING MOTHERS AND CHILD 

CARE

In 2010, 70.8 percent of women with children under 18 years of age were in the labor 

force (either employed or looking for work), 

and 64.4 percent were employed. Among men 

with children, 93.7 percent were in the labor 

force and 86.6 percent were employed. Employment among women varied by a number 

of factors. Of mothers with children from birth 

through age 5, 63.9 percent were in the labor 

force and 57.0 percent were employed. Of 

women whose youngest child was aged 6–17 

years, 76.5 percent were in the labor force and 

70.5 percent were employed. Employed mothers with children birth to age five were more 

likely to be employed part-time than mothers 

with older children (28.9 versus 24.6 percent, 

data not shown). 

Although the proportion of mothers with 

children under the age of 18 who were employed was similar regardless of marital status 

(64.6 percent of married women versus 64.0 

percent of those who were never married, separated, widowed, or divorced), the unemployment rate among those who were married with 

a spouse present was lower (6.3 percent) than 

that among mothers of other marital statuses 

(14.6 percent). Unemployment rates, which 

count individuals who are not employed but are 

available for and actively looking for work, increased between 2009 and 2010 for mothers of 

all marital statuses (data not shown).

In 2010, 48.2 percent of pre-school aged 

children were cared for by their mother, father, 

grandparent or some other relative while their 

mother worked. About one-quarter (23.7 percent) were cared for in a center-based setting, 

e.g., day care, and 13.5 percent were care for 

by a non-relative in a home-based setting, such 

as a family day care provider or nanny. Primary 

child care arrangements varied by poverty status. Among children with household incomes 

below the Federal poverty level, 15.4 percent 

were cared for in a center, compared to 25.6 

percent of children with household incomes 

above poverty (data not shown).

Primary Childcare Arrangements* for Children Aged 0-4 Years with

Employed Mothers, 2010 

Source (I.11): U.S. Census Bureau, Survey of Income and Program Participation

Percent of Parents 20

40

60

80

100

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

Fathers 93.7 94.7

63.9

70.8

76.5

92.8

*The arrangement used for the greatest number of hours per week while the mother worked. **Includes family day care

providers, in-home babysitters, and other nonrelatives providing care in either the child’s or provider’s home. †

Includes children in kindergarten or grade school, self-care, and with no regular arrangement; does not include

school-based activities.

Mothers

Parents’ Labor Force* Participation Rate, by Age of

Youngest Child,** 2010 

Source (I.10): US Department of Labor, Bureau of Labor Statistics

Percent of Children

18.6 19.4

23.7

4.4 5.8

14.1 13.5

*Includes people who are employed and those who are actively seeking work.

**Children include sons, daughters, step-children, and adopted children.

6

12

18

24

30

Other Grandparent Other Relative Center-Based Other Non-Relative** † Mother Father 
 CHILD HEALTH USA 2012 POPULATION CHARACTERISTICS 15

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 prescription medications and/

or specialized therapies.13 In 2009-10, 15.1 percent of U.S. children under the age of 18 had a 

special health care need, representing 11.2 million children. Among households with children 

under the age of 18 years, 18.3 percent have 

one child with special health care needs and 4.7 

percent have two or more children with such 

needs, representing 8.7 million households with 

at least one child who has special health care 

needs (data not shown). 

The prevalence of special health care needs 

in 2009-10 varied by sociodemographic characteristics. Significantly more males than females were reported to have such conditions, 

17.4 percent compared to 12.7 percent, as were 

school-aged children compared to children aged 

0-5 years. Approximately 18 percent of children 

ages 6-11 and 12-17 years were reported to have 

a special health care need, compared to 9.3 percent of those aged 0-5 years. 

The proportion of children with reported 

special health care needs also varied by race 

and ethnicity; non-Hispanic children of multiple races had the highest rate (20.0 percent) 

while non-Hispanic Asian and Native Hawaiian or Other Pacific Islander children had the 

lowest (7.7 and 8.7 percent, respectively). NonHispanic Black children had a slightly higher 

rate (17.5 percent) than non-Hispanic Whites 

(16.3) while Hispanics had a slightly lower rate 

(11.2 percent). No significant difference was 

observed between non-Hispanic Whites and 

American Indian/Alaska Native children. 

Children Under Age 18 with Special Health Care Needs, by

Race/Ethnicity, 2009-10

Source (I.12): 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 with Special Health Care Needs Percent of Children

15.1

Children Under Age 18 with Special Health Care Needs, by

Sex and Age, 2009-10 

Source (I.12): 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 with Special Health Care Needs Percent of Children 6

12

18

24

30

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

Total

17.4

12.7

15.1

9.3 7.8

10.7

13.8

Males

Females 17.7

21.5

16.6

18.4

20.2

17.5

11.2

20.0

16.3 15.6

8.7 7.7

6

12

18

24

30

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
16 CHILD HEALTH USA 2012

HEALTH STATUS

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 

intervention 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 

whenever multiple years of data are available. 

In the following section, mortality, disease, 

injury, 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. Populationbased 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 2012 HEALTH STATUS – INFANTS 17

HEALTH STATUS - INFANTS
18 HEALTH STATUS – INFANTS CHILD HEALTH USA 2012

LOW BIRTH WEIGHT AND VERY 

LOW BIRTH WEIGHT

Infants born at low birth weight (less than 

2,500 grams or 5.5 pounds) and especially very 

low birth weight (less than 1,500 grams or 3.25 

pounds) are more likely to experience physical 

and developmental health problems and to die 

in the first year of life than are infants of normal birth weight. The developmental problems 

of low birth weight infants exact a significant 

emotional and financial toll, often requiring 

increased levels of medical, educational, and 

parental care. 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, or inadequate weight gain during 

pregnancy.14

In 2010, 8.15 percent of infants were born 

at low birth weight, including 1.45 percent 

who were born at very low birth weight. After 

steady increases, rates of low and very low birth 

weight peaked in 2006 at 8.26 and 1.49 percent, respectively, and have declined only slightly since then. Reasons for the increase in low 

birth weight may mirror those behind increases 

in prematurity, including increases in obstetric 

interventions, maternal age, and fertility treatments.15 A rise in multiple births, which increase with maternal age and fertility treatments 

and are at high risk of low birth weight, has 

strongly influenced the rise in low birth weight; 

however, rates of low birth weight have also increased for singleton births.15

Infants born to non-Hispanic Black women 

have the highest rates of low and very low birth 

weight (13.53 and 2.98 percent, respectively), 

levels that are about two or more times greater 

than for infants born to women of other racial 

and ethnic groups. For example, low and very 

low birth weight rates among non-Hispanic 

Whites were 7.14 and 1.16 percent, respectively. Given their heightened risk of death, 

the large disparity in very low birth weight is a 

major contributor to the mortality gap between 

non-Hispanic Black and White infants.16

Low and Very Low Birth Weight, by Maternal Race/Ethnicity,* 2010

Source (II.1): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

*Includes Hispanics. †Separate data for Asians and Native Hawaiians and Other Pacific Islanders

not available. Percent of Live Births

Very Low Birth Weight, <1,500 grams

Low Birth Weight, <2,500 grams

4

8

12

16

20

Asian/ Pacific Islander*†American Indian/

Alaska Native*

Non-Hispanic Hispanic BlackNon-Hispanic White

1.16

7.14

2.98

13.53

1.28

7.61 1.17

8.49

6.97

1.20

Low and Very Low Birth Weight, 1990—2010

Source (II.1, II.2): Centers for Disease Control and Prevention, National Center for

Health Statistics, National Vital Statistics System

2

4

6

8

10

1990 1995 2000 2005 2010

Percent of Live Births

Low Birth Weight <2,500 grams

Very Low Birth Weight <1,500 grams

1.45

8.15
 CHILD HEALTH USA 2012 HEALTH STATUS – INFANTS 19

PRETERM BIRTH

Babies born preterm, before 37 completed 

weeks of gestation, are at increased risk of immediate and long-term complications, as well 

as death. Complications that can occur during 

the newborn period include respiratory distress, 

jaundice, anemia, and infection, while long-term 

complications can include learning and behavioral problems, cerebral palsy, lung problems, 

and vision and hearing loss. As a result of these 

risks, preterm birth is a leading cause of infant 

death and childhood disability. Although the risk 

of complications is greatest among those babies 

who are born the earliest, even those babies born 

“late preterm” (34 to 36 weeks of gestation) are 

more likely than full-term babies to experience 

morbidity and mortality.17

In 2010, 11.99 percent of infants were born 

preterm. Overall, 8.49 percent of babies were 

born at 34 to 36 weeks’ gestation, 1.53 percent 

were born at 32-33 weeks, and 1.96 percent were 

“very preterm” (less than 32 weeks). Between 

1990 and 2006, the preterm birth rate increased 

more than 20 percent, from 10.61 to 12.80 percent, but has declined in the 4 years since 2006 

(data not shown). The greatest trends in preterm 

birth have been observed among the largest category of late preterm infants born at 34 to 36 

weeks’ gestation. For example, late preterm birth 

decreased by 7.1 percent from 2006 to 2010 

(9.14 to 8.49 percent) while very preterm birth 

decreased by only 3.4 percent during the same 

time period (2.04 to 1.97 percent).

The preterm birth rate varies by race and ethnicity. In 2010, 17.12 percent of babies born to 

non-Hispanic Black women were born preterm, 

compared to 10.69 percent of babies born to 

Asian/Pacific Islander women. Among babies 

born to non-Hispanic White women, 10.77 

percent were born preterm, while the same was 

true of 11.79 percent of babies born to Hispanic women and 13.60 percent of babies born 

to American Indian/Alaska Native women. 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.18

Preterm Birth, by Completed Weeks of Gestation, 1990−2010

Source (II.1, II.3): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

Preterm Birth, by Maternal Race/Ethnicity,* 2010

Source (II.1): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

*Includes Hispanics. †Separate data for Asians and Native Hawaiians and Other Pacific Islanders

not available. Percent of Live Births

10.77

17.12

11.79 10.69

13.60

4

8

12

16

20

Asian/Pacific

Islander*†

American Indian/

Alaska Native*

Non-Hispanic Hispanic

Black

Non-Hispanic

White

4

8

12

16

20

1990 1995 2000 2005 2010

Percent of Live Births

Less than 32 weeks

32-33 weeks

34-36 weeks

Total 10.61

7.30

10.99

7.68

11.64

8.22

12.73

9.09

11.99

8.49

1.40

1.92

1.42

1.89

1.49

1.93

1.60

2.03

1.53

1.96
20 HEALTH STATUS – INFANTS CHILD HEALTH USA 2012

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 benefits, such as a decreased risk 

of breast and ovarian cancers.19 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 supplemental 

breastfeeding through at least the first year.20

Breastfeeding practices vary considerably by 

a number of factors including maternal age, 

maternal education, household income, and 

race/ethnicity.21 Among infants born in 2007, 

75.0 percent were breastfed or fed breastmilk 

at least once. While this represents a substantial increase in breastfeeding initiation over 

the past 25 years, the overall prevalence of any 

breastfeeding for 6 months and the prevalence 

of exclusive breastfeeding for 6 months remain 

below national objectives.22 Less than half (43.0 

percent) of infants born in 2007 were breastfed 

for 6 months and only 22.4 percent were exclusively breastfed.

Children born to mothers aged 30 years or 

older were the most likely to have been breastfed 

(79.3 percent), while children born to mothers 

aged 20 years or younger were the least likely to 

(59.7 percent). A similar pattern exists for exclusive breastfeeding, as 27.1 percent of children 

born to mothers aged 30 years or older were 

exclusively breastfed for 6 months compared to 

10.7 percent of children born to mothers aged 

20 years or less. Increased maternal education 

is also associated with successful breastfeeding 

practices. Mothers who had graduated from college were more likely to both initiate breastfeeding and to breastfeed for 6 months exclusively 

than those with less education.

Breastfeeding Among Children Born in 2007, by Maternal Age

and Duration

Source (II.4): Centers for Disease Control and Prevention, National Immunization Survey Percent of Infants 20

40

60

80

100

Total 20 Years or Less 21-29 Years 30 Years or Older

20

40

60

80

100

College

Graduate

Some

College

High School

Graduate

Not a High

School Graduate

Total

*Reported that child was ever breastfed or fed human breastmilk. **Exclusive breastfeeding is defined as

only human breastmilk—no solids, water, or other liquids. 

Breastfeeding Among Children Born in 2007, by Maternal

Education and Duration 

Source (II.4): Centers for Disease Control and Prevention, National Immunization Survey Percent of Infants *Reported that child was ever breastfed or fed human breastmilk. **Exclusive breastfeeding is defined

as only human breastmilk—no solids, water, or other liquids. 

75.0

43.0

22.4

67.0

21.9

37.0

66.1

15.1

31.4

76.5

20.5

41.0

88.3

31.1

59.9

75.0

22.2

10.7

59.7

22.4

43.0

69.7

16.1

33.4

79.3

27.1

50.5

Ever Breastfed* Any at 6 Months Exclusively at 6 Months** Ever Breastfed* Any at 6 Months Exclusively at 6 Months**
 CHILD HEALTH USA 2012 HEALTH STATUS – INFANTS 21

PREGNANCY-RELATED 

MORTALITY

A pregnancy-related death is defined as a 

death which occurs during or within 1 year after 

the end of a pregnancy, from any cause related 

to or aggravated by the pregnancy or its management, but not from accidental or incidental 

causes such as injury.23 This definition includes 

more deaths than the traditional definition of 

maternal mortality, which counts pregnancy-related deaths only up to 42 days after the end of 

pregnancy. Although maternal mortality in the 

United States declined dramatically over the last 

century, this trend has reversed somewhat in the 

last several decades, and racial and ethnic disparities in both maternal and pregnancy-related 

mortality persist.24,25,26

In 2006-2007, the latest years for which 

data are available, a total of 1,294 deaths were 

found to be pregnancy-related (15.1 deaths 

per 100,000 live births). This represents a substantial increase from 1987 levels of 7.2 pregnancy-related deaths per 100,000 live births.26

However, the extent to which this increase 

may reflect improved identification and coding of pregnancy-related deaths is unclear.25 The 

pregnancy-related mortality ratio among Black 

women was approximately 3.2 times the rate for 

White women in 2006-2007 (34.8 versus 11.0 

per 100,000), a disparity that has remained relatively constant. The pregnancy-related mortality 

ratio also increased with age. Women aged 35-

39 years were more than twice as likely to die 

from pregnancy-related causes as women aged 

20-24; for women older than 39 years, the risk 

increased five-fold (data not shown).25

Some of the most common causes of pregnancy-related death in 2006−2007 were cardiovascular disease (13.5%), diseases of the heart 

muscle (cardiomyopathy, 12.6%), uncontrolled 

bleeding (hemorrhage, 11.9%), and non-cardiovascular medical conditions (11.8%). In 

1987−1990, hemorrhage was the leading cause 

of pregnancy-related deaths (29%); hypertensive 

disorders of pregnancy, including preeclampsia 

and eclampsia, accounted for almost 18 percent 

of pregnancy-related deaths, compared to 11.1 

percent in 2006-2007.23,26

Pregnancy-Related Mortality Ratios, by Race, 2006–2007

Source (II.5): Centers for Disease Control and Prevention, National Center for Chronic

Disease Prevention and Health Promotion, Pregnancy Mortality Surveillance System

Leading Causes of Pregnancy-Related Deaths,* 2006–2007

Source (II.5): Centers for Disease Control and Prevention, National Center for Chronic

Disease Prevention and Health Promotion, Pregnancy Mortality Surveillance System

*The cause of death was unknown for 5.6% of all pregnancy-related deaths.

Deaths per 100,000 live births

15.1

11.0

15.7

34.8

8

16

24

32

40

Total White Black Other 4 8 12 16 20

Anesthesia Complications

Cerebrovascular

Accidents (Stroke)

Amniotic Fluid Embolism

Thrombotic Pulmonary

Embolism (Blood Clot in Lung)

Infection/Sepsis

Hypertensive Disorders

of Pregnancy

Non-Cardiovascular

Diseases

Hemorrhage

(Uncontrolled Bleeding)

Cardiomyopathy (Heart

Muscle Diseases)

Cardiovascular Disease 13.5

12.6

11.9

11.8

11.1

11.1

10.9

5.6

5.3

0.6

Percent of Pregnancy-Related Deaths
22 HEALTH STATUS – INFANTS CHILD HEALTH USA 2012

INFANT MORTALITY

In 2010, 24,586 infants died before their first 

birthday, reflecting an infant mortality rate of 

6.15 deaths per 1,000 live births. This represents 

a decrease of 3.8 percent from the 2009 rate (6.39 

deaths per 1,000 live births) and 10.5 percent 

from the 2005 rate (6.87 per 1,000 live births). 

Currently, about two-thirds of infant deaths in 

the United States occur before 28 days (neonatal 

mortality: 4.05 per 1,000 live births), with the 

remaining third occurring in the postneonatal 

period between 28 days and under 1 year (2.10 

per 1,000 live births). Neonatal mortality is generally related to short gestation and low birth 

weight, maternal complications of pregnancy, 

and congenital malformations, while postneonatal mortality is generally related to Sudden Infant 

Death Syndrome (SIDS), congenital malformations, and unintentional injuries.27 In 2010, the 

leading causes of infant mortality were congenital 

malformations, followed by disorders related to 

short gestation and low birth weight, and SIDS.28

With the exception of 2000 to 2005, infant 

mortality had been consistently declining at least 

every few years since it was first assessed in 1915. 

The substantial infant mortality decline over the 

20th century has been attributed to economic 

growth, improved nutrition, and new sanitary 

measures, as well as advances in clinical medicine 

and access to care.29,30 Infant mortality declines 

in the 1990s were aided particularly by the approval of synthetic surfactants to reduce the severity of respiratory distress syndrome (RDS), a 

common affliction of preterm infants, and the 

recommendation that infants be placed on their 

backs to sleep to prevent Sudden Infant Death 

Syndrome (SIDS). The lack of progress between 

2000 and 2005 has been attributed to increases 

in preterm birth,31 which have begun to decline 

in the last several years, perhaps due to practicebased efforts to reduce preterm deliveries that are 

not medically necessary.32

Infant, Neonatal, and Postneonatal Mortality Rates,* 1915-2010** Source (II.6, II.7, II.8): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital

Statistics System

6.15

4.05

2.10

Rate Per 1,000 Live Births

Postneonatal

Neonatal

Infant

20

40

60

80

100

1915 1925 1935 1945 1955 1965 1975 1985 1995 2005 2010

*Infant deaths are under 1 year; neonatal deaths are under 28 days; postneonatal deaths are between 28 days and under 1 year.

**Data from 1915-1932 are a subset from states with birth registration, which became 100% by 1933.
 CHILD HEALTH USA 2012 HEALTH STATUS – INFANTS 23

Despite improvements in infant mortality 

over time, disparities by race and ethnicity persist. Due to inconsistencies in the reporting of 

race and ethnicity on the birth and death certificate, infant mortality rates by race and ethnicity are more accurately assessed from maternal 

race and ethnicity, which is achieved by linking 

infant death certificates to their corresponding birth certificates. In 2008, the latest year 

for which linked data are available, the infant 

mortality rate was highest for infants of nonHispanic Black mothers (12.67 per 1,000 live 

births)—a rate 2.3 times that of non-Hispanic 

Whites (5.52 per 1,000). Infant mortality was 

also higher among infants born to American 

Indian/Alaska Native and Puerto Rican mothers (8.42 and 7.29 per 1,000, respectively). 

Although infant mortality was lowest among 

Asian/Pacific Islanders (4.51 per 1,000), there 

is considerable variability within this population and higher infant mortality rates have been 

shown among Native Hawaiians.33 

Similar to overall infant mortality, neonatal 

mortality was highest among infants of non-Hispanic Black mothers (8.28 per 1,000), followed 

by Puerto Rican and American Indian/Alaska 

Native mothers (4.98 and 4.18 per 1,000, respectively). Postneonatal mortality was more than 

twice as high for both non-Hispanic black and 

American Indian/Alaska Native mothers (4.39 

and 4.24 per 1,000, respectively) than for nonHispanic Whites (2.02 per 1,000). Consistent 

with these patterns in the timing of excess infant 

mortality, the majority of the infant mortality 

disparity for non-Hispanic Blacks compared to 

non-Hispanic Whites is due to causes related to 

prematurity and, to a lesser extent, SIDS, congenital malformations, and injury.34,35 The American Indian/Alaska Native infant mortality gap is 

mostly explained by SIDS, congenital malformations, prematurity, and injury while the excess 

among Puerto Rican mothers is almost entirely 

related to prematurity.34,35 

Infant, Neonatal, and Postneonatal Mortality Rates,* by Race/Ethnicity, 2008

Source (II.9): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital

Statistics System

*Infant deaths are under 1 year; neonatal deaths are under 28 days; postneonatal deaths are between 28 days and under 1 year.

**Includes Hispanics

Neonatal

Postneonatal

3

6

9

12

15

Rate Per 1,000 Live Births

6.61

4.29

2.32

8.28

4.51

4.24

4.18 3.76

1.83

3.78 3.23

4.98 1.62

2.30

1.80

1.43

4.39

5.52

3.08

5.59 5.58

4.85

7.29

3.50

2.02

8.42

12.67

3.19

1.57

4.76

3.76

2.11

5.87

Other and

Unknown

Origin

Central

and

South

American

Puerto Cuban

Rican

Asian/ Hispanic Mexican 

Pacific

Islander**

American

Indian/

Alaska

Native** 

NonHispanic

Black

NonHispanic

White

Total

Infant
24 HEALTH STATUS – INFANTS CHILD HEALTH USA 2012

INTERNATIONAL INFANT 

MORTALITY

In 2008, the U.S. infant mortality rate (6.6 

infant deaths per 1,000 live births) was higher 

than the rate for many other industrialized nations. Differences in infant mortality rates among 

industrialized nations may reflect variation in the 

definition, measurement, and reporting of fetal 

and infant deaths. However, recent analyses of 

the differences in gestational age-specific infant 

mortality indicate that this disparity is most 

likely related to the high rate of preterm birth 

in the United States.36 Infants born preterm (or 

less than 37 weeks gestation) have higher rates 

of death and disability than infants born at term 

(37 weeks gestation or more).37 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 overall significantly impacts the infant mortality rate. 

In 2008, the United States ranked 28th in 

infant mortality among industrialized nations. 

In comparison, Iceland and Sweden, both with 

infant mortality rates of 2.5 deaths per 1,000 live 

births, were ranked first, followed by Finland and 

Japan, both with a rate of 2.6 deaths per 1,000. 

The United States did not always rank this low; 

in 1960, it ranked 12th, with Iceland, Norway 

and the Netherlands reporting the three lowest 

rates among industrialized nations that year. 

International Infant Mortality Rates and Rankings,* Selected Countries,** 1960 and 2008

Source (II.10): The Organization for Economic Co-operation and Development (OECD)

Country Rank 1960 Rank 2008

Australia 6 21

Austria 20 13

Belgium 18 13

Canada 13 24

Chile 28 29

Czech Republic 5 7

Denmark 9 19

Finland 7 3

France 14 15

Germany 19 11

Greece 21 5

Hungary 24 25

Iceland 1 1

Ireland 16 15

Israel --- 15

Italy 23 8

Japan 17 3

Mexico 27 30

Netherlands 3 15

New Zealand 11 23

Norway 2 5

Poland 25 25

Portugal 26 8

Republic of Korea --- 11

Slovak Republic 15 26

Spain 22 8

Sweden 4 1

Switzerland 8 19

Turkey 29 30

United Kingdom 10 22

United States 12 28

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

**Countries with at least 2.5 million population and listed in the OECD database. 

--- Data not available.
 CHILD HEALTH USA 2012 HEALTH STATUS – CHILDREN 25

HEALTH STATUS - CHILDREN
26 HEALTH STATUS – CHILDREN CHILD HEALTH USA 2012

VACCINE-PREVENTABLE 

DISEASES

The number of reported cases of vaccine-preventable diseases has generally decreased over 

the past several decades. In 2009, there were no 

reported cases of diphtheria, polio, or smallpox 

in the United States, and no cases of tetanus or 

of rubella (German measles) among children 

under 5 years of age. 

From 2008 to 2009, the number of reported 

cases of hepatitis A, measles, and meningococcal 

disease decreased among children under 5 years 

of age. The overall incidence of hepatitis A began dropping dramatically once routine vaccination for children living in high-risk areas was 

recommended beginning in 1996, and in 2005, 

the Centers for Disease Control and Prevention 

(CDC) instituted the recommendation that all 

children be immunized for hepatitis A starting 

at 1 year of age. The latter recommendation was 

made because two-thirds of cases were occurring in States where the vaccine was not currently recommended. 

The number of cases of pertussis (or whooping cough) and mumps among children aged 

0 to 4 years increased between 2008 and 2009 

from 3,468 to 5,189 and from 60 to 141, respectively. According to the CDC, pertussis 

occurs cyclically and decreases in the incidence 

of the disease may not be due to increases in 

immunization rates. The highest reported rate 

occurred among infants under 6 months of age, 

a population that is too young to be fully vaccinated. In 2006, the United States experienced 

a multi-state outbreak of mumps, primarily in 

Midwestern states. In the following 2 years, the 

number of reported cases returned to usual levels; however, beginning in July 2009, another 

outbreak has been documented primarily in 

New York and New Jersey.38 Reported cases of 

hepatitis B and H. influenzae remained relatively unchanged from 2008 to 2009.
 CHILD HEALTH USA 2012 HEALTH STATUS – CHILDREN 27

PEDIATRIC HIV AND AIDS

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. Estimates presented in previous editions of Child Health USA have included the 

estimated numbers and rates of diagnoses of 

HIV infection based on data from 45 areas (40 

States and 5 U.S. dependent areas) that have 

had confidential name-based HIV infection reporting for a sufficient length of time. We are 

now able to present results from 51 areas that 

meet this standard of reporting. 

In 2010, an estimated 219 children younger 

than 13 years of age were diagnosed with HIV, 

and 23 were diagnosed with AIDS. HIV and 

AIDS disproportionately affect racial and ethnic minorities. In 2010, there were four times as 

many diagnoses of HIV infection among NonHispanic Black as compared to Non-Hispanic 

White children, but Non-Hispanic Blacks represented only 15 percent of the total U.S. population in this age group.

The number of pediatric AIDS cases has declined substantially since 1992, when an estimated 961 cases were reported. A major factor 

in this decline is the increasing use of antiretroviral therapy before, during, and after pregnancy to reduce perinatal transmission of HIV 

and the promotion of universal prenatal HIV 

testing. Perinatal transmission accounts for 91 

percent of all AIDS cases among children in 

the United States. Antiretroviral therapy during 

pregnancy can reduce the transmission rate to 

2 percent or less, while without treatment the 

transmission rate is 25 percent.39

Estimated Numbers of Diagnoses of HIV Infection* Reported in

Children Under Age 13, by Race/Ethnicity, 2010

Source (II.12): Centers for Disease Control and Prevention. HIV Surveillance Report, 2010 

Number of Cases

219

143

2

*Includes persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. *United States and 6 dependent areas.

Estimated Number of AIDS Diagnoses in Children Aged 13 Years

and Younger in the U.S.,* by Year of Diagnosis, 1992-2010 

Source (II.12): Centers for Disease Control and Prevention. HIV Surveillance Report, 2010 Number of Diagnoses

0

35

34

0

5

119 75 60 41 36

260

131

709

961

208

540

934

137

355

850

57 40

50 100 150 200 250

Non-Hispanic Multiple Races

Non-Hispanic

Native Hawaiian/

Other Pacific Islander

Asian

American Indian/

Alaska Native

Hispanic

Non-Hispanic Black

Non-Hispanic White

Total

23

200

400

600

800

1,000

1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

14
28 HEALTH STATUS – CHILDREN CHILD HEALTH USA 2012

HOSPITALIZATION

In 2010, there were over 3.0 million hospital discharges among people aged 1‒21 years, 

equaling 3.5 hospital discharges per 100 children, adolescents, and young adults. While 

injuries are the leading cause of death among 

this age group, they were not the most common 

cause of hospitalization. In 2010, diseases of the 

respiratory system, including asthma and pneumonia, were the most common causes of hospitalization among children aged 1‒4 and 5‒9 

years. Among children aged 1‒4 years, diseases 

of the respiratory system accounted for 38.4 

percent of discharges; the same was true for 

26.8 percent of 5- to 9-year-olds. Mental disorders were the most common cause of hospitalization among children aged 10‒14 years (29.0 

percent of discharges) and the second most 

common cause among adolescents aged 15-19 

years (16.6 percent of discharges) and young 

adults aged 20‒21 years (10.3 percent). Among 

adolescents aged 15-19 years and young adults 

aged 20‒21 years, labor and delivery (among 

females) was the most common cause of hospitalization, resulting in 371,000 and 321,000 

discharges, respectively.

Between 1990 and 2010, overall hospital 

discharge rates among children, adolescents and 

young adults aged 1‒14 years did not change 

significantly. However, there was a change in the 

rate for at least one of the most common individual category of discharges: the rate of discharge related to injury and poisoning decreased 

by 40.2 percent over the last two decades.

Major Causes of Hospitalization, by Age, 2010

Source (II.13): Centers for Disease Control and Prevention, National Hospital Discharge Survey

179

321

46

302

227

58

38

36

98

40

39

33

110

110

71

65

50

371

41

46

48

786

418

393

Number of Hospital Discharges (in thousands)

80 160 240 320 400 480 560 640 720 800

Injury and Poisoning

Complications of pregnancy/childbirth

Mental Disorders

Pregnancy/Childbirth

20-21 Years

Complications of pregnancy/childbirth

Injury and Poisoning

Mental Disorders

Pregnancy/Childbirth

15-19 Years

Diseases of the Respiratory System

Diseases of the Digestive System

Injury and Poisoning

Mental Disorders

10-14 Years

Mental Disorders

Injury and Poisoning

Diseases of the Digestive System

Diseases of the Respiratory System

5-9 Years

Disease of the Skin and Subcutaneous Tissue

Endocrine, Nutritional and Metabolic

Diseases, and Immunity Disorders

Injury and Poisoning

Diseases of the Respiratory System

1-4 Years

Injury and Poisoning

Mental Disorders

Diseases of the Respiratory System

Pregnancy/Childbirth

Total
 CHILD HEALTH USA 2012 HEALTH STATUS – CHILDREN 29

ABUSE AND NEGLECT

State child protective services (CPS) agencies received approximately 3.3 million referrals, 

involving an estimated 5.9 million children, alleging abuse or neglect in 2010. Investigations 

determined that an estimated 695,000 unique 

children were victims of abuse or neglect in 

2010, equaling a 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 (17.6 percent), sexual abuse (9.2 

percent), psychological maltreatment (8.1 percent), and medical neglect (2.4 percent). About 

10 percent of victims experienced other types of 

maltreatment including abandonment, threats of 

harm, or congenital drug addiction.

In 2010, children aged 0−3 years accounted 

for 34.0 percent of all victims, with 12.7 percent younger than 1 year of age. About onequarter of victims were between the ages of 4 

and 7 years, 18.7 percent were aged 8−11 years, 

17.3 percent were aged 12−15 years, and 6.2 

percent were aged 16−17 years. Victimization 

was split between the sexes, with boys accounting for 48.5 percent and girls accounting for 

51.2 percent (data not shown). 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.40

The effects of child maltreatment can be serious and long-lasting, ranging from increased 

risk of chronic emotional, behavioral and physical illness41 to delinquency and criminality42 to 

lower levels of socioeconomic achievement.43

Taken together, the lifetime cost per victim of 

nonfatal child maltreatment has been estimated 

at $210,012, while the lifetime cost associated 

with 1 year of all confirmed cases has been estimated at $124 billion.44

Overall, 81.2 percent of perpetrators of abuse 

or neglect were parents of the victim (either alone 

or in conjunction with another person). Additional categories of perpetrators included other 

relatives (6.1 percent), unmarried partners of 

parents (4.4 percent), and professionals such as 

childcare workers (0.4 percent; data not shown). 

Other types of perpetrators included foster parents, friends and neighbors, and legal guardians.

Abuse and Neglect Among Children Under Age 18, by Type of

Maltreatment, 2010

Source (II.14): Administration for Children and Families, National Child Abuse and Neglect

Data System

Percent of Victims

78.3

9.2

8.1

17.6

2.4

10.3

Abuse and Neglect Victims, by Age, 2010

Source (II.14): Administration for Children and Families, National Child Abuse

and Neglect Data System Percent of Victims

10 20 30 40 50 60 70 80

Other

Medical Neglect

Psychological

Maltreatment

Sexual Abuse

Physical Abuse

Neglect < 1 Year

12.7%

2 Years

7.2%

1 Year

7.4%

4-7 Years

23.4%

3 Years

6.7%

8-11 Years

18.7%

12-15 Years

17.3%

16-17 Years

6.2%

Unknown

0.4%
30 HEALTH STATUS – CHILDREN CHILD HEALTH USA 2012

CHILD INJURY AND MORTALITY

In 2010, the mortality rate among children 

aged 1–4 years was 26.5 per 100,000 children 

in that age group, and the rate among children 

aged 5–14 years was 12.9 per 100,000. Only 

the mortality rate for children aged 5–14 years 

declined significantly from 2009 levels, by 1 

death per 100,000 or 7.2 percent.45 However, 

both the 1–4 year and 5–14 year age groups 

experienced significant mortality declines from 

2000, by 17.9 and 28.9 percent, respectively.45,46

These declines may be largely attributed to decreases in unintentional injury,47 which remains 

the leading cause of child death, accounting for 

over 30 percent of all deaths in 2010. Congenital anomalies (or birth defects) were the second 

most common cause of death for 1- to 4-yearolds (3.1 per 100,000) and the third leading 

cause for 5- to 14-year-olds (0.7 per 100,000). 

The rate of cancer death was similar for both age 

groups, about 2 deaths per 100,000, but constituted a greater proportion of deaths among 

children aged 5–14 years (second leading cause) 

compared to 1– to 4-year-olds (fourth leading 

cause) due to their lower overall mortality rate. 

The leading causes of unintentional injury 

also vary by age. In 2009, drowning accounted 

for the largest number of unintentional injury 

deaths among children aged 1–4 years, while motor vehicle accidents was the leading cause among 

children aged 5–14 years (data not shown).48

Child injury and mortality vary greatly by 

race and ethnicity. In 2010, mortality rates 

among children aged 1–14 years were at least 

twice as high among non-Hispanic American 

Indian/Alaska Native and non-Hispanic Black 

children as non-Hispanic Asian/Pacific Islander 

children, who had the lowest rates. For example, 

there were 50.1 and 40.2 deaths per 100,000 

non-Hispanic American Indian/Alaska Native 

and non-Hispanic Black children aged 1–4 

years, respectively, compared to 18.5 deaths per 

100,000 non-Hispanic Asian/Pacific Islander 

children of the same age. Unintentional injury 

death rates are also highest among non-Hispanic American Indian/Alaska Native and non-Hispanic Black children (data not shown).48

Mortality Rates Among Children Aged 1–14, by Race/Ethnicity*

and Age, 2010

Source (II.8): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

*May include Hispanics.

†

Separate estimates for Asians and Native Hawaiians and Other Pacific Islanders were not available.

Mortality Rates Among Children Aged 1–14, by Selected Leading

Cause and Age, 2010

Source (II.8): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

Rate Per 100,000 (Rank)

Rate Per 100,000

5-14 Years

1-4 Years

40.1 31.8

10

20

30

40

50

Asian/Pacific

Islander*†

American Indian/

Alaska Native* 

Non-Hispanic Hispanic

Black

Non-Hispanic

White

5-14 Years

1-4 Years

24.7

8.5

18.1

22.7

12.6

40.2

10.2

24.0

18.5

50.1

6 12 18 24 30

Influenza and

Pneumonia

Heart Disease

Cancer

Homicide

Congenital

Anomalies

Unintentional

Injury

All Causes 26.5

12.9

8.6 (1)

4.0 (1)

3.1 (2)

2.4 (3)

2.1 (4)

2.2 (2)

1.0 (5)

0.5 (6)

0.6 (6)

0.2 (10)

0.6 (5)

0.7 (3)
 CHILD HEALTH USA 2012 HEALTH STATUS – CHILDREN 31

ENVIRONMENTAL HEALTH

Secondhand Smoke (SHS) includes smoke 

from a burning cigarette, cigar or pipe as well as 

smoke that has been exhaled by someone using 

these products. SHS contains more than 7,000 

chemicals, including more than 250 which are 

toxic or known to cause cancer. Exposure to 

SHS among children has been linked to ear infections, increased severity of asthma symptoms, 

respiratory symptoms and infections, and increased risk of Sudden Infant Death Syndrome 

(SIDS).49,50 According to the Surgeon General, 

there is no safe level of SHS exposure for children; even brief periods can be harmful.50

In 2009-2010, 29.9 percent of children aged 

3−11 years and 31.0 percent of children aged 

12−19 years were exposed to SHS, representing 

nearly 5.5 and 4.4 million children, respectively, 

in each age group (data not shown). Children 

were identified as having been exposed to SHS 

if they had a serum cotinine level greater than 

or equal to 0.05 ng/mL and less than or equal 

to 10 ng/mL. Exposure to SHS among children 

aged 3−19 years varied by poverty and race/ethnicity. More than 45 percent of children living 

in households with incomes below 100 percent 

of poverty were exposed to SHS compared to 

17.2 percent of children living in households 

with incomes above 300 percent of poverty. 

Non-Hispanic Black children were most likely 

to have been exposed to SHS (50.2 percent) 

compared to less than 30 percent among children of all other racial/ethnic groups (data not 

shown).

Environmental contaminants to the air, water, food, and soil can adversely affect children’s 

health and development. Children are particularly vulnerable to environmental toxins because they may be exposed to relatively higher 

amounts of contaminants than adults through 

engagement in developmentally-appropriate 

activities, such as putting their hands in their 

mouths or playing on the ground, and because 

their organs are still developing.51,52 One example of a common environmental exposure 

among children is lead, which can cause delays 

in children’s cognitive development and attention deficit disorders. Since lead was removed 

from gasoline, the major source of lead exposure 

is contaminated dust, paint, and soil. There is 

no safe level of lead in blood, but a blood lead 

level of 10 micrograms per deciliter (μg/dL) is 

considered elevated. In 2009-2010, 50 percent 

of children aged 1−5 had lead levels below 1.2 

μg/dL, and 95 percent of children had levels 

below 3.4 μg/dL (data not shown). These levels represented a decline of 66 percent and 72

percent, respectively, from those reported in 

1988-1991.53

Exposure to Secondhand Smoke,* Among Children Aged 3-19 Years, 2009-2010

Source (II.15): Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey Percent of Children

31.2

46.0

31.5

39.8

17.2

*Defined as having a serum cotinine level greater than or equal to 0.05 ng/mL and less than or equal to 10 ng/mL. **Poverty guideline defined by

the U.S. Department of Health and Human Services was $22,050 for a family of four in 2010.

10

20

30

40

50

Total Less than 100% of Poverty 100-199% of Poverty 200-299% of Poverty 300% or More of Poverty
32 CHILD HEALTH USA 2012

HEALTH STATUS - ADOLESCENTS
 CHILD HEALTH USA 2012 HEALTH STATUS – ADOLESCENTS 33

SEXUAL ACTIVITY AND 

EDUCATION

In 2011, 47.4 percent of high school students 

reported having had sexual intercourse at least 

once, while the remaining 52.6 percent were 

abstinent. Sexual activity increased with grade 

level: 32.9 percent of 9th grade students reported 

having had sexual intercourse, compared to 43.8 

percent of 10th graders, 53.2 percent of 11th 

graders and 63.1 percent of 12th graders (data 

not shown). Within each grade, no difference 

was observed between males and females in the 

proportion having had sexual intercourse, with 

the exception of 9th grade, where males were significantly more likely to report having had sexual 

intercourse than females (37.8 versus 27.8 percent). Males were also significantly more likely to 

report having had sexual intercourse for the first 

time before age 13 than females (9.0 versus 3.2 

percent; data not shown).

Contraceptive use also varies significantly by 

sex. Overall, 67.0 percent of males and 53.6 percent of females reported condom use at last intercourse. Use of a hormonal contraceptive (by 

self or partner) was less common than condom 

use and was reported by 16.6 percent of males 

and 30.0 percent of females. Less than 10 percent 

of adolescents used both a condom and a form 

of hormonal contraception during last sexual intercourse. Among females, 15.1 percent reported 

not using any method to prevent pregnancy at 

last sexual intercourse, compared to 10.6 percent 

of males. 

According to data from the National Survey 

of Family Growth, 16 percent of females and 

28 percent of males had their first experience of 

sexual intercourse with someone they had just 

met or with whom they were “just friends” (data 

not shown).54 There were large differences by race 

and ethnicity in the percentage of females whose 

first sex was with someone they were not regularly involved with. Hispanic female teenagers were 

less likely than their non-Hispanic White or nonHispanic Black counterparts to have had first sex 

with someone they had just met (8.7, 16.0, and 

21.0 percent, respectively). There was no significant difference between non-Hispanic Black and 

non-Hispanic White females in the percentage 

who had ‘‘just met’’ their first sexual partner. 

Contraceptive Method Used* Among High School Students Who

Are Currently Sexually Active, by Sex, 2011

Source (II.16): Centers for Disease Control and Prevention, Youth Risk Behavior

Surveillance System

High School Students Who Have Ever Had Sexual Intercourse,

by Sex and Grade Level, 2011 

Source (II.16): Centers for Disease Control and Prevention, Youth Risk Behavior

Surveillance System

*Used during last sexual intercourse by student or their partner. **Hormonal contraceptive refers to birth

control pills, Depo-Provera or other injectable, Nuva Ring or other birth control ring, Implanon or other

implant, or any IUD. Percent of Students

Percent of Students 10

20

30

40

50

60

70

Total 9th Grade 10th Grade 11th Grade 12th Grade

Female

Male

Total

47.4 45.6

27.8

37.8

49.2

32.9

63.1 63.6 62.6

43.8 44.5 43.0

53.2 54.5 51.9

10

20

30

40

50

60

70

Did not use

any Contraceptive

Both a Condom and

Hormonal Contraceptive**

Hormonal

Contraceptive**

Condom

Female

Male

Total 60.2

23.3

53.6

67.0

12.4 9.5

16.6

30.0

6.6

15.1 12.9 10.6
34 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2012

ADOLESCENT CHILDBEARING

In 2010, the birth rate among adolescent 

females aged 15–19 years decreased to 34.2 

per 1,000 females—the lowest rate ever 

recorded. This continues the general decline 

in teen birth rates since the most recent peak 

in 1991, when the rate was 61.8 per 1,000 

females, and represents a decline of 44 percent 

over that period. In 2010, the birth rate among 

adolescents aged 15–17 years was lower than 

for 18– to 19-year-olds (17.3 versus 58.2 births 

per 1,000) and adolescents aged 15–17 years 

experienced larger declines in childbearing from 

the 1991 peak compared with 18– to 19-yearolds (55 versus 38 percent).

Although adolescent birth rates reached 

historic lows for all race and ethnic groups in 

2010, disparities remained. Among adolescents 

aged 15–19 years, Hispanic and non-Hispanic 

Black females had the highest birth rates in 

2010 (55.7 and 51.5 births per 1,000)—rates 

more than five times higher than those of Asian/

Pacific Islander females (10.9 births per 1,000) 

and twice as high as non-Hispanic White 

females (23.5 births per 1,000). American 

Indian/Alaska Native adolescents aged 15–19 

years also had higher birth rates (38.7 births 

per 1,000) than Asian/Pacific Islander and 

non-Hispanic White females. These disparities 

persist for both younger and older adolescents, 

aged 15–17 years and 18–19 years, respectively.

Declines in adolescent childbearing over the 

past two decades have been attributed to delays 

in the age at first intercourse and increased 

use of highly effective contraceptive methods, 

including IUDs or hormonal methods.55 Racial 

and ethnic disparities in the age of sexual debut 

have been eliminated due to delays in sexual 

initiation for non-Hispanic Black and Hispanic 

females compared with non-Hispanic White 

females. However, racial and ethnic disparities 

in contraceptive use persist. In 2006-2010, 

65.7 percent of sexually active non-Hispanic 

White adolescent females used highly effective 

contraceptive methods, compared to 46.5 

percent non-Hispanic Black and 53.7 percent of 

Hispanic adolescent females (data not shown).55

Birth Rates Among Adolescent Females Aged 15–19 Years, by

Race/Ethnicity* and Age, 2010

Source (II.1): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System Live Births per 1,000 Females

23.5

10.0 10.9

27.4

42.6

55.7 51.5

32.3

18.7

85.6

20.1

90.7

66.1

38.7

5.1

Birth Rates Among Adolescent Females Aged 15–19 Years,

1990–2010

Source (II.1, II.2): Centers for Disease Control and Prevention, National Center for

Health Statistics, National Vital Statistics System

20

40

60

80

100

Asian/Pacific

Islander*†

American Indian/

Alaska Native* 

Non-Hispanic Hispanic

Black

Non-Hispanic

White

*May include Hispanics.

†

Separate estimates for Asians and Native Hawaiians and Other Pacific Islanders were not available.

15–19 Years

15–17 Years

18–19 Years

Live Births per 1,000 Females 20

40

60

80

100

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

58.2

34.2

17.3

18–19 Years

15–17 Years

15–19 Years
 CHILD HEALTH USA 2012 HEALTH STATUS – ADOLESCENTS 35

SEXUALLY TRANSMITTED 

INFECTIONS

Sexually transmitted infections (STIs), such 

as chlamydia, gonorrhea, and genital human 

papillomavirus (HPV) can pose serious, longterm health complications for adolescents and 

young adults.56 Although young people aged 

15–24 years represent only one-quarter of the 

sexually experienced population, they acquire 

nearly half of all new STIs.57

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). There 

were 2,049 chlamydial infections per 100,000 

adolescents aged 15-19 years and 2,270 per 

100,000 young adults aged 20-24 years in 2010. 

Gonorrhea was less common, with rates of 410 

and 490 per 100,000 in these age groups, respectively. Rates for both diseases vary by race 

and ethnicity. Among adolescents aged 15-19 

years, the highest rate of chlamydia was reported among non-Hispanic Blacks (4,993 per 

100,000), followed by American Indian/Alaska 

Natives (1,992 per 100,000). Rates of gonorrhea were also highest among these two racial/

ethnic groups for adolescents and young adults. 

Unlike chlamydia and gonorrhea, HPV infections are not required to be reported to the 

CDC; however, persistent infection of specific 

types of HPV can lead to cancer.58 The overall 

prevalence of all types of HPV among females 

aged 14-59 is estimated to be 42.5 percent.59 A 

vaccine for certain types of HPV was approved 

in 2006 for use in females aged 9–26 years and 

licensed in October 2009 for use in males aged 

9-26 years.60 In 2010, 53.0 percent of females 

aged 13–17 years had received at least one dose 

of the three-dose series.61

1,000

2,000

3,000

4,000

5,000

6,000

American Indian/

Alaska Native*†

Asian/

Pacific Islanders*†

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total

Reported Gonorrhea Infections Among Adolescents and Young

Adults, by Age and Race/Ethnicity, 2010

Source (II.17): Centers for Disease Control and Prevention, STD Surveillance System

*Separate estimates for Asians and Native Hawaiians and Other Pacific Islanders were not available. †

May include Hispanics.

*Separate estimates for Asians and Native Hawaiians and Other Pacific Islanders were not available. †

May include Hispanics.

Reported Chlamydia Infections Among Adolescents and Young

Adults, by Age and Race/Ethnicity, 2010

Source (II.17): Centers for Disease Control and Prevention, STD Surveillance System Rate Per 100,000 Population

Rate Per 100,000 Population

20-24 Years

15-19 Years 10.8

11.8

14.7

28.2

4.4

5.9

32.9 33.9

39.3 21.6

42.6 16.2

40.1 31.8

40.8 13.1

22.6 62.4

33.6 40.1

2,270 28.1 15.0 2,049

1,316

1,713

374 662 875

4,993 5,254

630

1,992

2,577

1,000

2,000

3,000

4,000

5,000

6,000

American Indian/

Alaska Native*†

Asian/

Pacific Islanders*†

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total

20-24 Years

15-19 Years

410 72

1,521

1,882

490

116 141 213 43 73 293 397
36 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2012

ADOLESCENT AND YOUNG 

ADULT HIV AND AIDS

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. HIV prevention is a particularly important 

issue for adolescents and young adults, as these 

groups experience the majority of new HIV infections. In 2009, those aged 15−29 accounted 

for 39 percent of all new HIV infections in the 

U.S., while this age group represented 21 percent 

of the U.S. population in 2010.62 Early age at 

sexual initiation, unprotected sex, drug use, older 

sex partners and lack of awareness places adolescents at an increased risk of contracting HIV. 

In 2009, more than 37,000 adolescents and 

young adults between 13−24 years of age were 

living with a diagnosed HIV infection. Between 

2007 and 2010, the rate of diagnosed HIV infection remained stable for younger adolescents 

(aged 13−14 years) while increasing for those 

aged 15−24 years (data not shown). A similar 

pattern by age group was observed for the rate of 

AIDS diagnosis, with rates increasing for those 

aged 15−24 years. In 2009, 11,094 persons aged 

13−24 years were living with an AIDS diagnosis. 

Between 2007 and 2009, the rate of deaths with 

an AIDS diagnosis remained stable for the U.S. 

population as a whole, but increased among persons aged 20−24 years (data not shown). 

Abstaining from sex and drug use is the most 

effective way to avoid HIV infection. Adolescents and young adults can also reduce their 

risks by informing themselves of how to negotiate safer sex, where to get tested for HIV, and 

how to use a condom correctly. The 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 for those older than 16 

years of age and living with HIV infection or 

AIDS or at high risk for HIV.63

1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000

Died with

an AIDS

Diagnosis†

Living with

an AIDS

Diagnosis†

Living with

Diagnosed

HIV Infection†

Diagnosed

with AIDS

Diagnosed with

HIV Infection**

27,000

34

2,232

7,675

52

3

35

531

2,280

491

197

2,791

7,258

1,249

7,155

26,329

13–14 Years

15–19 Years

20–24 Years

Selected Data on HIV* and AIDS Among Adolescents and Young Adults,

by Age, 2009

Source (II.18): Centers for Disease Control and Prevention. HIV Surveillance Report, 2010 

Number of Persons*

*Estimated numbers reflect statistical adjustment for reporting delays and missing risk-factor information, but not for incomplete reporting.

Data for United States and dependent areas. **Estimates for 2010. †

Estimates for 2009.
 CHILD HEALTH USA 2012 HEALTH STATUS – ADOLESCENTS 37

PHYSICAL ACTIVITY

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.64 Data from 

the 2011 Youth Risk Behavior Surveillance System showed that 28.7 percent of high school 

students were physically active for at least 60 

minutes on each of the 7 previous days. This 

represents an increase in adolescent physical activity from the 2009 level of 19.4 percent. 

Overall, 13.8 percent of students did not 

participate in 60 or more minutes of physical 

activity on any day in the preceding week. The 

rate was higher for females (17.7 percent) than 

males (10.0 percent) and among Asian (22.2 

percent), non-Hispanic Black (19.6 percent), 

and Hispanic (15.9 percent) high school students compared to non-Hispanic Whites (11.0 

percent; data not shown).

Participation in recommended levels of 

physical activity varied by 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 seven days than males. Among 9th graders, 

22.2 percent of females achieved recommended 

levels of physical activity, compared to 38.8 percent of their male counterparts. By 12th grade, 

only 14.9 percent of females met the recommended levels compared to 34.9 percent of 

males in the same grade.

In 2011, 51.8 percent of high school students attended physical education (PE) classes 

at least one day per average school week. The 

rate decreased with each grade level: 68.1 percent of 9th grade students attended PE class on 

one or more days in an average week, while the 

same was true for 54.6 percent of 10th graders, 

42.9 percent of 11th graders and 38.5 percent 

of 12th grade students. Overall, only 31.5 percent of high school students attended daily PE 

classes in 2011 (data not shown). 

In 2011, 58.4 percent of high school students reported playing on at least one sports 

team in the past year. This was more common 

among younger adolescents than older adolescents (61.4 percent of 9th graders compared 

to 52.5 percent of 12th graders). Sports participation also varied by sex. Just over one-half 

of adolescent females (52.6 percent) reported 

playing on at least one sports team in the past 

year, compared to 64.0 percent of males. These 

differences increased with age: while 57.1 percent of 9th grade females reported sports participation in 2011, only 44.5 percent of 12th 

grade females did so. Among males, the rates 

of past-year sports team participation declined 

from 65.6 percent among 9th graders to 60.2 

percent among 12th graders (data not shown).

Physical Activity* Among High School Students, by Sex and Grade Level, 2011

Source (II.19): Centers for Disease Control and Prevention, High School Youth Risk Behavior Survey Percent of High School 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. 

Total Male Female

28.7

38.8

18.5

38.3

30.7

22.2

14.9

30.8

17.9

42.6

27.3

18.0

36.2

25.1

34.9

10

20

30

40

50

Total 9th Grade 10th Grade 11th Grade 12th Grade
38 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2012

SEDENTARY BEHAVIORS

The American Academy of Pediatrics recommends that parents limit children’s media time 

to 1−2 hours per day.65 This includes time spent 

watching TV or videos as well as time spent 

playing video games. In 2011, 32.4 percent 

of high school students reported watching 3 

or more hours of television per day on an average school day. There was no significant difference in the proportion of males and females 

who reported this behavior. However, younger 

students, those in 9th grade, were slightly more 

likely to watch 3 or more hours of television 

(33.9 percent) than the oldest students, those 

in 12th grade (30.4 percent; data not shown). 

The proportion of students who reported 

3 or more hours of television watching varied 

significantly by race/ethnicity. Over half (54.6 

percent) of non-Hispanic Black students reported this behavior, while the same was true for 

about one-quarter of non-Hispanic White and 

Asian students (25.6 percent and 26.1 percent, 

respectively), and slightly more than one-third 

of Hispanic (37.8 percent) and non-Hispanic 

American Indian/Alaska Native (36.0 percent) 

students. 

In the same year, nearly one-third (31.1 

percent) of high school students reported using computers for something other than school 

work, such as video or computer games, for 3 or 

more hours per day on an average school day. 

The proportion varied by sex and grade level. 

Overall, males were more likely to report nonschool related computer usage of 3 or more 

hours than females (35.3 percent versus 26.6 

percent) as were 9th grade students (32.5 percent) compared to those in 12th grade (28.8 

percent). Across all grade levels, a greater proportion of males reported 3 or more hours of 

daily non-school related computer use during 

weekdays. Daily computer use also varied by 

race/ethnicity, with non-Hispanic Asians and 

Blacks more likely to report this level of computer use than non-Hispanic White or Hispanic 

students (data not shown).

High School Students Who Used Computers for 3 or More Hours per

Day for Something Other than School Work,* by Sex and Grade, 2011

Source (II.19): Centers for Disease Control and Prevention, High School Youth Risk

Behavior Survey

High School Students Who Watched 3 or More Hours of

Television per Day,* by Race/Ethnicity, 2011

Source (II.19): Centers for Disease Control and Prevention, High School Youth Risk

Behavior Survey

*On an average school day. *On an average school day. Percent of Students

Total

Male Female

10 20 30 40 50 60

Non-Hispanic

Multiple Race

Non-Hispanic Native Hawaiian or Other Pacific Islander

Non-Hispanic Asian

Non-Hispanic American Indian/Alaska Native

Hispanic

Non-Hispanic Black

Non-Hispanic White

Total

10

20

30

40

50

Total 9th Grade 10th Grade 11th Grade 12th Grade 

Percent of Students

32.4

25.6

54.6

37.8

36.0

30.3

33.5

26.1

31.1

35.3

26.6

32.5

35.5

29.5 31.6

36.1

26.7

30.7

36.7

24.6

28.8

32.4

25.0
 CHILD HEALTH USA 2012 HEALTH STATUS – ADOLESCENTS 39

DIETARY BEHAVIORS

The Dietary Guidelines for Americans 2010

recommends eating a variety of nutrient-dense 

foods and beverages while maintaining calorie 

balance to reach and maintain a healthy weight. 

The Guidelines encourage all individuals aged 2 

years and older to consume a variety of fruits 

and vegetables, whole grains, fat-free or low-fat 

milk products, as well as a variety of protein 

foods, including seafood, lean meats and poultry, eggs, beans and peas, soy products, and nuts 

and seeds, while limiting sodium, solid fats, 

added sugars, and refined grains.66

In 2011, 5.7 percent of high school students 

reported that they did not eat any vegetables 

during the past 7 days, while 11.7 percent reported that they did not eat any fruit during 

the past week. Overall, males were more likely 

than females to report no vegetable or fruit consumption in the past week (6.9 percent versus 

4.5 percent and 12.6 percent versus 10.7 percent, respectively; data not shown). The proportion of adolescents who reported neither vegetable nor fruit consumption also varied by race 

and ethnicity. Non-Hispanic White and Asian 

students were generally less likely to report no 

vegetable consumption than non-Hispanic 

Black and Hispanic students. Non-Hispanic 

Blacks were also more likely to report no fruit 

consumption in the past week.

Overall, 15.3 percent of high school students 

reported eating vegetables three or more times 

per day and nearly one-quarter (22.4 percent) 

reported eating fruit or drinking 100% fruit 

juice three or more times per day in the past 

7 days. Males were more likely to report this 

level of fruit and vegetable consumption than 

females; no trends were observed by grade level 

(data not shown).

Because soda, energy drinks, and sports 

drinks are a major source of added sugar for 

Americans, the Guidelines recommend limiting the consumption of such beverages in order 

to lower calorie consumption. In 2011, nearly 

one-fifth (19.0 percent) of high school students 

drank two or more cans, bottles or glasses of 

soda per day during the last 7 days.67 Males were 

more likely than females to consume two or 

more sodas a day (21.8 percent versus 16.1 percent; data not shown). Few racial/ethnic differences were observed, with the notable exception 

of non-Hispanic Asian students, of whom only 

12.4 percent reported consuming this amount 

of soda.
40 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2012

OVERWEIGHT AND OBESITY

Body mass index (BMI) is the ratio of weight 

to height, which is used to define overweight 

and obesity as well as normal weight status and 

underweight. In children, BMI is used in conjunction with age and sex, since both of these 

factors affect body composition. Children who 

fall between the 85th and 94th percentile of 

BMI-for-age are considered overweight, while 

children who are in the 95th percentile or above 

are considered obese; those who fall below the 

5th percentile are considered underweight and 

those between the 5th and 84th percentile are 

considered to be normal weight. In 2009−10, 

14.7 percent of children aged 2−19 years were 

overweight, 16.9 percent were obese, 64.1 percent were normal weight, and 4.3 percent were 

underweight based on measured height and 

weight (data not shown). 

Weight status among children varies by a 

number of factors, including age and sex, race/

ethnicity, and household income. School-aged 

children were more likely to be obese than preschool-aged children: approximately 18 percent 

of children aged 6−11 years and 12−19 years 

were considered to be obese, compared to 11.8 

percent of children aged 2−5 years. 

The prevalence of overweight and obesity 

also varied by race/ethnicity. Nearly one-quarter 

of non-Hispanic Black children were considered to be obese in 2009−10 and another 15 

percent considered to be overweight. Similarly, 

nearly 40 percent of Mexican-American and 

other Hispanic children were either overweight 

or obese. In comparison, approximately 28 

percent of non-Hispanic White children were 

overweight or obese. Racial/ethnic differences 

were particularly pronounced among females: 

between 18-24 percent of non-Hispanic Black, 

Mexican-American, and other Hispanic girls 

were obese, compared to 11.5 percent of their 

non-Hispanic White counterparts. 

Weight Status* Among Children Aged 2-19 Years, by Age

and Sex, 2009-10

Source (II.15): CDC, National Health and Nutrition Examination Survey

Weight Status* Among Children Aged 2-19 Years, by Race/Ethnicity

and Sex, 2009-10 

Source (II.15): CDC, National Health and Nutrition Examination Survey

*Underweight is a BMI-for-age under the 5th percentile, normal weight is a BMI-for-weight between

the 5th and 84th percentile, overweight is a BMI-for-age between the 85th and 94th percentile, and

obesity is a BMI-for-age in the 95th percentile or above; based on parent-reported height and weight.

*Underweight is a BMI-for-age under the 5th percentile, normal weight is a BMI-for-weight between the 5th and

84th percentile, overweight is a BMI-for-age between the 85th and 94th percentile, and obesity is a BMI-for-age

in the 95th percentile or above; based on parent-reported height and weight. 

20 40 60 80 100

12-19

6-11

2-5

12-19

6-11

2-5

12-19

6-11

2-5

Total Males Females

4.9 69.2 14.1 11.8

4.5 62.7 14.7 18.1

4.1 67.0 14.8 14.1

5.0 61.6 13.2 20.3

5.7 71.5 13.3 9.4

3.8 62.7 15.0 18.5

3.4 61.8 14.7 20.1

3.9 64.0 16.4 15.7

4.3 63.6 15.3 16.8

Underweight Normal Weight Overweight Obese Underweight Normal Weight Overweight Obese

20 40 60 80 100

Other Hispanic, Females

Other Hispanic,

Males

Mexican-American, Females

Mexican-American,

Males

Non-Hispanic

Black, Females

Non-Hispanic

Black, Males

Non-Hispanic

White, Females

Non-Hispanic

White, Males 4.5 65.2 13.8 16.5

4.1 70.5 14.0 11.5

4.1 55.3 16.7 23.9

4.0 58.6 19.4 18.1

2.7 60.2 12.9 24.2

4.0 55.8 16.5 23.7

4.2 58.9 14.6 22.3

4.1 56.3 19.3 20.3

Percent of Children Aged 2-19 Years Percent of Children Aged 2-19 Years
 CHILD HEALTH USA 2012 HEALTH STATUS – ADOLESCENTS 41

WEIGHT CONTROL BEHAVIORS

In 2011, 46.0 percent of high school students 

reported that they were trying to lose weight. 

Nearly twice as many adolescent females (61.2 

percent) reported that they were trying to lose 

weight as males (31.6 percent); this ratio persisted across all grade levels (data not shown). 

Non-Hispanic Black students were less likely to 

report trying to lose weight (40.9 percent) than 

non-Hispanic Whites (44.8 percent), and Hispanic students (52.6 percent). Among all racial/

ethnic groups, with the exception of non-Hispanic American Indian/Alaska Native students, 

females were more likely to report trying to lose 

weight than males.

The Youth Risk Behavior Surveillance System asked students about behaviors to lose or 

keep from gaining weight in the 30 days prior to 

the survey: fasting for 24 hours or more, taking 

supplements, including diet pills, powders or 

liquids, and vomiting or taking laxatives. Overall, 12.2 percent, 5.1 percent, and 4.3 percent of 

high school students reported engaging in each 

of these behaviors, respectively. 

The proportion of students reporting each 

of these behaviors was similar across grade 

level; however, significant sex differences were 

observed. For example, more than twice as 

many females reported fasting for 24 hours or 

more than males (17.4 percent compared to 

7.2 percent) and 6.0 percent of females reporting vomiting or taking laxatives, compared to 

2.5 percent of males. The prevalence of weight 

control behaviors also varied by race/ethnicity. 

Non-Hispanic American Indian/Alaska Native 

students were more likely than non-Hispanic 

Black, Asian, and White students to report either fasting for 24 hours or more or vomiting/

taking laxatives (data not shown). 
42 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2012

MENTAL HEALTH

In 2010, 8.0 percent of adolescents aged 

12–17 years, or 1.9 million adolescents, experienced at least one major depressive episode 

(MDE), which is defined as having at least 2 

weeks of a depressed mood or loss of interest 

or pleasure in daily activities, plus a majority of 

specific depression symptoms, such as altered 

sleeping patterns, fatigue, and feelings of worthlessness (data not shown).68 Females were more 

likely than males to experience MDE (11.8 percent versus 4.4 percent). Occurrence of MDE 

increased with age, from 3.3 percent among 

children age 12 years to 10.9 and 10.3 percent 

among children ages 16 and 17, respectively 

(data not shown). 

Among adolescents experiencing MDE in 

2010, over two-thirds (1.3 million) also experienced severe impairment, defined by the degree 

to which activities and roles, such as completing chores at home, going to school or work, 

or maintaining close family relationships, are affected. MDE with severe impairment was more 

common among older adolescents and females 

(data not shown).

In 2010, adolescents aged 12 to 17 with pastyear MDE were more likely than those without 

MDE to have used illicit drugs in the past year 

(37.2 compared to 17.8 percent). Adolescents 

with past-year MDE were also more likely to report daily cigarette and heavy alcohol use in the 

past month compared with those without pastyear MDE. Among adolescents with past-year 

MDE who used illicit drugs, 25.3 percent reported using marijuana or hashish, and 17.0 percent 

reported non-medical use of psychotherapeutics 

such as pain relievers, tranquilizers, stimulants, 

and sedatives. Among adolescents who did not 

experience past-year MDE, the proportion who 

reported using these substances was 12.9 and 6.5 

percent, respectively (data not shown).

*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. †

Heavy Alcohol Use is defined as drinking five or more drinks on

the same occasion on each of 5 or more days in the past 30 days.

*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.

Percent of Adolescents

Occurrence of Major Depressive Episode (MDE)* in the Past

Year Among Adolescents Aged 12–17 Years, by Age and Sex, 2010

Source (II.20): Substance Abuse and Mental Health Service Administration, National

Survey of Drug Use and Health Percent of Adolescents

Substance Use Among Adolescents Aged 12–17 Years, by

Past-Year Major Depressive Episode (MDE)*, 2010

Source (II.20): Substance Abuse and Mental Health Service Administration, National

Survey of Drug Use and Health

8

16

24

32

40

Total Age 12 Age 13 Age 14 Age 15 Age 16 Age 17

3.8 4.2 6.3

2.0 2.1

4.8

11.8

4.4

8.3

15.8

12.1 13.5 15.7

7.3

Male

Female

8

16

24

32

40

Past Month

Heavy Alcohol Use†

Past Month

Daily Cigarette Use

Past Year

Illicit Drug Use**

3.1 1.8 2.5

37.2

17.8

1.6

Past Year MDE

No Past Year MDE
 CHILD HEALTH USA 2012 HEALTH STATUS – ADOLESCENTS 43

SUICIDE

In 2009, the latest year for which mortality 

data were available, suicide was the third leading 

cause of death among persons aged 15−24 years, 

resulting in over 4,300 deaths, for a rate of 10.2 

deaths per 100,000 population. The most common methods used in suicides of adolescents 

and young adults include firearms (45.6 percent), suffocation (38.6 percent), and poisoning 

(8.0 percent).69 

In 2011, data from the Youth Risk Behavior 

Surveillance System showed that 15.8 percent 

of high school students had seriously considered attempting suicide during the 12 months 

prior to the survey. Younger students, those in 

9th and 10th grade, were more likely than the 

oldest students to consider suicide (17.1 and 

16.5 percent, respectively versus 13.6 percent). 

Female students were more likely than males to 

have considered suicide at each grade level, with 

the exception of 11th grade, in which no significant difference by sex was observed.

In the same year, 7.8 percent of high school 

students reported having attempted suicide one 

or more times in the past 12 months, reflecting 

a significant increase since 2009 (6.3 percent). 

Overall, females (9.8 percent) were more likely 

to report at least one suicide attempt than males 

(5.8 percent; data not shown). The proportion 

of students who reported having attempted 

suicide also varied by race/ethnicity. Non-Hispanic White students were less likely to report 

attempted suicide (6.2 percent) than students 

of all other racial and ethnic groups. Female 

students were significantly more likely to report 

attempted suicide among all racial and ethnic 

groups except non-Hispanic Blacks and students of more than one race (data not shown).

High School Students Who Attempted Suicide One or More Times in

the Past 12 Months, by Race/Ethnicity, 2011

Source (II.19): Centers for Disease Control and Prevention, Youth Risk Behavior Surveillance

System

High School Students Who Considered Attempting Suicide in

the Past 12 Months, by Grade Level and Sex, 2011

Source (II.19): Centers for Disease Control and Prevention, Youth Risk Behavior

Surveillance System

Percent of Students

Percent of Students 6

12

18

24

30

Total 9th Grade 10th Grade 11th Grade 12th Grade

MaleFemale

Total

15.8

12.5 12.9

21.5

19.3

17.1

11.5

13.6

15.8 16.5

22.3

11.4

15.5 16.7

14.3

4

8

12

16

20

NonHispanic

Multiple

Races

Non-Hispanic

Native

Hawaiian/

Other

Pacific Islander

NonHispanic

American Indian/

Alaska Native

NonHispanic

Asian

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

7.8 8.3

10.2

6.2

14.7

10.8 9.9

11.6
44 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2012

VIOLENCE

 Physical violence among adolescents occurs 

in multiple forms and is a critical public health 

issue in the United States. Instances of violence 

include homicide, which was the second leading 

cause of death among all persons aged 10–24 

years in 2009 (the latest year for which data 

are available).70 For non-Hispanic Blacks aged 

10−24 years, homicide was the leading cause of 

death, among Hispanics it was the second leading cause of death, and among non-Hispanic 

American Indians and Alaska Natives it was the 

third leading cause of death. Among both nonHispanic Whites and Asian/Pacific Islanders it 

was the fourth leading cause of death among 

individuals in this age group (data not shown).70

Data from the Youth Risk Behavior Surveillance System show that, in 2011, 12.0 percent 

of high school students reported being in a 

physical fight on school property during the 

preceding 12 months. Among males, 16.0 percent reported having been in a fight; this is more 

than twice the rate reported by females (7.8 

percent). This disparity was most pronounced 

among non-Hispanic Whites, where males were 

almost three times as likely as females to have 

been in a fight (13.8 percent versus 5.6 percent), although significant sex differences were 

observed across all racial/ethnic groups. Overall, 

non-Hispanic Asian students were least likely to 

report having been in a fight (6.2 percent) while 

over one-fifth of non-Hispanic Native Hawaiian or Other Pacific Islander students reported 

having been in a physical fight on school property in the past year.

Approximately 1 out of every 10 high school 

students reported that they were hit, slapped, or 

physically hurt on purpose by their boyfriend or 

girlfriend at least once in the past 12 months. 

The prevalence of dating violence was similar 

across grade levels and among males and females.

High School Students Experiencing Dating Violence* in

the Past 12 Months, by Grade Level and Sex, 2011

Source (II.19): Centers for Disease Control and Prevention, Youth Risk

Behavior Surveillance System

High School Students in a Physical Fight on School Property in the

Past 12 Months, by Race/Ethnicity* and Sex, 2011

Source (II.19): Centers for Disease Control and Prevention, Youth Risk Behavior Surveillance

System

*Dating violence was defined as having been hit, slapped, or physically hurt on purpose by a

boyfriend or girlfriend.

Percent of Students *Sex-specific data for American Indian/Alaska Natives and Native Hawaiian/Other Pacific Islanders do not meet

standards for reliability or precision.

6

12

18

24

30

NonHispanic

Multiple

Races

Non-Hispanic

Native

Hawaiian/

Other

Pacific Islander

NonHispanic

American Indian/

Alaska Native

NonHispanic

Asian

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Male

Female

Total

12.0

16.0

13.8

5.6

7.8

9.9 10.0

1.7

6.2

16.4

13.1

19.6

12.0

20.9

* *

14.4

9.0

19.4

16.6

14.4

19.0

Percent of Students

9.4 9.5 9.3

7.5 7.4 7.6

9.6 9.5 9.8 10.3 10.3 10.7 10.0 11.2

9.3 7.7

16.0

6

12

18

24

30

Total 9th Grade 10th Grade 11th Grade 12th Grade

Total 

Male

Female
 CHILD HEALTH USA 2012 HEALTH STATUS – ADOLESCENTS 45

BULLYING

Bullying is defined as unwanted, aggressive 

behavior among school-aged children that may 

be repeated, or has the potential to 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. 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 (LGBT) 

youth, youth with disabilities, and socially isolated youth may be at higher risk. 

Being bullied has been associated with a wide 

range of both 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. Cyberbullying, or bullying that takes place using 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, 

and can be very difficult to delete after posting.71 

In 2011, 20.1 percent of high school students 

reported that they had been bullied on school 

property in the past year. The likelihood of a 

child being bullied varied by a number of factors including sex and grade level. Females were 

more likely than males to have been bullied overall (22.0 percent versus 18.2 percent) while 24.2 

percent of 9th graders reported being bullied 

compared to 15.2 percent of 12th graders. 

Approximately one in six (16.2 percent) of 

high school students reported having been electronically bullied through email, chat rooms, 

instant messaging, Web sites or texting in the 

prior 12 months. Females were approximately 

twice as likely as males to have been electronically bullied at all grade levels (data not shown). 

Females were also more likely than males to 

have been electronically bullied across all racial 

and ethnic groups for whom race- and sex-specific data are available. 

High School Students Who Were Electronically Bullied in the

Past Year, by Sex and Race/Ethnicity, 2011

Source (II.19): Centers for Disease Control and Prevention, High School Youth Risk Behavior Survey

*Sex-specific data for non-Hispanic Native Hawaiian/Other Pacific Islanders do not

meet standards for reliability or precision.

High School Students Who Were Bullied on School Property

in the Past Year, by Sex and Grade, 2011

Source (II.19): Centers for Disease Control and Prevention, High School Youth

Risk Behavior Survey

Percent of Students

11.0 9.3

13.6

8.9

22.1

6.9

16.2

Percent of Students

27.1

24.6

20.4 22.0 22.4 24.2

18.2

21.5 20.1

8

16

24

32

40

Total 9th Grade 10th Grade 11th Grade 12th Grade

17.1 17.5 16.7 17.2 15.2 13.4

Total 

MaleFemale

8

16

24

32

40

Non-Hispanic

Native

Hawaiian/

Other Pacific

Islander

NonHispanic

Multiple

Race

NonHispanic

Asian

Non-Hispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

10.8

25.9

18.6

11.8

18.0

9.5

16.2

23.6

18.3

14.4

11.2 12.0

21.0

29.6

19.6

* *

Total 

MaleFemale
46 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2012

CIGARETTE SMOKING

In 2012, a report by the Surgeon General 

found that the majority of cigarette use begins 

in adolescence or young adulthood and reported that, “of every three young smokers, only one 

will quit, and one of those remaining smokers 

will die from tobacco-related causes.”72

The percent of teens who report smoking 

in the past month began a rapid increase in 

the early 1990s, with the rates among 8th and 

10th grade students reaching a peak in 1996 

(at 21.0 and 30.4 percent, respectively), and 

the rate among 12th grade students peaking a 

year later (36.5 percent). After years of steady 

progress, declines in the use of cigarettes by adolescents and young adults have decelerated. In 

2009, cigarette smoking among adolescents decreased to 12.7 percent, according to the annual 

Monitoring the Future study.73 Between 2009 

and 2010, the overall percentage of high school 

students who reported smoking cigarettes in the 

past 30 days rose from 12.7 percent in 2009 to 

12.8 percent, but this change was not statistically significant. In 2011, declines in past-month 

smoking occurred among students in all three 

grades to 6.1 percent of 8th, 11.8 percent of 

10th and 18.7 percent of 12th grade students. 

The decline between 2010 and 2011 was statistically significant for 10th grade students only. 

Despite a population-wide decline, certain 

subgroups of adolescents remain significantly 

more likely to smoke than their peers. Students who plan to complete a four-year college 

education are less than half as likely to smoke 

than students who either do not plan to attend 

college or plan to attend college for less than 

four years. This difference exists at each grade 

level. With regard to race and ethnicity, nonHispanic White students are the most likely to 

report smoking in the past month, followed by 

Hispanic students (data not shown).

Cigarette Use Among Students in the Past 30 Days, by College

Plans, 2010–2011

Source (II.21): National Institutes of Health, National Institute on Drug Abuse,

Monitoring the Future Study

Cigarette Use Among Students in the Past 30 Days, by Grade,

1991–2011

Source (II.21): National Institutes of Health, National Institute on Drug Abuse,

Monitoring the Future Study

10

20

30

40

6.1

11.8

18.7

Percent of Students

Percent of Students

8th Grade

10th Grade

12th Grade

10

20

30

40

None or Under Four Years of College Complete 4 Years of College

18.2

28.5

32.2

5.1

9.9

15.6

8th Grade 10th Grade 12th Grade

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011
 CHILD HEALTH USA 2012 HEALTH STATUS – ADOLESCENTS 47

SUBSTANCE ABUSE

In 2010, the percent of adolescents aged 

12–17 years who reported using illicit drugs in 

the past month was 10.1, similar to the 2009 

estimate (10.0). Illicit drug use varied by age, 

with 4.0 percent of youth aged 12–13 years 

reporting drug use in the past month, compared 

to 9.3 percent of youth aged 14–15 years and 

16.6 percent of youth aged 16–17 years (data 

not shown). There was also variation by race/

ethnicity, with rates ranging from 4.1 percent 

among non-Hispanic Asian youth to 12.7 

percent among non-Hispanic American Indian/

Alaska Native youth. Rates for non-Hispanic 

White, non-Hispanic Black, and Hispanic 

youth were 9.7 percent, 10.8 percent, and 11.8 

percent, respectively (data not shown). 

Marijuana is consistently the most commonly 

used illicit drug among adolescents overall, 

with 7.4 percent reporting past-month use in 

2010. This was followed by nonmedical use 

of prescription-type psychotherapeutics, such 

as pain relievers, tranquilizers, stimulants, and 

sedatives (3.0 percent). Differences by age were 

observed, however, with younger adolescents 

aged 12-13 years being more likely to report 

non-medical use of psychotherapeutic drugs.

Illicit drug use is associated with other 

health risk behaviors. In 2010, 52.9 percent 

of adolescents who reported cigarette use in 

the past month also reported illicit drug use, 

compared to only 6.2 percent of adolescents 

who did not report smoking. Adolescents who 

reported alcohol use in the past month were also 

more likely to use illicit drugs than adolescents 

who did not report alcohol use: 70.6 percent of 

heavy drinkers (i.e., adolescents who consumed 

five or more drinks on the same occasion on 

each of 5 or more days in the past 30 days), also 

used illicit drugs.

Alcohol continues to be the most commonly 

used drug among adolescents, with 13.6 

percent reporting past-month use in 2010. The 

prevalence of alcohol use among males and 

females was similar: 13.7 and 13.5 percent, 

respectively). Greater variation was evident 

by race/ethnicity, with rates ranging from 4.8 

percent among Asian youth to 14.9 percent of 

non-Hispanic White youth (data not shown).

In 2010, 30.1 percent of adolescents 

perceived smoking marijuana once a month to 

be a great risk, while 49.5 percent perceived the 

same risk regarding cocaine use. Smoking one 

or more packs of cigarettes a day was considered 

a great risk by 65.5 percent of adolescents. 

Drinking five or more drinks once or twice per 

week was considered a great risk by 40.8 percent 

of adolescents (data not shown).

While 14.3 percent of adolescents were 

approached by someone selling drugs in the 

past month, nearly 50 percent reported that 

marijuana would be fairly or very easy to obtain; 

22.1 percent reported the same for crack, 19.0 

percent for cocaine, 12.9 percent for LSD, and 

11.6 percent for heroin (data not shown).

Past Month Drug Use Among Adolescents Aged 12-17 Years, by Drug Type, 2010

Source (II.22): Substance Abuse and Mental Health Service Administration, National Survey of Drug Use and Health

*Includes non-medical use of pain relievers, sedatives, stimulants, and tranquilizers; does not include over-the-counter substances.

**Includes LSD, PCP, and Ecstasy. Percent of Children Aged 12-17 Years

10.1

13.6

7.4

1.1

3.0

0.9

4

8

12

16

20

Nonmedical Use Inhalants Hallucinogens**

of Psychotherapeutics*

Alcohol Any Illicit Drug Marijuana
48 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2012

ADOLESCENT MORTALITY

In 2010, the latest year for which data are 

available, there were 10,887 deaths among adolescents aged 15–19 years, representing a rate of 

49.4 per 100,000.74 The rate of adolescent mortality declined by 7.7 percent from the previous 

year and 26.4 percent from 2000. This decline 

may be largely attributable to decreases in unintentional injury,75 which remains the leading 

cause of adolescent death, followed by homicide, suicide, cancer, and heart disease. 

The mortality rate of adolescent males aged 

15–19 was more than twice that of females in 

2010 (69.6 versus 28.1 per 100,000, respectively). This disparity is largely due to higher rates 

of unintentional injury, homicide, and suicide 

death among male adolescents. For example, 

homicide death rates were more than five times 

higher among males than females (14.0 versus 

2.3 per 100,000). Homicide and suicide, when 

combined, account for almost as many deaths as 

unintentional injuries among male adolescents. 

Racial and ethnic disparities also exist, with 

non-Hispanic American Indian/Alaska Native 

adolescents experiencing the highest rate of 

mortality among both males and females (138.6 

and 57.6 per 100,000, respectively). Non-Hispanic Black males had the second highest rate 

of adolescent mortality (108.0 per 100,000) 

while non-Hispanic Asian/Pacific Islander females had the lowest rate (16.0 per 100,000). 

Unintentional injury was the leading cause of 

death among male and female adolescents of 

all racial/ethnic groups, except non-Hispanic 

Black males, for whom homicide was the leading cause of death (data not shown). 

The primary cause of unintentional injury 

death was motor vehicle crashes (63.8 percent), 

followed by poisoning (16.4 percent) which is 

the only unintentional injury mechanism to 

increase over the past decade.74,75 Poisoning includes prescription drug overdoses. Homicide 

deaths to adolescents were predominantly attributable to firearms (84.8 percent) while both 

firearms and suffocation were leading mechanisms of suicide death (40.3 and 45.3 percent, 

respectively; data not shown).74 

Mortality Rates Among Adolescents Aged 15–19 Years, by

Race/Ethnicity* and Sex, 2010

Source (II.23): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

*Multiple-race data were bridged to single-race categories **Separate estimates for Asians and Native

Hawaiians and Other Pacific Islanders were not available.

Mortality Rates Among Adolescents Aged 15–19 Years, by

Selected Leading Cause and Sex, 2010

Source (II.23): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

Rate Per 100,000 (Rank)

Rate Per 100,000

Female

Male

40.1

32

64

96

128

160

Non-Hispanic

Asian/Pacific

Islander**

Non-Hispanic

American Indian/

Alaska Native 

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Female

Male

63.9

27.9 31.9

61.2

30.1

108.0

20.4 16.0

57.6

138.6

20 40 60 80 100

Heart Disease

Cancer

Suicide

Homicide 

Unintentional Injury

All Causes 69.6

28.1

28.3

12.4

2.3

3.1

3.2

2.2

2.1

0.9

11.7

14.0
 CHILD HEALTH USA 2012 HEALTH STATUS – ADOLESCENTS 49

CHILDREN WITH SPECIAL 

HEALTH CARE NEEDS

The National Survey of Children with Special Health Care Needs (NS-CSHCN) asks 

parents about the types of chronic health conditions experienced by their children and how 

these conditions impact both the child and 

their family. These chronic conditions include 

developmental difficulties such as Down Syndrome and Autism Spectrum Disorder, seizure 

disorders such as epilepsy, mental health disorders such as depression and anxiety, and other 

conditions which have lasted, or are expected to 

last, 12 or more months. Among CSCHN, the 

conditions (from a list of 20 specific conditions) 

that children are most commonly reported to 

have are allergies, asthma, ADD/ADHD, and 

developmental delay. Co-morbidities are common, as more than half of all CSHCN experience more than one chronic condition. In 

the 2009−10 NS-CSHCN, 28.0 percent of all 

CSHCN reported 2 conditions, while an additional 29.1 percent of CSHCN reported 3 or 

more conditions.

The impact of these conditions on the 

child varies by a number of factors. In general, 

CSHCN are as likely to participate in organized 

activities, volunteer and work for pay as those 

children without special health care needs; however, children with functional limitations experience additional barriers to participation.76 The 

parents of over one-third of CSHCN reported 

that in the past 12 months their child’s condition never affected the child’s ability to do the 

things that other children could do. A consistent barrier, where the condition always limited the child, was reported for 15.3 percent of 

CSHCN. 

CSCHN who only require prescription medication to care for their condition are the least 

likely to experience a great deal of difficulty doing the things that other children can do (5.1 

percent) as compared to children who require 

additional services (13.6 percent) or who have 

a functional limitation (40.9 percent). Only 

10.7 percent of CSHCN who have a functional 

limitation experience “very little” difficulty in 

participation.

Degree to Which Special Health Care Need Affects the Child’s Ability to

Do Things, by Type of Special Health Care Need, 2009–10

Source (II.24): 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 with Special Health Care Needs

Number of Health Conditions* Reported for CSHCN,

2009–10

Source (II.24): 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 with Special Health

Care Needs

*Of 20 addressed in the survey. Because CSHCN status is determined by the presence of healthrelated impacts rather than a specific diagnosis, children may have a special health care need

without having been diagnosed with one of the 20 conditions parents were asked about on the survey.

Percent of Children

31.8

47.5

5.1

11.7

36.5

51.8

13.6

38.9

63.1

No Conditions

Reported

12.3%

1 Condition

Reported

30.6% 3 or More

Conditions

Reported

29.1%

Percent of CSHCN

2 Conditions

Reported

28.0% 16

32

48

64

80

Has Functional

Limitations

Needs Services and

Prescription Medications

Needs Prescription Needs Services

Medications

48.5

40.9

10.7

Very Little

Some

A Great Deal
50 CHILD HEALTH USA 2012

HEALTH SERVICES FINANCING 

AND UTILIZATION

The availability of and access to quality health 

care directly affects the health of the population. 

This is especially 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 employer-based or purchased 

directly, and public programs, such as Medicaid 

or the Children’s Health Insurance Program 

(CHIP). Eligibility for public programs is 

based on a family’s income compared to the 

Federal poverty level. Nearly every state has 

CHIP programs that help to expand coverage 

to children who would otherwise be uninsured. 

Despite the progress achieved through public 

programs, approximately 7.3 million children 

remain uninsured in the United States. 

This section presents data on the health 

insurance status and utilization of health services 

within the maternal and child population. Data 

are summarized by source of payment, type of 

care, and place of service delivery. This section 

also provides the latest data on the health care 

needs and financing of care for children with 

special health care needs. 
 CHILD HEALTH USA 2012 HEALTH SERVICES FINANCING AND UTILIZATION 51

HEALTH CARE FINANCING

In 2010, approximately 7.3 million U.S. 

children under 18 years of age had no health 

insurance coverage, representing 9.8 percent of 

the population. This was not statistically different 

from the previous year (9.7 percent). More than 

one-third of children were insured through public 

programs77 such as Medicaid, the Children’s 

Health Insurance Program, and military health 

insurance (37.9 percent), and 59.6 percent were 

covered by private insurance. 

Children’s insurance status varies by race 

and ethnicity. In 2010, 73.1 percent and 68.6 

percent of non-Hispanic White and Asian 

children, respectively, had private coverage, while 

the same was true for only 52.7 percent of nonHispanic Native Hawaiian and Other Pacific 

Islander children, 42.6 percent of non-Hispanic 

American Indian/Alaska Native children, 41.8 

percent of non-Hispanic Black children, and 

37.7 percent of Hispanic children. Over half 

of non-Hispanic Black and Hispanic children 

were publicly insured (56.3 percent and 51.7 

percent, respectively) followed by 49.8 percent 

of non-Hispanic American Indian/Alaska Native 

children.

As family income increases, private health 

insurance coverage among children rises and the 

proportions of children with public coverage and 

no coverage decrease. In 2010, children living 

in households with incomes below 100 percent 

of the U.S. Census Bureau’s poverty threshold 

($22,314 for a family of four in 2010) were most 

likely to have public coverage (73.7 percent) or to 

be uninsured (15.4 percent); a similar proportion 

of children living in near-poor households 

(between 100-199 percent of the poverty 

threshold) were also uninsured (14.1 percent). 

Children with family incomes of 400 percent or 

more of the poverty threshold were most likely 

to have private coverage (92.2 percent), and least 

likely to have public coverage (10.5 percent) or to 

be uninsured (3.5 percent).

In 2009, the Children’s Health Insurance 

Program was reauthorized and states were given 

incentives to provide coverage to additional 

children. Although designed to cover children 

with family incomes below 200 percent of 

the poverty level, many States have expanded 

eligibility to children with higher family incomes.

20

40

60

80

100

NonHispanic

Multiple Race

NonHispanic

Native

Hawaiian/

Other Pacific Islander

NonHispanic

Asian

Non-Hispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Health Insurance Coverage Among Children Under Age 18, by

Poverty Status* and Type of Coverage,** 2010

Source (III.1): U.S. Census Bureau, Current Population Survey

*Totals equal more than 100 percent because children may have more than one source of coverage.

**Due to small sample size, estimate did not meet criteria for reliability.

*The U.S. Census Bureau’s poverty threshold for a family of four was $22,314 in 2010. 

**Totals equal more than 100 percent because children may have more than one source of coverage.

Health Insurance Coverage Among Children Under Age 18, by

Race/Ethnicity and Type of Coverage,* 2010

Source (III.1): U.S. Census Bureau, Current Population Survey Percent of Children

Rate Per 100,000 Population

Public Coverage

No Coverage

Private Coverage

32.9

92.2

15.9 15.4

73.7

9.9 3.5

84.2

29.1

5.4

17.8

69.9

41.8

53.3

10.5 14.1

73.1

37.9 41.8

27.4

6.9

56.3 59.6

9.8 16.3

42.6

51.7

37.7

17.9

10.6

49.8 52.7

6.6

58.4

68.6

8.9

46.6

n/a**

27.4

45.0

20

40

60

80

100

400% of

poverty or more

300-399%

of poverty 

200-299%

of poverty

100-199%

of poverty

Less than

100% of poverty

Public Coverage

No Coverage

Private Coverage
52 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2012

HEALTH CARE FINANCING 

FOR CHILDREN WITH SPECIAL 

HEALTH CARE NEEDS

The consistency and adequacy of health insurance can have a significant impact on children’s access to needed health care services. 

This is particularly true for children with special health care needs (CSHCN). In 2009−10, 

the National Survey of Children with Special 

Health Care Needs asked parents whether their 

child had insurance coverage in the past 12 

months and, if so, what kind they had. Overall, 

90.7 percent of CSHCN were insured for all of 

the previous 12 months, while the remaining 

9.3 percent were uninsured for all or some part 

of the year (data not shown). 

At the time of the interview, 96.5 percent 

of CSHCN were reported to have some type 

of insurance: 52.4 percent had private insurance and 35.9 percent had public insurance, 8.2 

percent had both private and public insurance, 

while 3.6 percent were uninsured at the time of 

the interview. The proportion of CSHCN with 

private and public insurance coverage changed 

significantly over the last decade. In 2001, 64.7 

percent of CSHCN had private and 21.7 percent had public coverage. This reflects a decline 

of over 20 percent in the proportion of CSHCN 

with private coverage and a nearly 60 percent 

increase in the proportion with public coverage 

over the decade (data not shown).

CSHCN without health insurance are less 

likely to receive the health care they need than 

those with insurance. CSHCN without current 

health insurance coverage were less likely than 

those with insurance to have a usual source of 

sick care (85.6 percent versus 92.9 percent), to 

receive all needed dental care (79.2 versus 95.1 

percent) and prescription medications (84.1 

percent versus 97.9 percent) and to receive all 

needed mental health services (85.1 versus 94.7 

percent). 

Access to Services, by Health Insurance Coverage, Among CSHCN,

2009–10

Source (III.3): 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 with Special Health Care Needs

Health Insurance Coverage Among CSHCN at Time of

Survey, 2009–10

Source (III.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 with Special Health Care Needs

Private Insurance Only

85.6

95.1 97.9

84.1 79.2

92.9

Private Only

52.4%

Public Only

35.9%

Uninsured

3.6%

Combination of

Private and Public

8.2%

Percent of CSHCN

20

40

60

80

100

Received All Needed

Mental Health Services

Received all Needed

Prescriptions

Received all

Needed Dental Care

Usual Source

of Sick Care

94.7

85.1

Currently Insured

Not Currently Insured
 CHILD HEALTH USA 2012 HEALTH SERVICES FINANCING AND UTILIZATION 53

VACCINATION COVERAGE

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.78 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.79 

Currently, there are 12 different vaccines recommended by the Centers for Disease Control 

and Prevention from birth through age 18, many 

of which require multiple doses for effectiveness 

as well as boosters to sustain immunity—see the 

following page for a summary of the vaccination 

schedule. 

In 2010, 72.7 percent of children 19–35 

months of age received each of six vaccines in 

a modified series of recommended vaccines 

(4:3:1:3:X:1:4). This series includes four doses of 

diphtheria, tetanus, and acellular pertussis vaccine (DTaP/DT/DTP); three doses of poliovirus 

vaccine; one dose of measles, mumps, and rubella 

vaccine (MMR); 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). Because of 

changes in measurement of the Haemophilus 

influenzae type b (Hib) vaccine and the vaccine 

shortage that occurred during December 2007– 

June 2009, coverage estimates included here are 

based on the modified series that excludes the 

Hib vaccine. Although the 2010 level of vaccine 

series coverage is below the Healthy People 2020 

objective of 80 percent, there were no significant 

disparities by race and ethnicity. 

The human papillomavirus (HPV) vaccine 

protects against certain strains of HPV that can 

cause cervical cancer and genital warts and was 

first recommended in 2006 for females aged 

11–12 years and more recently recommended 

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.80 In 2010, only 48.7 percent of females aged 13–17 years had received at least 1 

of the 3 necessary doses of HPV vaccine, among 

whom about two-thirds with adequate time to 

complete the series had done so (69.6 percent). 

Hispanic and non-Hispanic American Indian/

Alaska Native females were significantly more 

likely to have initiated HPV vaccination than 

non-Hispanic White females (56.2 and 64.8 percent versus 45.8 percent, respectively). However, 

compared to non-Hispanic White females, Hispanic and non-Hispanic Black females were less 

likely to complete the vaccine series (74.7 percent 

versus 56.1 and 65.4 percent, respectively), while 

non-Hispanic Asian females were more likely 

to do so (86.0 percent). A new requirement of 

health plans to monitor the proportion of females completing 3 doses by 13 years of age may 

help to increase HPV vaccination.81 

Receipt of Selected Vaccinations Among Children, by Recommended Age Group and

Race/Ethnicity,* 2010

Source (III.4): Centers for Disease Control and Prevention, National Immunization Survey Percent of Children

74.7

65.4

48.9

69.6 69.3 72.7

48.7 45.8

72.7

20

40

60

80

100

Non-Hispanic

Asian

Non-Hispanic

American Indian/

Alaska Native

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total

74.1 74.5

56.2 56.1

50.1

86.0

64.8 64.0

70.2

19-35 Months 4:3:1:x:3:1:4 Modified Series**

13-17 Years HPV initiation†

13-17 Years HPV completion††

*The sample of Native Hawaiian/Pacific Islanders was too small to produce reliable results. **4+ DTaP, 3+ Polio, 1+ MMR, 3+ HepB,

1+ Varicella, 4+ PCV; excludes Hib, due to the 2007-2009 shortage. †

1+ HPV among females only. ††3+ doses among females who had at least one HPV dose and at least 24 weeks between the first dose and time of the survey.
54 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2012

Recommended Routine Immunizations for Children from Birth Through 18 Years Old, 2012

Source (III.5): Department of Health and Human Services, Centers for Disease Control and Prevention

Note: If your child misses a shot, you don’t need to start over, just 

go back to your child’s doctor for the next shot. The doctor will keep 

your child up-to-date on vaccinations. There are certain health conditions and other situations that might cause some of these vaccines 

to be recommended at other than routine ages. Talk with your health 

care provider for more information. 

*Tdap vaccine is a combination vaccine that is recommended at 

age 11 or 12 to protect against tetanus, diphtheria, and pertussis. If 

your child has not received any or all of the DTaP vaccine series, or 

if you don’t know if your child have received these shots, you child 

needs a single dose of Tdap when they are 7−10 years old. Talk to 

your child’s health care provider to find out if they need additional 

catch-up vaccines.

**Two doses of HepA vaccine are needed for lasting protection. The 

first dose of HepA vaccine should be given between 12 months and 

23 months of age. The second dose should be given 6 to 18 months 

later.

†All 11 or 12 year olds—both girls and boys—should receive 3 doses 

of HPV vaccine to protect against HPV-related disease. Either HPV 

vaccine (Cervarix® or Gardasil®) can be given to girls and young 

women; only one HPV vaccine (Gardasil®) can be given to boys and 

young men.

††Everyone 6 months of age and older—including children, teens, 

and adults—should get a flu vaccine each fall or winter. Children 

6 months through 8 years of age may need two doses, at least 4 

weeks apart. Ask your health care provider for more information.

‡6-month doses of Hib and RV may not be necessary depending on 

the brand of vaccine used. Your health care provider will know how 

many doses to administer.

For more information, call toll free 1-800-CDC-INFO (1-800-232-

4636) or visit http://www.cdc.gov/vaccines
 CHILD HEALTH USA 2012 HEALTH SERVICES FINANCING AND UTILIZATION 55

MENTAL HEALTH TREATMENT

In 2010, 2.9 million, or 12.2 percent, of adolescents aged 12 to 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 inpatient and outpatient care (data not 

shown). Inpatient care includes treatment or 

counseling from an overnight or longer stay in 

a hospital, residential treatment center, or foster 

care or therapeutic foster care home, and outpatient care includes services from a private therapist, psychologist, psychiatrist, social worker, or 

counselor; mental health clinic or center; partial 

day hospital or day treatment program; or inhome therapist, counselor, or family preservation worker.

A similar proportion of adolescents received 

mental health services in an educational setting, 

including counseling from a school social worker, 

psychologist, or counselor (12.3 percent), while 

2.5 percent received services from a pediatrician 

or other family doctor in a medical setting; less 

than 1 percent of adolescents received mental 

health services in a juvenile justice setting in the 

past 12 months. Approximately 5 percent of adolescents received mental health services in both a 

specialty mental health setting and either an educational or a medical setting.

A greater proportion of females received specialty mental health services (14.4 percent) than 

males (10.1 percent) (data not shown). In general, few racial or ethnic differences in service site 

for past-year treatment were observed. However, 

non-Hispanic Asian children were least likely to 

receive services in a specialty mental health setting (3.5 percent) while non-Hispanic Black 

children were more likely to receive services in 

an educational setting (15.5 percent) than nonHispanic White and Hispanic children (11.6 and 

11.8 percent, respectively; data not shown).

The most common reported reason for service 

use was feeling depressed. This was the case for 

nearly half of adolescents who received services 

in a specialty mental health setting, and over onethird of those who received services in an educational setting. Overall, reasons for treatment or 

counseling varied by service site. For example, 

problems with home/family was reported as the 

reason for seeking services by 30.5 percent of 

those seeking care in a specialty mental health 

setting compared to 20.5 and 10.7 percent of 

those treated in educational and medical settings, 

respectively.

Selected Reasons* for Mental Health Service Use Among

Adolescents Aged 12-17,** by Service Site, 2010

Source (III.6): Substance Abuse and Mental Health Service Administration, National Survey

of Drug Use and Health

Past-Year Mental Health Service Use Among Adolescents

Aged 12-17,* by Service Site, 2010

Source (III.6): Substance Abuse and Mental Health Service Administration, National

Survey of Drug Use and Health

*Among adolescents who received past-year mental health treatment or counseling for problems with

emotions or behavior. **Inpatient or Outpatient services in addition to services received in either an

educational or medical setting.

*Respondents could report multiple reasons. **Among adolescents who received past-year mental health

treatment or counseling.

Percent of Adolescents

Percent of Adolescents

International

25%

10

20

30

40

50

Problems

at School

Problems with

Friends

Problems with

Home/Family

Rule Breaking/

Acting Out

Suicidal Depressed

Thoughts/Actions

10

20

30

40

50

Educational Medical Multiple**

Specialty Mental Health

Education

Medical

10.5 11.8

34.9

39.2

20.8

47.6

25.0

30.5

16.3

20.6

10.7

20.5

12.3

2.5 5.2 10.9

2.4 11.8

3.3

19.0 17.9

12.4

22.3

Specialty Mental Health Setting

Outpatient

Inpatient
56 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2012

DENTAL CARE

According to the Centers for Disease Control 

and Prevention, dental caries (tooth decay) is the 

most common chronic infectious disease among 

children in the United States.82 Untreated tooth 

decay causes pain and infections, which may 

affect children’s ability to eat, speak, play, and 

learn. Tooth decay, however, is preventable with 

proper dental care for cleaning, brushing and 

flossing instruction, sealants, and fluoride treatment. For this reason, the American Academy 

of Pediatric Dentistry recommends that children have their first dental checkup at the eruption of the first tooth or by age 1,83 with two 

visits per year thereafter.84

In 2010, 62.4 percent of children aged 2–17 

years received dental care in the past 6 months, 

while 13.5 percent had not received such care in 

more than 2 years. Receipt of dental care varied 

by a number of factors, including poverty and 

insurance status. Children living in households 

with incomes at or below 100 or 200 percent 

of the poverty level were less likely than children living in households with incomes above 

200 percent of the poverty threshold to have 

received dental care in the past 6 months (53.0 

and 54.2 percent, respectively, compared to 

69.1 percent). Uninsured children were about 

half as likely to have received a dental visit in 

the past 6 months (30.8 percent) as those with 

public (58.8 percent) or private insurance (68.9 

percent; data not shown).

Similar patterns were observed for unmet dental care needs. Overall, 4.3 million or 6.6 percent 

of children had unmet dental care needs in 2010. 

However, the proportion of children with unmet 

needs was substantially higher among those who 

were uninsured (26.4 percent) compared to those 

with either private (4.1 percent) or public (6.1 

percent) insurance. With respect to poverty, children living in households below 100 or between 

100 and 199 percent of the poverty level were at 

least twice as likely to have an unmet dental care 

need in the past year as children at 200 percent 

or more of poverty (8.7 and 10.4 percent, respectively, compared to 4.3 percent, data not shown). 

Unmet Dental Need* in the Past Year Among Children Aged

2–17 Years, by Insurance Type and Status, 2010

Source (III.7): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Health Interview Survey

Time Since Last Dental Visit Among Children Aged 2–17 Years,*

by Poverty Status,** 2010

Source (III.7): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Health Interview Survey

*Based on parent report that services were needed but were not affordable; all estimates are

age-adjusted. Percent of Population

6

12

18

24

30

Total Private Insurance Public Insurance Uninsured

Less than 6 Months

Between 1 and 2 Years

More than 2 Years

Between 6 Months

and 1 Year

6.1

26.4

6.6

4.1

*All estimates are age-adjusted and may not total to 100 due to rounding.

**Poverty level, defined by the U.S. Census Bureau, was $22,314 for a family of four in 2010.

20

40

60

80

100

200% or More

of Poverty

100-199%

of Poverty

Less Than

100% of Poverty

Total

62.4 53.0 54.2 69.1

17.0

21.1 20.3

14.1

7.1 10.3 8.6

5.4

13.5 15.7 16.9 11.5

Percent of Population
 CHILD HEALTH USA 2012 HEALTH SERVICES FINANCING AND UTILIZATION 57

WELL-CHILD VISITS

In 2010, 79.9 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.85 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 wellchild visits declines with age. In 2010, 89.9 percent of children 4 years of age and younger had 

received a preventive visit in the past year, compared to 77.4 percent of children 5–11 years of 

age and 73.9 percent of children 12–17 years of 

age. Among the oldest adolescents, the rate was 

even lower (69.0 percent).

Receipt of preventive medical care also varies by several other factors, including type of 

insurance and race and ethnicity. In 2010, only 

55.6 percent of uninsured children had received 

a well-child visit in the past year, compared to 

about 80 percent of those with public or private insurance (79.4 and 83.3, respectively; data 

not shown). With respect to race and ethnicity, non-Hispanic children of more than one 

race and non-Hispanic Black children were 

most likely to have received a well-child visit 

in the past year (87.1 and 83.3 percent, respectively), followed by non-Hispanic White (80.5 

percent), non-Hispanic Asian (76.4), and Hispanic children (75.4). Non-Hispanic American 

Indian/Alaskan Native children had the lowest 

reported rate of preventive care in the past year 

(63.2 percent).

Receipt of Preventive Health Care in the Past Year Among Children

Under Age 18, by Age, 2010

Source (III.8): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Health Interview Survey Percent of Children

73.9 79.9 77.4

Receipt of Preventive Health Care in the Past Year Among

Children Under Age 18,* by Race/Ethnicity,** 2010

Source (III.8): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Health Interview Survey

89.9

20

40

60

80

100

Total 0-4 years 5-11 years 12-17 years

Percent of Children

63.2

87.1

80.5 79.2 83.3

75.4 76.4

20

40

60

80

100

Non-Hispanic

Multiple Race

Non-Hispanic

Asian

Non-Hispanic

American

Indian/

Alaska Native

Non-Hispanic Hispanic

Black

Non-Hispanic

White

*All estimates are age-adjusted. **The sample of Native Hawaiian/Pacific Islander children was too small

to produce reliable results.
58 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2012

HEALTH CARE VISITS

In 2010, 9.3 percent of children under 18 

years of age had not seen a physician or other 

health care professional in the past year for either sick or routine care (not including overnight hospitalization, emergency department 

visits, home health care, or dental care). Older 

children were more likely than younger children to go 12 months without seeing a health 

care provider. More than 12 percent of children 

aged 12–17 years (12.2 percent) had not seen a 

health care provider in the past year, compared 

to only 4.5 percent of children under 5 years 

of age.

Health care visits also vary by insurance type 

and status. In 2010, more than one in four children without health insurance (26.7 percent) had 

not seen a physician or other health professional 

in the past year, compared to 9.8 percent with 

public insurance and 6.4 percent of privately insured children. Across all age groups, uninsured 

children were most likely to have gone without 

a health visit in the past year, while privately insured children were the least likely. Across all insurance groups, older children were more likely 

than those less than 5 years old to have not seen 

a health care professional. Thus, having no pastyear visit ranged from 2.9 percent among privately insured children under 5 years of age to 34.3 

percent among uninsured children aged 12−17 

years—a ten-fold difference.

The proportion of children going without 

health care also varies by poverty level and race 

and ethnicity. In 2010, children living in households with incomes below the poverty level or 

between 100−199 percent of poverty were about 

twice as likely as those at 200 percent or more 

of poverty to have not seen a physician or other 

health professional in the past year (12.5 and 

13.3 percent, respectively, compared to 6.5 percent). About 7 percent of non-Hispanic White 

children lacked a health care visit (6.8 percent) 

compared to 10−14 percent of children of other 

racial/ethnic groups (data not shown). 

No Contact with a Health Care Professional* in the Past Year Among Children Under Age

18, by Age and Insurance Type and Status, 2010

Source (III.8): Centers for Disease Control and Prevention, National Center for Health Statistics, National Health

Interview Survey

*Does not include overnight hospitalizations, emergency department visits, home health care, and dental care; all total estimates are

age-adjusted. 

Total

0–4 Years

5–11 Years

12–17 Years

9.3

31.1

34.3

13.7

9.8 10.7 10.0

2.9

6.4

4.5

8.2

9.2

7.3

26.7

5.7

12.2

8

16

24

32

40

Total Private Insurance Public Insurance Uninsured

Percent of Children
 CHILD HEALTH USA 2012 HEALTH SERVICES FINANCING AND UTILIZATION 59

USUAL PLACE FOR SICK CARE

Having a usual place or source of health care 

is an important indicator of care continuity 

that has been linked to improvements in care 

quality, preventive care utilization, and health 

status.86 In 2010, the majority of children were 

reported by their parents to have a usual place of 

health care when they are sick or need of health 

advice (95.1 percent); however, about a quarter 

of uninsured children (25.4 percent) did not 

have a usual place of care. 

Receiving regular primary and preventive 

care in a doctor’s office or clinic can help to 

avoid unnecessary hospitalizations and emergency room visits. In 2010, among children 

with a usual source of care, 74.3 percent of 

children used a doctor’s office or health maintenance organization (HMO) as their usual place 

of care, 23.6 percent used a clinic or health center, and 2.1 percent usually used other places, 

including emergency rooms and hospital outpatient departments; however, this varied greatly 

by poverty status. Children with household incomes below the poverty level were more than 

three times as likely to use a clinic or health center as a usual source of care than children living 

at 400 percent or more of poverty (38.4 versus 

12.3 percent). Conversely, 86.9 percent of children living at 400 percent or more of poverty 

used a doctor’s office or HMO as a usual source 

of care, compared to 58.5 percent of children 

living in households with incomes below the 

poverty threshold. 

The location where children usually received 

care also varied by race and ethnicity and insurance type and status. Clinics and health centers 

were more likely to serve as a usual place of care 

for American Indian/Alaska Native (52.9 percent), Native Hawaiian/Other Pacific Islander 

(45.1 percent), and Hispanic children (39.0 

percent) compared to about 25 percent or less 

of children of other racial/ethnic groups (data 

not shown). Despite being rare overall, about 

one-tenth (9.5 percent) of uninsured children 

usually relied on hospital emergency and outpatient departments and other sources of care.

Location of Usual Place of Care* Among Children Under Age

18, by Poverty Status,** 2010

Source (III.8): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Health Interview Survey

*Has a place where the child is usually taken when sick or in need of health advice; all estimates are

age-adjusted.

*The place where the child is usually taken when sick or in need of health advice; all estimates are

age-adjusted; percentages may not total to 100 due to rounding. **Poverty level, defined by the U.S.

Census Bureau, was $22,314 for a family of four in 2010. †

Includes emergency room, hospital

outpatient department, some other place, and not using one place most often.

Usual Place of Care* Among Children Under Age 18, by Insurance

Type and Status, 2010

Source (III.7): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Health Interview Survey

Percent of ChildrenPercent of Children

32.9 33.9

2.1 4.9

23.6

74.3

9.9

1.6 0.8

18.9

86.9

67.5

79.6

58.5

38.4

12.3

29.2

3.2 3.2

20

40

60

80

100

400% or More

of Poverty

200-399%

of Poverty

100-199%

of Poverty

Less Than 100%

of Poverty

Total

Clinic or Health Center

Hospital or Other Place†

Doctor’s Office or HMO

20

40

60

80

100

Total Private Insurance Public Insurance Uninsured

Yes No 95.1

2.5

97.5

3.8

96.2

25.4

74.6
60 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2012

EMERGENCY DEPARTMENT 

UTILIZATION

In 2010, 22.0 percent of children had at least 

one visit to a hospital emergency department 

(ED) in the past year and 8.4 percent had multiple visits. Children younger than 5 years of age 

were more likely to have had a past-year ED visit (28.1 percent) than children aged 5–11 years 

or 12–17 years (20.4 percent and 19.0 percent, 

respectively; data not shown).

Emergency department utilization also varies by poverty and race and ethnicity. In 2010, 

almost one-third of children living in households with incomes below the poverty level had 

visited an ED in the past year (30.2 percent), 

compared to 17.3 percent of children living in 

households at 200 percent or more of the poverty level. Children in poverty were more than 

twice as likely to have had multiple ED visits 

as non-poor children living at 200 percent or 

more of poverty (13.2 versus 5.6 percent, respectively). With respect to race and ethnicity, 

non-Hispanic Black and Hispanic children were 

most likely to have visited an ED (26.9 and 

23.1 percent, respectively) while Asian children 

were least likely to have done so (14.9 percent). 

Compared to the overall average, Asian children 

had a similar proportion of multiple ED visits 

but a lower proportion of single visits, whereas 

non-Hispanic Black children had a higher proportion of both single and multiple visits. 

According to the 2009 National Hospital 

Ambulatory Medical Care Survey, the most 

common reason for a visit to the emergency 

department among children under 15 years of 

age was fever (19.7 percent of visits), followed 

by cough (7.6 percent), and vomiting (4.5 

percent).86 The three most common primary 

diagnoses treated in ED visits among both 

males and females were acute upper respiratory 

infections (10.8 percent, combined), fever 

of unknown origin (6.6 percent, combined), 

and otitis media (middle ear infection) and 

Eustachian tube disorders (5.1 percent, 

combined), followed by unspecified viral and 

chlamydial infection for females (3.2 percent) 

and open wound of head (4.1 percent) for males. 

Asthma ranked as the seventh most common 

diagnosis for males (3.4 percent) compared 

to the thirteenth most common diagnosis for 

females (1.9 percent, data not shown).86

Visits to the Emergency Department in the Past Year Among

Children Under Age 18,* by Poverty Status,** 2010

Source (III.7): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Health Interview Survey Percent of Children

Visits to the Emergency Department in the Past Year Among

Children Under Age 18,* by Race/Ethnicity,** 2010

Source (III.7): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Health Interview Survey Percent of Children

8

16

24

32

40

Non-Hispanic

Asian

Non-Hispanic

American Indian/

Alaska Native

Non-Hispanic Hispanic

Black

Non-Hispanic

White

*All estimates are age-adjusted. **Poverty level, defined by the U.S. Census Bureau, was $22,314 for

a family of four in 2010.

*All estimates are age-adjusted. **The sample of

Native Hawaiian/Pacific Islander children was too small to produce reliable results.

54.6

66.1

55.9

78.9

One Visit

Two or More Visits

Any Visit (Total)

13.1

8.3

14.8

7.4

14.8

6.3

13.4

7.3

7.7

12.2

23.1

20.5 19.7

14.9

26.9

8

16

24

32

40

200% or More

of Poverty

100-199%

of Poverty

Less Than

100% of Poverty

Total

13.6 11.6

17.0 15.3

8.4

22.0 13.2

30.2

10.0

25.3

5.6

17.3

One Visit

Two or More Visits

Any Visit (Total)
 CHILD HEALTH USA 2012 HEALTH SERVICES FINANCING AND UTILIZATION 61

PRENATAL CARE

Prenatal care—especially care beginning in 

the first trimester—allows health care providers 

to identify and manage a pregnant woman’s risk 

factors and health conditions and to provide expectant parents with relevant health care advice. 

In 2010, in the 33 States that had implemented 

the 2003 revision to the standard birth certificate as of January 1st and collected prenatal care 

information in the same format,87 73.1 percent 

of women giving birth were determined to 

have received prenatal care in the first trimester, while 6.2 percent of women began prenatal 

care in the third trimester or did not receive any 

prenatal care. 

The timing of prenatal care initiation differs by race/ethnicity. Non-Hispanic Asian and 

non-Hispanic White mothers were most likely 

to begin prenatal care in the first trimester (78.6 

and 78.3 percent, respectively) and least likely to 

begin prenatal care in the third trimester or not 

all (4.5 and 4.3 percent, respectively). The lowest rates of early prenatal care—received within 

the first trimester—were observed among nonHispanic Native Hawaiian and Other Pacific 

Islander and non-Hispanic American Indian/

Alaska Native mothers (53.2 and 57.8 percent, 

respectively), followed by non-Hispanic Black 

mothers (62.5 percent). These same racial and 

ethnic groups also had the highest rates of receiving late (third trimester) or no prenatal care 

(16.7, 11.9, and 10.3 percent, respectively).

Timing of prenatal care initiation also varies 

by maternal education, with early prenatal care 

entry increasing with greater educational attainment. For example, in 2010, first trimester prenatal care was obtained by only 57.6 percent of 

mothers with less than a high school diploma, 

compared to 86.7 percent of mothers with a 

bachelor’s degree or higher. Conversely, only 

2.5 percent of mothers with a bachelor’s degree 

received late or no prenatal care, compared to 

11.6 percent of mothers with less than a high 

school diploma. 

Timing of Prenatal Care Initiation,* by Maternal Race/Ethnicity, 2010

Source (III.9): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System Percent of Mothers

Timing of Prenatal Care Initiation,* by Maternal Education, 2010

Source (III.9): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System Percent of Mothers 20

40

60

80

100

Bachelor's

Degree

or Higher

Some College or

Technical School

High School

Diploma

or GED 

Less than

High School

Diploma

Total

*Data are from 33 states that implemented the 2003 revision of the birth certificate as of January 1, 2010,

representing 67% of all US births; percentages may not total to 100 due to rounding.

*Data are from 33 states that implemented the 2003 revision of the birth certificate as of January 1, 2010,

representing 67% of all US births; percentages may not total to 100 due to rounding.

20

40

60

80

100

NonHispanic

Multiple

Race

NonHispanic

Native Hawaiian/Other

Pacific Islander

NonHispanic

Asian

NonHispanic

American

Indian/Alaska

Native

Non- Hispanic

Hispanic

Black

NonHispanic

White 

Total

73.1

20.6

6.2

70.4

22.8

6.9

78.3

17.4

4.3

62.5

27.3

10.3

53.2

30.2

16.7

67.6

24.3

8.1

57.8

30.2

11.9

78.6

16.9

4.5

First

Trimester

Second

Trimester

Third

Trimester

or No Care

73.1

11.6

24.6

6.2 7.3

57.6

20.6

68.1

19.3

4.9

75.8

10.8

2.5

86.7

30.8

First

Trimester

Second

Trimester

Third

Trimester

or No Care
62 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2012

HRSA SERVES CHILDREN

The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the 

primary Federal agency responsible for improving access to health care services for people who 

are uninsured, isolated or medically vulnerable. 

The agency is made up of 6 bureaus and 10 offices. One of these bureaus, the Maternal and 

Child Health Bureau (MCHB) takes the lead 

in promoting the physical and mental health, 

safety and well-being of the Nation’s maternal 

and child health (MCH) population, which 

includes all women, infants, children and their 

families.

To support its mission, MCHB oversees Federal funding to States authorized under Title V 

of the Social Security Act. Title V authorizes appropriations to States to improve the health of 

mothers and children, including children with 

special health care needs (CSHCN). Each year, 

States report on the numbers of people served 

by Title V-funded programs. In 2010, programs 

overseen by MCHB and funded through Title 

V served over 41 million people within the 

MCH population, the majority of whom were 

children under the age of 22 years. Additionally, 

Federal programs administered by MCHB serve 

subsets of the MCH population, such as children with autism, sickle cell diseases, traumatic 

brain injury and epilepsy. 

HRSA-supported community health centers 

seek to provide comprehensive, culturally competent, quality primary health care services to 

medically underserved communities and vulnerable populations. In 2011, over 20 million 

people were provided with medical, dental, 

mental health, substance abuse or other services 

across 1,128 locations. Children aged 0 to 18 

years accounted for 33.5 percent of those served 

by community health centers, with women representing a majority of users (58.7 percent; data 

not shown).

Number of Persons Served, in Millions, Through the Title V

Maternal and Child Health Block Grant, 2010

Source (III.10): Health Resources and Services Administration, Title V Information System Persons Served in Millions

28.5

41.6

4.1

Number of Patients, in Millions, Served in HRSA-Funded Community

Health Centers by Age and Sex, 2011

Source (III.11): Health Resources and Services Administration, Uniform Data System

2.5 2.0

4.5

10

20

30

40

50

Children Other*

with Special

Health Care Needs

Children Aged

 1 to 22 Years

Infants Less

than 1 Year

Pregnant

Women

Total 

Number of Patients in Millions

1.32

1.97

0.55

0.85

1.13 1.09

2.74

1.34

2.31

1.41

2.31

1.41

1

2

3

4

5

Under 5 Years 5 to 12 Years 13 to 24 Years 25 to 44 Years 45 to 64 Years 65 and Over

*"Others" usually represents services to reproductive-age women.

Male

Female
 CHILD HEALTH USA 2012 63

STATE DATA

While the indicators presented in the previous sections are representative of the U.S. population as a whole, the following section presents 

data at the State level. Geographic differences 

in health status and health care utilization play 

an important role in tailoring health programs 

and interventions to specific populations. Included are data on infant, neonatal, and perinatal mortality, low birth weight, preterm birth, 

health care financing, Medicaid enrollment and 

expenditures, and CHIP enrollment. 

The following pages reveal important disparities in these measures across States. For instance, 

the proportion of infants born low birth weight 

(less than 2,500 grams, or 5 pounds 8 ounces) 

was highest in Mississippi, followed by Louisiana and several other southern States. Births to 

unmarried women tended to be highest in these 

States as well. 

All of the issues presented here have geographic program and policy implications. State 

and local leaders can use this information to 

better serve their maternal and child populations in need.
64 STATE DATA CHILD HEALTH USA 2012

*CHIP and Medicaid enrollment data are for Fiscal Year (FY) 2011 (October 2010 through September 2011). Income thresholds for eligibility and data on enrollment processes reflect rules in effect as of January 1, 2011.

**Programs may be an expansion of Medicaid (M), a separate CHIP program (S), or a combination (C).

†

Income eligibility levels may refer to either gross or net income depending on state and reflect the highest eligibility level in the state using CHIP/Medicaid funds. ◊ Presumptive eligibility provides immediate but temporary benefits for applicants who appear to meet eligibility requirements but have not yet been officially approved; in some States, this is only available for certain 

populations (e.g., infants).

Children’s Health Insurance Program (CHIP) and Medicaid Enrollment and Eligibility, 2011*

Source (IV.1, IV.2): Centers for Medicare and Medicaid Services, CHIP Statistical Enrollment Data System; Kaiser Commission on Medicaid and the Uninsured

State Medicaid 

Enrollment

CHIP Enrollment 

(program type**)

Upper

Eligibility†

Presumptive 

Eligibility◊

Medicaid

Presumptive 

Eligibility◊

CHIP

Total 35,571,506 7,970,879

Alabama 866,094 109,255 (S) 300% N N

Alaska 79,286 12,787 (M) 175% N n/a

Arizona 947,977 20,043 (S) 200% N N

Arkansas 410,602 103,693 (M) 200% N n/a

California 4,565,016 1,763,831 (C) 250% Y Y

Colorado 453,719 105,255 (S) 250% Y Y

Connecticut 301,545 20,072 (S) 300% Y N

Delaware 93,598 15,348 (C) 200% N N

District of Columbia 106,500 8,675 (M) 300% N n/a

Florida 2,019,075 431,717 (C) 200% N N

Georgia 1,168,338 248,536 (S) 235% N N

Hawaii 140,150 30,584 (M) 300% N n/a

Idaho 178,249 42,604 (C) 185% N N

Illinois 2,178,950 336,885 (C) 200% Y Y

Indiana 698,383 158,138 (C) 250% N N

Iowa 306,158 75,133 (C) 300% Y Y

Kansas 215,703 60,431 (S) 241% Y Y

Kentucky 478,670 84,551(C) 200% N N

Louisiana 671,651 152,404 (C) 250% N N

Maine 142,931 32,994 (C) 200% N N

Maryland 465,409 119,906 (M) 300% N n/a

Massachusetts 500,534 144,767 (C) 300% Y Y

Michigan 1,205,449 83,004 (C) 200% Y Y

Minnesota 495,509 4,461 (M) 275% N n/a

Mississippi 468,183 91,470 (S) 200% N N

State Medicaid 

Enrollment

CHIP Enrollment 

(program type**)

Upper

Eligibility†

Presumptive 

Eligibility◊

Medicaid

Presumptive 

Eligibility◊

CHIP

Missouri 566,293 96,014 (C) 300% Y N

Montana 76,514 24,365 (C) 250% Y Y

Nebraska 166,277 52,852 (M) 200% N n/a

Nevada 236,360 29,760 (S) 200% N N

New Hampshire 96,625 10,801(C) 300% Y N

New Jersey 639,764 198,283 (C) 350% Y Y

New Mexico 380,373 9,635 (M) 235% Y n/a

New York 2,124,322 552,068 (S) 400% Y Y

North Carolina 1,194,999 254,460 (C) 200% N N

North Dakota 48,486 7,112 (C) 160% N N

Ohio 1,214,287 280,650 (M) 200% Y n/a

Oklahoma 507,378 120,501 (M) 185% N n/a

Oregon 385,131 112,165 (S) 300% N N

Pennsylvania 1,300,042 272,492 (S) 300% N N

Rhode Island 110,208 24,815 (M) 250% N n/a

South Carolina 501,025 72,084 (M) 200% N n/a

South Dakota 47,469 16,623 (C) 200% N N

Tennessee 792,302 96,028 (C) 250% N N

Texas 3,471,310 972,715 (S) 200% N N

Utah 247,298 59,698 (S) 200% N N

Vermont 72,826 7,054 (S) 300% N N

Virginia 625,438 182,128 (C) 200% N N

Washington 764,662 43,364 (S) 300% N N

West Virginia 249,203 37,631 (S) 250% N N

Wisconsin 537,093 172,451 (M) 300% Y n/a

Wyoming 59,142 8,586 (S) 200% N N
 CHILD HEALTH USA 2012 STATE DATA 65

State Children Eligible for EPSDT

through Medicaid/CHIP* EPSDT Participation Ratio**

Alabama 559,430 54%

Alaska 90,258 55%

Arizona 805,482 65%

Arkansas 417,502 46%

California 4,697,466 88%

Colorado 420,327 56%

Connecticut† 300,731 65%

Delaware 101,208 59%

District of Columbia 91,341 81%

Florida 2,035,073 66%

Georgia 1,206,083 51%

Hawaii 152,235 76%

Idaho 180,096 47%

Illinois 1,631,168 77%

Indiana 772,155 50%

Iowa 299,743 81%

Kansas 245,034 14%

Kentucky 541,565 57%

Louisiana 809,804 71%

Maine 145,543 43%

Maryland 591,820 63%

Massachusetts 615,599 75%

Michigan 1,247,782 50%

Minnesota 465,712 72%

Mississippi 427,655 42%

Missouri 686,693 73%

EPSDT◊ Eligibility and Utilization among Children Under 21, FY 2010

Source (IV.3): Centers for Medicare and Medicaid Services. Annual EPSDT Participation Report and Medicaid Statistical Information System.

◊

Early and Periodic Screening, Diagnosis, and Treatment Program is the child health component of Medicaid. It is designed to improve the health of low-income children by financing appropriate and necessary pediatric 

services.

*Total unduplicated number of individuals under the age of 21 enrolled in Medicaid or a Children’s Health Insurance Program (CHIP) Medicaid expansion program determined to be eligible for EPSDT services.

**The ratio of eligibles receiving any EPSDT Services to the number of eligibles who should have received such services. †

Data for Connecticut are from 2009.

State Children Eligible for EPSDT

through Medicaid/CHIP* EPSDT Participation Ratio**

Montana 79,443 56%

Nebraska 164,960 92%

Nevada 228,169 68%

New Hampshire 100,381 73%

New Jersey 696,923 62%

New Mexico 374,082 71%

New York 2,150,748 61%

North Carolina 1,115,753 55%

North Dakota 50,372 46%

Ohio 1,379,150 57%

Oklahoma 569,228 56%

Oregon 339,022 63%

Pennsylvania 1,222,852 55%

Rhode Island 111,774 54%

South Carolina 591,865 62%

South Dakota 89,232 51%

Tennessee 880,919 64%

Texas 3,347,025 65%

Utah 212,960 61%

Vermont 62,862 52%

Virginia 653,352 73%

Washington 782,424 64%

West Virginia 219,576 46%

Wisconsin 564,011 74%

Wyoming 59,949 51%
66 STATE DATA CHILD HEALTH USA 2012

Health Insurance Status* of Children Under 18, 2010

Source (IV.4): US Census Bureau, Current Population Survey, Annual Social and Economic Supplement.

*Children may have more than one type of coverage.

**Includes children covered by Medicare, Medicaid, CHIP, state-specific plans, military health insurance, and the Indian Health Service.

State Percent with 

Private Insurance

Percent with 

Public Insurance**

Percent 

Uninsured

Total 59.6% 37.9% 9.8%

Alabama 60.5% 46.7% 7.9%

Alaska 56.4% 46.1% 9.9%

Arizona 53.1% 41.7% 13.4%

Arkansas 52.5% 46.4% 11.5%

California 55.1% 40.8% 10.7%

Colorado 68.9% 30.4% 9.6%

Connecticut 72.0% 21.3% 7.7%

Delaware 64.1% 31.1% 8.8%

District of Columbia 47.4% 54.6% 8.0%

Florida 55.3% 34.2% 17.9%

Georgia 56.7% 36.0% 11.3%

Hawaii 62.6% 44.3% 3.5%

Idaho 63.1% 31.1% 10.2%

Illinois 59.1% 37.0% 9.1%

Indiana 64.3% 38.3% 8.6%

Iowa 69.8% 33.5% 5.9%

Kansas 64.2% 35.0% 8.1%

Kentucky 58.8% 40.3% 8.2%

Louisiana 45.4% 39.9% 8.4%

Maine 65.0% 43.4% 4.0%

Maryland 68.1% 27.4% 7.0%

Massachusetts 73.6% 33.1% 2.9%

Michigan 65.8% 32.5% 5.6%

Minnesota 74.4% 29.6% 5.5%

Mississippi 43.9% 51.6% 10.9%

State Percent with 

Private Insurance

Percent with 

Public Insurance**

Percent 

Uninsured

Missouri 67.2% 35.0% 9.7%

Montana 60.7% 35.8% 10.4%

Nebraska 66.5% 33.2% 6.7%

Nevada 62.2% 26.9% 13.4%

New Hampshire 82.5% 22.0% 3.8%

New Jersey 69.4% 23.7% 9.2%

New Mexico 47.4% 50.0% 14.0%

New York 60.1% 41.4% 7.5%

North Carolina 50.8% 38.7% 11.8%

North Dakota 73.0% 27.3% 5.9%

Ohio 64.8% 31.3% 8.7%

Oklahoma 56.0% 45.1% 12.6%

Oregon 62.5% 32.4% 11.9%

Pennsylvania 66.1% 32.4% 6.8%

Rhode Island 65.7% 39.9% 6.0%

South Carolina 56.2% 31.4% 12.3%

South Dakota 69.0% 36.4% 8.4%

Tennessee 58.3% 44.9% 6.6%

Texas 47.1% 40.2% 16.5%

Utah 73.0% 20.2% 11.3%

Vermont 63.2% 47.4% 5.6%

Virginia 71.0% 31.2% 7.5%

Washington 55.3% 46.1% 4.8%

West Virginia 63.0% 46.6% 6.2%

Wisconsin 72.5% 32.1% 4.7%

Wyoming 63.7% 32.1% 9.6%
 CHILD HEALTH USA 2012 STATE DATA 67

Health Insurance Status: Percent of Children Aged 18 and Younger Who Are Uninsured, by State, 2010

Source (IV.4): US Census Bureau, Current Population Survey, Annual Social and Economic Supplement.
68 STATE DATA CHILD HEALTH USA 2012

Low Birth Weight and Preterm Birth (Percent), by State and Maternal Race/Ethnicity, 2009

Source (IV.5): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System

*Note: 

NH: Non Hispanic

AI/AN: American Indian/Alaska Native. May include Hispanics.

A/PI: Asian/Pacific Islander; separate estimates for Asians and Native Hawaiians and Other Pacific Islanders were not available. May include Hispanics.

N/A: Figure does not meet standards of reliability or precision; based on fewer than 20 deaths in the numerator.

State

Low Birth Weight (<2,500 grams or 5.5 pounds) Preterm Birth (<37 weeks’ gestation) 

Total NH* 

White

NH* 

Black

HispanicAI/

AN* A/PI* Total NH* White

NH* 

Black

Hispanic AI/AN* A/PI*

United States 8.2 7.2 13.6 6.9 7.3 8.3 12.2 10.9 17.5 12.0 13.5 10.8

Alabama 10.3 8.4 15.3 6.0 10.2 9.0 15.6 13.1 20.6 15.0 18.0 12.6

Alaska 5.9 5.1 13.0 6.2 6.3 5.9 11.0 8.8 17.8 11.4 13.6 11.9

Arizona 7.1 6.9 12.6 6.7 6.3 8.6 12.7 11.9 18.3 12.8 14.3 12.5

Arkansas 8.9 7.6 14.8 6.2 6.1 9.7 13.1 11.9 18.3 11.3 10.7 13.5

California 6.8 6.2 11.8 6.2 6.7 8.0 10.3 9.3 14.3 10.3 11.2 9.9

Colorado 8.8 8.4 13.5 8.4 9.7 10.3 11.3 10.6 14.8 11.9 11.9 12.7

Connecticut 8.0 7.0 11.9 8.5 8.0 9.0 10.2 9.2 13.3 11.2 10.2 10.2

Delaware 8.6 6.8 13.3 6.1 N/A 9.3 12.5 9.9 17.7 12.6 N/A 11.8

DC 10.3 7.0 13.0 7.5 N/A 5.5 14.2 8.7 17.4 13.6 N/A 11.2

Florida 8.7 7.3 13.4 7.1 5.6 8.8 13.5 11.4 18.2 13.3 14.9 12.1

Georgia 9.4 7.5 13.5 6.4 9.3 8.4 13.8 11.6 17.7 12.0 11.5 11.5

Hawaii 8.4 6.8 12.7 9.2 N/A 8.9 12.6 10.0 14.6 12.8 10.5 13.6

Idaho 6.5 6.1 8.0 8.2 7.0 10.2 10.1 9.4 12.4 13.1 13.3 10.5

Illinois 8.4 7.1 14.1 6.8 11.5 9.2 12.4 10.9 17.9 12.0 16.4 10.6

Indiana 8.3 7.7 13.8 6.8 N/A 9.1 11.9 11.1 17.0 11.8 8.5 11.8

Iowa 6.7 6.5 12.4 5.9 N/A 7.4 11.3 10.9 17.0 11.2 9.8 11.1

Kansas 7.3 6.8 12.9 6.4 6.7 9.1 11.2 10.6 16.6 10.9 11.0 12.5

Kentucky 8.9 8.5 13.9 7.3 13.4 7.8 13.6 13.2 18.2 13.5 19.5 10.7

Louisiana 10.6 8.2 14.7 7.0 10.6 8.8 14.7 12.0 19.3 11.1 13.3 11.8

Maine 6.3 6.3 4.3 10.6 N/A 5.5 9.9 9.9 11.2 9.6 N/A 9.3

Maryland 9.1 7.1 13.0 6.6 8.0 8.4 12.7 10.5 16.4 12.4 11.9 10.5

Massachusetts 7.8 7.2 10.9 8.6 6.4 7.7 10.9 10.3 14.0 11.5 15.1 10.3

Michigan 8.4 7.0 13.8 6.5 6.8 9.3 12.4 11.1 18.0 11.0 11.8 11.3

Minnesota 6.5 6.0 10.1 5.8 7.5 7.6 10.1 9.8 12.2 9.6 14.2 9.7

Mississippi 12.2 9.1 16.4 6.9 10.0 6.9 18.0 14.5 22.3 14.2 21.5 12.1

State

Low Birth Weight (<2,500 grams or 5.5 pounds) Preterm Birth (<37 weeks’ gestation) 

Total NH* 

White

NH* 

Black

HispanicAI/

AN* A/PI* Total NH* White

NH* 

Black

Hispanic AI/AN* A/PI*

Missouri 8.1 7.0 14.2 6.9 8.3 7.4 12.2 10.9 18.5 13.1 12.0 10.8

Montana 7.1 7.2 N/A 6.4 6.9 N/A 10.9 10.5 N/A 9.2 13.9 N/A

Nebraska 7.1 6.5 13.2 7.0 9.7 9.9 11.5 10.8 16.7 12.6 12.6 12.9

Nevada 8.1 7.7 13.9 6.7 8.3 9.5 13.8 12.2 19.4 13.6 13.5 15.9

New Hampshire 6.9 6.7 9.2 8.9 N/A 8.3 9.9 9.7 18.5 10.9 N/A 9.4

New Jersey 8.3 7.2 13.1 7.1 6.7 8.6 12.0 10.6 16.7 12.3 12.9 9.9

New Mexico 8.3 7.8 16.8 8.4 7.8 8.9 12.3 10.4 18.9 12.6 14.5 11.4

New York 8.2 6.9 12.9 7.8 7.5 7.6 12.2 10.4 16.8 13.1 11.4 10.6

North Carolina 9.0 7.5 14.3 6.4 11.3 8.5 13.0 11.3 17.6 12.1 15.0 11.1

North Dakota 6.4 6.1 N/A 6.7 8.8 N/A 10.6 10.0 13.6 9.9 15.3 6.9

Ohio 8.6 7.5 14.0 7.4 8.0 8.1 12.3 11.1 17.9 12.7 11.5 10.7

Oklahoma 8.4 8.1 14.4 6.7 7.1 8.0 13.8 13.2 19.3 13.3 13.8 12.2

Oregon 6.3 6.1 10.0 6.2 6.5 7.3 9.8 9.6 11.6 10.3 10.0 10.0

Pennsylvania 8.3 7.2 13.3 9.1 10.4 7.9 11.5 10.3 16.1 13.0 14.9 9.9

Rhode Island 8.0 7.4 10.5 7.8 7.9 9.7 11.4 10.2 15.5 12.3 14.0 12.7

South Carolina 10.0 7.9 14.7 6.6 5.8 8.4 14.5 12.4 19.0 12.4 18.0 11.3

South Dakota 5.8 5.6 12.2 5.9 5.7 9.2 10.9 10.0 18.6 13.4 13.7 13.7

Tennessee 9.2 8.1 13.8 6.4 7.5 8.8 13.0 11.7 17.6 11.7 12.3 11.6

Texas 8.5 7.8 14.2 7.6 7.8 9.1 13.1 11.8 17.6 13.1 12.8 11.3

Utah 7.0 6.7 9.1 7.6 7.3 9.2 11.3 10.6 17.0 13.6 14.5 13.7

Vermont 6.7 6.7 N/A N/A N/A N/A 9.3 9.2 N/A 12.8 N/A 10.8

Virginia 8.4 7.1 13.1 6.2 N/A 7.8 11.4 10.0 15.4 11.2 7.8 11.0

Washington 6.3 5.9 10.3 5.9 7.0 7.3 10.3 9.5 13.3 11.2 14.1 11.0

West Virginia 9.2 9.0 14.7 6.1 N/A N/A 12.9 12.7 18.7 8.7 N/A 9.6

Wisconsin 7.1 6.3 14.2 6.1 5.2 7.3 10.9 9.9 17.5 11.8 10.8 10.2

Wyoming 8.4 7.9 N/A 10.4 9.8 12.7 11.2 10.7 N/A 13.1 14.2 15.8
 CHILD HEALTH USA 2012 STATE DATA 69

State Total NonHispanic 

White

Non-Hispanic 

Black

Hispanic American Indian/ 

Alaska Native*

Asian/ Pacific 

Islander†

Rate Ratio: NonHispanic Black to 

Non-Hispanic White

United States 6.68 5.58 13.11 5.50 8.65 4.62 2.35

Alabama 9.47 7.67 13.73 7.50 N/A N/A 1.79

Alaska 6.54 4.10 N/A N/A 12.24 N/A N/A

Arizona 6.54 6.04 14.85 6.13 7.57 6.54 2.46

Arkansas 7.89 6.70 13.53 5.71 N/A N/A 2.02

California 5.12 4.51 10.72 4.88 7.05 4.30 2.38

Colorado 6.04 5.13 11.97 6.96 N/A 4.90 2.33

Connecticut 6.27 4.80 13.11 6.35 N/A 5.73 2.73

Delaware 8.03 5.89 13.46 7.10 N/A N/A 2.29

DC 11.97 4.46 17.68 N/A N/A N/A 3.96

Florida 7.21 5.71 12.83 5.38 N/A 5.75 2.25

Georgia 8.02 5.87 12.70 5.06 N/A 4.37 2.16

Hawaii 6.04 4.58 18.54 4.98 N/A 6.27 4.05

Idaho 6.46 5.95 N/A 7.91 N/A N/A N/A

Illinois 7.10 5.70 13.45 5.91 N/A 5.31 2.36

Indiana 7.44 6.47 15.36 6.28 N/A N/A 2.37

Iowa 5.43 5.06 11.10 6.61 N/A N/A 2.19

Kansas 7.50 6.94 14.62 7.15 N/A 5.36 2.11

Kentucky 7.04 6.62 12.13 5.07 N/A N/A 1.83

Louisiana 9.38 6.62 13.88 3.92 N/A 7.19 2.10

Maine 6.04 5.90 N/A N/A N/A N/A N/A

Maryland 7.98 5.50 12.98 5.33 N/A 5.33 2.36

Massachusetts 4.94 4.04 10.90 6.08 N/A 3.06 2.70

Michigan 7.56 5.87 14.70 7.09 N/A 4.89 2.50

Minnesota 5.55 4.77 11.33 4.64 10.25 5.65 2.38

Mississippi 10.16 7.07 13.82 6.64 N/A N/A 1.95

Infant Mortality by State and Maternal Race/Ethnicity, 2008

Source (IV.6): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System

*May include Hispanics. †

Separate estimates for Asians and Native Hawaiians and Other Pacific Islanders were not available. May include Hispanics.

N/A: Figure does not meet standards of reliability or precision; based on fewer than 20 deaths in the numerator

State Total NonHispanic 

White

Non-Hispanic 

Black

Hispanic American Indian/ 

Alaska Native*

Asian/ Pacific 

Islander†

Rate Ratio: NonHispanic Black to 

Non-Hispanic White

Missouri 7.34 6.18 14.49 5.12 N/A 4.02 2.34

Montana 6.47 5.89 N/A N/A 9.22 N/A N/A

Nebraska 5.93 5.33 12.98 5.21 N/A N/A 2.44

Nevada 6.10 5.29 12.54 5.69 N/A 4.96 2.37

New Hampshire 5.10 5.00 N/A N/A N/A N/A N/A

New Jersey 5.35 3.78 12.06 5.12 N/A 2.90 3.19

New Mexico 5.81 6.12 N/A 5.60 5.70 N/A N/A

New York 5.57 4.29 11.29 5.01 N/A 3.35 2.63

North Carolina 8.29 6.17 14.62 6.32 15.37 5.62 2.37

North Dakota 6.44 5.63 N/A N/A 12.27 N/A N/A

Ohio 7.74 6.25 15.03 6.88 N/A 4.59 2.40

Oklahoma 7.85 7.52 13.91 5.09 8.36 5.64 1.85

Oregon 5.41 5.22 10.16 5.36 9.34 4.78 1.95

Pennsylvania 7.52 5.78 14.04 7.94 N/A 6.06 2.43

Rhode Island 6.47 4.28 10.56 7.77 N/A N/A 2.47

South Carolina 8.30 6.04 12.97 5.87 N/A 5.32 2.15

South Dakota 7.15 5.59 N/A N/A 13.00 N/A N/A

Tennessee 8.37 6.54 15.36 6.47 N/A 5.78 2.35

Texas 6.22 5.48 11.69 5.61 7.47 4.16 2.13

Utah 4.94 4.73 N/A 5.03 N/A 7.10 N/A

Vermont 5.12 4.95 N/A N/A N/A N/A N/A

Virginia 7.24 5.48 13.40 5.97 N/A 4.74 2.45

Washington 5.01 4.33 7.66 5.28 9.15 4.26 1.77

West Virginia 7.38 7.11 14.93 N/A N/A N/A 2.10

Wisconsin 6.57 5.37 15.14 6.34 9.92 6.84 2.82

Wyoming 7.05 6.32 N/A 7.90 N/A N/A N/A
70 CHILD HEALTH USA 2012

RURAL AND URBAN DATA

The following section compares rural to ur-

ban residence for several infant health indicators. 

In 2009, 15.2 percent of births were to mothers 

who resided in rural or non-metropolitan coun-

ties. Rural counties tend to be disadvantaged in 

a variety of areas, including poorer health care 

access, greater poverty, and higher rates of in-

jury and smoking, which may affect maternal 

and infant health.88

,89 These comparisons of low 

birth weight, preterm birth, and infant mortal-

ity indicate that the health status of infants liv-

ing in rural counties, and especially small rural 

counties, is generally poorer than that of infants 

in urban or metropolitan counties. For exam-

ple, in 2008, the rate of postneonatal mortality 

(deaths from 1 month to under 1 year) was 27 

percent higher in small rural counties than ur-

ban counties (2.84 versus 2.23 deaths per 1,000 

live births, respectively).
 CHILD HEALTH USA 2012 RURAL AND URBAN DATA 71

LOW BIRTH WEIGHT AND 

PRETERM BIRTH

Disorders related to low birth weight (LBW) 

and preterm birth (PTB) are a leading cause of 

infant mortality in the United States, and particularly neonatal mortality (deaths within the 

first month of life). The causes of LBW and 

PTB are not fully known, but have been linked 

to maternal smoking and substance use, chronic 

conditions, and infections (see pages on Low 

Birth Weight and Preterm Birth). 

In 2009, 8.31 percent of infants residing in 

small rural counties were LBW (weighing less 

than 2,500 grams, or 5.5 pounds). This was 

slightly higher than the LBW rate among residents of urban or large rural counties (8.15 and 

8.16 percent, respectively). The greater rate of 

LBW for residents of small rural counties was 

due entirely to a greater proportion of infants 

born at moderately LBW (from 1,500 grams 

or 3.25 pounds to less than 2,500 grams or 5.5 

pounds) as opposed to very LBW (less than 

1,500 grams or 3.25 pounds). The proportion 

of infants born at moderately LBW was highest among infants both in small rural counties 

(6.91 percent), followed by those in large rural 

counties (6.77 percent), and was lowest among 

those in urban counties (6.69 percent). However, the difference between small rural and urban 

counties was less than 5 percent. 

Similar to LBW, there were small differences 

in PTB (delivering at less than 37 weeks’ completed gestation) by rural and urban residence. 

These differences were largely confined to infants born at the late preterm range of 34 to 36 

weeks’ gestation. Late PTB, for example, ranged 

from 8.63 percent among infants born to residents of urban counties to 8.98 percent among 

those in small rural counties; however, this difference was less than 5 percent. Though not at 

highest risk, late preterm and moderately LBW 

infants are still at elevated risk for mortality and 

morbidity particularly for developmental delays, compared to their term and normal birth 

weight counterparts.90,91

Low Birth Weight (LBW),* by Rural/Urban Residence,** 2009

Source (V.1): Centers for Disease Control and Prevention, National Center for

Health Statistics, National Vital Statistics System Percent of Live Births

Preterm Birth (PTB),* by Rural/Urban Residence,** 2009

Source (V.1): Centers for Disease Control and Prevention, National Center for

Health Statistics, National Vital Statistics System

*Low birth weight, <2,500 grams or 5.5 pounds; moderately low birth weight, 1,500 to 2,499 grams or 3.25

to 5.5 pounds; very low birth weight, <1,500 grams or 3.25 pounds. **Urban includes all metropolitan

counties regardless of size, large rural includes non-metropolitan counties with a city of 10,000 or more

residents, small rural includes non-metropolitan counties without a city of 10,000 or more residents; follows

the National Center for Health Statistics’ Urban-Rural Classification Scheme for Counties.

*Preterm birth, <37 weeks’ gestation; late preterm birth, 34-36 weeks’ gestation; moderately preterm birth,

32-33 weeks’ gestation; very preterm birth, <32 weeks’ gestation. **Urban includes all metropolitan

counties regardless of size, large rural includes non-metropolitan counties with a city of 10,000 or more

residents, small rural includes non-metropolitan counties without a city of 10,000 or more residents; follows

the National Center for Health Statistics’ Urban-Rural Classification Scheme for Counties.

Very LBW

Moderately LBW

Total LBW

4

8

12

16

20

Urban Large Rural Small Rural

1.46 1.39 1.40

6.69

8.15

6.77 6.91

8.16 8.31

Percent of Live Births

66.1

55.9

78.9

4

8

12

16

20

Urban Large Rural Small Rural

1.96 2.0 2.01

1.54

8.63

12.13

8.78

12.58

1.54

12.32

8.98

Very PTB

Moderately PTB

Total PTB

Late PTB

1.89
72 RURAL AND URBAN DATA CHILD HEALTH USA 2012

INFANT MORTALITY

In 2008, 4,662 infants born to residents of 

rural or non-metropolitan counties died in the 

first year of life. The infant mortality rate was 

higher in small and large rural counties (7.31 

and 7.10 deaths per 1,000 live births, respectively) than in urban counties (6.51 per 1,000). 

Although the infant mortality rate in rural counties was higher than urban counties in both the 

neonatal (<28 days) and postneonatal periods 

(28 to 364 days), disparities were only significant in the postneonatal period. For example, 

postneonatal mortality was 27 percent higher in 

small rural counties than urban counties, while 

neonatal mortality was only 5 percent higher. 

The major causes of postneonatal mortality include sudden infant death syndrome (SIDS), 

congenital anomalies, injury, and infection.92

These causes may be addressed through improved education for safe sleep practices and 

injury prevention as well as improved access to 

health care. SIDS and infection have also been 

associated with environmental tobacco smoke 

exposure,93 and smoking has been shown to be 

higher in rural areas.94

Infant, Neonatal, and Postneonatal Mortality Rates,* by Rural/Urban Residence,** 2008

Source (V.1): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital

Statistics System Rate per 1,000 Live Births

*Infant deaths are under 1 year; neonatal deaths are under 28 days; postneonatal deaths are between 28 days and under 1 year. **Urban

includes all metropolitan counties regardless of size, large rural includes non-metropolitan counties with a city of 10,000 or more residents,

small rural includes non-metropolitan counties without a city of 10,000 or more residents; follows the National Center for Health Statistics’

Urban-Rural Classification Scheme for Counties.

Infant

Postneonatal

Neonatal

2

4

6

8

10

Urban Large Rural Small Rural

4.27 4.37 4.47

2.23

2.73 2.84

6.51

7.10 7.31
 CHILD HEALTH USA 2012 ENDNOTES 73

ENDNOTES

Population Characteristics

1. DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith, U.S. Census Bureau, Current Population 

Reports, P60-239, Income, Poverty, and Health Insurance 

Coverage in the United States: 2010, U.S. Government 

Printing Office, Washington, DC, 2011.

2. US Department of Agriculture, Food and Nutrition 

Service. Child nutrition tables: National Level Annual 

Summary Tables. Retrieved from: http://www.mypyramidforkids.gov/pd/cnpmain.htm. Accessed: March 26, 

2012.

3. Cherry DC, Huggins B, Gilmore K. Children’s health in 

the rural environment. Pediatric Clinics of North America 

54 (2007):121-133. 

4. Johnston LD, O’Malley PM, Bachman JG, Schulenberg 

JE. (2009) Monitoring the Future: National Survey 

Results on Drug Use, 1975-2008. (NIH Publication No. 

09-7402.) Bethesda, MD: National Institute on Drug 

Abuse. 

5. Maine Rural Health Research Center. Research and Policy 

Brief. Substance Abuse Among Rural Youth: A Little 

Meth and a Lot of Booze. Retrieved from: http://muskie.

usm.maine.edu/Publications/rural/pb35a.pdf. Accessed: 

September 9, 2012.

6. 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. Retrieved from: http://rhr.

sph.sc.edu/report/SCRHRC_KF_DietandPhysicalActivity.pdf. Accessed: September 9, 2012.

7. Probst JC, Laditka SH, Wang J-Y, Johnson AO. Effects 

of residence and race on burden of travel for care: cross 

sec¬tional analysis of the 2001 US National Household 

Travel Survey. BMC Health Serv Res 2007 Mar 9;7-40.

8. Status completion rates include individuals who are not 

enrolled in high school and who have earned a high 

school diploma or an alternative credential, including a 

GED certificate.

9. National Center for Education Statistics. The Nation’s 

Report Card: Mathematics 2011 (NCES 2012–458). 

Institute of Education Sciences, U.S. Department of 

Education, Washington, D.C.

10. Martin, JA, Hamilton BE, Ventura SJ, Osterman, MK, 

Wilson, EC, Mathews, TJ. Births: Final data for 2010. 

National vital statistics reports; vol 61 no 1. Hyattsville, 

MD: National Center for Health Statistics. 2012.

11. Mathews TJ, Hamilton BE. Delayed childbearing: More 

women are having their first child later in life. NCHS 

data brief, no 21. Hyattsville, MD: National Center for 

Health Statistics. 2009

12. Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final 

data for 2009. National vital statistics reports; vol 60 no 

1. Hyattsville, MD: National Center for Health Statistics. 

2011.

13. McPherson M, Arango P, Fox H, et al. A new definition 

of children with special health care needs. Pediatrics. 

1998;102(1): 137–139. 

Health Status

14. March of Dimes. Low Birth Weight. Retrieved from: 

http://www.marchofdimes.com/professionals/medicalresources_lowbirthweight.html. Accessed: July 2, 2012.

15. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et 

al. Births: Final data for 2006. National vital statistics 

reports; vol 57 no 7. Hyattsville, MD: National Center 

for Health Statistics. 2009.

16. Wise PH. The anatomy of a disparity in infant mortality. 

Annu Rev Public Health. 2003;24:341-62.

17. Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Prematurity. 

November 2009. Retrieved from: http://www.cdc.gov/

Features/PrematureBirth/. Accessed: March 2, 2011.

18. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet. 2008 Jan 

5;371(9606):75-84.

19. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine 

D, et al. Breastfeeding and maternal and infant health 

outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007(153):1-186. 

20. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare 

D, Schanler RJ, et al. Breastfeeding and the use of human 

milk. Pediatrics. 2005;115(2):496-506.

21. Li R, Darling N, Maurice E, Barker L, Grummer-Strawn 

LM. Breastfeeding rates in the United States by characteristics of the child, mother, or family: the 2002 National 

Immunization Survey. Pediatrics. 2005;115(1):e31-37

22. US Department of Health and Human Services. Healthy 

People 2020. Retrieved from: www.healthypeople.gov. 

Accessed: May 3, 2012.

23. Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Pregnancy Mortality Surveillance System. 

Pregnancy-Related Mortality in the U.S. Retrieved 

from: http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/Pregnancy-relatedMortality.htm#data. 

Accessed March 2, 2012.

24. Singh GK. Maternal Mortality in the United States, 

1935-2007. Rockville, MD: US Department of Health 

and Human Services; 2010.

25. Berg CJ, Callaghan WM, Syverson C, Henderson Z. 

Pregnancy-related mortality in the United States, 1998-

2005. Obstet Gynecol. 2010;116:1302-1309. 

26. Koonin LM, MacKay AP, Berg CJ, Atrash HK, Smith JC. 

Pregnancy-related mortality surveillance -- United States, 

1987-1990. CDC surveillance summaries (Aug 1997). 

MMWR 1997;46(No. SS-4):17-36.

27. Centers for Disease Control and Prevention. Quick Stats: 

Leading Causes of Neonatal and Postneonatal Deaths — 

United States, 2002. MMWR. 2005; 54(38):966.

28. Murphy SL, Xu JQ, Kochanek KD. Deaths: Preliminary 

Data for 2010. National Vital Statistics Reports; vol 

60 no 4. Hyattsville, MD: National Center for Health 

Statistics. 2012.
74 ENDNOTES CHILD HEALTH USA 2012

29. 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;106:1307-17.

30. Centers for Disease Control and Prevention. Advancements in public health, 1900-1999: healthier mothers and 

babies. MMWR. 1999; 48:849-58.

31. 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.

32. Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final 

data for 2009. National vital statistics reports; vol 60 no 

1. Hyattsville, MD: National Center for Health Statistics. 

2011.

33. 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.

34. 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.

35. Mathews TJ, MacDorman, MF. Infant Mortality Statistics 

from the 2008 Period Linked Birth/Infant Death Data 

Set. National Vital Statistics Reports; vol 60 no 5. Hyattsville, MD: National Center for Health Statistics. 2012.

36. MacDorman MF and Mathews TJ. Behind international 

rankings of infant mortality: how the US compares with 

Europe. Int J Health Serv. 2010;40(4):577-88.

37. MacDorman, MF, and Mathews, TJ. Recent Trends in 

Infant Mortality in the United States. NCHS Data Brief 

No. 9. National Center for health Statistics, Hyattsville, 

MD, 2008.

38. Centers for Disease Control and Prevention. Mumps 

Outbreaks. Retrieved from: http://www.cdc.gov/mumps/

outbreaks.html. Accessed: April 30, 2012.

39. Centers for Disease Control and Prevention. One Test 

Two Lives. HIV Screening for Prenatal Care. Retrieved 

from: http://www.cdc.gov/Features/1Test2Lives/. Accessed May 5, 2012

40. 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. Retrieved from: http://www.

childwelfare.gov/can/factors/contribute.cfm. Accessed: 

May 18, 2012.

41. 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.

42. Widom CS and Maxfield MG. An update on the ‘cycle of 

violence’ research in brief. Retrieved from: https://www.

ncjrs.gov/pdffiles1/nij/184894.pdf. Accessed: May 18, 

2012.

43. Currie J and CS Widom. Long-term consequences of 

child abuse and neglect on adult economic well-being. 

Child Maltreatment, 2010; 15 (2):111–120.

44. 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.

45. Murphy SL, Xu JQ, Kochanek KD. Deaths: Final data for 

2010. National vital statistics reports; vol 61 no 4. Hyattsville, MD: National Center for Health Statistics. 2012.

46. Centers for Disease Control and Prevention, National 

Center for Health Statistics. Compressed Mortality File 

1999-2009. Retrieved from: http://wonder.cdc.gov/cmficd10.html. Accessed: August 23, 2012.

47. Centers for Disease Control and Prevention (CDC). Vital 

signs: Unintentional injury deaths among persons aged 

0-19 years - United States, 2000-2009. Morbidity and 

Mortality Weekly Report. 2012 Apr 20;61:270-6.

48. Centers for Disease Control and Prevention, National 

Center for Injury Prevention and Control. Web-based 

Injury Statistics Query and Reporting System (WISQARS). Retrieved from: http://www.cdc.gov/injury/wisqars. 

Accessed: August 23, 2012. 

49. Centers for Disease Control and Prevention. Smoking and 

Tobacco Use: Secondhand Smoke Facts. Retrieved from: 

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/

secondhand_smoke/general_facts/index.htm. Accessed: 

August 30, 2012.

50. Children and Secondhand Smoke Exposure – Excerpts 

from The Health Consequences of Involuntary Exposure 

to Tobacco Smoke: A Report of the Surgeon General, 

2007. Retrieved from: http://www.surgeongeneral.gov/

library/reports/smokeexposure/index.html. Accessed: 

August 30, 2012.

51. Environmental Protection Agency. Americas Children and 

the Environment: Background. Retrieved from: http://

www.epa.gov/envirohealth/children/basic_info/background.html. Accessed: September 4, 2012.

52. National Institute of Environmental Health Sciences. 

Children’s Health. Retrieved from: http://www.niehs.nih.

gov/health/topics/population/children/#geninfo. Accessed: September 4, 2012.

53. U.S. Environmental Protection Agency. America’s Children and the Environment, Third Edition (forthcoming). 

Retrieved from: www.epa.gov/ace.

54. Martinez G, Copen CE, Abma JC. Teenagers in the 

United States: Sexual activity, contraceptive use, and 

childbearing, 2006–2010 National Survey of Family 

Growth. National Center for Health Statistics. Vital 

Health Stat 23(31). 2011.

55. Centers for Disease Control and Prevention (CDC). 

Sexual experience and contraceptive use among female 

teens - United States, 1995, 2002, and 2006-2010. 

Morbidity and Mortality Weekly Report. 2012 May 

4;61(17):297-301.

56. Centers for Disease Control and Prevention. Sexually 

Transmitted Diseases (STD). CDC Fact Sheets. Retrieved 

from: Available at http://www.cdc.gov/std/healthcomm/

fact_sheets.htm. Accessed: August 31, 2012.
 CHILD HEALTH USA 2012 ENDNOTES 75

57. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and 

prevalence estimates, 2000. Perspect Sex Reprod Health. 

2004:36(1):6-10.

58. Centers for Disease Control and Prevention. Human 

Papillomavirus (HPV). HPV and Cancer. Retrieved from: 

http://www.cdc.gov/hpv/cancer.html. Accessed: August 

31, 2012.

59. Hariri S, Unger ER, Sternberg M, Dunne EF, Swan D, 

Patel S, et al. Prevalence of genital human papillomavirus 

among females in the United States, the National Health 

and Nutrition Examination Survey, 2003–2006. J Infect 

Dis. 2011; 204(4):566-73.

60. Centers for Disease Control and Prevention. Sexually 

Transmitted Disease Surveillance 2010. Atlanta: U.S. 

Department of Health and Human Services; 2011. 

61. Centers for Disease Control and Prevention. National 

and state vaccination coverage among adolescents aged 

13 through 17 years—United States, 2010. MMWR 

2011;60:1117–23

62. Centers for Disease Control and Prevention. HIV Among 

Youth. Retrieved from: http://www.cdc.gov/hiv/youth/. 

Accessed: May 20, 2012.

63. Centers for Disease Control and Prevention. HIV Surveillance Report, 2010; Retrieved from: http://www.cdc.gov/

hiv/surveillance/resources/reports/2010report/index.htm. 

Accessed: May 20, 2012.

64. U.S. Department of Health and Human Services. 2008 

Physical Activity Guidelines for Americans. Retrieved 

from http://www.health.gov/paguidelines/. Accessed: June 

20, 2012.

65. Committee on Public Education. Children, Adolescents, 

and Television. Pediatrics. 2001;107(2):423-426.

66. U.S. Department of Agriculture and U.S. Department 

of Health and Human Services. Dietary Guidelines for 

Americans, 2010. Retrieved from: http://www.cnpp.usda.

gov/DietaryGuidelines.htm. Accessed: August 9, 2012.

67. Does not include diet soda or diet pop.

68. Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug 

Use and Health: Mental Health Findings, NSDUH Series 

H-42, HHS Publication No. (SMA) 11-4667. Rockville, 

MD: Substance Abuse and Mental Health Services 

Administration, 2012.

69. Centers for Disease Control and Prevention, National 

Center for Injury Prevention and Control. Retrieved 

from: http://www.cdc.gov/injury/wisqars/index.html. 

Accessed: July 2012. 

70. Centers for Disease Control and Prevention, National 

Center for Injury Prevention and Control. Retrieved 

from: http://www.cdc.gov/injury/wisqars/index.html. 

Accessed: June 2012. 

71. U.S. Department of Health and Human Services. Stop 

Bullying. Retrieved from: http://www.stopbullying.gov/

index.html. Accessed: August 2012.

72. U.S. Department of Health and Human Services. 

Preventing Tobacco Use Among Youth and Young Adults: 

A Report of the Surgeon General. Atlanta, GA: 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, 2012.

73. Johnston, L. D., O’Malley, P. M., Bachman, J. G., 

& Schulenberg, J. E. (2012). Monitoring the Future 

national results on adolescent drug use: Overview of key 

findings, 2011. Ann Arbor: Institute for Social Research, 

The University of Michigan.

74. Centers for Disease Control and Prevention, National 

Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). 

Retrieved from: http://wonder.cdc.gov/injury/wisqars.

Accessed: October 23, 2012.

75. Centers for Disease Control and Prevention (CDC). Vital 

signs: Unintentional injury deaths among persons aged 

0-19 years - United States, 2000-2009. Morbidity and 

Mortality Weekly Report. 2012 Apr 20;61:270-6.

76. Houtrow A, Jones JR, Ghandour R, Strickland B, Newacheck P. Participation of Children with Special Health 

Care Needs in School and the Community. Academic 

Pediatrics. 12(4): 326-34.

Health Services Financing and Utilization

77. Public or Government health insurance includes federal 

programs such as Medicare, Medicaid, and military health 

care; the Children’s Health Insurance Program (CHIP); 

and individual state health plans.

78. Centers for Disease Control and Prevention (CDC). 

Achievements in public health, 1900–1999: Control of 

infectious diseases. MMWR. 1999 Jul 30;48(29):621-9.

79. 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.

80. Centers for Disease Control and Prevention (CDC). HPV 

Vaccination. Retrieved from: http://www.cdc.gov/vaccines/vpd-vac/hpv/default.htm. Accessed: July 5, 2012.

81. National Committee for Quality Assurance. Healthcare 

Effectiveness Data and Information Set (HEDIS) 2012 

technical specifications for health plans. Volume 2. 

Washington, DC: National Committee for Assurance; 

2011. Retrieved from: http://www.ncqa.org/LinkClick.

aspx?fileticket=O-31v4G27sU%3d&tabid=1415. Accessed: July 5, 2012. 

82. Centers for Disease Control and Prevention, Division 

of Oral Health. Children’s Oral Health. Retrieved from: 

http://www.cdc.gov/OralHealth/topics/child.htm. Accessed: August 30, 2012.

83. American Academy of Pediatric Dentistry. Preventive 

Dentistry. Retrieved from http://www.aapd.org/publications/brochures/ Accessed on 08/30/12.

84. American Academy of Pediatrics. Recommendations for 

Preventive Pediatric Health Care. Retrieved from: http://

brightfutures.aap.org/clinical_practice.html. Accessed: 

September 8, 2012.
76 ENDNOTES CHILD HEALTH USA 2012

85. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University 

Press; 1998

86. National Center for Health Statistics. National Hospital 

Ambulatory Medical Care Survey: 2009 Emergency 

Department Summary Tables.

Retrieved from: http://www.cdc.gov/nchs/fastats/ervisits.

htm. Accessed: September 3, 2012.

87. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et 

al. Births: Final data for 2010. National vital statistics 

reports; vol 61 no 1. Hyattsville, MD: National Center 

for Health Statistics. 2012.

88. National Center for Health Statistics. Health, United 

States, 2001 With Urban and Rural Health Chartbook. 

Hyattsville, Maryland: 2001.

89. National Center for Health Statistics. Health, United 

States, 2011: With Special Feature on Socioeconomic 

Status and Health. Hyattsville, MD. 2012.

90. Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Prematurity. 

November 2011. Retrieved from: http://www.cdc.gov/

Features/PrematureBirth/. Accessed: August 29, 2012.

91. Reichman NE. Low birth weight and school readiness. 

Future Child. 2005 Spring;15(1):91-116.

92. Centers for Disease Control and Prevention. Quick Stats: 

Leading Causes of Neonatal and Postneonatal Deaths — 

United States, 2002. MMWR. 2005; 54(38):966.

93. Klerman L. Protecting children: reducing their environmental tobacco smoke exposure. Nicotine Tob Res. 2004 

Apr; 6 Suppl 2:S239-53.

94. National Center for Health Statistics. Health, United 

States, 2011: With Special Feature on Socioeconomic 

Status and Health. Hyattsville, MD. 2012.
 CHILD HEALTH USA 2012 REFERENCES 77

REFERENCES

Population Characteristics

I.1 U.S. Census Bureau. Statistical Abstract of the United 

States 1996. Retrieved from: http://www.census.gov/

prod/2/gen/96statab/pop.pdf. Accessed: March 26, 

2012. Analyses conducted by the Maternal and Child 

Health Bureau.

I.2 U.S. Census Bureau, Population Division. Intercensal 

Estimates of the Resident Population by Single Year of 

Age, Sex, Race, and Hispanic Origin for the United 

States: April 1, 2000 to July 1, 2010. Retrieved from: 

http://www.census.gov/popest/data/intercensal/national/

nat2010.html. Accessed: March 22, 2012. Analyses 

conducted by the Maternal and Child Health Bureau.

I.3 U.S. Census Bureau, Current Population Survey (CPS) 

Table Creator II for the Annual Social and Economic 

Supplement. Retrieved from: http://www.census.gov/

hhes/www/cpstc/cps_table_creator.html. Accessed: 

March 26, 2012.

I.4 U.S. Census Bureau, Housing and Household Economic 

Statistics Division, Fertility & Family Statistics Branch. 

America’s Families and Living Arrangements: 2010. 

Retrieved from: http://www.census.gov/population/

www/socdemo/hh-fam/cps2010.html. Accessed: March 

27, 2012. 

I.5 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. The 

Health and Well-Being of Children in Rural Areas: A 

Portrait of the Nation 2007. September 2011. Retrieved 

from: http://mchb.hrsa.gov/nsch/07rural/. Accessed: 

September 4, 2012.

I.6 Chapman, C., Laird, J., Ifill, N., and KewalRamani, A. 

Trends in High School Dropout and Completion Rates 

in the United States: 1972–2009 (NCES 2012-006). 

U.S. Department of Education. Washington, DC: National Center for Education Statistics. 2011. Retrieved 

from: http://nces.ed.gov/pubs2012/2012006.pdf. Accessed: March 27, 2012.

I.7 U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 

National Assessment of Educational Progress. Retrieved 

from: http://nces.ed.gov/nationsreportcard/naepdata/. 

Accessed: April 1, 2012.

I.8 Martin, JA, Hamilton BE, Ventura SJ, Osterman, MK, 

Wilson, EC, Mathews, TJ. Births: Final data for 2010. 

National vital statistics reports; vol 61 no 1. Hyattsville, 

MD: National Center for Health Statistics. 2012. 

I.9 Mathews TJ, Hamilton BE. Delayed childbearing: More 

women are having their first child later in life. NCHS 

data brief, no 21. Hyattsville, MD: National Center for 

Health Statistics. 2009

I.10 US Department of Labor, Bureau of Labor Statistics. Employment Characteristics of Families, 2010. 

Retrieved from: http://www.bls.gov/news.release/famee.

htm; Accessed: April 8, 2012.

I.11 Federal Interagency Forum on Child and Family 

Statistics. America’s Children: Key National Indicators of 

Well-Being, 2011. Retrieved from: http://childstats.gov/

americaschildren/index.asp. Accessed: April 8, 2012.

I.12 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 with Special 

Health Care Needs. Unpublished data. Analyzed by the 

Health Resources and Services Administration’s Maternal 

and Child Health Bureau.

Health Status

II.1 Martin, JA, Hamilton BE, Ventura SJ, Osterman, MK, 

Wilson, EC, Mathews, TJ. Births: Final data for 2010. 

National vital statistics reports; vol 61 no 1. Hyattsville, 

MD: National Center for Health Statistics. 2012.

II.2 Martin JA, Hamilton BE, Ventura SJ, et al. Births: 

Final data for 2009. National vital statistics reports; vol 

60 no 1. Hyattsville, MD: National Center for Health 

Statistics. 2011.

II.3 Centers for Disease Control and Prevention. National 

Center for Health Statistics. VitalStats. Retrieved from: 

http://www.cdc.gov/nchs/vitalstats.htm.

Accessed: July 2, 2012.

II.4 Centers for Disease Control and Prevention. Breastfeeding Among U.S. Children Born 1999-2007, CDC 

National Immunization Survey, Data Tables. August 01, 

2011. Retrieved from: http://www.cdc.gov/breastfeeding/data/NIS_data/. Accessed: May 10, 2012.

II.5 Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Pregnancy Mortality Surveillance System. 

Pregnancy-Related Mortality in the U.S. Retrieved 

from: http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/Pregnancy-relatedMortality.htm#data. 

Accessed: March 2, 2012.

II.6 National Center for Health Statistics. Vital statistics 

of the United States, 1993, Vol 11, mortality, part A. 

Hyattsville, MD. 2002.

II.7 Miniño AM, Murphy SL, Xu JQ, Kochanek KD. 

Deaths: Final data for 2008. National Vital Statistics Reports; vol 59 no 10. Hyattsville, MD: National Center 

for Health Statistics. 2011.

II.8 Murphy SL, Xu JQ, Kochanek KD. Deaths: Final Data 

for 2010. National Vital Statistics Reports; vol 61 no 4. 

Hyattsville, MD: National Center for Health Statistics. 

2012.
78 REFERENCES CHILD HEALTH USA 2012

II.9 Mathews TJ, MacDorman, MF. Infant Mortality Statistics from the 2008 Period Linked Birth/Infant Death 

Data Set. National Vital Statistics Reports; vol 60 no 5. 

Hyattsville, MD: National Center for Health Statistics. 

2012.

II.10 Centers for Disease Control and Prevention, National 

Center for Health Statistics. Health, United States, 

2011: With Special Feature on Death and Dying. Retrieved from: http://www.cdc.gov/nchs/hus.htm.

Accessed: May 18, 2012.

II.11 Centers for Disease Control and Prevention. Summary 

of notifiable diseases—United States, 2009. Retrieved 

from: http://www.cdc.gov/mmwr/preview/mmwrhtml/

mm5853a1.htm. Accessed: April 30, 2012.

II.12 Centers for Disease Control and Prevention. HIV 

Surveillance Report, 2010; vol. 22. HIV Surveillance 

Report, Data Tables. Accessed: February 28, 2012. 

II.13 Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. National 

Hospital Discharge Survey, 2010. Unpublished data. 

Analyses conducted by the National Center for Health 

Statistics.

II.14 U.S. Department of Health and Human Services, Administration for Children and Families, Administration 

on Children, Youth and Families, Children’s Bureau. 

Child Maltreatment 2010. Retrieved from: http://www.

acf.hhs.gov/programs/cb/pubs/cm10/index.htm. Accessed: May 17, 2012. 

II.15 Centers for Disease Control and Prevention, National 

Health and Nutrition Examination Survey 2009-2010. 

Analysis conducted by the Maternal and Child Health 

Epidemiology and Statistics Program.

II.16 Centers for Disease Control and Prevention (CDC). 

Youth Online: High School Youth Risk Behavior Survey. 

Retrieved from: http://apps.nccd.cdc.gov/youthonline. 

Accessed: June 20, 2012.

II.17 Centers for Disease Control and Prevention. Sexually 

Transmitted Disease Surveillance 2010. Atlanta: U.S. 

Department of Health and Human Services; 2011.

II.18 Centers for Disease Control and Prevention. HIV 

Surveillance Report, 2010; vol. 22. HIV Surveillance 

Report, Data Tables. Retrieved from: http://www.cdc.

gov/hiv/surveillance/resources/reports/2010report/index.

htm. Accessed: May 23, 2012.

II.19 Centers for Disease Control and Prevention (CDC). 

Youth Online: High School Youth Risk Behavior Survey. 

Retrieved from: http://apps.nccd.cdc.gov/youthonline. 

Accessed: June 20, 2012.

II.20 Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey 

on Drug Use and Health: Mental Health Findings, 

NSDUH Series H-42, HHS Publication No. (SMA) 

11-4667. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 2012. Retrieved from: 

http://www.samhsa.gov/data/NSDUH/2k10MH_

Findings/2k10MHResults.htm#LOT. Accessed: May 

18, 2012.

II.21 National Institutes of Health, National Institute on 

Drug Abuse, Monitoring the Future Study, 2011

Monitoring the Future, Data Tables. Retrieved from: 

http://www.monitoringthefuture.org/data/data.html. 

Accessed: May 20, 2012.

II.22 Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey 

on Drug Use and Health: Summary of National 

Findings, NSDUH Series H-41, HHS Publication 

No. (SMA) 11-4658. Rockville, MD: Substance 

Abuse and Mental Health Services Administration, 

2011. Retrieved from: http://www.samhsa.gov/data/

NSDUH/2k10NSDUH/2k10Results.htm#6.2.

Accessed: May 18, 2012.

II.23 Centers for Disease Control and Prevention, National 

Center for Health Statistics. Compressed Mortality File 

1999-2010. CDC WONDER Online Database, compiled from Compressed Mortality File 1999-2010 Series 

20 No. 2O, 2012. Retrieved from: http://wonder.cdc.

gov/ucd-icd10.html. Accessed: November 15, 2012.

II.24 Child and Adolescent Health Measurement Initiative, 

Data Resource Center for Child and Adolescent Health. 

2009/2010 National Survey of Children with Special 

Health Care Needs. Retrieved from: www.childhealthdata.org. Accessed: September 9, 2012.

Health Services Utilization and Financing

III.1 U.S. Census Bureau, Current Population Survey, Annual 

Social and Economic Supplement. CPS Table Creator. 

http://www.census.gov/cps/data/cpstablecreator.html#. 

III.2 Health Resources and Services Administration, Maternal 

and Child Health Bureau and Centers for Disease 

Control and Prevention, National Center for Health 

Statistics. 2009-2010 National Survey of Children with 

Special Health Care Needs. Data analyzed by the Health 

Resources and Services Administration’s Maternal and 

Child Health Bureau.

III.3 Child and Adolescent Health Measurement Initiative, 

Data Resource Center for Child and Adolescent Health. 

2009/2010 National Survey of Children with Special 

Health Care Needs. Retrieved from: www.childhealthdata.org. Accessed: September 2012.

III.4 Centers for Disease Control and Prevention. U.S. 

Vaccination Coverage Reported by the National Immunization Survey. Retrieved from: http://www.cdc.gov/

vaccines/stats-surv/nis/. Accessed: July 5, 2012.

III.5 Centers for Disease Control and Prevention. Childhood 

immunization schedule, 2012. Retrieved from: http://

www.cdc.gov/vaccines/schedules/downloads/child/0-

18yrs-11x17-fold-pr.pdf. Accessed: August 23, 2012.
 CHILD HEALTH USA 2012 REFERENCES 79

III.6 Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey 

on Drug Use and Health: Mental Health Findings, 

NSDUH Series H-42, HHS Publication No. (SMA) 

11-4667. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 2012. Retrieved from: 

http://www.samhsa.gov/data/NSDUH/2k10MH_

Findings/2k10MHResults.htm#3.2. Accessed: May 18, 

2012.

III.7 Bloom B, Cohen RA, Freeman G. Summary health 

statistics for U.S. children: National Health Interview 

Survey, 2010. National Center for Health Statistics. Vital 

Health Stat 10(250). 2011.

III.8 Centers for Disease Control and Prevention, National 

Center for Health Statistics. 2010 National Health 

Interview Survey with multiply imputed poverty data. 

Unpublished estimates. Analyzed by the Maternal and 

Child Health Bureau.

III.9 Centers for Disease Control and Prevention, National 

Center for Health Statistics. 2010 Natality Public Use 

File. Analysis conducted by the Maternal and Child 

Health Bureau.

III.10 Health Resources and Services Administration. Title V 

Information System. Retrieved from: https://perfdata.

hrsa.gov/MCHB/TVISReports/ProgramData/NumIndiServe.aspx. Accessed: September 10, 2012.

III.11 Health Resources and Services Administration, Uniform 

Data System, Online Data Tables. Retrieved from: 

http://bphc.hrsa.gov/healthcenterdatastatistics/nationaldata/index.html. Accessed: September 8, 2012.

State Data

IV.1 Centers for Medicare and Medicaid Services. FY2011 

CHIP Annual Enrollment Report. Retrieved from: 

http://www.insurekidsnow.gov/chipraannualreport.pdf. 

Accessed: August 28, 2012. 

I.2 Georgetown University Center for Children and Families and The Henry J. Kaiser Family Foundation, Kaiser 

Commission on Medicaid and the Uninsured. Holding 

Steady, Looking Ahead: 50-State Survey of Eligibility 

Rules, Enrollment and Renewal Procedures and CostSharing Practices in Medicaid and CHIP, 2010-2011. 

Retrieved from: http://www.kff.org/medicaid/upload/8130.pdf. Accessed: August 28, 2012.

I.3 Centers for Medicare and Medicaid Services. 2010 

Annual EPSDT Reports (Form 416). Retrieved from: 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-Periodic-ScreeningDiagnosis-and-Treatment.html#TopOfPage. Accessed: 

August 28, 2012. 

I.4 U.S. Census Bureau, Housing and Household Economic 

Statistics Division. Current Population Survey, Annual 

Social and Economic Supplement, 2011. CPS Table 

Creator. Retrieved from: http://www.census.gov/cps/

data/cpstablecreator.html#. Accessed: August 29, 2012.

I.5 Centers for Disease Control and Prevention (CDC), 

National Center for Health Statistics (NCHS), Division 

of Vital Statistics, Natality public-use data 2007-2009, 

on CDC WONDER Online Database, March 2012. 

Retrieved from: http://wonder.cdc.gov/natality-current.

html. Accessed: August 27, 2012.

I.6 Mathews TJ, MacDorman MF. Infant mortality statistics 

from the 2008 period linked birth/infant death data set. 

National Vital Statistics Report. 2012;60(5):1-34.

Rural and Urban Data

V.1 Centers for Disease Control and Prevention, National 

Center for Health Statistics. 2009 Natality Restricted 

Access File with Geographic Detail. Analysis conducted 

by the Maternal and Child Health Bureau.
80 CONTRIBUTORS CHILD HEALTH USA 2012

CONTRIBUTORS

This publication was developed by the U.S. 

Department of Health and Human Services, Health 

Resources and Services Administration, Maternal 

and Child Health Bureau (MCHB). It was produced 

for MCHB by the Maternal and Child Health 

Epidemiology and Statistics Program under contract.

Federal Contributors within the U.S. 

Department of Health and Human Services

Administration for Children and Families

Centers for Disease Control and Prevention

Centers for Medicare and Medicaid Services

National Institutes of Health, National Institute on 

Drug Abuse

Substance Abuse and Mental Health Services 

Administration

Other Federal and Non-Governmental 

Contributors

Child and Adolescent Health Measurement 

Initiative, Data Resource Center for Child and 

Adolescent Health

U.S. Environmental Protection Agency

Federal Interagency Forum on Child and Family 

Statistics

Kaiser Commission on Medicaid and the Uninsured

Organization for Economic Co-operation and 

Development

U.S. Census Bureau

U.S. Department of Education

U.S. Department of Housing and Urban 

Development

U.S. Department of Labor

Photography Credits

Cover and title page, clockwise from top left: first photo, Kelly Sanders; second photo, iStockPhoto; third 

photo, iStockPhoto; fourth photo, Beth Costello; fifth photo, iStockPhoto; page 4, Jessica Clark; page 7, 

iStockPhoto; page 16, Jessica Clark; page 17, top photo, Julie Anne Mutersbaugh, bottom photo, Christina 

Ciucci; page 25, top photo, Selma Kunitz, bottom photo, Sandra Dennis; page 32, top photo iStockPhoto, 

bottom photo, Beth Costello; page 50, Naomi Tein; page 63, Huiqing You; pages 70 and 80, Julie Anne 

Mutersbaugh; page 77, Monica Jorge; Page 79, Antigone Dempsey; all other photos, iStockPhoto.