CHILD HEALTH USA 2013 TITLE 1

Child

Health

USA

2013

October 2013

U.S. Department of Health and Human Services

Health Resources and Services Administration
Child Health USA 2013 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 2013. 

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

8280 Greensboro Drive, Suite 300 

McLean, VA, 22102 

1-888-ASK-HRSA or ask@hrsa.gov
 CHILD HEALTH USA 2013 CONTENTS 3

PREFACE AND READERS GUIDE 4

INTRODUCTION 5

PERINATAL HEALTH STATUS INDICATORS 7

Preterm Birth 7

Low Birth Weight 8

Infant Morbidity 9

Infant Mortality 10

International Infant Mortality 12

Fetal Mortality 13

Birth Defects 14

SIDS/SUID 15

Maternal Morbidity 16

Pregnancy-Related Mortality 17

Cesarean Delivery 18

Postpartum Depressive Symptoms 19

PERINATAL RISK FACTORS AND 

BEHAVIORS 20

Maternal Age 20

Unintended Pregnancy and Contraception Use 21

Pregnancy Spacing 22

Preconception Health 23

Smoking During Pregnancy 24

Alcohol Use During Pregnancy 25

Weight Gain During Pregnancy 26

Stress During Pregnancy 27

Intimate Partner Violence and Pregnancy 28

Breastfeeding 29

Safe Sleep Behaviors 30

Impaired Fecundity and Infertility Services 31

HEALTH SERVICES UTILIZATION 32

Prenatal Care Utilization 32

Barriers to Prenatal Care 33

Counseling Received During Prenatal Care 34

Postpartum Visit and Well-Baby Care 35

Maternal and Infant Vaccination 36

Health Insurance – Women of Reproductive Age 37

Health Insurance – Infants 38

PROGRAMS AND POLICIES 39

Federal Nutrition Programs Serving Women 39

Maternity Leave 40

Affordable Care Act 41

Selected Federal Efforts to Reduce Infant

Mortality and Improve Birth Outcomes 42

ENDNOTES 44

DATA SOURCES 49

CONTRIBUTORS 51
4 INTRODUCTION CHILD HEALTH USA 2013

PREFACE AND READERS GUIDE

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

(MCHB) is pleased to present Child Health 

USA 2013. Now in its 23rd year, Child Health 

USA provides a centralized resource for data on 

the health and well-being of America’s mothers 

and children for policy makers, program managers, and maternal and child health professionals. 

While previous editions of Child Health USA

focused broadly on health status and health care 

indicators for the maternal and child population, this year’s edition provides an in-depth 

look at perinatal health and health care access. 

Similar to previous editions, however, the data 

book provides both graphical and textual summaries of relevant data, and addresses long-term 

trends where applicable and feasible.

All of the data discussed within the text of 

Child Health USA are from the same sources as 

the information in the corresponding graphs, 

unless otherwise noted. Data are presented for 

two important target populations of the Title V 

Maternal and Child Health Block Grant: pregnant women and infants, as well as women who 

may become pregnant. Child Health USA 2013

addresses health status and health service utilization within these populations, 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 perinatal health in the 

United States.

Perinatal Health Status Indicators is the 

first section and presents statistics on maternal and infant health outcomes ranging from 

infant and fetal mortality to cesarean delivery 

and postpartum depressive symptoms. The second section, entitled Perinatal Risk Factors 

and Behaviors, contains vital statistics and 

health behavior data for women before, during 

and after pregnancy. Health Services Utilization, the third section, includes data regarding 

health care financing and utilization of selected 

perinatal health services. Programs and policies 

relevant to pregnant and parenting women are 

presented in the final section, Programs and 

Policies. 

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. 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, 8280 Greensboro Drive, 

Suite 300, McLean, VA 22102.

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

ask@hrsa.gov.
 CHILD HEALTH USA 2013 INTRODUCTION 5

INTRODUCTION

The health of children is reflective of the 

overall health of a nation, and has many implications for the nation’s future as these children 

grow into adults. Children’s long-term health 

and development can be highly influenced by 

early life events, beginning even before birth 

with the health of their mother. Effective policies and programs are important for ensuring 

the health of women before, during and after 

pregnancy to optimize both maternal and infant 

outcomes. Additionally, minimizing adverse 

birth and infant outcomes is critical to mitigating risk factors for disease later in life. However, 

the health and health care needs of mothers 

and infants change over time, and current data 

on these issues is critically important as policy 

makers and program planners seek to improve 

the health of children, now and into the future.

Research suggests that efforts to improve 

pregnancy outcomes and the health of mothers 

and infants may be most effective if they begin 

before a woman is pregnant. It is important to 

establish healthy behaviors and achieve optimal health before pregnancy, as many women 

are not aware of their pregnancy until several 

weeks or more after conception. In 2009–2010, 

about one in four recent mothers in a 30-state 

area reported binge drinking (consuming 4 or 

more drinks in a sitting) at least once within 3 

months prior to pregnancy and 24.2 percent reported smoking during the same time period. 

Both smoking and alcohol use during pregnancy have been associated with adverse birth outcomes, including preterm birth and low birth 

weight.

In 2011, 11.73 percent of infants were born 

preterm and 8.10 were born at low birth weight. 

Preterm birth and low birth weight have been 

associated with a range of short- and long-term 

consequences for children’s health and development. The prevalence of both preterm and low 

birth weight births varies by race and ethnicity, 

with infants born to non-Hispanic Black mothers most likely to experience either of these outcomes. Although both preterm and low birth 

weight increased through the middle of the last 

decade, the prevalence of both indicators has 

declined since. 

Diabetes and hypertension are the most 

commonly reported health conditions among 

pregnant women and pose health risks to both 

a woman and her baby. In 2010, chronic or 

pre-existing diabetes was reported in 7.0 per 

1,000 live births, while gestational diabetes 

was reported in 44.2 per 1,000 live births and 

chronic and pregnancy-associated hypertension 

were reported in 12.7 and 43.4 per 1,000 live 

births, respectively. Maternal morbidity—or illness—is significantly more common than maternal mortality. Nonetheless, in 2006-2008, 

the latest years for which data are available, a 

total of 1,953 maternal deaths were found to be 

pregnancy-related, for a rate of 15.2 deaths per 

100,000 live births. These include deaths which 

occurred during or within one 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. Pregnancy-related mortality is 

more common among non-Hispanic Black 

mothers and older mothers.

A number of perinatal risk factors and behaviors can affect both the health of the mother 
6 INTRODUCTION CHILD HEALTH USA 2013

and the infant. Gaining too much or too little 

weight during pregnancy can result in immediate and long-term health risks to a woman and 

her infant. Among recent mothers in 2009–

2010, only about 1 in 3 or 31.5 percent gained 

the recommended amount of weight and nearly 

half (47.1 percent) gained an excessive amount 

of weight during pregnancy. About one in five 

women (21.4 percent) gained an inadequate 

amount of weight in pregnancy. Excessive 

weight gain may increase the risk of pregnancy 

complications, cesarean delivery, larger infant 

birth weight, and postpartum weight retention.

Experiencing stressful events or environmental hardships, such as financial instability, the 

death of a loved one, or divorce, while pregnant 

can place an additional strain on a woman and 

increase her likelihood of adverse birth outcomes, including preterm birth and low birth 

weight. In 2009-2010, nearly three-fourths of 

recent mothers in a 30-state reporting area reported that they had experienced at least one 

stressful event in the 12 months prior to delivery of their child. Intimate partner violence, 

including physical, sexual, and psychological 

abuse, before and during pregnancy has also 

been associated with adverse maternal and infant outcomes. In 2009-2010, approximately 

4 percent of recent mothers reported that they 

had been pushed, hit, slapped, kicked, choked, 

or physically hurt in some other way by an intimate partner in the 12 months prior to becoming pregnant and 3.2 percent reported experiencing this type of abuse during their most 

recent pregnancy.

Health behaviors after a baby is born are also 

important to ensuring optimal health and development. Safe sleep behaviors are practices 

that reduce the risk of Sudden Infant Death 

Syndrome (SIDS) and sleep-related suffocation. 

In 2009, SIDS and other sleep-related infant 

deaths accounted for 15.1 percent of all infant 

deaths. To reduce the risk of SIDS, it is recommended that infants be placed on their backs for 

every sleep until 1 year of age. In 2009-2010, 

70.5 percent of recent mothers in a 30-state area 

reported that their infant was laid down to sleep 

on his or her back most of the time. 

The health care utilization rates, programs, 

and policies described 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 mothers and infants 

relies on effective public health efforts that include ensuring access to early and adequate 

prenatal care and related counseling as well as 

post-partum and well-baby care, providing vaccinations against preventable diseases, and supporting the dissemination and implementation 

of evidence-based programs to promote optimal 

maternal and infant health outcomes. 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 2013 PERINATAL HEALTH STATUS INDICATORS 7

PRETERM BIRTH

Babies born preterm, before 37 completed 

weeks of gestation, are at increased risk of immediate life-threatening health problems, as well as 

long-term complications and developmental 

delays. Among preterm infants, 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’ gestation) are more likely than 

full-term babies to experience morbidity and 

mortality.1

According to preliminary data for 2012, 

11.54 percent of infants were born preterm. 

Overall, 8.13 percent of babies were born at 34 

to 36 weeks’ gestation, 1.49 percent were born 

at 32-33 weeks’ gestation, and 1.93 percent were 

“very preterm” (less than 32 weeks’ gestation). 

Between 1990 and 2006, the preterm birth rate 

increased more than 20 percent from 10.62 to 

12.80 percent, but has declined by nearly 10 

percent since 2006. Recent declines are greatest 

among the largest category of late preterm 

infants born at 34 to 36 weeks’ gestation, which 

may be linked to practice-based efforts to reduce 

“elective” deliveries prior to 39 weeks that are 

not medically necessary.2

The preterm birth rate varies by race and ethnicity. In 2012, according to preliminary data, 

16.53 percent of babies born to non-Hispanic 

Black women were born preterm, compared to 

10.29 percent of babies born to non-Hispanic 

White women, and 10.15 percent of babies 

born to Asian/Pacific Islander women. Among 

babies born to Hispanic women, 11.58 percent 

were born preterm, while the same was true for 

13.25 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.3

Preterm Birth, by Completed Weeks of Gestation, 1990–2012* 

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

for Health Statistics, National Vital Statistics System

Preterm Birth, by Maternal Race/Ethnicity, 2012*

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

Statistics, National Vital Statistics System

*Data are preliminary. **Includes Hispanics. †Separate data for Asians and Native Hawaiians and Other

*Data for 2012 are preliminary. Pacific Islanders not available. Percent of Live Births

10.29

16.53

11.58

10.15

13.25

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 2006 2012

Percent of Live Births

Less than 32 weeks

32-33 weeks

34-36 weeks

Total 10.62

7.30

10.99

7.68

11.64

8.22

12.81

9.15

11.54

8.13

1.40

1.92

1.42

1.89

1.49

1.93

1.62

2.04

1.49

1.93
8 PERINATAL HEALTH STATUS INDICATORS CHILD HEALTH USA 2013

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 than infants of normal 

birth weight to die in the first year of life and 

to experience long-range physical and developmental health problems. 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, which may be related to 

factors such as maternal hypertension, tobacco 

smoke exposure, or inadequate weight gain during pregnancy.4

According to preliminary data for 2012, 

7.99 percent of infants were born at low birth 

weight, including 1.42 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.5 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.5

Infants born to non-Hispanic Black women 

have the highest rates of low and very low birth 

weight (13.18 and 2.94 percent, respectively), 

levels that are about two or more times greater 

than for infants born to women of other race and 

ethnic groups. For example, low and very low 

birth weight rates among non-Hispanic Whites 

were 6.97 and 1.13 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.6 In 2009, 23.1 percent 

of very low birth weight infants died in the first 

year of life, compared to 5.3 percent of all low 

birth weight infants and 0.2 percent of normal 

birth weight infants.7

Low and Very Low Birth Weight, by Maternal Race/Ethnicity, 2012*

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

Statistics, National Vital Statistics System

*Data for 2012 are preliminary. **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

Black

Non-Hispanic

White

1.13

6.97

2.94

13.18

1.33

7.61

1.13

8.21 6.96

1.22

Low and Very Low Birth Weight, 1990–2012*

Source (I.1, I.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 2012

Percent of Live Births

Low Birth Weight <2,500 grams

Very Low Birth Weight <1,500 grams

1.42

7.99

*Data for 2012 are preliminary.
 CHILD HEALTH USA 2013 PERINATAL HEALTH STATUS INDICATORS 9

INFANT MORBIDITY

Morbidity is a measure of disease, illness or 

injury within a population. Like infant mortality, conditions resulting from prematurity and 

low birth weight are strongly associated with 

infant morbidity.8,9 Infant morbidity can be 

measured by the presence of diagnosed conditions, such as respiratory distress and hyperbilirubinemia (or jaundice), as well as by service 

utilization indicators, including admission to a 

neonatal intensive care unit (NICU) and length 

of hospital stay.10

In 2009-2010, 12.1 percent of infants in a 

30-state area were reported to have been admitted to a neonatal intensive care unit (NICU). 

A NICU is a department within the hospital 

that provides constant, specialized care for infants who are born sick, prematurely and/or at 

a very low birth weight. Not all hospitals have 

a NICU. NICU admission varied by maternal 

characteristics. NICU admission was lowest 

among infants born to mothers with 16 or more 

years of education (10.7 percent, compared to 

12.9 percent of infants born to mothers with 

less than 12 years of education and approximately 12.5 percent of those born to mothers with 12 to 15 years of education; data not 

shown). Rates of NICU admission were highest among infants born to non-Hispanic Black 

mothers, with one-sixth (15.5 percent) having 

been admitted to the NICU, compared to 11.6 

percent of infants born to non-Hispanic White 

mothers, 12.6 percent born to Hispanic mothers, and 12.8 percent born to non-Hispanic 

Asian mothers.

In 2009-2010, more than 7 percent of infants 

stayed in the hospital for 6 or more days. The 

proportion of infants with the longest hospital 

stays varied by maternal age, education, and 

race/ethnicity factors. Infants born to mothers aged 35 years and older were more likely to 

have a stay of this duration than those born to 

mothers aged 20-34 years, as were infants born 

to mothers with less education and infants born 

to non-Hispanic Black mothers. For example, 

8.4 percent of infants born to mothers with 12 

years of education had long hospital stays of six 

or more days, compared to 5.6 percent of those 

born to mothers with 16 or more years of education (data not shown).

NICU Admission, by Race/Ethnicity, 2009-2010*

Source (I.3): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System Percent of Infants

Hospital Length of Stay, by Maternal Age, 2009-2010*

Source (I.3): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

*Includes data from a total of 30 states and New York City; 25 states contributed both years. Mothers

completed surveys between 2 and 9 months postpartum.

*Includes data from a total of 30 states and New York City; 25 states contributed both years. Mothers

completed surveys between 2 and 9 months postpartum. **Totals may not equal 100 due to rounding.

11.6 12.1 12.6 12.8

11.0 11.7 10.8

15.5

Percent of Infants**

66.1

55.9

78.9

20

40

60

80

100

Total 20-24 Years 25-29 Years 30-34 Years

1-2 Days

6 or More Days

3-5 Days

3.6 4.8 3.8 3.4 3.5 2.7

7.1 7.8 6.8 6.8 6.9 7.9

59.4 56.8

30.0 30.6

61.8

30.9 35.3 27.6 28.5

54.1

61.4 58.7

4

8

12

16

20

NonHispanic

Multiple Race

NonHispanic

Pacific

Islander

NonHispanic

Asian

NonHispanic American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total
10 PERINATAL HEALTH STATUS INDICATORS CHILD HEALTH USA 2013

Infant, Neonatal, and Postneonatal Mortality Rates,* 1915-2011** Source (I.4, I.5, I.6): Centers for Disease Control and Prevention, National Center for Health Statistics, National

Vital Statistics System

6.05

4.04

2.01

Rate Per 1,000 Live Births

Postneonatal

Neonatal

Infant

20

40

60

80

100

1915 1925 1935 1945 1955 1965 1975 1985 1995 2005 2011

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

**2011 data are preliminary; data from 1915-1932 are a subset from states with birth registration, which became 100% by 1933.

INFANT MORTALITY

Based on preliminary data for 2011, 23,910 

infants died before their first birthday, reflecting an infant mortality rate of 6.05 deaths per 

1,000 live births. This represents a decrease of 

11.9 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: 4.04 per 1,000 live births), 

with the remaining third occurring in the postneonatal period between 28 days and under 

1 year (2.01 per 1,000 live births). Neonatal 

mortality is generally related to short gestation 

and low birth weight and other perinatal conditions related to prematurity as well as congenital 

malformations, while postneonatal mortality is 

mostly related to Sudden Infant Death Syndrome 

(SIDS), congenital malformations, and unintentional injuries.11 In 2011, the leading causes of 

infant mortality were congenital malformations, 

followed by disorders related to short gestation 

and low birth weight, and SIDS.12 However, 

when multiple causes related to prematurity are 

grouped, preterm birth becomes the leading 

cause of infant death in the United States, accounting for over a third of all infant deaths.13 

With the exception of plateaus in 1955-1959 

and 2000-2005, infant mortality has generally 

declined 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.14,15 Infant mortality declines in the 

1990s were aided particularly by the approval of 

synthetic surfactants (or substance in the lungs 

needed for breathing) 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 SIDS. The lack of progress 

between 2000 and 2005 has been attributed to 

increases in preterm birth,16 which have begun 

to decline in the last several years, perhaps due 

to practice-based efforts to reduce “elective” deliveries prior to 39 weeks that are not medically 

necessary.17
 CHILD HEALTH USA 2013 PERINATAL HEALTH STATUS INDICATORS 11

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 2009, the latest year of available 

linked data, the infant mortality rate was highest for infants of non-Hispanic Black mothers 

(12.40 per 1,000 live births)—a rate 2.3 times 

that of non-Hispanic Whites (5.33 per 1,000). 

Infant mortality was also higher among infants 

born to American Indian/Alaska Native and 

Puerto Rican mothers (8.47 and 7.18 per 1,000, 

respectively). Although infant mortality was 

lowest among Asian/Pacific Islanders (4.40 per 

1,000), there is considerable variability within 

this population and higher infant mortality has 

been shown among Native Hawaiians.18 

Similar to overall infant mortality, neonatal 

mortality was highest among infants of nonHispanic Black mothers (8.13 per 1,000), followed by Puerto Rican and American Indian/

Alaska Native mothers (4.76 and 4.38 per 1,000, 

respectively). Postneonatal mortality was more 

than twice as high for infants of both non-Hispanic black and American Indian/Alaska Native 

mothers (4.27 and 4.09 per 1,000, respectively) 

than for non-Hispanic Whites (1.93 per 1,000). 

Consistent with these patterns in the timing of 

excess infant mortality, the majority of the infant 

mortality disparity between non-Hispanic Blacks 

and non-Hispanic Whites is due to causes related to prematurity and to a lesser extent, SIDS, 

congenital malformations, and injury.13,19 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 mostly related to prematurity.13,19 

Infant, Neonatal, and Postneonatal Mortality Rates,* by Race/Ethnicity, 2009

Source (I.7): 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. Infant deaths

are weighted, so numbers may not exactly add to totals due to rounding. **Includes Hispanics.

Neonatal

Postneonatal

3

6

9

12

15

Central and

South

American

Puerto Cuban

Rican

Asian/ Hispanic Mexican 

Pacific

Islander**

American

Indian/Alaska

Native** 

NonHispanic

Black

NonHispanic

White

Total

Rate Per 1,000 Live Births

6.39

4.18

2.21

8.13

4.40

4.09

4.38

3.56

1.73

3.44

4.76

1.62

4.98

1.67

1.29

4.27

5.33

3.11

5.29 5.12

2.42

7.18

3.40

1.93

8.47

12.40

3.61

2.10

5.77

3.17

1.30

4.47

Infant
12 PERINATAL HEALTH STATUS INDICATORS CHILD HEALTH USA 2013

INTERNATIONAL INFANT 

MORTALITY

In 2009, the U.S. infant mortality rate (6.4 

infant deaths per 1,000 live births) ranked 27th 

in infant mortality among industrialized nations 

with populations of 2.5 million or greater, behind 

most European countries, Canada, Australia, Israel, and Republic of Korea. Japan was ranked 

first with the lowest infant mortality rate of 2.4 

per 1,000 live births, followed by Sweden and 

Finland with infant mortality rates of with 2.5 

and 2.6 deaths per 1,000 live births, respectively. 

The U.S. did not always rank this low; in 1960, it 

ranked 11th, with Norway, the Netherlands and 

Sweden reporting the three lowest rates among 

industrialized nations that year.

Differences in infant mortality rates among 

industrialized nations may reflect variation in 

the definition, measurement, and reporting of 

fetal and infant deaths. However, analyses by 

gestational age indicate that this disparity is most 

likely related to the high rate of preterm birth 

in the United States.20 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). 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 U.S. 

overall significantly impacts the infant mortality 

rate. Mortality among infants born at term (37+ weeks’ gestation) is also higher in the United 

States.

International Infant Mortality Rates and Rankings,* Selected Countries,** 1960 and 2009

Source (I.8): The Organisation for Economic Co-operation and Development (OECD)

Infant Mortality Rates per 1,000 live births Infant Mortality Rankings*

Country 1960 2009 1960 2009

Australia 20.2 4.3 5 19

Austria 37.5 3.8 19 14

Belgium 31.4 3.5 17 11

Canada 27.3 4.9 12 22

Chile 120.3 7.9 27 28

Czech Republic 20.0 2.9 4 4

Denmark 21.5 3.1 8 5

Finland 21.0 2.6 6 3

France 27.7 3.9 13 17

Germany 35.0 3.5 18 11

Greece 40.1 3.1 20 5

Hungary 47.6 5.1 23 23

Ireland 29.3 3.3 15 10

Israel --- 3.8 --- 14

Italy 43.9 3.9 22 17

Japan 30.7 2.4 16 1

Mexico 92.3 14.6 26 30

Netherlands 16.5 3.8 2 14

New Zealand 22.6 5.2 10 24

Norway 16.0 3.1 1 5

Poland 56.1 5.6 24 25

Portugal 77.5 3.6 25 13

Republic of Korea --- 3.2 --- 8

Slovak Republic 28.6 5.7 14 26

Spain 43.7 3.2 21 8

Sweden 16.6 2.5 3 2

Switzerland 21.1 4.3 7 19

Turkey 189.5 10.2 28 29

United Kingdom 22.5 4.6 9 21

United States 26.0 6.4 11 27

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

affected if not all counties have reported data. **Countries with at least 2.5 million population and listed in the OECD database.

---Data not available
 CHILD HEALTH USA 2013 PERINATAL HEALTH STATUS INDICATORS 13

FETAL MORTALITY

Fetal mortality is defined as the death of a fetus 

prior to birth, regardless of gestational age. Based 

on survey data, more than a million fetal losses 

are estimated to occur annually in the United 

States, most of which are early fetal losses, also 

called miscarriages.21 Only fetal deaths at 20 or 

more weeks’ gestation—often called stillbirths—

are generally reported by states in the National 

Vital Statistics System. In 2006, the latest year 

for which national data have been reported, there 

were 25,972 fetal deaths at 20 or more weeks’ 

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

live births plus fetal deaths. The number of fetal 

deaths is similar to the number of infant deaths 

(28,509 in 2006).22 

Similar to trends for infant mortality, fetal 

mortality rates have generally declined over time. 

Since 1990, fetal mortality rates at 20 weeks or 

more have fallen by nearly 20 percent from 7.49 

to 6.05 per 1,000 in 2006. Most of this decline 

is attributed to reductions in fetal mortality at 28 

weeks or more, which declined from 4.30 to 2.97 

per 1,000 between 1990 and 2006. 

As with infant mortality, there are large differences in fetal mortality by race and ethnicity. 

In 2006, fetal mortality rates at 20+ weeks were 

more than twice as high among non-Hispanic 

Black women as for non-Hispanic White women (10.73 versus 4.81 per 1,000). The majority 

of this disparity (64 percent) was due to higher 

non-Hispanic Black fetal mortality rates at 20-

27 weeks’ gestation. Relative to non-Hispanic 

Whites, fetal mortality rates were also higher for 

non-Hispanic American Indian/Alaska Native 

and Hispanic women (6.04 and 5.29 per 1,000, 

respectively). 

Causes of fetal death include preterm labor, 

birth defects, infection, placental problems, 

such as abruption or inadequate blood flow, and 

chronic conditions, such as hypertension and 

diabetes.23,24 Avoiding smoking and substance 

use, maintaining a healthy weight, and preventing and managing chronic conditions prior to 

and during pregnancy through preconception 

and prenatal care, may help to reduce risk of stillbirth.24 

Fetal Mortality Rates,* by Maternal Race/Ethnicity, 2006

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

National Vital Statistics System

Fetal Mortality Rates,* 1990–2006

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

Health Statistics, National Vital Statistics System

*Fetal deaths with stated or presumed period of gestation of 20 weeks or more; cases of

unknown gestational age are proportionally assigned according to the known gestational age

distribution; rates do not sum to the total due to slight differences in the denominator.

*Fetal deaths with stated or presumed period of gestation of 20 weeks or more; cases of unknown gestational age

are proportionally assigned according to the known gestational age distribution; rates do not sum to the total due

to slight differences in the denominator. **Includes Hispanics. †

Separate data for Asians and Native Hawaiians

and Other Pacific Islanders not available.

Per 1,000 Live Births and Fetal Deaths

2

4

6

8

10

1990 1992 1994 1996 1998 2000 2002 2004 2006

6.05

2.97

3.10

Total

20-27 weeks’ gestation

28 weeks or more gestation

4

8

12

16

20

Asian/

Pacific

Islander**†

American

Indian/

Alaska Native**

Non- Hispanic

Hispanic

Black

NonHispanic

White

Per 1,000 Live Births and Fetal Deaths

20-27 weeks’ gestation

28 weeks or more gestation

4.81 Total

10.73

4.65

5.29 6.04

4.89

2.48

2.34

6.14 2.79

2.51

3.45

2.61

2.28

2.62
14 PERINATAL HEALTH STATUS INDICATORS CHILD HEALTH USA 2013

BIRTH DEFECTS

Birth defects occur in approximately 3 percent of all live births and are the leading cause of 

infant mortality, accounting for approximately 

20 percent of all infant deaths in the United 

States in 2009.25,26 Birth defects are conditions 

present at birth that cause structural changes in 

one or more parts of the body.27 Birth defects 

develop before a baby is born and generally occur during the first trimester of pregnancy.

Although the causes of most birth defects 

are unknown, birth defects are thought to be 

caused by a combination of genetic, behavioral, 

and environmental factors. Some factors that 

have been linked to birth defects include: tobacco, alcohol and illicit drug use during pregnancy; uncontrolled medical conditions such as 

diabetes and obesity; use of some medications 

during pregnancy; maternal age younger than 

20 and over 35 years; a family history of birth 

defects; and inadequate levels of folic acid (a B 

vitamin used by our bodies to make new cells) 

before and during pregnancy.28 Taking folic acid 

before becoming pregnant has been shown to 

reduce the risk for neural tube defects by 50-70 

percent.28

Congenital heart defects are the most common type of birth defect in the United States, affecting nearly 1% of—or about 40,000—births 

per year.29 Trisomy 21, or Down syndrome, is a 

common birth defect with an estimated 6,000 

cases identified annually.26 Orofacial clefts, including cleft lip and cleft palate, are another 

common type of birth defect with approximately 7,000 cases identified annually.26

Screening tests that can identify some birth 

defects can be administered during both the 

first and second trimesters of pregnancy and 

may include blood tests, ultrasounds and/or 

testing of the placenta or amniotic fluid. Screening healthy newborns using pulse oximetry can 

be a useful and cost-effective way to identify 

babies born with critical congenital heart defects before they are discharged from the birth 

hospital.30 Although the survival of babies and 

children with birth defects has been improving, racial and socioeconomic disparities in the 

survival of these individuals with very special 

health care needs still persist.31,32

Selected Birth Defects, 2004-2006*

Source (I.10): National Birth Defects Prevention Network

Birth Defects Cases per Births Estimated Annual Number of 

Cases

Prevalence per 10,000 Live 

Births

Chromosomal anomalies**

Trisomy 21 (Down syndrome) 1 in 691 6037 14.47

Trisomy 18 1 in 3,762 1109 2.66

Trisomy 13 1 in 7,906 528 1.26

Neural tube defects***

Spina bifida without anencephaly 1 in 2,858 1460 3.50

Anencephaly 1 in 4,859 859 2.06

Encephalocele 1 in 12,235 341 0.82

Orofacial defects

Cleft lip with and without cleft palate 1 in 940 4437 10.63

Cleft palate without cleft lip 1 in 1,574 2651 6.35

Cardiovascular defects

Atrioventricular septal defect 1 in 2,122 1966 4.71

Tetralogy of Fallot 1 in 2,518 1657 3.97

Transposition of great arteries 1 in 3,333 1252 3.00

Hypoplastic left heart syndrome 1 in 4,344 960 2.30

Common truncus 1 in 13,876 301 0.72

*14 programs contributed data: Arkansas, Arizona, California [8-county Central Valley], Colorado, Georgia [5-county metropolitan Atlanta], Illinois, Iowa, Kentucky, Massachusetts, North Carolina, Oklahoma, Puerto Rico, Texas, and Utah. The number of live births represented by these 

14 programs from 2004-2006 was 4,038,506. **Estimates adjusted for maternal age. ***Estimates adjusted for maternal race/ethnicity.
 CHILD HEALTH USA 2013 PERINATAL HEALTH STATUS INDICATORS 15

SIDS/SUID

In 2010, there were a total of 3,610 or 0.9 

sudden unexpected infant deaths (SUID) per 

1,000 live births, accounting for 15 percent of 

all infant deaths. SUID includes sudden infant 

death syndrome (SIDS) and other sleep-related 

infant deaths due to unknown cause and accidental suffocation and strangulation in bed.33

These causes of death have been grouped due to 

evidence that some deaths previously classified 

as SIDS are now being assigned to other sleeprelated causes of death.34 For example, SIDS rates 

declined from 1998 to 2001 while death rates 

due to other unknown causes and accidental suffocation and strangulation in bed were rising. 

Altogether, SUID generally declined from 1990 

to 1998 and has remained relatively stable since 

then without significant multi-year changes. 

SUID rates vary greatly by race and ethnicity. In 2009, SUID rates were highest for infants born to American Indian/Alaska Native 

and non-Hispanic Black mothers (2.14 and 

1.92 per 1,000, respectively); these rates were 

more than twice the rate among infants born 

to non-Hispanic Whites (0.94 per 1,000). The 

SUID disparity explained 38 percent of the total 

infant mortality gap between American Indian/

Alaska Natives and non-Hispanic Whites and 14 

percent of the excess non-Hispanic Black infant 

mortality compared with non-Hispanic Whites 

(data not shown). SUID rates were generally lowest for infants born to Hispanic mothers (0.53 

per 1,000), except for Puerto Ricans (1.15 per 

1,000), and those born to Asian/Pacific Islander 

mothers (0.37 per 1,000). However, SUID rates 

have been shown to be higher among infants 

born to Native Hawaiian mothers.35 Racial/ethnic differences in safe sleep practices may contribute to SUID disparities (see page 30). 

In 2012, the American Academy of Pediatrics 

released expanded recommendations to promote 

safe sleep environments and other protective 

factors that can reduce the risk of sleep-related infant deaths.36 These form the basis of the 

new Safe to Sleep campaign (formerly Back to 

Sleep),37 and go beyond the back sleep position, 

including recommendations such as use of a firm 

sleep surface without soft bedding, room-sharing 

without bed-sharing, breastfeeding, and avoiding 

exposure to tobacco smoke and other drugs.

SUID* Mortality Rates, by Maternal Race/Ethnicity, 2009

Source (I.13): Centers for Disease Control and Prevention, National Center for Health Statistics,

National Vital Statistics System

SUID* Mortality Rates, by Listed Cause of Death, 1990-2010

Source (I.11, I.12): Centers for Disease Control and Prevention, National Center

for Health Statistics, National Vital Statistics System

*Sudden Unexpected Infant Deaths (SUID) includes SIDS (798.0/R95), Unknown Cause

(799.9/R99), and Accidental Suffocation or Strangulation in Bed (E913.0/W75).

*Sudden Unexpected Infant Deaths (SUID) includes SIDS (R95), Unknown Cause (R99), and Accidental

Suffocation or Strangulation in Bed (W75) **Includes Hispanics. N/R: Fewer than 20 deaths; data did not

meet the standard of reliability or precision.

Per 1,000 Live Births

1

2

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

0.90

0.52

0.23

0.16

Total SUID*

Accidental Suffocation and Strangulation in Bed

SIDS

Unknown Cause

Per 1,000 Live Births

0.94

0.37 0.53 0.46

1.92 2.14

1.15

N/R 0.33

1

2

3

4

5

Central

and South

American

Puerto Cuban

Rican

Asian/ Hispanic Mexican Pacific

Islander**

American

Indian/ Alaska Native** 

NonHispanic

Black

NonHispanic

White
16 PERINATAL HEALTH STATUS INDICATORS CHILD HEALTH USA 2013

MATERNAL MORBIDITY

Diabetes and hypertension are the most 

commonly reported health conditions among 

pregnant women. Diabetes, both chronic and 

gestational (developing only during pregnancy), may pose health risks to a woman and her 

baby. Women with gestational diabetes are at 

increased risk for developing diabetes later in 

life.38 In 2011, among the 36 states and District 

of Columbia that collected this information 

on the revised birth certificate, chronic or preexisting diabetes was reported in 7.4 per 1,000 

live births while gestational diabetes was reported 

in 48.2 per 1,000 live births. Chronic diabetes 

was highest among non-Hispanic American Indian/Alaska Native mothers (17.0 per 1,000 live 

births) and lowest among non-Hispanic White 

and non-Hispanic Asian mothers (6.4 and 6.6 

per 1,000, respectively). However, non-Hispanic 

Asian mothers had the highest rate of gestational 

diabetes at 86.8 per 1,000 live births, followed by 

non-Hispanic Native Hawaiian/Pacific Islander 

(65.8 per 1,000). 

Hypertension during pregnancy can also be 

either chronic in nature or gestational. Severe 

hypertension during pregnancy can result in preeclampsia, fetal growth restriction, and early delivery.39 In 2011, in the 36 states and District of 

Columbia that used the revised birth certificate, 

chronic and pregnancy-associated hypertension 

was reported in 14.0 and 44.8 per 1,000 live 

births, respectively. Chronic hypertension was 

most common in non-Hispanic Black women 

(29.0 per 1,000 live births) and least common 

among Hispanic and non-Hispanic Asian women (7.7 and 7.9 per 1,000, respectively). Pregnancy-associated hypertension was reported in 

about 50 per 1,000 live births to non-Hispanic 

Black, non-Hispanic American Indian/Alaska 

Native, and non-Hispanic White mothers and 

was lowest among non-Hispanic Asian mothers 

(24.8 per 1,000). Although these conditions are 

known to be under-reported on the birth certificate, patterns by race and ethnicity are not likely 

to be affected.40

A recent national study of hospital discharge 

data found that severe maternal morbidity, 

which includes life-threatening complications 

such as kidney or heart failure, blood clots, 

infection, and hemorrhage, occurs at a rate of 

12.9 per 1,000 delivery hospitalizations.41 Severe maternal morbidity is more than 100 times 

as common as pregnancy-related mortality—

translating to about 52,000 women affected 

annually—and it is estimated to have increased 

by 75 percent over the past decade. Rises in 

chronic conditions, including obesity, diabetes, 

hypertension, and cardiovascular disease, are 

likely to have contributed to this increase.

Selected Maternal Morbidities and Risk Factors in Pregnancy, by Race/Ethnicity, 2011*

Source (I.14): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System Rate per 1,000 Live Births

Chronic Diabetes Gestational Diabetes

Chronic Hypertension

7.4

49.0

Pregnancy- Associated Hypertension

18

36

54

72

90

NonHispanic

Multiple Race

Non-Hispanic Native

Hawaiian/Other

Pacific Islander

NonHispanic

Asian

Non-Hispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanicWhiteTotal

6.6 7.9

86.8

24.8

44.8 45.0

14.5 13.0

65.8

45.7

7.8

15.5

*Data are from 36 states and the District of Columbia that implemented the 2003 revision of the death certificate as of January 1, 2011,

representing 83 percent of all U.S. births.

48.2 44.8 45.6

14.0

6.4

13.5 9.9

56.6 52.3

7.8

49.1

17.0

40.1

18.6

50.3

33.8

7.7

29.0
 CHILD HEALTH USA 2013 PERINATAL HEALTH STATUS INDICATORS 17

PREGNANCY-RELATED 

MORTALITY

A pregnancy-related death is defined as a 

death which occurs during or within one year of 

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.42 This definition includes 

more deaths than the traditional definition of 

maternal mortality, which counts pregnancyrelated deaths only up to 42 days after the end 

of pregnancy. Although maternal mortality in 

the United States declined dramatically over the 

last century, there has been some reversal of this 

trend in the last several decades, and racial and 

ethnic disparities in maternal and pregnancyrelated mortality persist.42-44

In 2006–2009, the latest years for which data 

are available, a total of 2,689 deaths were found 

to be pregnancy-related at a rate of 15.8 deaths 

per 100,000 live births. The pregnancy-related 

mortality rate has more than doubled from 1987 

levels of 7.2 deaths per 100,000.42 This dramatic rise may reflect improved ascertainment 

of pregnancy-related deaths as well as increases 

in chronic conditions and severe maternal morbidity.41,44 The pregnancy-related mortality ratio 

among Black women was 3 times the rate for 

White women in 2006-2008 (35.6 versus 11.7 

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

ratio also increases with age. Women aged 35–39 

years are more than twice as likely to die from 

pregnancy-related causes as women aged 20–24; 

for women older than 39 years, the risk increases 

five-fold (data not shown).44

Some of the most common causes of pregnancy-related death in 2006–2009 were cardiovascular disease (14.6%), infection or sepsis (14.0%), 

non-cardiovascular medical conditions (11.9%) 

diseases of the heart muscle (cardiomyopathy, 

11.8%), and uncontrolled bleeding (hemorrhage, 11.0%). The proportion of pregnancyrelated deaths due to cardiovascular disease and 

cardiomyopathy have increased significantly 

since 1987, while the percentage of deaths attributable to hemorrhage and hypertensive disorders 

of pregnancy have declined.44

Pregnancy-Related Mortality Ratios, by Race, 2006–2009

Source (I.15): 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,* 2006–2009

Source (I.15): 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 5.3% of all pregnancy-related deaths.

Deaths per 100,000 Live Births

15.8

11.7

17.6

35.6

8

16

24

32

40

Total White Black Other 4 8 12 16

Anesthesia Complications

Amniotic Fluid Embolism

Cerebrovascular

Accidents (Stroke)

Thrombotic Pulmonary

Embolism (Blood Clot in Lung)

Hypertensive Disorders

of Pregnancy

Hemorrhage

(Uncontrolled Bleeding)

Cardiomyopathy

(Heart Muscle Diseases)

Non-Cardiovascular Diseases

Infection/Sepsis

Cardiovascular Disease 14.6

11.8

11.9

11.0

14.0

9.9

9.4

5.4

6.1

0.6

Percent of Pregnancy-Related Deaths
18 PERINATAL HEALTH STATUS INDICATORS CHILD HEALTH USA 2013

CESAREAN DELIVERY

Cesarean delivery represents a potentially lifesaving procedure for both mother and infant in 

cases of labor complications and health conditions that require early or immediate delivery.45

However, in the absence of medical indications, 

cesarean sections can pose avoidable risks, including longer maternal recovery, neonatal respiratory 

problems, and potentially severe complications 

in subsequent pregnancies.45,46 After increasing 

every year from 1996 to 2009, the U.S. cesarean 

delivery rate declined slightly between 2009 and 

2010 from 32.9 percent to 32.8 percent and remained unchanged through preliminary data for 

2012. Though no longer increasing, the current 

rate of about one in three births far exceeds the 

upper limit of 15 percent advised by the World 

Health Organization.47 

Healthy People 2020 has set national objectives to reduce the cesarean delivery rate by ten 

percent among low-risk women giving birth for 

the first time and among low-risk women with 

a prior cesarean section.48 Low-risk is defined as 

non-breech, singleton deliveries at 37 weeks or 

more gestation. In 2011, among the 36 states 

and District of Columbia that had implemented the 2003 revision to the standard birth certificate as of January 1st, 26.2 percent of lowrisk women giving birth for the first time and 

89.5 percent of low-risk women with a prior 

cesarean section delivered by cesarean. Cesarean 

delivery among low-risk, first births increased 

greatly with maternal age from 18.7 percent of 

women less than 20 years of age to 51.6 percent 

of women aged 40 and older. This pattern may 

partly reflect age-related increases in medical 

indications for cesarean delivery. However, the 

repeat cesarean rate among low-risk women was 

about 90 percent, regardless of maternal age. 

Recently, cesarean delivery rates among lowrisk pregnancies were found to vary fifteen-fold 

across U.S. hospitals from 2.4 percent to 36.5 

percent, highlighting the importance of quality 

improvement and standardization in maternity 

care.5

 To reduce cesarean delivery rates, there 

have been calls to expand public and provider education, to tie payments to quality improvement, 

and to publicly report hospital-level data.49,50

Percent of Women

Percent of Live Births

Primary and Repeat Cesarean Delivery Rates Among Low-Risk

Women,* by Age, 2011

Source (I.14): Centers for Disease Control and Prevention, National Center for

Health Statistics, National Vital Statistics System

Cesarean Delivery Rate, 1990-2012*

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

Statistics, National Vital Statistics System

*Low risk is defined as non-breech, singleton deliveries at 37 weeks or more gestation; Data are from

36 states and the District of Columbia that implemented the 2003 revision of the birth certificate as of

*Data for 2012 are preliminary. January 1, 2011, representing 83% of all US births.

10

20

30

40

50

60

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

20

40

60

80

100

40 Years

and Older

35-39

Years

30-34

Years

25-29

Years

20-24

Years

Less than

20 Years

Total

18.7

90.6

23.7

90.6

27.2

89.3

31.9

89.1

40.7

89.6

51.6

89.6

Primary Cesarean Among First Births

Repeat Cesarean Among Women with Prior Cesarean

Cesarean Section

32.8

22.7

26.2

89.5
 CHILD HEALTH USA 2013 PERINATAL HEALTH STATUS INDICATORS 19

POSTPARTUM DEPRESSIVE 

SYMPTOMS

The birth of a child is a major life event that 

can be joyous, but also stressful, as a result of new 

demands and responsibilities. Hormonal changes 

and lack of sleep can contribute to “baby blues” 

or mild depressive symptoms, such as sadness, 

crying, irritability, and trouble concentrating, 

which are common and may last for a few days 

to a week or two.51 Postpartum depression occurs when these symptoms, including depressed 

mood and loss of interest in activities, are severe 

and last for more than two weeks.52 Other symptoms can include changes in appetite, feelings 

of worthlessness or guilt, and suicidal thoughts. 

Postpartum depression can occur any time within the first year after childbirth.53

In 2009-2010, 11.8 percent of recent mothers in a 30-state area reported postpartum depressive symptoms since the birth of a child in 

the previous 2–9 months. Postpartum depressive symptoms were least common (8.1 percent) 

among mothers with at least 16 years of education as compared to mothers of all other educational groups. By maternal age, 14.6 percent 

of mothers aged 20-24 years experienced postpartum depression, compared to 10.2 percent 

of mothers 35 years or older (data not shown). 

Postpartum depressive symptoms also varied 

by race and ethnicity. The proportion of mothers reporting such symptoms varied between 

some racial and ethnic groups. Non-Hispanic 

American Indian/Alaska Native mothers (16.6 

percent) were significantly more likely to report 

such symptoms as compared to non-Hispanic 

Native Hawaiian/Other Pacific Islander mothers (11.4 percent). Factors that may increase the 

risk of postpartum depression include previous 

depressive episodes, stressful life events, financial instability and limited social support.51,52

Early diagnosis and treatment are important 

as postpartum depression can interfere with 

maternal-infant bonding and child development.52 Treatment for postpartum depression 

may include both counseling and medications. 

Screening for depression is encouraged by the 

American College of Obstetricians and Gynecologists both during and after pregnancy, 

particularly for women with a history of major 

depression.54 

Postpartum Depressive Symptoms* Among Mothers with a

Recent Live Birth, by Maternal Education, 2009-2010**

Source (I.3): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System Percent of Mothers

Postpartum Depressive Symptoms* Among Mothers with a Recent

Live Birth, by Race/Ethnicity, 2009-2010**

Source (I.3): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

*Defined as a sum of 10 or higher in response to 3 questions of how often the mother reported feeling down,

depressed, or sad; hopeless; or slowed down since the birth of the baby, where 1=never, 2=rarely,

3=sometimes, 4=often, 5=always. **Includes data from a total of 30 states and New York City; 25 states

contributed both years. Mothers completed surveys between 2 and 9 months postpartum.

*Defined as a sum of 10 or higher in response to 3 questions of how often the mother reported feeling down,

depressed, or sad; hopeless; or slowed down since the birth of the baby, where 1=never, 2=rarely,

3=sometimes, 4=often, 5=always. **Includes data from a total of 30 states and New York City; 25 states

contributed both years. Mothers completed surveys between 2 and 9 months postpartum.

14.1

11.8 12.6

8.1

13.4

Percent of Mothers

4

8

12

16

20

16 Years

or More 

13-15

Years

12

Years

Less than

12 Years

Total

4

8

12

16

20

NonHispanic

Multiple

Race

NonHispanic

Native

Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

11.8 11.7 13.4 14.8

11.5

7.4

16.6

11.4
20 PERINATAL RISK FACTORS AND BEHAVIORS CHILD HEALTH USA 2013

MATERNAL AGE

Adverse perinatal outcomes, including low 

birth weight, preterm birth, birth defects, and 

infant mortality, are generally higher for births 

to teenagers and women aged 35 and older.55,56

According to preliminary data for 2012, there 

were 48.3 births per 1,000 women aged 35-39 

years, a birth rate higher than those for teens 

aged 15-19 years (29.4 per 1,000 women), representing a reversal from just one to two decades 

earlier. However, birth rates were highest among 

women aged 25–29 years (106.5 births per 

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

years (97.3 births per 1,000 women).

In 2012, according to preliminary data, the 

overall fertility rate among women aged 15-44 

years was 63.0 births per 1,000 women—the 

lowest level ever reported. Only birth rates among 

women aged 30 years and older are higher now 

than in 1990, and those for 40- to 44-year-olds 

increased from 5.5 in 1990 to 10.4 per 1,000 in 

2011. Conversely, birth rates among teenagers 

aged 15- 19 years and young women aged 20–24 

years reached historic lows in 2012 (29.4 and 

83.1 per 1,000 women, respectively).

A general decline in teen birth rates began after 1991, with rates having dropped in half since 

then. Although recent declines have been greater 

for teens from minority racial and ethnic groups, 

disparities persist. Birth rates among Hispanic 

and non-Hispanic Black teens aged 15-19 years 

(46.3 and 43.9 per 1,000, respectively) are more 

than twice that of non-Hispanic White teens 

(20.5 per 1,000) and over 4 times as high as that 

of Asian/Pacific Islander teens (9.7 per 1,000).

Birth rates for older women aged 35-39 and 

40-44 years were highest among Asian-Pacific Islander women (68.1 and 16.1 per 1,000, respectively) and Hispanic women (51.5 and 13.2 per 

1,000, respectively). Reflecting the racial/ethnic 

differences in age patterns of childbearing, birth 

rates peaked among 20- to 24-year-olds for nonHispanic Black and American Indian/Alaska Native women (109.0 and 81.7 births per 1,000, 

respectively), compared to 25- to 29-year-olds 

for Hispanics and non-Hispanic Whites (119.6 

and 104.4 per 1,000, respectively), and 30- to 

34-year-olds for Asian/Pacific Islanders (121.4 

per 1,000).

Live Births per 1,000 Women, by Age, 1990-2012* 

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

Vital Statistics System

Live Births per 1,000 Women, by Age and

Race/Ethnicity, 2012*

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

Center for Health Statistics, National Vital Statistics System

Race/Ethnicity Total 15-19 

Years

20-24 

Years

25-29 

Years

30-34 

Years

35-39 

Years

40-44 

Years

Total 63.0 29.4 83.1 106.5 97.3 48.3 10.4

Non-Hispanic White 58.7 20.5 70.2 104.4 100.5 46.8 9.1

Non-Hispanic Black 65.0 43.9 109.0 101.7 75.1 38.9 9.6

Hispanic 74.4 46.3 111.4 119.6 94.3 51.5 13.2

American Indian/Alaska Native**

Asian/Pacific Islander**†

47.0 34.9 81.7 73.9 49.7 23.3 5.5

62.2 9.7 41.4 95.8 121.4 68.1 16.1

*Data are preliminary. **Includes Hispanics. †

Separate data for Asians and Other

*Data for 2012 are preliminary. Pacific Islanders are not available.

20

40

60

80

100

120

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

10.4

29.4

48.3

63.0

83.1

97.3

106.5

40-44 years

20-24 years

25-29 years

35-39 years

15-19 years

30-34 years

Total

Rate per 1,000 Women
 CHILD HEALTH USA 2013 PERINATAL RISK FACTORS AND BEHAVIORS 21

UNINTENDED PREGNANCY AND 

CONTRACEPTION USE

An unintended pregnancy is one that is 

mistimed (occurred too soon) or unwanted 

(occurred when the woman wanted no future 

pregnancies) at the time of conception. Unintended pregnancies that result in births are 

associated with both short- and long-term 

negative outcomes for both mother and child, 

including delayed prenatal care, reduced likelihood of breastfeeding, maternal depression, increased risk for intimate partner violence, and 

poor developmental and educational outcomes 

for children.57 However, in 2006-2010, women 

reported that 37.1 percent of live births occurring in the past 5 years were unintended at the 

time of conception. This includes 13.8 percent 

of pregnancies that were unwanted and 23.3 

percent that were mistimed. Fourteen percent 

of all births were reported by the mother to 

have occurred 2 or more years too soon (data 

not shown). Overall, the proportion of births 

reported to be unintended did not change significantly between 1982 and 2010.58

Unintended pregnancy varies by a variety 

of factors, including maternal age, race/ethnicity, poverty and education. In 2006–2010, 

over three-quarters of births in the past 5 years 

to mothers aged 15-19 years were reported to 

be unintended at the time of conception. The 

same was true for half of births to women aged 

20-24 years and one-quarter to women aged 

25-44 years. Births to non-Hispanic Black and 

Hispanic women were more likely than those 

to non-Hispanic White women to have been 

unintended (53.5 and 42.9 versus 30.7 percent, 

respectively; data not shown).59

Unintended pregnancies can be averted with 

proper use of effective contraceptives. In 2006–

2010, 4.7 million, or 11.0 percent, of women 

at risk of unintended pregnancy—who were 

having intercourse and not sterile, pregnant, 

postpartum, or trying to get pregnant—reported that they were not using contraception. 

Non-Hispanic Black women were more likely 

than women of other race or ethnic groups to 

not use contraception while at risk of pregnancy (17.2 percent).

No Current Contraceptive Use Among Women Aged 15-44 Years,

at Risk of Unintended Pregnancy,* by Race/Ethnicity,** 2006–2010

Source (II.3): Centers for Disease Control and Prevention, National Survey of Family Growth

*At risk of unintended pregnancy is defined as having had intercourse in the last 3 months among those

who were not currently pregnant, postpartum, trying to get pregnant, or sterile for health reasons.

**Estimates for other racial/ethnic groups were not available.

*Limited to births occurring in the 5 years before the interview. Percentages may not add to 100

due to rounding.

Intendedness of Births at Conception* Among Women Aged

15-44 Years, by Age, 2006–2010 

Source (II.2): Centers for Disease Control and Prevention, National Survey of Family Growth

20 40 60 80 100

25-44 Years

20-24 Years

15-19 Years

Total 23.3

57.9

33.6

13.7

19.3

16.5

13.8

11.8

Intended Births Unwanted Births Mistimed Births

62.9

22.8

49.9

74.6 4

8

12

16

20

Non-Hispanic

Asian

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total

Percent of Births

Percent of Women

11.0 10.4 10.3

17.2

9.5
22 PERINATAL RISK FACTORS AND BEHAVIORS CHILD HEALTH USA 2013

PREGNANCY SPACING

The amount of time between a live birth and 

the beginning of the next pregnancy, or the 

interpregnancy interval (IPI), can impact the 

health of both mother and infant. Short IPIs 

(generally defined as less than 18 months)57,60

have been associated with adverse perinatal 

outcomes, including preterm birth, low birth 

weight, and small size for gestational age61 as 

well as adverse maternal outcomes including 

uterine rupture among women attempting a 

vaginal birth after a cesarean, placental abruption and placenta previa.62

In 2006-2010, 33.1 percent of pregnancies 

among females aged 15-44 years were conceived 

within 18 months of a previous live birth. This 

includes 6.4 percent that were conceived within 

less than 6 months of a previous live birth, 12.2 

percent that were conceived between 6 and 12 

months of a previous live birth, and 14.5 percent that were conceived between 12 and 18 

months of a previous live birth. The remaining 

66.9 percent of pregnancies were conceived at 

least 18 months after a previous live birth.

Few differences were observed among women 

with respect to the proportion who conceived 

within 18 months of a previous live birth. Hispanic women were less likely than non-Hispanic 

White and non-Hispanic Black females to conceive a pregnancy within 18 months of a previous live birth (25.3 percent compared to 35.5 

and 39.0 percent, respectively) as were women 

with incomes at or above 100% of poverty (30.9 

percent) compared to those with incomes below 

poverty (38.5 percent; data not shown). 

Non-Hispanic Black women were more likely than non-Hispanic Whites to conceive within 

6 months of a previous birth (10.3 percent versus 5.4 percent) as were those living in poverty 

(10.9 percent) compared to those with incomes 

at or above poverty (4.6 percent), and those 

with less than a high school education (11.3 

percent) compared to those with some college 

(5.3 percent; data not shown).

Pregnancy Spacing Among Women Aged 15-44 Years with a

Previous Live Birth,* 2006-2010

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

Family Growth

Percent of Women

Pregnancy Spacing Among Women Aged 15-44 Years with a

Previous Live Birth,* by Race/Ethnicity, 2006-2010 

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

Family Growth Percent of Women 20

40

60

80

100

Non-Hispanic

Other**

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total

*Limited to births occurring in the 5 years before the interview. Percentages may not add to 100 due

to rounding.

*Limited to births occurring in the 5 years before the interview. Percentages may not add to 100 due

to rounding. **Includes individuals of two or more races.

33.1

61.0

35.5

66.9

39.0

74.7

25.3

70.5

29.5

64.5
 CHILD HEALTH USA 2013 PERINATAL RISK FACTORS AND BEHAVIORS 23

PRECONCEPTION HEALTH

Efforts to improve pregnancy outcomes and 

the health of mothers and infants should begin 

prior to conception, whether before a first or 

subsequent pregnancy.63 As many women are not 

aware of being pregnant at first, it is important 

to establish healthy behaviors and achieve optimal health well before pregnancy. Key indicators 

of preconception health include not smoking 

or abusing alcohol prior to pregnancy, taking a 

daily multi-vitamin, and maintaining a healthy 

weight.64

Frequent use of alcohol, especially early in 

pregnancy, can cause fetal alcohol syndrome 

and alcohol-related birth defects.63,65 Smoking 

also increases the risk of pregnancy complications, preterm birth, and low birth weight.63 In 

2009–2010, about one in four recent mothers 

in a 30-state area reported binge drinking (consuming 4 or more drinks in a sitting) at least 

once within 3 months prior to pregnancy (26.6 

percent) and 24.2 percent reported smoking 

during the same time period. Smoking prior to 

pregnancy varied by maternal education, ranging from 9.6 percent of mothers with 16 or more 

years of education to 34.3 percent of mothers 

with 12 years of education. Binge drinking was 

most common among mothers with 13-15 years 

of education (31.9 percent), and least common 

among those who had less than 12 years (16.3 

percent). Binge drinking and smoking in the 

three months prior to pregnancy also tend to 

be more common among younger mothers. For 

example, among 20- to 24-year-old women, 

31.1 percent reported binge drinking in the 3 

months prior to pregnancy and 35.3 percent 

reported smoking, compared to 18.6 and 13.3 

percent, respectively, among women aged 35 

and older (data not shown).

Daily use of multi-vitamins containing folic 

acid can reduce the risk of neural tube defects in 

infants by two-thirds.28 In 2009-2010, only 30.1 

percent of recent mothers reported daily multivitamin use in the month prior to pregnancy. 

With regard to maternal education, half (48.2 

percent) of women with 16 or more years of education reported taking a daily multi-vitamin in 

the month prior to pregnancy compared to about 

20 percent of women with 12 years or less. 

Women should also attain a healthy weight 

prior to pregnancy to prevent complications, 

such as diabetes and hypertension, which may 

increase the risk of preterm delivery.63 About 

half of new mothers (50.1 percent) reported a 

healthy pre-pregnancy weight. This proportion 

varied by maternal age, with teenage mothers 

being the most likely to have had a normal 

pre-pregnancy weight (58.7 percent; data not 

shown). With respect to race and ethnicity, 

Non-Hispanic Asian mothers were most likely 

to have a healthy pre-pregnancy weight (66.2 

percent, as compared to mothers of all other racial and ethnic groups (data not shown). 

Selected Preconception Health Indicators Among Recent Mothers, by Maternal Education,

2009-2010*

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk Assessment Monitoring System

*Includes data from a total of 30 states and New York City; 25 states contributed both years. Mothers completed surveys between 2 and 9

months postpartum. **Defined as drinking 4 or more alcohol drinks in one sitting at least once in the 3 months prior to pregnancy. †

Defined as a pre-pregnancy body mass index (ratio of weight to height) between 18.5 and 24.9.

Total

Less than 12 Years

12 Years 13-15 Years

16 Years or More 45.7

59.7

27.4

34.3

9.6

31.9

14

28

42

56

70

Normal Weight Binge Drinking** Smoking Daily Multi-vitamin Use †

Percent of Recent Mothers

48.2 48.3 44.9

19.3

50.1

27.1 26.9

20.7

30.1

16.3

24.2 27.7 28.6 26.6
24 PERINATAL RISK FACTORS AND BEHAVIORS CHILD HEALTH USA 2013

SMOKING DURING PREGNANCY

Smoking during pregnancy can have a negative impact on the health of women, infants, 

and children by increasing the risk of fertility 

problems and pregnancy complications, as well 

as preterm birth, low birth weight, some birth 

defects, and sudden infant death syndrome.66

Secondhand smoke exposure during pregnancy 

has also been associated with increased risk for 

low birth weight.67 

In 2009–2010, 11.6 percent of recent mothers in a 30-state area reported that they had 

smoked in the last 3 months of pregnancy. 

Smoking in the last 3 months of pregnancy varied significantly by race and ethnicity. About 

one-quarter of non-Hispanic American Indian/

Alaska Native mothers (26.3 percent) reported 

having smoked in the last 3 months of pregnancy, while fewer than 5 percent of non-Hispanic 

Asian and Hispanic mothers reported doing so 

(1.8 and 3.6 percent, respectively). Smoking in 

the last 3 months of pregnancy also varied by 

maternal education, and was least common (2.0 

percent) among mothers with at least 16 years of 

education. This behavior also tends to be more 

common among younger mothers: among 20- 

to 24-year-old women, 17.8 percent reported 

smoking during the last 3 months of pregnancy, 

compared to 6.1 percent among women aged 35 

years and older (data not shown). 

Due to awareness of the neonatal health 

consequences of smoking, pregnancy may be 

a period of heightened motivation to quit. In 

2009–2010, 52.9 percent of recent mothers 

who reported smoking in the 3 months prior to 

pregnancy had not smoked in the last 3 months 

of pregnancy. Prenatal smoking cessation increased with maternal education, ranging from 

39.1 percent of mothers with less than 12 years 

of education to 80.0 percent of mothers with at 

least 16 years of education. Non-Hispanic Asian 

and Hispanic mothers had the highest rates of 

perinatal smoking cessation at 74.0 and 71.6 

percent, respectively, as compared to mothers 

of all other racial and ethnic groups (data not 

shown). In addition to clinical screening and 

counseling,68 increases in state tobacco taxes and 

smoke-free laws have been shown to improve 

prenatal smoking cessation.69

Cigarette Smoking in the Last 3 Months of Pregnancy, by

Race/Ethnicity, 2009-2010*

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

Percent of Recent Mothers

Smoking Cessation During Pregnancy,* by Maternal Education,

2009-2010**

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

*Includes data from a total of 30 states and New York City; 25 states contributed both years. Mothers

completed surveys between 2 and 9 months postpartum.

*Defined as the proportion of mothers who reported not smoking in the last 3 months of pregnancy among

those who reported smoking in the three months prior to pregnancy. **Includes data from a total of 30

states and New York City; 25 states contributed both years. Mothers completed surveys between 2 and 9

months postpartum.

48.1 52.9 58.5

80.0

39.1

Percent of Recent Mothers

20

40

60

80

100

16 Years

or More

13-15

Years

12

Years

Less than

12 Years

Total

15.3

11.6

3.6 1.8

26.3

1.8

11.8 10.2

6

12

18

24

30

NonHispanic

Multiple

Race

NonHispanic

Native

Hawaiian/

Other Pacific

Islander

NonHispanic

Asian

NonHispanic

American

Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total
 CHILD HEALTH USA 2013 PERINATAL RISK FACTORS AND BEHAVIORS 25

ALCOHOL USE DURING 

PREGNANCY

Drinking alcohol, in any amount, is not recommended for women who are pregnant or may 

become pregnant.70 When a pregnant woman 

consumes alcohol, the alcohol passes across the 

placenta to the fetus and can increase the risks of 

miscarriage, stillbirth, and serious and lifelong 

disorders known as fetal alcohol spectrum disorders (FASDs). Children with FASD may experience delayed development, poor muscle tone, 

heart defects, and malformation in their faces.71

In order to prevent FASD, a woman should not 

drink alcohol during pregnancy, when she is trying to conceive, or if she is sexually active and not 

using effective contraception.72

In 2009-2010, any alcohol use during the 

last three months of pregnancy was reported 

by 6.8 percent of mothers. The proportion of 

mothers reporting alcohol use during the last 

trimester of pregnancy increased with maternal 

age, ranging from 2.4 percent of those aged 19 

years or younger to about 10 percent of women 

aged 30 years or older. With respect to maternal 

education, drinking during the last trimester of 

pregnancy was more common among mothers 

with 16 years or more of education (11.4 percent) and least common among those with less 

than 12 years of education (3.5 percent) (data 

not shown).

Cessation of alcohol use during pregnancy is a 

key public health issue, as more than half (52.8 

percent) of mothers reported that they had consumed alcohol during the three months prior to 

pregnancy (data not shown). Among those who 

had consumed alcohol prior to pregnancy, 87.5 

percent reported that they did not drink during 

their third trimester. Non-Hispanic Asian mothers (81.7 percent) were significantly less likely to 

stop consuming alcohol as compared to mothers 

of all other racial and ethnic groups. The proportion of mothers to report cessation of alcohol use 

varied by maternal age, with cessation more common among younger mothers (data not shown).

Some women may need professional help 

in order to overcome dependency on alcohol. 

The Centers for Disease Control and Prevention recommends that women contact their 

doctors, Alcoholics Anonymous, or a local alcohol treatment center.72 The Substance Abuse 

and Mental Health Services Administration 

(SAMHSA) has a treatment facility locator

(http://findtreatment.samhsa.gov/).

Cessation of Alcohol Use Prior to the Last 3 Months of Pregnancy, by

Race/Ethnicity, 2009-2010*,**

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

Any Alcohol Use During the Last 3 Months of Pregnancy,

by Maternal Age, 2009-2010*

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk

Assessment Monitoring System Percent of Mothers

Percent of Mothers

6.8

2.4

4.1

10.5

6.4

9.6

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

87.5 87.7 88.4 86.4 81.7 90.8 88.6 87.7

*Includes data from a total of 30 states and New York City; 25 states contributed both years;

mothers completed surveys between 2 and 9 months postpartum.

*Includes data from a total of 30 states and New York City; 25 states contributed both years; mothers completed surveys

between 2 and 9 months postpartum. **Includes data from mothers who reported alcohol use prior to pregnancy. 

4

8

12

16

20

35 Years

or Older

30-34

Years

25-29

Years

20-24

Years

19 Years

or Younger

Total
26 PERINATAL RISK FACTORS AND BEHAVIORS CHILD HEALTH USA 2013

WEIGHT GAIN DURING 

PREGNANCY

Gaining too much or too little weight during pregnancy can produce immediate and 

long-term health risks to a woman and her infant.73 Excessive weight gain may increase the 

risk of pregnancy complications, cesarean delivery, larger infant birth weight, and postpartum 

weight retention that may lead to obesity and 

other related health risks in subsequent pregnancies. Although inadequate weight gain poses little 

health risk to mothers, it may result in small or 

growth-restricted infants, which increases the risk 

for infant mortality and developmental delays.73

Recommendations regarding gestational 

weight gain vary based on a woman’s pre-pregnancy body mass index—a ratio of weight to 

height. According to the Institute of Medicine, 

women of normal weight are recommended to 

gain between 25 and 35 pounds while those who 

are underweight should gain slightly more and 

those who are overweight or obese at the beginning of pregnancy should gain significantly less. 

Weight gains below these recommended levels 

may be considered inadequate, while those above 

may be excessive. Among women in a 30-state 

reporting area who delivered singleton infants at 

37+ weeks’ gestation in 2009–2010, only about 

1 in 3 or 31.8 percent gained the recommended 

amount of weight and nearly half (47.8 percent) 

gained an excessive amount of weight during 

pregnancy. About one in five women (20.5 percent) gained an inadequate amount of weight in 

pregnancy. 

Compared to women of other racial and ethnic groups, non-Hispanic Asian women were 

most likely to gain the recommended amount 

of weight (39.3 percent) and least likely to gain 

an excessive amount (33.3 percent). Excessive 

weight gain exceeded 50 percent among nonHispanic Native Hawaiian/Other Pacific Islander 

and non-Hispanic women of multiple races, with 

rates that were significantly higher than those for 

non-Hispanic Black, Hispanic and non-Hispanic 

Asian women. Conversely, about 1 in 4 Hispanic, non-Hispanic Black, and non-Hispanic Asian 

women had inadequate weight gain. Prenatal care 

appointments provide an important opportunity 

to monitor weight gain and receive counseling 

for dietary and physical activity modifications to 

meet recommended levels.73 

14

28

42

56

70

NonHispanic

Multiple

Race

NonHispanic

Native

Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American

Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

*Defined according to IOM gestational weight gain recommendations for women delivering singleton infants

at term (37+ weeks’ gestation). **Includes data from a total of 30 states and New York City; 25 states

contributed all 3 years. Mothers completed surveys between 2 and 9 months postpartum.

Gestational Weight Gain Adequacy*, by Race/Ethnicity, 2009-2010**

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System Percent of Mothers

Adequate

Excessive

Inadequate

17.9

31.8

25.0

32.6

49.5

27.3

20.5

47.8 44.8

22.5

31.3

23.9

49.1 47.7

28.4

16.6

53.5

21.5

27.4

33.3 29.2

54.1

39.3

24.9

Recommended Total Gestational Weight Gain (Pounds), by

Pre-Pregnancy Weight,* Institute of Medicine, 2009

Source (II.6): Institute of Medicine

Pre-pregnancy Weight* Inadequate Adequate Excessive

Underweight <28 28-40 >40

Normal Weight <25 25-35 >35

Overweight <15 15-25 >25

Obese <11 11-20 >20

*Underweight is defined as having a Body Mass Index (BMI) of less than 18.5; Normal Weight is defined

as having a BMI between 18.5 and 24.9; Overweight is defined as having a BMI between 25.0 and 29.9;

Obesity is defined as having a BMI of 30.0 or more; recommendations for total weight gain apply to

women delivering singleton infants at term (37+ weeks’ gestation).
 CHILD HEALTH USA 2013 PERINATAL RISK FACTORS AND BEHAVIORS 27

STRESS DURING PREGNANCY

The health and emotional well-being of a 

woman, both before and during her pregnancy, 

can impact the future health of her child. Experiencing stressful events or environmental hardships, such as financial instability, the death of a 

loved one, or divorce, while pregnancy can place 

an additional strain on a woman and increase her 

likelihood of adverse birth outcomes, including 

preterm birth and low birthweight.74,75 Pregnant 

women are encouraged to utilize their support 

networks to help manage stress and to speak with 

their provider if they experience depression.76

In 2009-2010, nearly three-fourths of recent 

mothers in a 30-state area reported that they had 

experienced at least one stressful event in the 12 

months prior to delivery of their child. The most 

commonly reported stressful events were moving 

to a new address (33.7 percent), arguing with 

husband or partner more than usual (24.7 percent), serious illness and hospitalization of a family member (22.9 percent), and inability to pay 

lots of bills (22.7 percent). 

The proportion of mothers reporting that they 

had experienced at least one stressful event ranged 

from 80.1 percent among Non-Hispanic American Indian/Alaska Native women to 56.4 percent 

among non-Hispanic Asian women. Experiencing six or more stressful events was most common 

among non-Hispanic American Indian/Alaska 

Native mothers (13.6 percent), and least common 

among non-Hispanic Asian mothers (1.0 percent). 

Mothers Experiencing Stressful Events* During the 12 Months Prior to

Delivery, by Number of Events and Race/Ethnicity, 2009-2010**

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

Stressful Events Experienced During the 12 Months Prior

to Delivery, 2009-2010*

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk

Assessment Monitoring System

*Includes data from a total of 30 states and New York City; 25 states contributed both years.

Mothers completed surveys between 2 and 9 months postpartum.

*Total number of stressful events experienced by the mother from the following: moved to a new address, argued more

than usual with husband/partner, serious illness and hospitalization of a family member, unable to pay lots of bills, death

of someone close to her, husband/partner lost job, drug use by someone close to her, lost job, was divorced or separated,

husband/partner did not want job, experience homeless, husband/partner went to jail, was in a fight. **Includes data from

a total of 30 states and New York City; 25 states contributed both years. Mothers completed surveys between 2 and 9

months postpartum. Percent of Mothers

8 16 24 32 40

Mother was in a fight

Experienced homelessness

Husband/partner went to jail

Husband/partner did

not want pregnancy

Was separated or divorced

from husband/partner

Mother lost her job

Drug use by someone

close to her

Husband or partner lost his job

Death of someone close to her

Unable to pay lots of bills

Serious illness and hospitalization of a family member

Argued more than usual

with husband/partner

Moved to a new address 33.7

24.7

22.9

22.7

17.2

15.2

12.6

11.7

8.2

8.3

3.8

4.1

4.4

Percent of Mothers

12

24

36

48

60

NonHispanic

Multiple

Race

NonHispanic

Native Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

28.5

42.0

23.6

5.9

19.9

37.3

29.2

13.6

25.5

42.8

25.7

6.0

22.1

37.2

30.9

10.0

29.2

36.3

27.5

7.0

23.6

36.5

30.9

9.0

30.3

42.9

21.8

5.1

43.7 43.7

11.7

1.0

None

1-2 3-5

6 or more
28 PERINATAL RISK FACTORS AND BEHAVIORS CHILD HEALTH USA 2013

INTIMATE PARTNER VIOLENCE 

AND PREGNANCY

In 2009-2010, 3.9 percent of women with a recent live birth in a 30-state area reported that they 

had been pushed, hit, slapped, kicked, choked or 

physically hurt in some other way by an intimate 

partner in the 12 months prior to becoming pregnant, and 3.2 percent reported experiencing this 

type of abuse during their most recent pregnancy. 

Intimate partner violence (IPV), including physical, sexual, and psychological abuse, before and 

during pregnancy has been associated with adverse maternal and infant outcomes, including 

preterm birth and low birth weight.77

The prevalence of IPV during pregnancy 

among women with a recent live birth varied by 

maternal characteristics. Teen mothers were more 

likely than older mothers to have experienced 

physical abuse by an intimate partner during 

their pregnancy. Nearly 7 percent of teen mothers 

reported IPV during pregnancy, compared to 5.0 

percent of mothers aged 20-24 years, 2.7 percent 

of those aged 25-29 years, and less than 2 percent 

of those 30 and older (data not shown). Rates 

of IPV during pregnancy were similar for mothers with 12 years of education or less (approximately 4.5 percent) while less than 1.0 percent 

of women with 16 or more years of education experienced such abuse. Non-Hispanic American 

Indian/Alaska Native and non-Hispanic Black 

women were most likely to experience IPV during pregnancy (6.5 and 5.8 percent, respectively) 

while non-Hispanic Asian mothers were least 

likely (1.5 percent; data not shown).

IPV in the year prior to pregnancy was also 

more common among younger mothers and 

mothers with less education. In 2009-2010, more 

than 7 percent of teen mothers reported experiencing physical abuse in the year prior to their 

pregnancy, compared to less than 2 percent of 

mothers aged 35 years and older. Similarly while 

approximately 5.6 percent of mothers with 12 

years of education or less reported past-year abuse, 

the same was true for 1.0 percent of women with 

16 years of education or more (data not shown). 

Experience of past-year abuse remained highest 

among non-Hispanic American Indian/Alaska 

Native and non-Hispanic Black women (7.6 

and 6.1 percent, respectively), compared to 3.1 

percent of non-Hispanic White mothers and 4.8 

percent of Hispanic mothers (data not shown).

Intimate Partner Violence* During Pregnancy, by Maternal

Education, 2009-2010**

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

Intimate Partner Violence* During 12 Months Prior to Pregnancy,

by Maternal Age, 2009-2010**

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

*Defined as having been pushed, hit, slapped, kicked, choked or physically hurt in some other way by

an intimate partner. **Includes data from a total of 30 states and New York City; 25 states contributed

both years. Mothers completed surveys between 2 and 9 months postpartum. Percent of Mothers

3.9

7.1 6.5

1.8

3.2

2.2

2

4

6

8

10

Total 20-24 Years 25-29 Years 30-34 Years

*Defined as having been pushed, hit, slapped, kicked, choked or physically hurt in some other way by an

intimate partner. **Includes data from a total of 30 states and New York City; 25 states contributed both

years. Mothers completed surveys between 2 and 9 months postpartum. Percent of Mothers

3.2

4.5 4.6

0.9

3.4

2

4

6

8

10

Total 12 Years 13-15 Years
 CHILD HEALTH USA 2013 PERINATAL RISK FACTORS AND BEHAVIORS 29

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 and other chronic 

conditions, including cardiovascular disease.78,79

Among infants born in 2009, 76.9 percent were 

reported to have ever been breastfed, representing a significant increase over the 70.9 percent of 

infants ever breastfed in 2000.80 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.81

Studies have indicated that if 90 percent of US 

newborns breastfed exclusively for their first 6 

months, direct medical costs could be reduced 

by $2.2 billion annually.82 Breastfeeding practices vary considerably by maternal race/ethnicity, education, age, and income. With respect 

to race and ethnicity, the proportion of infants 

to have ever been breastfed was higher among 

Asian, Hispanic, and non-Hispanic White infants (84.2, 82.6, and 78.4 percent, respectively) 

as compared to non-Hispanic Black infants (58.8 

percent). The proportion of infants to breastfeed 

was highest among those born to mothers with at 

least a college education (89.0 percent) as compared to mothers of all other educational levels. 

Children born to mothers aged 30 years or older 

were the most likely to have been breastfed (81.7 

percent), while children born to mothers aged 

less than 20 years were the least likely to (55.4 

percent; data not shown).

Overall, less than half (47.2 percent) of infants born in 2009 were fed breastmilk for the 

first six months of life and 16.3 percent were exclusively breastfed. The proportion of infants to 

exclusively breastfeed was highest among those 

born to mothers with at least a college education 

(21.3 percent) as compared to mothers all other 

educational levels. Common barriers to exclusive 

breastfeeding include maternal employment, 

pain related to breastfeeding, and unsupportive 

hospital policies.83 The Patient Protection and 

Affordable Care Act requires most health insurance plans to provide breastfeeding support, 

counseling, and equipment to pregnant and 

nursing women (see page 41).84

Infants* Who Are Breastfed by Race/Ethnicity and Duration, 2009

Source (II.7): Centers for Disease Control and Prevention, National Immunization Survey Percent of Infants 20

40

60

80

100

Native

Hawaiian/

Other

Pacific Islander††

American

Indian/

Alaska Native††

Asian Non- Hispanic ††

Hispanic

Black

NonHispanic

White

Total

20

40

60

80

100

Some College

College

High

School

Less than

High School

Total

*Includes only infants born in 2009; data are preliminary. **Reported that child was ever breastfed or fed

human breastmilk. †

Exclusive breastfeeding is defined as only human breastmilk—no solids, water, or

other liquids. ††Includes Hispanics. 

Infants* Who Are Breastfed by Maternal Education and Duration,

2009 

Source (II.7): Centers for Disease Control and Prevention, National Immunization Survey Percent of Infants *Includes only infants born in 2009; data are preliminary. **Reported that child was ever breastfed or fed

human breastmilk. †

Exclusive breastfeeding is defined as only human breastmilk—no solids, water, or

other liquids. 

76.9

47.2

16.3

70.5

10.7

38.7

67.1

14.4

34.8

76.5

16.2

45.4

89.0

21.3

63.9

76.9

16.3 17.4

10.0 8.0

17.0 18.2 17.2

58.8

50.4

78.4

47.2

32.0

47.9

82.6 84.2

59.0 61.6

33.0 33.1

71.5

Ever Breastfed** Exclusively at 6 Months† Any at 6 Months

Ever Breastfed** Exclusively at 6 Months Any at 6 Months †
30 PERINATAL RISK FACTORS AND BEHAVIORS CHILD HEALTH USA 2013

SAFE SLEEP BEHAVIORS

Safe sleep behaviors are practices that reduce 

the risk of Sudden Infant Death Syndrome 

(SIDS) and sleep-related suffocation. SIDS 

and other sleep-related infant deaths, sometimes called Sudden Unexpected Infant Deaths 

(SUID), accounted for 15 percent of all infant 

deaths in 2010 (see page on SIDS/SUID).

To reduce the risk of SIDS and other sleeprelated infant deaths, the American Academy of 

Pediatrics (AAP) recommends that all infants 

be placed on their backs (known as supine position) by their caregiver for every sleep until 1 

year of age.85 In 2009-2010, 70.5 percent of recent mothers reported that their infant was laid 

down to sleep on his or her back most of the 

time. The proportion of mothers reporting this 

safe sleep behavior was highest among non-Hispanic White, non-Hispanic American Indian/

Alaska Native, and non-Hispanic Asian mothers 

(76.4, 77.0 , and 76.5 percent, respectively) and 

was lowest among non-Hispanic Black mothers 

(52.3 percent). 

It is also recommended that infants sleep on a 

firm sleep surface, without loose bedding, in the 

same room but not the same bed or sleep surface as parents or other persons.85 Bed-sharing 

can increase the risk of SIDS and suffocation. 

The proportion of mothers reporting that they 

never practiced bed-sharing was highest among 

non-Hispanic White mothers (44.9 percent) and 

lowest among non-Hispanic Black and Asian 

mothers (19.1 and 19.9 percent, respectively). 

Conversely, non-Hispanic Black, non-Hispanic 

Asian and non-Hispanic Native Hawaiian/Other 

Pacific Islander mothers were the most likely to 

report that they always or often shared a bed with 

their infant (37. 6, 41.4 and 39.2 percent, respectively), while non-Hispanic White women were 

least likely to do so (16.5 percent). 

Resources to educate caregivers regarding 

ways to reduce the risk for SIDS and other sleeprelated causes of infant death are provided by the 

Safe to Sleep® campaign (previously known as the 

Back to Sleep campaign).86 This collaborative effort was renamed and expanded in 2012 to reflect the AAP’s broader recommendations and to 

address all sleep-related infant deaths. 

Women with a Recent Live Birth Who Reported That Their

Infants Were Usually Placed on Their Backs to Sleep,

by Maternal Race/Ethnicity, 2009-2010*

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk

Assessment Monitoring System

Bed-Sharing Among Recent Mothers, by Maternal Race/Ethnicity,

2009-2010*

Source (II.5): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

*Includes data from 30 states and New York City; 25 states contributed both years. Mothers

completed surveys between 2 and 9 months postpartum.

*Includes data from 16 states; 13 states contributed both years. Mothers completed surveys between 2 and

9 months postpartum.

Always/Often Sometimes/Rarely Never

70.5 76.4 77.0 69.5 70.5

52.3

65.1

76.5

Percent of Recent Mothers

Percent of Women

with a Recent Live Birth

20 40 60 80 100

Non-Hispanic Multiple Race

Non-Hispanic Native Hawaiian/

Other Pacific Islander

Non-Hispanic Asian

Non-Hispanic American

Indian/Alaska Native

Hispanic

Non-Hispanic Black

Non-Hispanic White

Total

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

24.9 39.4 39.4

16.5 38.6 44.9

37.6 43.4 19.1

32.5 38.9 28.6

28.2 45.7 26.1

41.4 38.7 19.9

39.2 37.3 23.5

25.3 41.4 33.3
 CHILD HEALTH USA 2013 PERINATAL RISK FACTORS AND BEHAVIORS 31

IMPAIRED FECUNDITY AND 

INFERTILITY SERVICES

Infertility generally refers to difficulties in becoming pregnant after trying for 1 year, whereas 

impaired fecundity includes problems either 

in becoming pregnant or carrying a pregnancy 

to term.87 Factors that can increase a women’s 

risk of infertility or impaired fecundity include 

older age, smoking, excessive alcohol use, being 

severely over- or underweight, a history of sexually transmitted infections, and certain health 

conditions such as polycystic ovarian syndrome 

(PCOS) which can interfere with ovulation.87

In 2006–2010, 10.9 percent of women aged 

15-44 had impaired fecundity (data not shown). 

Among nulliparous women—those without a 

previous birth—prevalence of impaired fecundity increased with age from 6.4 percent of women 

aged 15-24 to 30.2 percent of women aged 40-

44. In contrast, impaired fecundity did not vary 

greatly with age among women with a previous 

birth, ranging from 9 to 12 percent across age 

groups. Among women with a previous birth, the 

proportion who are surgically sterile (i.e., tubal 

ligation or hysterectomy) increases to 55.4 percent of women by age 40-44, and thus a smaller 

proportion are at risk of impaired fecundity (data 

not shown).

Difficulties having a baby can be addressed 

with medicines, surgery, artificial insemination, 

and assisted reproductive technology (ART).87 In 

2006–2010, 11.9 percent of women aged 15-44 

years reported that they or their spouses or partners had ever received some form of infertility 

service and 4.9 percent had received medical help 

to prevent a miscarriage (data not shown). The 

most common type of infertility service received 

was advice (6.5 percent), followed by infertility 

testing (5.0 percent) and medications to improve 

ovulation (4.0 percent). Between one-fifth and 

one-quarter of nulliparous women aged 35-39 

and 40-44, respectively, had ever received infertility services. 

Between 2000-2009, the number of ART 

treatment cycles (or fertility treatments in which 

both eggs and sperm are handled) performed in 

the U.S. increased from 99,629 to 146,244 and 

the resulting number of infants born more than 

doubled (from 35,025 to 60,190).88 

Impaired Fecundity* Among Females Aged 15-44 Years, by Age

and Parity, 2006–2010

Source (II.8): Centers for Disease Control and Prevention, National Survey of

Family Growth

Types of Infertility Services Received by Females Aged 15-44

Years, 2006–2010

Source (II.8): Centers for Disease Control and Prevention, National Survey of

Family Growth

Percent of Females 10

20

30

40

50

Total 15-29 Years 30-34 Years 35-39 Years 40-44 Years

*Impaired fecundity is defined as having problems getting pregnant or carrying a baby to term, for

reasons unrelated to surgical sterility.

*Assisted reproductive technology (ART) includes all fertility treatments in which both eggs and sperm

are handled outside of the body. Generally, ART procedures involve surgically removing eggs from a

woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s

body or donating them to another woman.

No Births

1 or More Births

4 8 12 16 20

Assisted

reproductive technology*

Artificial insemination

Surgery or treatment

of blocked tubes

Ovulation medication

Infertility Testing (of

female or male partner)

Advice

Any service

Percent of Females

11.9

6.5

5.0

4.0

0.9

1.2

0.4

11.2 10.8 8.0

16.9

26.5

30.2

10.6 10.9 11.3 9.3
32 HEALTH SERVICES UTILIZATION CHILD HEALTH USA 2013

PRENATAL CARE UTILIZATION

Early and adequate prenatal care helps to promote healthy pregnancies through screening and 

management of a woman’s risk factors and health 

conditions, as well as education and counseling on 

healthy behaviors during and after pregnancy.89 In 

2011, among the 36 states and District of Columbia that had implemented the 2003 revision to the 

standard birth certificate as of January 1st and collected prenatal care information in the same format, 73.7 percent of women giving birth received 

early prenatal care in the first trimester, while 6.0 

percent of women began prenatal care in the third 

trimester or did not receive any prenatal care. 

Rates of first trimester prenatal care increased 

with greater educational attainment, from only 

58.0 percent of mothers with less than a high 

school diploma to 86.3 percent of mothers with 

a bachelor’s degree or higher. First trimester prenatal care initiation was highest among nonHispanic White and non-Hispanic Asian women 

(78.8 and 77.8 percent, respectively), followed 

by Hispanic (68.3 percent) and non-Hispanic 

Black women (63.4 percent), while non-Hispanic 

American Indian/Alaska Native and non-Hispanic Native Hawaiian/Other Pacific Islander women had the lowest rates of early prenatal care (59.0 

and 55.7 percent, respectively; data not shown). 

In 2011, 84.8 percent of women in 37 jurisdictions received adequate prenatal care, defined 

as receiving 80 percent or more of expected visits 

given the timing of prenatal care entry and gestational age at delivery. Non-Hispanic American 

Indian/Alaska Native and non-Hispanic Native 

Hawaiian and Other Pacific Islander mothers 

were least likely to receive adequate care (76.7 

and 77.9 percent, respectively), followed by 

non-Hispanic Black mothers (80.8 percent). Of 

women with a college degree, 88.1 percent had 

received adequate care upon initiation compared 

to 79.2 percent of women without a high school 

diploma (data not shown).

Timing of Prenatal Care Initiation,* by Maternal Education, 2011

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

Statistics, National Vital Statistics System Percent of Mothers

Adequacy of Prenatal Care Utilization Upon Initiation,* by Maternal

Race/Ethnicity, 2011

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

Health Statistics, National Vital Statistics System Percent of Mothers 20

40

60

80

100

NonHispanic

Multiple

Race

Non-Hispanic

Native

Hawaiian/

Other

Pacific Islander

NonHispanic

Asian

NonHispanic

American

Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White 

Total

*Data are from 36 states and the District of Columbia that implemented the 2003 revision of the birth

certificate as of January 1, 2011, representing 83% of all U.S. births. Percentages may not total to

100 due to rounding.

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

73.7

20.3

6.0

58.0

30.7

11.3

68.6

24.3

7.1

76.1

19.1

4.8

First

Trimester

Second

Trimester

Third

Trimester

or No Care

84.8

16.3

3.3 7.0

11.8

76.7

11.5

2.1

86.4

15.1

7.0

77.9

13.0

3.9

83.1

Adequate

Intermediate

Inadequate

86.3

11.1

2.6

5.9

80.8

13.3

4.0

83.3

12.7

2.4

86.6

11.0
 CHILD HEALTH USA 2013 HEALTH SERVICES UTILIZATION 33

BARRIERS TO PRENATAL CARE

Early and adequate prenatal care is important 

for ensuring a healthy pregnancy. It is recommended that women schedule their first prenatal visit as soon as they think they might be 

pregnant.90 Unfortunately, not all mothers are 

able to access early prenatal care (see also Prenatal Care Utilization). 

 In 2009-2010, 17.2 percent of recent mothers in a 30-state area reported that they were 

not able to access prenatal care as early as they 

had wanted. Mothers aged 19 years or younger 

were the most likely to report delayed prenatal 

care (29.8 percent) as compared to all other age 

groups. With respect to race and ethnicity, the 

proportion of mothers reporting delayed access 

to care was highest among non-Hispanic American Indian/Alaska Native mothers, non-Hispanic mothers of multiple race, and non-Hispanic 

Black mothers (24.2 percent, 23.2, and 22.2 percent, respectively), as compared to non-Hispanic 

Asian mothers, and was lowest among non-Hispanic White mothers (15.1 and 14.7 percent, 

respectively; data not shown). These patterns are 

consistent with first trimester entry rates into 

prenatal care (see also Prenatal Care Utilization).

Common barriers to getting prenatal care as 

early as desired (or at all) can include limited resources, transportation issues, and not knowing 

that one is pregnant. In 2009-2010, more than 

one-third (37.1 percent) of mothers who reported delayed care attributed this to not knowing 

that they were pregnant. Additionally, a lack of 

resources was a common barrier, as 38.7 percent 

of mothers reported that care had been delayed 

because they lacked the money or insurance to 

pay for their visits, while 36.4 percent of mothers 

cited not having a Medicaid card. More than half 

(59.0 percent) of women who reported experiencing a delay in care listed 1 or 2 of the barriers 

described below, while 34.9 percent reported experiencing 3 or more of the listed barriers.

Mothers Who Experienced Barriers to Receiving Prenatal Care

as Early as Desired, by Maternal Age, 2009–2010*

Source (III.2): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

Barriers to Receiving Prenatal Care at All or as Early as Desired

Among Women Who Reported Delayed Care, 2009–2010*

Source (III.2): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

*Includes data from a total of 30 states and New York City; 25 states contributed both years. Mothers

completed surveys between 2 and 9 months postpartum.

*Includes data from a total of 30 states and New York City; 25 states contributed both years.

Mothers completed surveys between 2 and 9 months postpartum. Percent of Recent Mothers

17.2

23.8

15.7

11.2 10.9

29.8

6

12

18

24

30

Total 20-24 Years 25-29 Years 30-34 Years 10 20 30 40 50

Needed childcare

for other children

Could not take time off work or school

Didn’t want anyone to

know about pregnancy

Lacked transportation to

clinic or doctors office

Mother was too busy

Doctor or health plan did

not start as early as desired

Didn’t have a Medicaid card

Didn’t know she was pregnant

Couldn’t get appointment

when desired

Lacked money

or insurance for visits 38.7

37.8

37.1

36.4

24.1

19.7

13.9

13.9

9.8

7.9

Percent of Recent Mothers
34 HEALTH SERVICES UTILIZATION CHILD HEALTH USA 2013

COUNSELING RECEIVED 

DURING PRENATAL CARE

Prenatal care visits are an opportunity for a 

health care provider to discuss a variety of health 

and safety topics with the expectant mother. This 

can include such topics as injury prevention, genetic screening, infant care, and domestic violence. 

In 2009-2010, more than three quarters of recent mothers in a 30-state area reported that their 

doctor had discussed at least one of the following 

topics with them during a prenatal visit: safe use 

of medications while pregnant (88.8 percent), 

genetic testing (86.7 percent), what to do in the 

case of early labor (82.2 percent) and signs of preterm labor (78.5 percent). Illegal drug use was 

discussed with 64.3 percent of expectant mothers, while approximately half (52.2 percent) received counseling on seat belt use. Public health 

efforts to increase prenatal counseling on seat belt 

use remain critical for reducing the number of 

traffic related deaths and hospitalizations that occur during pregnancy.91

Alcohol use was more likely to be discussed 

with those who had Medicaid coverage than any 

other type of insurance. Women with private 

insurance (62.3 percent) were the least likely to 

receive counseling on smoking during pregnancy 

compared to women with Medicaid coverage, 

other types of insurance, or no insurance (82.6, 

75.2, and 70.1 percent, respectively).

Physical abuse by a husband or partner was 

discussed with half of all women. Women with 

private insurance (40.7 percent) were the least 

likely to have received counseling on this issue, 

while women with Medicaid coverage were the 

most likely (61.5 percent). The proportion of 

women to receive counseling on domestic abuse 

also varied by maternal age, ranging from 61.7 

percent of women aged 19 years or younger to 

about 43 percent of women aged 30 years and 

older (data not shown). Studies have shown 

that women in need of counseling on domestic 

abuse, breastfeeding, and preterm labor are not 

more likely to receive this information than those 

without reported risk factors, such as having had 

a previous preterm birth.92

Topics Discussed by Health Care Provider

During Prenatal Care Visits, 2009–2010*

Source (III.2): Centers for Disease Control and Prevention,

Pregnancy Risk Assessment Monitoring System

Topics Discussed by Health Care Provider During Prenatal Care Visits, by 

Insurance Type, 2009–2010*

Source (III.2): Centers for Disease Control and Prevention, Pregnancy Risk Assessment Monitoring System

*Includes data from a total of 30 states and New York City; 25 states contributed

both years. Mothers completed surveys between 2 and 9 months postpartum.

*Includes data from a total of 30 states and New York City; 25 states contributed both years. Mothers completed surveys between

2 and 9 months postpartum.

Percent of Mothers

Percent of Mothers

20

40

60

80

100

Seat belt useIllegal

drug

use

Signs of

preterm

labor

What to do

if labor

begins early

Genetic

testing

Safe medication

use

88.8 86.7 82.2

64.3

52.2

78.5

20

40

60

80

100

Breastfeeding HIV Testing Alcohol Use Smoking Depression Physical Abuse

82.9

89.687.5

81.1

75.4

82.5

75.4

69.8 70.6 72.7

81.475.9

71.4

65.4

71.5

82.6

75.2

70.1

62.3

70.3 75.072.5

61.9 67.1

50.4

61.5

57.0

47.6

40.7

Total Private Insurance Medicaid Other No Insurance

77.4
 CHILD HEALTH USA 2013 HEALTH SERVICES UTILIZATION 35

POSTPARTUM VISIT AND WELLBABY CARE

Care for a mother and her infant continues 

after delivery through postpartum check-ups and 

well-baby exams. Well-baby exams provide an 

opportunity for a mother to monitor her infant’s 

development and establish a relationship with 

her infant’s pediatrician.93 The American Academy of Pediatrics recommends that the first wellbaby exam take place 3 to 5 days after birth.94

During this visit, the physician will measure the 

infant’s height, weight, and head circumference 

in addition to examining the infant.93

In 2009-2010, 93.2 percent of women reported that their infant was seen by a health care provider for a check-up within one week after birth. 

The proportion of mothers reporting these visits 

varied significantly by race and ethnicity and was 

highest among non-Hispanic Native Hawaiian/

Other Pacific Islander mothers (97.1 percent), 

and lowest among non-Hispanic American Indian/Alaska Native mothers (89.0 percent). 

Postpartum visits provide a woman and her 

health care provider with the opportunity to assess the mother’s current physical health, including the status of pregnancy-related conditions 

like gestational diabetes, screen for postpartum 

depression, provide counseling on infant care 

and family planning as well as screening and 

referrals for the management of chronic conditions. Additionally, a provider may use this 

opportunity to conduct a breast exam and discuss breastfeeding.95 The American College of 

Obstetricians and Gynecologists recommends 

that mothers receive a postpartum care visit 4-6 

weeks after delivery.96 In 2009-2010, nearly 90 

percent of all mothers met this recommendation. The proportion of mothers to receive a 

postpartum visit varied significantly by education level, ranging from 78.6 percent of mothers with less than 12 years of education to 95.1 

percent of mothers with 16 or more years of 

education. With respect to race and ethnicity, 

81.8 percent of non-Hispanic American Indian/

Alaska Native mothers reported a postpartum 

visit compared to 91.9 percent of non-Hispanic 

White mothers (data not shown). 

Mothers Reporting that Their Infants had a 1-Week Checkup,

by Race/Ethnicity, 2009-2010*

Source (III.2): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

Mothers Who Had a Postpartum Checkup, by Maternal Education,

2009-2010*

Source (III.2): Centers for Disease Control and Prevention, Pregnancy Risk Assessment

Monitoring System

*Includes data from a total of 17 states and New York City; 14 states contributed both years; mothers

completed surveys between 2 and 9 months postpartum.

*Includes data from a total of 30 states and New York City; 25 states contributed both years; mothers

completed surveys between 2 and 9 months postpartum. Percent of Mothers

93.2 92.7 94.1 93.6 97.1 93.7 89.0 95.2

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

20 40 60 80 100

16 Years

or More

13-15

Years

12 Years

Less than

12 Years

Total

Percent of Mothers

88.9

78.6

86.7

91.0

95.1
36 HEALTH SERVICES UTILIZATION CHILD HEALTH USA 2013

MATERNAL AND INFANT 

VACCINATION

Vaccination is one of the greatest public 

health achievements of the 20th century, 

resulting in dramatic declines in mortality 

and morbidity for many infectious diseases.97

An annual influenza (flu) vaccination is now 

recommended for all persons aged 6 months 

and older; however, it is especially important 

for certain groups, including pregnant women 

and older adults, who are at higher risk for flu 

complications.98 By mid-April of 2013, only 

50.5 percent of pregnant women reported 

receiving flu vaccine for the 2012-2013 season. 

Those with insurance, either private/military 

or public insurance, were more likely to have 

received the flu vaccine (53.0 and 50.0 percent, 

respectively), compared to only 33.7 percent of 

pregnant women without insurance. Pregnant 

women are also specifically recommended to 

receive a tetanus, diphtheria, and acellular 

pertussis (whooping cough) vaccine (Tdap), 

regardless of whether they have been previously 

vaccinated, to prevent potentially fatal infection 

in the newborn.99 

The Centers for Disease Control and Prevention recommends a series of vaccinations from 

birth through 24 months of age, many of which 

require multiple doses for effectiveness as well 

as boosters to sustain immunity.100 In 2012, 

68.4 percent of children 19–35 months of age 

received each of seven vaccines in a series of 

recommended vaccines (4:3:1:3:3*: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 or four doses of the Haemophilus 

influenzae type b (Hib) vaccine, depending on 

brand type; 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). Children living 

in households below the poverty level were less 

likely to have completed the recommended vaccination series than those living at or above the 

poverty level (63.4 percent versus 71.6 percent). 

Hepatitis A and Rotavirus vaccinations are also 

recommended for children under age 2.

Influenza Vaccination Coverage* Among Pregnant Women,

by Insurance Type, 2013**

Source (III.3): Centers for Disease Control and Prevention, Internet Panel Survey

Recommended Vaccination Series Coverage* Among Children

Aged 19-35 Months, by Poverty Status,** 2012

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

*Receipt of 4+ DTaP, 3+ Polio, 1+ MMR, 3+ or 4+ Hib depending on brand type, 3+ HepB, 1+ Varicella,

4+ PCV; . **Poverty level, defined by the U.S. Census Bureau, was $23,681 for a family of four in 2012.

*Having received the influenza vaccination since July 1, 2012. **Women pregnant at any time from

October, 2012 to January, 2013 were surveyed in April, 2013. Percent of Women

Percent of Children

50.5 53.0

33.7

50.0

20

40

60

80

100

Total Private/Military Public Uninsured

68.4 71.6

63.4

20

40

60

80

100

Total Less than 100% of poverty 100% of poverty or more
 CHILD HEALTH USA 2013 HEALTH SERVICES UTILIZATION 37

HEALTH INSURANCE – WOMEN 

OF REPRODUCTIVE AGE

The preconception health of women has been 

strongly linked to future reproductive health outcomes for both women and infants. Preconception health care and counseling provide an important opportunity to deliver risk-appropriate 

screening, health promotion, and disease prevention services to improve the health of women and 

their infants.101 Individuals who are uninsured—

including women of reproductive age—are less 

likely to receive preventive health services and 

chronic disease management.102

In 2011, over one-fifth of reproductive-aged 

females were uninsured (21.3 percent) representing 13.3 million females aged 15-44 years. 

Younger (15-19 years) and older females (35-44 

years) were least likely to be uninsured, 14.6 percent and 19.2 percent, respectively, compared to 

over one-quarter of those aged 20-24 and 25-

29 years. Hispanic and non-Hispanic American 

Indian/Alaska Native females of reproductive 

age were most likely to lack insurance coverage 

in 2011, 37.5 percent and 32.9 percent, respectively, compared to about one-quarter of nonHispanic Black females (24.0 percent), one-fifth 

of non-Hispanic Asians (20.2 percent) and onesixth of non-Hispanic Whites (15.2 percent).

The majority of reproductive-aged females 

had private insurance coverage in 2011 (63.9 

percent) alone or in combination with some 

form of public coverage, while 14.8 percent had 

publicly-funded insurance such as Medicaid.103 

Non-Hispanic American Indian/Alaska Native 

and Black females of reproductive age were most 

likely to be publicly insured: 26.6 percent and 

23.5 percent, respectively, followed by Hispanic 

females (19.8 percent); 11.4 percent of non-Hispanic White females had public coverage.

Medicaid, in particular, is an important safety 

net for pregnant women, financing approximately 40 percent of all births in the United States. 

This coverage includes prenatal care, labor and 

delivery, and postpartum care up to 60 days after birth.104 Of the 14.8 percent or 9.2 million 

women of reproductive age who rely on publicly 

funded insurance, the majority (88.2 percent) are 

covered by Medicaid (data not shown).

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

*Estimates for private coverage include individuals that may have some other form of insurance; estimates for

public coverage exclude individuals with any form of private coverage. Estimates may not equal 100 due to

rounding. **Public or Government health insurance includes federal programs such as Medicare, Medicaid,

and military health care, and individual state health plans.

Health Insurance Coverage of Females Aged 15-44 Years, by Type of

Coverage* and Race/Ethnicity, 2011

Source (III.5): U.S. Census Bureau, Current Population Survey Percent of Females

Females Aged 15-44 Years Without Health Insurance, by

Age, 2011

Source (III.5): U.S. Census Bureau, Current Population Survey Percent of Females

Public**

Uninsured

Private

73.4

14.8

52.5

11.415.2

23.5

63.9

21.3

37.5 40.6

19.8

42.7

32.9

24.0 26.6

69.7

20.1

60.3

70.2

20.2

13.2

17.0

9.6

19.6

25.5

19.2 21.3

14.6

23.3

25.7

6

12

18

24

30

35-44

Years

30-34

Years

25-29

Years

20-24

Years

15-19

Years

Total
38 HEALTH SERVICES UTILIZATION CHILD HEALTH USA 2013

HEALTH INSURANCE – INFANTS

In 2011, approximately 441,000 U.S. infants 

under 1 year of age had no health insurance coverage, representing 11.3 percent of this population. About half of infants (50.2 percent) were 

covered by private insurance, alone or in combination with some form of public coverage, and 

38.5 percent were insured only through public 

programs such as Medicaid, the Children’s Health 

Insurance Program, and military health insurance. The majority of those with public insurance 

(93.7 percent) were covered by Medicaid.

Infants’ insurance status varies by race and 

ethnicity. In 2011, 67.7 percent and 63.4 percent of non-Hispanic Asian and White infants, 

respectively, had private coverage, while the same 

was true for approximately one-third of Hispanic 

and non-Hispanic Black infants (34.3 and 31.1 

percent, respectively). Conversely, over half of 

non-Hispanic Black and Hispanic infants were 

publicly insured, followed by 49.5 percent of 

non-Hispanic infants of more than one race.

As family income increases, private health 

insurance coverage among infants rises and the 

proportions of infants with public coverage and 

no coverage decrease. In 2011, infants in households with incomes below 100 percent of the 

poverty threshold were most likely to have public 

coverage (75.5 percent) or to be uninsured (14.1 

percent); a similar proportion of infants living 

in households with incomes above but less than 

twice the poverty threshold were also uninsured 

(13.7 percent). Infants with family incomes of 

four times or more of the poverty threshold were 

most likely to have private coverage, and least 

likely to have public coverage or to be uninsured.

Health Insurance Coverage Among Infants Under Age 1, by Type

of Coverage* and Race/Ethnicity,** 2011

Source (III.5): U.S. Census Bureau, Current Population Survey Percent of Infants

Health Insurance Coverage Among Infants Under Age 1, by Type

of Coverage* and Poverty Status,** 2011

Source (III.5): U.S. Census Bureau, Current Population Survey Percent of Infants 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

*Estimates for private coverage include individuals that may have some other form of insurance; estimates

for public coverage exclude individuals with any form of private coverage. Estimates may not total to 100

due to rounding. **The samples of American Indian/Alaska Native and Native Hawaiian and Other Pacific

Islander infants were too small to produce reliable estimates. ***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. n/r – not reportable, estimate did not meet

standard for reliability.

*Estimates for private coverage include individuals that may have some other form of insurance;

estimates for public coverage exclude individuals with any form of private coverage. Estimates may not

total to 100 due to rounding. **U.S. Census Bureau’s poverty threshold was $23,021 for a family of four

in 2011. ***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.

20

40

60

80

100

Non-Hispanic

Multiple Race

Non-Hispanic AsianNon-Hispanic Hispanic BlackNon-Hispanic WhiteTotal

50.2

38.5

11.3

49.5

63.4

26.6

31.1

10.0

39.8

n/r n/r

57.6

11.2

34.3

51.6

14.0

67.7

25.0

Private

Public***

Uninsured

Private

Public***

Uninsured

10.5

13.7

29.1

14.1 11.5

34.8

75.5

59.4

13.2

9.2

77.6

4.9

6.3

88.8

51.5
 CHILD HEALTH USA 2013 PROGRAMS AND POLICIES 39

FEDERAL NUTRITION 

PROGRAMS SERVING WOMEN

Federal programs can provide essential help 

to low-income women and their families in obtaining food and income support. The Special 

Supplemental Nutrition Program for Women, 

Infants, and Children (WIC) supports low-income women and families by providing supplementary nutritious foods, nutrition education, 

and referrals to health and other social services. 

Pregnant, postpartum, and breastfeeding women, as well as infants and children up to age 5, 

are eligible to receive WIC benefits. Between 

1974 and 2012, the number of women, infants, 

and children served by WIC has increased over 

100-fold from 88,000 to 8.9 million (data not 

shown).105

In 2012, 8.9 million women, infants and 

children received WIC benefits, averaging $45 

per participant each month.105 More than threequarters of all individuals receiving WIC benefits in 2012 were infants and children (76.5 percent); however, the program also served nearly 

2.1 million pregnant women and mothers, 

representing 23.5 percent of WIC participants. 

Of these women, 42.5 percent were pregnant, 

29.4 percent were postpartum (up to 6 months 

after the birth of the infant or the end of the 

pregnancy), and 28.1 percent were postpartum 

and breastfeeding (up to the infant’s first birthday). 

The Supplemental Nutrition Assistance Program (SNAP), formerly the Federal Food Stamp 

Program, also helps low-income individuals and 

families purchase food. SNAP is available to 

all individuals who meet the federal eligibility 

guidelines. In 2011, 44.1 million people living in 20.8 million households participated 

in SNAP on average each month (data not 

shown). Women comprised 62.5 percent of the 

24.2 million adult SNAP recipients in 2011, 

while children accounted for nearly half (45.2 

percent) of all recipients. Among the households that relied on SNAP in 2011, 5.1 million 

or 24.5 percent were female-headed households 

with children, accounting for 52.1 percent of 

all SNAP households with children (data not 

shown).106

SNAP Participants, by Age and Sex, 2011*

Source (III.8): U.S. Department of Agriculture, Food and Nutrition Service

*Based on Federal Fiscal Year (October 1 to September 30).

*Based on Federal Fiscal Year (October 1 to September 30).

**During pregnancy and up to 6 weeks after the birth of an infant or the end of the pregnancy;

†

Up to six months after the birth of the infant or the end of the pregnancy; ‡Up to the infant's first birthday.

WIC Participants, 2012* 

Source (III.6, III.7): U.S. Department of Agriculture, WIC Program Participation Data

Infants

23.2%

Women

23.5%

Pregnant**

42.5%

Breastfeeding‡

28.1%

Postpartum†

29.4%

Children

53.3%

Percent of Participants Percent of Women Participants SNAP Participants by Age SNAP Participants by Sex

0-4 Years

15.4%

5-17 Years

29.8%

Women

62.5%

Men

37.5%

18-35 Years

24.0%
40 PROGRAMS AND POLICIES CHILD HEALTH USA 2013

MATERNITY LEAVE

Maternity leave from a job after childbirth 

provides critical time for maternal-infant bonding and adjustment to life with a new baby. 

Longer maternity leave is associated with increased breastfeeding duration as well as improved maternal mental health and child development.107,108 The Family and Medical Leave 

Act (FMLA) guarantees both women and men 

up to 12 weeks of unpaid leave around the 

birth or adoption of a child, as long as they 

work for larger employers (50+ employees) and 

meet certain tenure and working hour requirements. However, many women do not qualify 

for FMLA or cannot afford to take unpaid leave 

and may use a combination of short-term disability, sick leave, vacation, and personal days in 

order to have some portion of their maternity 

leave paid. The U.S. is one of only 5 countries in 

the world that does not mandate paid maternity 

leave.109

In 2006-2010, 66.0 percent of women reported being employed during their last pregnancy, of whom 69.7 percent reported taking 

maternity leave. Thus, nearly one-third of employed women did not report taking any maternity leave (30.3 percent). Women with at least 

a college degree were more likely to have taken 

leave than those who had attended college but 

not graduated (80.0 versus 71.6 percent, respectively) while less than half of women without a 

high school degree reported having taken leave. 

Hispanic and non-Hispanic Black women were 

less likely to report having taken maternity leave 

than non-Hispanic White women (62.5 and 

64.3 percent, respectively, versus 72.2 percent). 

When taken, the average length of maternity 

leave was 10.0 weeks (data not shown). 

Among employed women who did not take 

maternity leave for their last pregnancy, 5.1 percent did not take it because it was not offered 

or allowed by their employer. Of non-Hispanic 

White women, 3.2 percent reported this reason, 

compared to 8.2 percent of Hispanic women and 

10.2 percent of non-Hispanic Black women.

Employed Women Aged 18-44 Years Who Took Maternity Leave

After Their Last Childbirth,* by Educational Attainment, 2006–2010

Source (III.9): Centers for Disease Control and Prevention, National Survey of Family

Growth

Employed Women Aged 18-44 Years Who Took Maternity

Leave After Their Last Childbirth*, and Reasons for Not Taking

Maternity Leave, by Race/Ethnicity,** 2006–2010

Source (III.9): Centers for Disease Control and Prevention, National Survey of

Family Growth

Percent of Women

20 40 60 80 100

Hispanic

Non-Hispanic

Multiple Race

Non-Hispanic

Black

Non-Hispanic

White

Total

*Following a live birth occurring in the 5 years before the survey. **The samples of American

*Following a live birth occurring in the 5 years before the survey. Indian/Alaska Native, Asian, and Native Hawaiian/Pacific Islander were too small to produce reliable results.

Took Maternity Leave Did Not Take Maternity Leave

Not Needed Due to Job Schedule or Self Employment

Not Offered or Allowed by Employer

Other Reasons

Percent of Women

69.7

48.1

65.9

80.0

71.6

20

40

60

80

100

Bachelor’s Degree

or Higher

Some

College

High School

or GED

Less than

High School Degree

Total

69.7

72.2

64.3

76.2

62.5

6.1 5.1 19.2

17.8

21.3

18.1

22.7

6.8 3.2

2.8

10.24.2

3.0

8.26.7
 CHILD HEALTH USA 2013 PROGRAMS AND POLICIES 41

AFFORDABLE CARE ACT

The Affordable Care Act was enacted March 

23, 2010. The Affordable Care Act contains 

provisions to expand access to health insurance 

coverage, contain costs and improve health care 

quality.110 Selected provisions with special significance for reproductive health are discussed on 

this page.

The Affordable Care Act includes several provisions that seek to expand access to health insurance coverage, including the establishment 

of Health Insurance Marketplaces, also known 

as Exchanges. These Marketplaces or Exchanges 

are one-stop marketplaces where consumers can 

choose a private health insurance plan based on 

their health needs. The Marketplaces or Exchanges identify qualified health plans; facilitate consumer assistance, shopping and enrollment; and 

monitor eligibility for premium assistance. The 

Affordable Care Act also extends dependent coverage, allowing children to remain on their parents’ insurance through age 26.111 This provides 

an important safety net for young adults who 

have some of the highest rates of uninsurance.112

The Affordable Care Act also includes provisions to extend access to preventive health care 

with no cost sharing. This includes eight preventive health services for women included in 

HHS Women’s Preventive Services Guidelines, 

based on recommendations by the Institute of 

Medicine.

Sixty-two percent of women of reproductive 

age are currently using contraception. The most 

common method used is the pill (28 percent).113

Because of the Affordable Care Act, most health 

insurance plans cover contraceptives without 

charging a co-pay or deductible.114

Breastfeeding is one of the most effective preventive measures mothers can take to protect 

their health and that of their children.115 Although three-quarters of infants start out being 

breastfed, only about 15 percent are exclusively 

breastfed by 6 months of age,116 as recommended by the Academy of Pediatrics. As part of the 

Affordable Care Act, pregnant and postpartum 

women have access to comprehensive lactation 

support and counseling from trained providers, as well as breastfeeding equipment, such as 

pumps for expressing milk when separated from 

their babies, through their insurance.

The Affordable Care Act also requires additional preventive services be covered for adults 

generally, including tobacco use screening and 

cessation services with expanded coverage of 

services for pregnant smokers. In 2008-2010, 

approximately 12 percent of mothers reported 

smoking during the last three months of pregnancy. Smoking during pregnancy has been associated with adverse maternal and infant outcomes, including premature birth, birth defects, 

infant death, difficulty conceiving, and miscarriage.117 Under the Affordable Care Act, private 

health insurance plans are required to cover tobacco cessation services, as is Medicaid for pregnant women, with no patient cost-sharing.118

Preventive Health Services for Women

Source (III.10): U.S. Department of Health and Human Services, Health Resources and Services Administration, 

Women’s Preventive Services Guidelines

Well-woman visits to obtain recommended preventive services

Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational 

diabetes

Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology 

results who are 30 or older

Sexually Transmitted Infections (STI) counseling for sexually active women

Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women

Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient 

education and counseling, not including abortifacient drugs

Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women

Domestic and interpersonal violence screening and counseling for all women
42 PROGRAMS AND POLICIES CHILD HEALTH USA 2013

SELECTED FEDERAL EFFORTS 

TO REDUCE INFANT MORTALITY 

AND IMPROVE BIRTH OUTCOMES

Part of the U.S. Department of Health and 

Human Services, the Health Resources and 

Services Administration’s (HRSA) Maternal 

and Child Health Bureau (MCHB) works to 

improve the physical and mental health, safety, 

and well-being of the maternal and child population through a variety of programs.

Enacted in 1935, the Title V Maternal and 

Child Health Block Grant Program is the Nation’s oldest Federal-State partnership. State maternal and child health agencies apply for and 

receive formula grants each year which support 

programs designed to provide and ensure access to quality care for at-risk mothers and children and reduce infant mortality. A total of 59 

states and jurisdictions receive Title V Maternal 

and Child Health Block Grant funding. In fiscal year 2011, Title V programs served over 44 

million individuals, including 2.4 million pregnant women, 4.3 million infants, 30.8 million 

children, and 2.9 million children with special 

health care needs.

The Healthy Start Program works to reduce 

the rate of infant mortality and improve perinatal outcomes through grants to communities 

with high infant mortality rates. The program 

began in 1991 with grants to 15 communities 

with infant mortality rates 1.5 to 2.5 times the 

national average. In 2013, 105 Healthy Start 

projects were providing services in 39 states, the 

District of Columbia and Puerto Rico, serving 

196 different communities. These projects provide core services: direct outreach and client recruitment, health education, case management, 

depression screening and referral, and services 

between pregnancies.

The Maternal, Infant, and Early Childhood 

Home Visiting Program facilitates collaboration and partnership at the federal, state, and 

community levels to improve health and development outcomes for at-risk children through 

evidence-based home visiting programs. The 

program provides grants to states, jurisdictions, 

Indian Tribes and Tribal/Indian organizations 

which support programs to improve maternal 

and newborn health, promote school readiness 

and achievement, prevent family violence and 

child injury, and develop family economic selfsufficiency. In 2012, HRSA awarded $125 million to the 54 eligible states and territories. In 

addition, approximately $84 million was awarded to 16 states to expand existing programs.

Collaborative Improvement and Innovation 

Network (CoIIN) to Reduce Infant Mortality: CoIIN is a public-private partnership which 

helps states utilize the science of quality improvement and collaborative learning to reduce infant 

mortality and improve birth outcomes. The 

CoIIN was launched July 2012 in the 13 southern states of Public Health Regions IV and VI 

focused on reducing elective deliveries prior to 

39 weeks of gestation; prenatal smoking cessation; promotion of safe infant sleep; expansion 

of Medicaid-financed interconception care for 

women with a prior adverse pregnancy outcome; 

and enhanced regional perinatal care systems. 

In March 2013, CoIIN was expanded to Public 

Health Region V. CoIIN will continue to expand 

to other Regions until it becomes a nationwide 

initiative by the end of 2014.

Interconception Care (ICC) Implementation 

Program is a national initiative to identify the 

components of effective ICC and develop strategies to improve perinatal outcomes. Using the 

life course perspective, the initiative focuses on 

promoting disease prevention and wellness before the next pregnancy. Program components 

include risk assessment, health promotion, and 

clinical and psychosocial interventions. A toolkit, practice curriculum, measures, and local assessments are planned.

National Maternal Health Initiative (NMHI) 

is a comprehensive national initiative to 

strengthen state and local systems capacity and 

infrastructure to promote, protect and improve 

maternal health. The initiative’s overarching 

goal is to reduce maternal morbidity and mortality by improving women’s health across the 

life course and by ensuring high quality and 

safety of maternity care. This will be achieved 
 CHILD HEALTH USA 2013 PROGRAMS AND POLICIES 43

by strengthening state and local systems capacity and infrastructure to identify maternal risks 

and enable linkages to prenatal/postpartum primary care, support the use of clinical guidelines 

and protocols for obstetric emergencies and referrals, and facilitate the translation of findings 

from surveillance and research into practice. 

Text4Baby is a free information service designed 

to promote maternal and child health through 

SMS text messaging. A project of the non-profit 

National Healthy Mothers, Healthy Babies 

Coalition (HMHB), Text4Baby is made possible through a broad public-private partnership 

of government, state, local, business, and community organizations, including HRSA and other agencies with the U.S. Department of Health 

and Human Services. Participants can voluntarily sign up for the service in English or Spanish 

and receive three weekly text messages timed to 

their due date or their baby’s birth date through 

age 1. Text message topics include labor signs 

and symptoms, prenatal care, immunizations, 

nutrition, and safe sleep, among many others. 

Text4baby is the largest national mobile health 

initiative in the U.S., reaching over 610,000 individuals since its launch in 2010.

The Centers for Disease Control and Prevention (CDC), the Centers for Medicare and 

Medicaid Services (CMS), and the Administration for Children and Families (ACF) are also 

agencies within the U.S. Department of Health 

and Human Services which play important roles 

in the Nation’s efforts to reduce infant mortality 

and improve birth outcomes.

A joint effort between CMS, HRSA, and ACF, 

the Strong Start for Mothers and Newborns 

Initiative aims to reduce preterm births and 

improve outcomes for newborns and pregnant 

women. The program works to achieve these 

goals through: 1) a public-private partnership 

and awareness campaign to reduce the rate of 

early elective deliveries prior to 39 weeks among 

all pregnant women; and 2) grants to states to 

test the effectiveness of enhanced prenatal care 

approaches to reduce the frequency of preterm 

births among pregnant Medicaid or Children’s 

Health Insurance Program (CHIP) beneficiaries 

at high risk for preterm births. The 27 awardees 

will test one of three approaches to enhanced 

prenatal care: through Centering/Group Visits, 

at birth centers, and at maternity care homes. 

The National Initiative on Preconception 

Health and Health Care (PCHHC) is a public-private partnership launched by the CDC 

to guide the implementation of 10 core recommendations to improve preconception health 

and health care as defined by the Select Panel 

on Preconception Care. These 10 recommendations were published in the Morbidity and 

Mortality Weekly Report in 2006 and identified approaches to improve preconception 

health and health care. Implementation of these 

recommendations and related action steps is 

supported by PCHHC workgroups focused on 

the clinical, policy and finance, consumer, public health, and surveillance and research aspects 

of preconception health. To date, the PCHHC 

has supported the inclusion of preconception 

care as part of the Institute of Medicine’s recommendations for women’s clinical preventive 

services, advanced state-level policy reforms to 

expand coverage of preconception care, and laid 

the groundwork for a national social marketing 

campaign to increase public awareness of the 

importance of preconception health. 

In partnership with HRSA, CDC and other 

private partners, the Eunice Kennedy Shriver 

National Institute for Child Health and Human Development at the National Institutes 

of Health supports the Safe to Sleep Public Education Campaign—formerly known 

as the Back to Sleep campaign—which works 

to educate parents, caregivers, and health care 

providers about ways to reduce the risk for 

Sudden Infant Death Syndrome (SIDS) and 

other sleep-related causes of infant death. The 

expanded Safe to Sleep campaign builds on the 

success and reach of the Back to Sleep campaign 

and promotes actions that parents and caregivers can take that, in addition to SIDS, will also 

reduce the risk of other sleep-related causes of 

infant death, such as suffocation.
44 ENDNOTES CHILD HEALTH USA 2013

ENDNOTES

Perinatal Health Status Indicators

1. Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Prematurity. 

November 2009. Available online: http://www.cdc.gov/

Features/PrematureBirth/. Accessed: 04/23/13.

2. March of Dimes. Less than 39 weeks toolkit. Available 

online: http://www.marchofdimes.com/professionals/

medicalresources_39weeks.html. Accessed: 04/23/13.

3. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet. 2008 Jan 

5;371(9606):75-84.

4. March of Dimes. Low Birth Weight. Retrieved from: 

http://www.marchofdimes.com/professionals/medicalresources_lowbirthweight.html. Accessed: 04/08/13.

5. 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.

6. Wise PH. The anatomy of a disparity in infant mortality. 

Annu Rev Public Health. 2003;24:341-62.

7. Mathews TJ, MacDorman, MF. Infant Mortality Statistics 

from the 2009 Period Linked Birth/Infant Death Data 

Set. National Vital Statistics Reports; vol 61 no 8. Hyattsville, MD: National Center for Health Statistics. 2013.

8. Teune MJ, Bakhuizen S, Gyamfi Bannerman C, Opmeer 

BC, van Kaam AH, van Wassenaer AG, et al. A systematic 

review of severe morbidity in infants born late preterm. 

Am J Obstet Gynecol 2011;205(4):374.e1–9. 

9. Fanaroff AA, Stoll BJ, Wright LL, Carlo WA, Ehrenkranz 

RA, Stark AR, et al. Trends in neonatal morbidity and 

mortality for very low birthweight infants. Am J Obstet 

Gynecol 2007;196(2):147e1-8. 

10. Shapiro-Mendoza CK, Tomashek KM, Kotelchuck 

M, Barfield W, Nannini A, Weiss J, Declercq E. 

Effect of late-preterm birth and maternal medical 

conditions on newborn morbidity risk. Pediatrics. 2008 

Feb;121(2):e223-32. doi: 10.1542/peds.2006-3629.

11. Heron M. Deaths: Leading Causes for 2009. National 

vital statistics reports; vol 61 no 7. Hyattsville, MD: 

National Center for Health Statistics. 2012.

12. Hoyert DL, Xu JQ. Deaths: Preliminary data for 2011. 

National vital statistics reports; vol 61 no 6. Hyattsville, 

MD: National Center for Health Statistics. 2012.

13. Mathews TJ, MacDorman, MF. Infant Mortality Statistics 

from the 2009 Period Linked Birth/Infant Death Data 

Set. National Vital Statistics Reports; vol 61 no 8. Hyattsville, MD: National Center for Health Statistics. 2013.

14. 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.

15. Centers for Disease Control and Prevention. Advancements in public health, 1900-1999: healthier mothers and 

babies. MMWR. 1999; 48:849-58.

16. 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.

17. Martin JA, Hamilton BE, 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.

18. 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.

19. 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.

20. MacDorman MF, Mathews TJ. Behind international 

rankings of infant mortality: How the United States compares with Europe. NCHS data brief, no 23. Hyattsville, 

MD: National Center for Health Statistics. 2009.

21. Ventura SJ, Curtin SC, Abma JC, Henshaw SK. Estimated pregnancy rates and rates of pregnancy outcomes 

for the United States, 1990-2008. National vital statistics 

reports; vol 60 no 7. Hyattsville, MD: National Center 

for Health Statistics. 2012.

22. MacDorman MF, Kirmeyer SE, Wilson EC. Fetal and 

perinatal mortality, United States, 2006. National vital 

statistics reports; vol 60 no 8. Hyattsville, MD: National 

Center for Health Statistics. 2012.

23. Stillbirth Collaborative Research Network Writing Group. 

Causes of death among stillbirths. JAMA. 2011 Dec 

14;306(22):2459-68.

24. March of Dimes. Stillbirth. Retrieved from: http://

www.marchofdimes.com/loss/stillbirth.aspx. Accessed: 

08/01/2013.

25. Parker SE, Mai CT, Canfield MA, Rickard R, Wang Y, 

Meyer RE, Anderson P, Mason CA, Collins JS, Kirby 

RS, Correa A; for the National Birth Defects Prevention 

Network. Updated national birth prevalence estimates for 

selected birth defects in the United States, 2004-2006. 

Birth Defects Res A Clin Mol Teratol. 2010 Sep 28.

26. Hoyert DL, Xu JQ. Deaths: Preliminary data for 2011. 

National vital statistics reports; vol 61 no 6. Hyattsville, 

MD: National Center for Health Statistics. 2012. Retrieved from: http://www.cdc.gov/nchs/data/nvsr/nvsr61/

nvsr61_06.pdf. Accessed: 8/2/13.

27. Centers for Disease Control and Prevention, National 

Center on Birth Defects and Developmental Disabilities. 

Facts about Birth Defects. Retrieved from: http://www.

cdc.gov/ncbddd/birthdefects/facts.html. Accessed: 8/1/13.

28. Centers for Disease Control and Prevention, National 

Center on Birth Defects and Developmental Disabilities. 

Facts about Folic Acid. Retrieved from: http://www.cdc.

gov/ncbddd/folicacid/about.html. Accessed: 8/1/13.

29. Reller MD, Strickland MJ, Riehle-Colarusso T, Mahle 

WT, Correa A. Prevalence of congenital heart defects in 

Atlanta, 1998-2005. J Pediatrics 2008;153:807-813.
 CHILD HEALTH USA 2013 ENDNOTES 45

30. Peterson, C, Grosse SD, Oster ME, Olney RS, Cassell 

CH. Cost-Effectiveness of Routine Screening for Critical 

Congenital Heart Disease in U.S. Newborns. Pediatrics. 

2013.

31. Kucik JE, Shin M, Siffel C, Marengo L, Correa A; 

Congenital Anomaly Multistate Prevalence and Survival 

Collaborative. Pediatrics. 2013 Jan;131(1)Le27-36. doi: 

10.1542/peds.2012-1616. Epub 2012 Dec 17.

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 CHILD HEALTH USA 2013 DATA SOURCES 49

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50 DATA SOURCES CHILD HEALTH USA 2013

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 CHILD HEALTH USA 2013 CONTRIBUTORS 51

CONTRIBUTORS

This publication was prepared by the U.S. 

Department of Health and Human Services, 

Health Resources and Services Administration, 

Maternal and Child Health Bureau (MCHB). 

Federal Contributors within the U.S. 

Department of Health and Human Services: 

•Centers for Disease Control and Prevention 

•Centers for Medicare and Medicaid Services

•National Institutes of Health

Other Federal and Non-Governmental 

Contributors 

•Institute of Medicine

•National Birth Defects Prevention Network

•Organization for Economic Co-operation and 

Development

•U.S. Census Bureau 

•U.S. Department of Agriculture

Photography Credits

Cover and title page, clockwise from top left: first photo, Julie Anne Mutersbaugh; second photo,

iStockPhoto; third photo, iStockPhoto; fourth photo, Kelly Sanders; fifth photo, iStockPhoto; TOC page: 

first photo, Christina Ciucci, second photo, iStockPhoto; page 4, iStockPhoto; page 6, Reem Ghandour; page 

51, Julie Anne Mutersbaugh