Child

Health

USA

2011

September 2011

U.S. Department of Health and Human Services

Health Resources and Services Administration
Child Health USA 2011 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: 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 2011.

Rockville, Maryland: U.S. Department of Health and Human Services, 2011.

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

HRSA Information Center

P.O. Box 2910

Merrifield, VA 22116

1-888-ASK-HRSA or ask@hrsa.gov
 CHILD HEALTH USA 2011 CONTENTS 3

PREFACE 4

INTRODUCTION 5

POPULATION CHARACTERISTICS 8

Population of Children 9

Children in Poverty 10

Children of Foreign-Born Parents 11

Adopted Children 12

Rural and Urban Children 13

Education 14

Homeless and Sheltered Families 16

Child-Family Connectedness 17

Maternal Age 18

Working Mothers and Child Care 19

HEALTH STATUS 20

Health Status-Infants

Low Birth Weight 22

Very Low Birth Weight 23

Preterm Birth 24

Breastfeeding 25

Infant Mortality 26

Neonatal and Postneonatal Mortality 27

International Infant Mortality 28

Maternal Mortality 29

Health Status-Children

Vaccine-Preventable Diseases 31

Pediatric HIV and AIDS 32

Hospitalization 33

Chronic Health Conditions 34

Abuse and Neglect 35

Child Mortality 36

Health Status-Adolescents

Sexual Activity and Education 38

Adolescent Childbearing 39

Sexually Transmitted Infections 40

Adolescent and Young Adult HIV and AIDS 41

Physical Activity 42

Sedentary Behaviors 44

Overweight and Obesity 45

Mental Health 46

Suicide 47

Violence 48

Bullying 49

Social Skills 50

Cigarette Smoking 51

Substance Abuse 52

Adolescent Mortality 53

HEALTH SERVICES FINANCING 

AND UTILIZATION 54

Health Care Financing 55

Levels of Insurance 56

Vaccination Coverage 57

Vaccination Schedule 58

Health Care Financing for CSHCN 59

Mental Health Treatment 60

Dental Care 61

Well-Child Visits 62

Health Care Visits 63

Usual Place for Sick Care 64

Medical Home 65

Emergency Department Utilization 66

Prenatal Care 67

STATE DATA 68

CHIP Enrollment 69

Medicaid Enrollment and Utilization 70

Health Insurance Status of Children 71

Health Insurance Status Map 72

Birth Outcomes 73

Infant and Neonatal Mortality 74

CITY DATA 75

Birth Weight 76

Infant Mortality 77

REFERENCES 78

CONTRIBUTORS 80
4 CHILD HEALTH USA 2011

PREFACE AND READER’S GUIDE

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

(MCHB) is pleased to present Child Health 

USA 2011, the 21st annual report on the health 

status and service needs of America’s children. 

MCHB envisions a Nation in which the right 

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

physical, psychological, and social needs of the 

maternal and child population. To assess the 

progress toward achieving this vision, MCHB 

has compiled this book of secondary data for 

more than 50 health status and health care indicators. It provides both graphical and textual 

summaries of relevant data, and addresses longterm trends where applicable and feasible. 

All of the data discussed within the text of 

Child Health USA are from the same sources as 

the information in the corresponding graphs, 

unless otherwise noted. Data are presented for 

the target population of the Title V Maternal 

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

care needs, and women of childbearing age. 

Child Health USA 2011 addresses health status 

and health services utilization within this population, and offers insight into the Nation’s progress toward the goals set out in the MCHB’s 

strategic plan—to assure quality of care, eliminate barriers and health disparities, promote an 

environment that supports maternal and child 

health, and improve the health infrastructure 

and system of care for women, infants, children, 

and families. 

Child Health USA is designed to provide the 

most current data available for public health 

professionals and other individuals in the public 

and private sectors. The book’s succinct format 

is intended to facilitate the use of the information as a snapshot of children’s health in the 

United States. 

Population Characteristics is the first section 

and presents statistics on factors that influence 

the well-being of children, including poverty, 

education, and child care. The second section, 

entitled Health Status, contains vital statistics 

and health behavior data for the maternal and 

child population. Health Services Financing 

and Utilization, the third section, includes data 

regarding health care financing and utilization 

of selected health services. The final sections, 

State Data and City Data, contain information 

on selected indicators at those levels.

Child Health USA is not copyrighted and 

readers may duplicate and use all of the information contained herein; however, the photographs are copyrighted and permission may be 

required to reproduce. This and all editions of 

Child Health USA since 1999 are available online at http://www.mchb.hrsa.gov/publications/

childhealthusa.html. 

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

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

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

ask@hrsa.gov.
 CHILD HEALTH USA 2011 5

INTRODUCTION

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

many implications for the Nation’s future as 

these children grow into adults. Physical, mental, and emotional health affect virtually every 

facet of life, such as learning, participation in 

leisure activities, and employment. Health 

habits established in childhood often continue 

throughout the lifespan, and many health problems in childhood, such as obesity and poor oral 

health, influence health into adulthood. Effective policies and programs are important to the 

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

health and health care needs of children change 

over time, and current data on these issues is 

critically important as policy makers and program planners seek to maximize the health of 

children, now and into the future.

In 2010, nearly 25 percent of the U.S. population was under 18 years of age. The racial 

and ethnic composition of the child population is shifting, with a growing population of 

Hispanics and a decline in the representation 

of non-Hispanic Whites. In addition to race 

and ethnicity, the demographic composition of 

a population can also be characterized by factors such as nativity, poverty, and geographic 

location. In 2009, 21.9 percent of children in 

the United States had at least one foreign-born 

parent. Of all children, 18.9 percent were U.S.-

born with a foreign-born parent or parents, and 

3.0 percent were themselves foreign-born. In 

the same year, over 15 million children under 

18 years of age lived in households with incomes below 100 percent of the U.S. Census 

Bureau’s poverty threshold ($21,954 for a family of four in 2009), representing 20.7 percent 

of all children in the United States. Differences 

in health risks have also been observed for children by geographic location. In 2007, about 82 

percent of children lived in urban areas while 

18 percent lived in either large or small/isolated 

rural areas. Children in rural areas—particularly 

those in small or isolated rural communities – 

were more likely to be overweight or obese than 

children living in urban areas. 

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

that can help protect the health of both mother 

and child. In 2008, 71.0 percent of women began prenatal care during the first trimester (according to data from areas using the “revised” 

birth certificate (For more information, please 

see page 67). A small proportion of women (7.0 

percent) did not receive prenatal care until the 

third trimester, or did not receive any at all. 

Following birth, there are a variety of preventive or protective factors that can affect a 

child’s health. Vaccination is a preventive health 

measure that begins immediately after birth and 

protects into adulthood. Vaccines are available 

for a number of public health threats, including measles, mumps, rubella (German measles), 

polio, diphtheria, tetanus, pertussis (whooping cough), hepatitis B, and varicella (chicken 

pox). In 2009, 70.5 percent of children 19–35 

months of age received this recommended series of vaccines. This estimate excludes receipt of 

the Haemophilus influenza type b vaccine (Hib) 

which has been presented in previous editions 

of Child Health USA. For more information, 

please see page 57. 

Breastfeeding is also an important protective 

factor, and rates have increased steadily since 

the beginning of the last decade. In 2007, 75.5 

percent of children through age 5 had been 

breastfed for some period of time. Although 

recommended by the American Academy of 

Pediatrics, only 12.4 percent of children were 

breastfed exclusively (without supplemental 

food or liquids) for the first 6 months of life. 

Exclusive breastfeeding through the first 6 

months of life was more common among older 

mothers and mothers with more than a high 

school level education.

Family and neighborhood characteristics can 

also play a role in the health and well-being of 

children. In 2009, 71.4 percent of women with 

children under 18 years of age were in the labor 

force (either employed or looking for work). 

Mothers with children under 6 years of age were 
6 INTRODUCTION CHILD HEALTH USA 2011

less likely to be in the labor force (64.2 percent). 

In 2007, 54.2 percent of children from birth 

through age 5 were in child care for 10 or more 

hours per week, but not all families were able to 

secure needed child care: nearly 20 percent of 

families who did not receive 10 or more hours of 

child care per week reported that they needed it. 

Family activities and parent-child relationships 

can affect health and well-being, and in 2007, 

nearly 70 percent of parents with children aged 

6-17 years reported that they could share ideas 

or talk about things that really matter with their 

children. The proportion of parents reporting 

that they could share ideas and have meaningful conversations with their child was higher 

among those with children aged 6-11 years than 

those with children aged 12-17 years.

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

the Youth Risk Behavior Surveillance System 

show that 18.4 percent of high school students 

met currently recommended levels of physical 

activity in 2009 (one hour or more of physical 

activity every day, most of which should be moderate- to vigorous-intensity aerobic activity). 

Nearly one-quarter of students did not participate in 60 or more minutes of physical activity 

on any day in the preceding week. Participation 

in physical activity can be adversely impacted by 

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

Academy of Pediatrics recommends that parents 

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

per day. Yet, in 2007, 12.8 percent of pre-school 

aged children and 10.8 percent of children aged 

6-17 years engaged in 4 or more hours of media 

use on an average weekday, including watching 

TV or videos or playing video games. 

Child Health USA also presents information 

on risk factors for adverse health outcomes. 

According to preliminary data, 8.2 percent of 

infants were born low birth weight (less than 

2,500 grams or 5 pounds 8 ounces) in 2009, 

and 1.5 percent of infants were born very 

low birth weight (less than 1,500 grams, or 3 

pounds 4 ounces). Children born underweight 

are more likely to suffer from long-term disability and have higher rates of mortality than 

children born of normal weight. 

Violence and neglect are also risk factors for 

poor health, and in 2009, investigations determined that an estimated 702,000 children 

were victims of abuse or neglect, equaling a 

victimization rate of 9.3 per 1,000 children in 

the population. Victimization rates were highest among young children. Among older children, peer violence is also of concern. In 2009, 

11.1 percent of high school students reported 

that they had been in a physical fight on school 

property in the prior 12 months and 9.8 percent reported that they had experienced dating 

violence—having been hit, slapped or physically hurt on purpose—at the hands of a boyfriend 

or girlfriend. 

Information on the prevalence of various diseases and conditions in childhood is also important in the effort to improve health in the child 

population. For instance, obesity is a serious 

health concern for children—obese children 

are more likely to have risk factors for cardiovascular disease, such as high blood pressure, 

high cholesterol, and Type 2 diabetes. Obese 

children are also at increased risk of obesity 

in adulthood, which is associated with a host 

of serious health consequences. In 2007, 15.3 

percent of children aged 10–17 years were overweight and 16.4 percent were obese, based on 

parent-reported height and weight. 

HIV/AIDS and other sexually transmitted 

infections (STIs) are also of concern. In 2009, 

an estimated 166 children younger than 13 

years of age and an estimated 8,294 people aged 

13–24 years were diagnosed with HIV. Chlamydia continues to be the most common STI 

among adolescents and young adults. Based 

on the number of cases reported to the Centers for Disease Control and Prevention, there 

were 2,000 chlamydial infections per 100,000 

adolescents and 2,165 infections per 100,000 

young adults in 2009. Rates of gonorrhea were 

405 and 479 per 100,000 adolescents and 

young adults, respectively. 

In 2009, there were nearly 3.1 million hospital discharges among people aged 1–21 years. 
 CHILD HEALTH USA 2011 INTRODUCTION 7

While injuries are the leading cause of death 

among this age group, they were not the most 

common cause of hospitalization. In 2009, diseases of the respiratory system were the most 

common cause of hospitalization among children aged 1–4 and 5–9 years, while mental 

disorders were the most common cause of hospitalization among children aged 10–14 years, 

and pregnancy and childbirth was the most 

common cause of hospitalization for adolescents aged 15–19 years and young adults aged 

20–21 years. 

Depression and suicide remain critical public health challenges for the adolescent population, in particular. In 2009, 2.0 million adolescents—or 8.1 percent of children aged 12-17 

years—experienced at least one major depressive 

episode (MDE). Occurrence of MDE was significantly higher among females (11.7 percent). 

In the same year, data from the Youth Risk Behavior Surveillance System found that 13.8 percent of all high school students had considered 

attempting suicide in past 12 months while 6.3 

percent reported at least one suicide attempt 

during the same period.

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

can help policymakers and public health officials better understand current trends in pediatric health and wellness and determine what programs might be needed to further improve the 

public’s health. These indicators can also help 

identify positive health outcomes which may 

allow public health professionals to draw upon 

the experiences of programs that have achieved 

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

include providing access to knowledge, skills, 

and tools; providing drug-free alternative activities; identifying risk factors and linking people 

to appropriate services; building community 

supports; and supporting approaches that promote policy change, as needed. Such preventive 

efforts and health promotion activities are vital 

to the continued improvement of the health and 

well-being of America’s children and families.
8 CHILD HEALTH USA 2011

POPULATION 

CHARACTERISTICS

The increasing diversity of the United States 

population is reflected in the sociodemographic 

characteristics of children and their families. 

The percentage of children who are Hispanic 

has more than doubled since 1980, while the 

percentage who are non-Hispanic White has de-

clined. The percentage of children who are Black 

has remained relatively stable. This reflects the 

changes in the racial and ethnic makeup of the 

population as a whole. 

At the national, State, and local levels, poli-

cymakers use population information to address 

health-related issues that affect mothers, chil-

dren, and families. By carefully analyzing and 

comparing available data, public health profes-

sionals can often identify high-risk populations 

that could benefit from specific interventions. 

This section presents data on several popula-

tion characteristics that influence maternal and 

child health program development and evalu-

ation. Included are data on the age and racial 

and ethnic distribution of the U.S. population, 

as well as data on the poverty status of children 

and their families, child care arrangements, and 

education.
 CHILD HEALTH USA 2011 POPULATION CHARACTERISTICS 9

POPULATION OF CHILDREN

In 2009, there were more than 74 million 

children under 18 years of age in the United 

States, representing nearly 25 percent of the 

population. Young adults aged 18–24 years 

made up another 9.9 percent of the population, 

while adults aged 25–64 years composed 52.9 

percent of the population, and adults aged 65 

years and older composed 12.9 percent. 

The age distribution of the population has 

shifted significantly in the past several decades. 

The percentage of the population that is under 18 fell from 28.2 percent in 1980 to 24.3 

percent in 2009. The representation of young 

adults (aged 18–24 years) has also declined, 

from 13.3 percent to 9.9 percent. During this 

time period, the percentage of the population 

that is aged 25–64 years increased from 47.3 

percent to 52.9 percent, and the percentage that 

is over 65 years increased from 11.3 percent to 

12.9 percent. The median age in the United 

States has increased from 30.0 years in 1980 to 

36.8 years in 2009 (data not shown).

The shifting racial/ethnic makeup of the 

child population (under 18 years) reflects 

the increasing diversity of the population as a 

whole. Hispanic children represented less than 9 

percent of children in 1980, compared to more 

than 22 percent in 2009, while the percentage 

of children who are Black remained relatively 

steady over the same period, around 15 percent. 

However, the percentage of children who are 

non-Hispanic White fell significantly, from 

74.3 percent in 1980 to 55.3 percent in 2009. 

Changes in the ways that racial and ethnic data 

were collected after 2000 limit comparison over 

time for some groups, including Asians and 

Native Hawaiians and Other Pacific Islanders, 

and individuals of more than one race.

Population of Children Under Age 18, by Race/Ethnicity, 1980 and 2009

Source (I.1): U.S. Census Bureau, Annual Population Estimates

U.S. Population, by Age Group, 1980 and 2009

Source (I.1): U.S. Census Bureau, Annual Population Estimates

10

20

30

40

50

60

70

80

Two or

More

Races*†

Native Hawaiian

or Other

Pacific Islander*†

Asian* American Indian/ †

Alaska Native*

Non-Hispanic Hispanic

Black

Non-Hispanic

White

*May include Hispanics. †

1980 data are not available.

Percent of Children

55.3

15.1

22.5

1.3 4.4 3.3 0.9 0.2

8.7

14.8

74.3

1980

2009

1980 2009

Under 5 Years

7.2% 5-13 Years

13.8% 14-17 Years

7.2%

18-24 Years

13.3%

25-64 Years

47.3%

Under 5 Years

6.9% 5-13 Years

11.9%

25-64 Years

52.9%

14-17 Years

5.5%

18-24 Years

9.9%

65 Years

and Older

11.3%

65 Years

and Older

12.9%
10 POPULATION CHARACTERISTICS CHILD HEALTH USA 2011

CHILDREN IN POVERTY

In 2009, more than 15 million children 

under 18 years of age lived in households 

with incomes below 100 percent of the U.S. 

Census Bureau’s poverty threshold ($21,954 

for a family of four in 2009); this represents 

20.7 percent of all children in the United 

States. Poverty affects many aspects of a child’s 

life, including living conditions, nutrition, 

and access to health care. A number of factors 

affect poverty status, and significant racial/

ethnic disparities exist. In 2009, 35.7 percent 

of non-Hispanic Black children, 34.0 percent of 

non-Hispanic American Indian/Alaska Native 

children, and 33.1 percent of Hispanic children 

lived in households with incomes below 100 

percent of the poverty threshold, compared to 

11.9 percent of non-Hispanic White children. 

Single-parent families are particularly 

vulnerable to poverty. In 2009, 44.3 percent of 

children living in a female-headed household 

experienced poverty, as did 26.5 percent of 

children living in a male-headed household. 

Only 11.1 percent of children living in marriedcouple families lived in poverty (data not 

shown). The proportion of children living in 

poverty varies by age and family type. In 2009, 

54.3 percent of children under 5 years of age 

living in female-headed households lived in 

poverty, while the same was true of 39.5 percent 

of children aged 6–17 years.

A number of Federal programs work to 

protect the health and well-being of children 

living in low-income families. One of these is the 

National School Lunch Program, administered 

by the U.S. Department of Agriculture’s Food 

and Nutrition Service. The program provides 

nutritionally-balanced low-cost or free lunches 

to children based on income. In 2009, the 

program served free lunch to 16.3 million 

children and reduced-price lunch to another 3.2 

million children. This represents 62.5 percent of 

all lunches served in participating schools.1

1 U.S. Department of Agriculture, Food and Nutrition 

Service. Child nutrition tables: National Level Annual 

Summary Tables. Available online: http://www.mypyramidforkids.gov/pd/cnpmain.htm. Accessed March 2011.

Children Under Age 18 Living in Households with Incomes Below

100 Percent of the Poverty Threshold,* by Race/Ethnicity, 2009 

Source (I.2): U.S. Census Bureau, Current Population Survey, Annual Social and Economic

Supplement Percent of Children

*The U.S. Census Bureau uses a set of money income thresholds to determine 

who is in poverty; the poverty threshold for a family of four was $21,954 in 2009.

Children Under Age 18 Living in Families* with Incomes

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

Family Type, 2009

Source (I.2): U.S. Census Bureau, Current Population Survey, Annual Social and

Economic Supplement

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

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

poverty; the poverty threshold for a family of four was $21,954 in 2009.

10

20

30

40

50

60

Male Householder,

no Wife Present

Female

Householder,

no Husband Present

Married-Couple

Families

Total

Percent of Children

23.8

18.2 13.4 9.8

54.3

39.5

29.4

24.9

Under 5 

Years 6-17 

Years

10

20

30

40

50

60

Non-Hispanic

Two or

More Races

Non-Hispanic

Native Hawaiian/

Other

Pacific Islander

NonHispanic

Asian

Non-Hispanic

American Indian/

Alaska Native

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total

20.7

26.0 24.0

11.9 14.2

35.7 33.1 34.0
 CHILD HEALTH USA 2011 POPULATION CHARACTERISTICS 11

CHILDREN OF FOREIGN-BORN 

PARENTS

The foreign-born population in the United 

States has increased substantially since the 1970s, 

largely due to immigration from Asia and Latin 

America. In 2009, 21.9 percent of children 

in the United States had at least one foreignborn parent. Of all children, 18.9 percent were

U.S.-born with a foreign-born parent or parents, 

and 3.0 percent were themselves foreign-born. 

Most children (73.8 percent) were native-born 

with native-born parents. 

Children’s poverty status varies with their 

nativity. In 2009, foreign-born children with 

foreign-born parents were most likely to live in 

poverty, with 32.7 percent living in households 

with incomes below 100 percent of the U.S. 

Census Bureau’s poverty threshold ($21,954 

for a family of four in 2009). Another 29.0 percent of these children lived in households with 

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

poverty, with 16.4 percent living in households 

with incomes below 100 percent of the poverty 

threshold, and another 19.4 percent living in 

households with incomes of 100–199 percent 

of the poverty threshold. 

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

parents. For instance, native-born children with 

native parents were most likely to have health 

insurance in 2009 (92.8 percent), while foreignborn children with foreign-born parents were 

least likely (66.3 percent). Almost 87 percent 

of native-born children with foreign-born parents had health insurance in 2009 (data not 

shown).

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

Poverty,** 2009

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

Supplement

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

that one or both parents were born outside of the United States. **The U.S. Census Bureau uses a set of money

income thresholds to determine who is in poverty; the poverty threshold for a family of four was $21,954 in 2009. 

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

that one or both parents were born outside of the United States, and “other” includes children with parents whose

native status is unknown and foreign-born children with native parents.

Children Under Age 18, by Nativity of Child and Parent(s),* 2009 

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

Supplement

32.7 29.0 38.3

16.4 19.4 64.1

23.8 28.0 48.2

20 40 60 80 100

Foreign-Born

Child and Parent

Native Child,

Foreign-Born Parent

Native Child

and Parent

Below 100% 

of Poverty

100–199% 

of Poverty

200% of Poverty 

and Above

Percent of Children

Native Child,

Foreign-Born Parent

18.9%

Foreign-Born Child

and Parent

3.0%

Other 4.3%

Native Child and Parent

73.8%
12 POPULATION CHARACTERISTICS CHILD HEALTH USA 2011

ADOPTED CHILDREN

In 2007, there were approximately 1.8 

million adopted children living in the United 

States. Of all adopted children, 38 percent were 

placed with families through private domestic 

adoption, meaning the child was voluntarily 

placed for adoption by his or her biological 

parents. Another 37 percent of adopted children 

were placed with their families through foster 

care adoption, and the remaining 25 percent of 

adopted children came to their families through 

international adoption (data not shown). 

Overall, the sex distribution of adopted 

children is about even, but this varies by 

adoption type. Only one-third of children 

adopted internationally are male (33 percent) 

compared to 57 percent of children adopted 

from foster care and 51 percent of children 

adopted privately in the U.S. The racial/ethnic 

distribution of adopted children also varies 

across adoption types, with private adoptions 

most likely to involve non-Hispanic White 

children and international adoptions most likely 

to involve Asian children (data not shown).

The majority of adopted children, 85 percent, 

were reported by their parents to be in “excellent” 

or “very good” health; however, nearly 40 

percent of adopted children have special health 

care needs. Children with special health care 

needs are those who have or are at increased 

risk for a chronic physical, developmental, 

behavioral, or emotional condition and who 

also require health and related services of a type 

or amount beyond that required by children 

generally.1

 Children adopted from foster care 

are more likely to have a special health care need 

(54 percent) compared to children adopted 

privately from the United States (32 percent) or 

internationally (29 percent). 

1 McPherson M, Arango P, Fox H, Lauver C, McManus 

M, Newacheck P, Perrin J, Shonkoff J, Strickland B. A 

new definition of children with special health care needs. 

Pediatrics, 102(1):137–140, 1998.

Adopted Children,* by Adoption Type and Selected Health Status

Indicators,** 2007

Source (I.4): Oce of the Assistant Secretary for Planning and Evaluation and the Administration

for Children and Families, National Survey of Adoptive Parents

Adopted Children,* by Adoption Type and Sex,** 2007

Source (I.4): Oce of the Assistant Secretary for Planning and Evaluation and the

Administration for Children and Families, National Survey of Adoptive Parents

*Adopted children were defined as those with at least one adoptive parent, but no biological parents, in the

household. **Published analyses of this data source round all estimates to the nearest whole number.

Percent of ChildrenPercent of Children

International

25%

*Adopted children were defined as those with at least one adoptive parent, but no biological parents, in

the household. **Published analyses of this data source round all estimates to the nearest whole number.

20

40

60

80

100

All Adopted Children Foster Care Private Domestic International

20

40

60

80

100

All Adopted Children Foster Care Private Domestic International

Male

Female

49 51 51 49

57

43

33

67

93

29

Health Status is excellent or very good

Special Health Care Needs

85 81

39

54

84

32
RURAL AND URBAN CHILDREN

The health risks facing children often vary by 

geographic location. For instance, children living 

in rural areas are more vulnerable to death from 

injuries,1 and are more likely to use tobacco than 

their urban counterparts.2 Rural families may also 

not have the same access to health care because 

health services are not always located nearby.3

Understanding these potential risks can provide 

program planners and policymakers information 

that can be used to design and target services.

In 2007, 81.7 percent of children lived in 

urban areas, while about 9 percent lived in large 

and small/isolated rural areas, respectively (data 

not shown). These areas were classified based on 

zip code, the size of the city or town, and the 

commuting pattern in the area. Urban areas 

include metropolitan areas and surrounding 

towns, large rural areas include towns with 

populations of 10,000 to 49,999 persons and 

their surrounding areas, and small/isolated rural 

areas include towns with populations of 2,500 to 

9,999 persons and their surrounding areas.

Rural and urban children did not differ in 

the proportion who were insured; however, 

rural children were more likely to have public 

insurance (38.3 percent among those in small/

isolated rural areas and 35.6 percent in large 

rural areas) compared to urban children (27.2 

percent). While the majority of children had a 

preventive physical or oral health visit in the past 

 CHILD HEALTH USA 2011 POPULATION CHARACTERISTICS 13

year (88.5 percent), children in both large and 

small/isolated rural communities were slightly 

less likely to have had either such visit compared 

to their urban counterparts (data not shown). 

Rural and urban children did not differ in 

their overall physical and oral health status; 

however, differences were found for specific 

health indicators by location. Children aged 10-

17 years in small/isolated rural areas were more 

likely to be overweight or obese than children in 

urban areas (35.2 versus 30.9 percent) and were 

also more likely to spend more than 1 hour per 

weekday watching TV or videos or playing video 

games than urban children of the same age (55.3 

versus 50.9 percent). However, children in small/

isolated rural areas were more likely to engage in 

physical activity everyday (28.9 percent) than 

those in urban (24.6 percent) or large rural areas 

(23.3 percent) and also had a higher rate of daily 

shared family meals than children living in urban 

areas (40.7 percent versus 35.0 percent).

1 Cherry DC, Huggins B, Gilmore K. Children’s health in the 

rural environment. Pediatric Clinics of North America 54 

(2007):121-133. 

2 Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. 

(2009) Monitoring the Future: National Survey Results on 

Drug Use, 1975-2008. (NIH Publication No. 09-7402.) 

Bethesda, MD: National Institute on Drug Abuse. 

3 Probst JC, Laditka SH, Wang J-Y, Johnson AO. Effects of 

residence and race on burden of travel for care: cross sectional analysis of the 2001 US National Household Travel 

Survey. BMC Health Serv Res 2007 Mar 9;7-40. 

Selected Indicators Among Children Aged 10-17, by Location,* 2007 

Source (I.5): Health Resources and Services Administration, Maternal and Child Health Bureau and Centers for Disease

Control and Prevention, National Center for Health Statistics, National Survey of Children’s Health. Percent of Children 10

20

30

40

50

60

Shared Family Meal

Every Day (past week)

More than 1 Hour of

Media Use per Weekday

Physical Activity Every Day

(past week) 

Overweight or Obese

Total

31.6 30.9

23.3 24.9

34.6

51.6 54.2 50.9

24.6

35.2

28.9

55.3

35.9 35.0

38.7 40.7

Large Rural

Urban

Small/Isolated Rural

*Urban areas include metropolitan areas and surrounding towns, large rural areas include towns with populations of 10,000 to 49,999 persons

and their surrounding areas, and small/isolated rural areas include towns with populations of 2,500 to 9,999 persons and their surrounding areas.
14 POPULATION CHARACTERISTICS CHILD HEALTH USA 2011

EDUCATION

In 2008, there were nearly 3.3 million high 

school status dropouts in the United States, 

representing a “status dropout” rate of 8.0 

percent. Status dropout refers to those 16–24 

years of age who are not enrolled in school 

and have not earned high school credentials 

(diploma or equivalent). This rate has declined 

steadily over the past several decades, with a 

decrease of 43 percent since 1980 (when the 

rate was 14.1 percent).

Historically, Hispanic students have had 

the highest dropout rates among youth of all 

racial/ethnic groups. Racial/ethnic differences 

in status dropout rates also vary by student sex 

and nativity. In 2008, the status dropout rate 

among Hispanics born in the United States 

(10.8 percent) was much lower than the rate 

for foreign-born Hispanics (34.6 percent; data 

not shown). Overall, 10.4 percent of males 

were status dropouts compared to 7.9 percent 

of females. The highest rate observed was for 

Hispanic males (21.9 percent).

Children are educated in a variety of settings, 

including public and private schools and at 

home. In 2007, the majority of all children 

aged 5-17 years attending kindergarten through 

12th grade were in public schools, including 

70.6 percent who attended their assigned public 

school and 15.0 percent who attended another 

public school of choice. An additional 11.4 

percent of students attended private schools 

while 2.9 percent were homeschooled.2

 School 

type and setting varied by race/ethnicity. A 

higher proportion of Hispanic students were 

enrolled in assigned public schools than nonHispanic Whites (74.6 versus 69.9 percent, 

respectively); non-Hispanic Whites were also 

less likely to be enrolled in a public school of 

choice (12.0 percent) than non-Hispanic Blacks 

(23.0 percent). Conversely, a higher proportion 

of non-Hispanic White children attended 

private school or were homeschooled.

2 Percentages may not sum to 100 due to rounding.

Students Aged 5-17 Years, by Race/Ethnicity and School Type or

Setting, 2007

Source (I.7): U.S. Department of Education, National Center for Education Statistics,

National Household Education Survey, Parent and Family Involvement in Education Survey

School Status Dropout* Rates Among Persons Aged 16–24 Years,

by Race/Ethnicity and Sex, 2008

Source (I.6): U.S. Census Bureau, American Community Survey

10

20

30

40

50

60

70

80

NonHispanic

Two or

More

Races

NonHispanic

American

Indian/

Alaska Native

NonHispanic

NativeHawaiian/

Other Pacific

Islander

NonHispanic

Asian

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Percent of PopulationPercent of Students

8.2 12.1

21.9

5.5 7.9 8.8 6.8 7.8 6.7 3.5 2.9

15.8 10.8

16.9 15.7

10.4

Male

Female

10

20

30

40

50

60

70

80

NonHispanic

Other

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Public Assigned Public Chosen Private Homeschooled

*Interpret with caution; coefficient of variation is >30 percent.

70.6

15.011.4

2.9

70.4

16.7

9.4

3.3

69.9

12.014.2

3.9

68.4

23.0

7.8

0.8*

74.6

17.5

6.3 1.5

*Status dropout refers to those 16-24 years of age who are not enrolled in school and have not earned

high school credentials (diploma or equivalent).
 CHILD HEALTH USA 2011 POPULATION CHARACTERISTICS 15
16 POPULATION CHARACTERISTICS CHILD HEALTH USA 2011

HOMELESS AND SHELTERED 

FAMILIES

Children and youth are considered to be 

homeless if they do not have a fixed, regular, 

and adequate nighttime residence. This includes 

children living in shelters, transitional housing, 

cars, campgrounds, motels and hotels, or sharing 

housing with others due to loss of housing or economic hardship.1

 The exact number of children 

and adults who are homeless is not known, however, the US Department of Housing and Urban 

Development (HUD) estimated that approximately 1.6 million people, or one in every 200 

Americans, spent at least one night in emergency 

shelter or transitional housing in 2009. Although 

the majority of those in shelter are individuals, 

persons in families – households with at least one 

adult and one child – accounted for 34.1 percent 

(or 535,477) of those using emergency shelters or 

transitional housing. Between 2007 and 2009, 

family homelessness (as reflected by emergency 

and transitional shelter use) increased approximately 30 percent while a decrease in the number 

of individuals using shelter was observed during 

the same period (data not shown).2

 

Homeless families in emergency shelter or 

transitional housing differ substantially from 

homeless individuals. While sheltered individuals 

are more likely to be male (72.7 percent), over the 

age of 30 (75.2 percent), disabled (42.9 percent), 

and of veteran-status (13.0 percent), the majority 

of persons in sheltered families are female (79.6 

percent), African American (47.9 percent), and 

under the age of 31 (82.4 percent). Overall, 22.2 

percent of all sheltered homeless persons are under the age of 18, the majority of whom (52.6 

percent) are under the age of 6 (data not shown). 

The path into and out of emergency shelter 

and transitional housing is also different for families and individuals. Among adults in families, 

62.6 percent entered emergency shelter or transitional housing from some other form of shelter, 

including a rented or owned housing unit. The 

same was true for only 36.6 percent of individuals, the majority of whom were already homeless 

before seeking emergency shelter. Families are 

also more likely to stay in shelter for longer periods of time than individuals. In 2009, the average number of nights spent in emergency shelter 

among persons in families was 36 compared to 

17 among individuals (data not shown).

1 National Coalition for the Homeless. Who is homeless? 

Available at: http://nationalhomeless.org/factsheets/who.

html. Accessed May 2011. 

2 U.S. Department of Housing and Urban Development. 

The 2009 Annual Homeless Assessment Report to Congress. 

Available at: http://www.hudhre.info/documents/5thHomel

essAssessmentReport.pdf. Accessed May 2011.

Sheltered Homeless Persons by Household Type and Age, 2009

Source (I.8): U.S. Department of Housing and Urban Development. Homeless

Management Information System.

Sheltered Homeless Persons by Household Type and Sex, 2009

Source (I.8): U.S. Department of Housing and Urban Development. Homeless

Management Information System.

Individuals Persons in Families

Females

27.3%

Males

72.7%

Females

79.6%

Males

20.4%

Individuals Persons in Families

18-30 Years

22.6%

31-50 Years

49.7%

Under 18 Years

2.2%

51-61 Years

21.3%

62 and Older

4.2%

18-30 Years

21.8%

31-50 Years

16.4%

Under 18 Years

60.6%

51-61 Years

1.1%

62 and Older

0.1%
 CHILD HEALTH USA 2011 POPULATION CHARACTERISTICS 17

CHILD-FAMILY CONNECTEDNESS

Family activities can promote bonding and 

help children lay the groundwork for future 

health and well-being. Sharing meals is a bonding activity that can also encourage good nutritional habits. In 2007, 45.8 percent of children 

under 18 years of age ate at least one meal every 

day with all other members of their household 

in the prior week while less than 5 percent of 

children did not share at least one meal with all 

the other members of their household. Sharing 

of meals varied by family income, with 58.2 

percent of children living in households with 

incomes below 100 percent of the Federal poverty level ($20,650 for a family of four in 2007) 

sharing meals daily compared to 48.8 and 42.9 

percent of children living in households with 

incomes between 100-199 and 200-399 percent 

of the Federal poverty level, respectively, sharing 

daily family meals. Only 38.9 percent of children with household incomes of 400 percent or 

more of the Federal poverty level shared a meal 

every day with all other members of their household in the prior week. 

In 2007, the parents of nearly 70 percent of 

children between the ages of 6 and 17 years reported that they could share ideas or talk about 

things that really matter very well with their children. Less than one third of parents (27.1 percent) reported that they could share ideas or talk 

about things that really mattered only somewhat 

well with their children and 3.1 percent reported 

that they could not share or talk about important 

issues well at all. This varied by age, with 75.4 

percent of parents with children between the ages 

of 6 and 11 years reporting that they could share 

ideas and talk about important issues very well 

and 64.5 percent of parents with children aged 

12-17 reporting the same level of communication with their children.

Parents and Children Sharing Ideas and Meaningful Conversation,*

by Age, 2007

Source (I.8): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health Percent of Children

10

20

30

40

50

60

70

80

Very Well Somewhat Well Not Very Well

Total

75.4

64.5

69.8

27.1 31.3

22.6

2.0

*Based on parent report of how well they share ideas or talk about things that really matter with their children.

6-11 Years

12-17 Years

Frequency of Family Meals* Among Children, by Poverty,** 2007 

Source (I.8): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health Percent of Children 10

20

30

40

50

60

70

80

400% or

more of Poverty

200-399%

of Poverty

100-199%

of Poverty

<100%

of Poverty

Total

0 Days

31.1

4.1

19.1

5.2

17.1

45.8

26.5

20.2

48.8

19.5

58.2

4.5

34.0

19.3

42.9

3.8

38.6

19.3

38.9

3.3

*Number of days that the child ate a meal with all other family members living in the household. **The U.S.

Department of Health and Human Services establishes poverty guidelines for determining financial

eligibility for Federal programs; the poverty level for a family of four was $20,650 in 2007.

4-6 Days

1-3 Days

Every Day

3.1 4.2
18 POPULATION CHARACTERISTICS CHILD HEALTH USA 2011

MATERNAL AGE

According to preliminary data, the general 

fertility rate fell slightly to 66.7 live births per 

1,000 women aged 15–44 years in 2009 (from a 

rate of 68.6 in 2008). Birth rates for nearly every 

age and racial/ethnic group declined. The rate for 

teenagers aged 15–19 years decreased to 39.1 per 

1,000 females in this age group, which continues the general decline in teenage birthrates since 

1991, when the rate was 61.8 births per 1,000. 

Although the birth rate for women aged 25–29 

years fell in 2009, this group still experienced the 

highest birth rate of all age groups (110.5 births 

per 1,000). Birth rates for women aged 35–39 

years (46.6 births per 1,000) also declined slightly (from 46.9 in 2008), representing the second 

year of decline after increasing rates for three decades. Birth rates for women aged 40–44 years 

(10.1 births per 1,000) increased slightly over the 

previous year.1

 Average age at first birth rose 3.6 

years between 1970 and 2006 to 25.0 years (the 

latest year for which data are available; data not 

shown).2

The age distribution of births varies by race/

ethnicity. Among non-Hispanic Black, Hispanic, 

and American Indian/Alaska Native women, 

16.5 percent, 13.8 percent, and 17.3 percent of 

births, respectively, were to females younger than 

20 years of age, compared to 7.3 percent of births 

to non-Hispanic White females. The percentage 

of births to women aged 20–24 years was higher 

among non-Hispanic Black and Hispanic women (31.8 percent and 27.5 percent, respectively) 

than among non-Hispanic White women (22.2 

percent). However, births to women aged 35 and 

older represented a higher proportion of births 

among non-Hispanic White and Asian/Pacific 

Islander women than among non-Hispanic 

Black and Hispanic women.

1 Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary 

data for 2009. National vital statistics reports; vol 59 no 

3. National Center for Health Statistics. 2010.

2 Mathews TJ, Hamilton BE. Delayed childbearing: More 

women are having their first child later in life. NCHS 

data brief, no 21. Hyattsville, MD: National Center for 

Health Statistics. 2009

8

16

24

32

40

Asian or Pacific Islander** Non-Hispanic White Non-Hispanic Black Hispanic American Indian/Alaska Native** † Total

3.1 2.8

6.9

11.5

24.4 23.1

28.2

1.9 3.0

5.4

12.3

22.2

25.5

29.7

5.5

2.2

11.0

8.2

31.8

16.2

25.1

5.0

2.3

8.8 9.7

27.5

19.6

27.1

5.7

1.6

11.6

6.6

33.4

15.2

26.0

0.8

4.2

2.0

19.2

11.7

34.0

28.1

Distribution of Births, by Maternal Age and Race/Ethnicity, 2009* 

Source (I.9): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System Percent of Births

*Preliminary data. **May include Hispanics. †Separate estimates were not available for Asians and Native Hawaiians and Other Pacific Islanders.

Under 18 Years 18-19 Years 20-24 Years 25-29 Years 30-34 Years 35-39 Years 40 Years and Older
 CHILD HEALTH USA 2011 POPULATION CHARACTERISTICS 19

WORKING MOTHERS AND

CHILD CARE

In 2009, 71.4 percent of women with children under 18 years of age were in the labor 

force (either employed or looking for work), and 

65.5 percent were employed (data not shown). 

Among men, rates were 93.8 percent and 86.8 

percent, respectively. Labor force participation 

among women varied by a number of factors. 

Of mothers with children aged birth through 5 

years, 64.2 percent were in the labor force, while 

among those whose youngest child was aged 

6–17 years, 77.3 percent were in the labor force. 

Employed mothers with children birth to age five 

were more likely to be employed part time than 

mothers with older children (29.2 versus 24.2 

percent, data not shown). 

In 2007, 54.2 percent of children aged birth 

through 5 years were in childcare for 10 or more 

hours per week. Overall, 29.1 percent of children 

were in the care of a non-relative, while 14.7 percent were cared for by a relative and 10.4 percent received both relative and non-relative care. 

Childcare arrangements varied by race/ethnicity: 

55.8 percent of Hispanic children did not receive 

10 or more hours of childcare per week while the 

same was true of 45.2 percent of non-Hispanic 

White children and 32.0 percent of non-Hispanic Black children. A greater proportion of both 

non-Hispanic Black and Hispanic children received 10 or more hours of childcare per week 

from a relative (20.5 percent and 15.6 percent, 

respectively) than non-Hispanic White children 

(13.2 percent).

Securing childcare can be difficult for families. 

In 2007, nearly 20 percent of families who did 

not receive 10 or more hours of childcare per 

week for their child reported that they needed 

child care during the prior month. Families with 

incomes of 400 percent or more of the Federal 

poverty level ($20,650 for a family of four in 

2007) were most likely to report needing care 

(27.3 percent) compared to 16.9 percent of children living in families with household incomes 

under 100 percent of the Federal poverty level 

(data not shown). 

Childcare Arrangements* for Children Aged 0-5 Years, by

Race/Ethnicity, 2007 

Source (I.5): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health 

Percent of Parents 20

40

60

80

100

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

Fathers 93.8 95.1

64.2

71.4

77.3

92.7

*10 or more hours of childcare per week.

Mothers

Parents’ Labor Force* Participation Rate, by Age of

Youngest Child,** 2009 

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

Percent of Children 20

40

60

80

100

Total Non-Hispanic White Non-Hispanic Black Hispanic

45.8

10.4

29.1

9.2

45.2

14.7

32.4 32.0 32.9

13.2 17.7

55.8

20.5

10.8

15.6 14.5

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

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

No Childcare

Relative Care

Non-Relative Care

Both Relative and Non-Relative Care
20 HEALTH STATUS CHILD HEALTH USA 2011

HEALTH STATUS

Monitoring the health status of infants, 

children, and adolescents allows health profes-

sionals, program planners, and policymakers 

to assess the impact of past and current health 

intervention and prevention programs and 

identify areas of need within the child popula-

tion. Although indicators of child health and 

well-being are often assessed on an annual basis, 

some surveillance systems collect data at regular 

intervals, such as every 2, 4, or 5 years. Trends 

can be identified by examining and comparing 

data from one data collection period to the next 

whenever multiple years of data are available. 

In the following section, mortality, disease, 

injury, and health behavior indicators are 

presented by age group. The health status 

indicators in this section are based on vital 

statistics and national surveys and surveillance 

systems. Population-based samples are designed 

to yield information that is representative of the 

maternal and child populations that are affected 

by, or in need of, specific health services or 

interventions.
 CHILD HEALTH USA 2011 HEALTH STATUS 21

HEALTH STATUS - INFANTS
22 HEALTH STATUS-INFANTS CHILD HEALTH USA 2011

LOW BIRTH WEIGHT

Low birth weight is a leading cause of neonatal 

mortality (death before 28 days of age). Low 

birth weight infants are more likely to experience 

physical and developmental health problems or 

die during the first year of life than are infants of 

normal weight.1,2

According to preliminary data, 8.2 percent 

of infants were born low birth weight (less than 

2,500 grams, or 5 pounds 8 ounces) in 2009. 

In 2006, the rate of low birth weight was the 

highest recorded in four decades (8.3 percent). 

The increase in multiple births, which are at high 

risk of low birth weight, strongly influenced this 

increase; however, rates of low birth weight also 

rose for singleton births.3

In 2009, the rate of low birth weight was much 

higher among infants born to non-Hispanic 

Black women (13.6 percent) than infants born to 

mothers of other racial/ethnic groups. The second 

highest rate, which occurred among Asian/Pacific 

Islanders, was 8.3 percent, followed by a rate of 

7.3 percent among American Indian/Alaska 

Natives. Low birth weight occurred among 7.2 

percent of infants born to non-Hispanic White 

women, while infants of Hispanic women 

experienced the lowest rate (6.9 percent). Low 

birth weight levels in 2009 were not significantly 

different from 2008 for non-Hispanic White, 

non-Hispanic Black, and Hispanic infants. 

Low birth weight also varied by maternal 

age. In 2008 (the latest year for which data are 

available), the rate of low birth weight was highest 

among babies born to women younger than 15 

years of age (12.4 percent), followed by babies 

born to women aged 40–54 years (11.8 percent). 

The lowest rates occurred among babies born to 

mothers aged 25–29 years and 30–34 years (7.4 

and 7.6 percent, respectively; data not shown).

1 Stein REK, Siegel MJ, Bauman LJ. Are children of moderately low birth weight at increased risk for poor health? 

A new look at an old question. Pediatrics 2006;118:

217-223. 

2 Matthews TJ, MacDorman MF. Infant mortality statistics 

from the 2006 period linked birth/infant death data set. 

National vital statistics reports; vol 58 no 17. Hyattsville, 

MD: National Center for Health Statistics. 2010.

3 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.

Low Birth Weight Among Infants, by Maternal Race/Ethnicity, 1990–2009*

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

System

13.6

8.2

8.3

7.3

6.9

Non-Hispanic Black

Non-Hispanic White

Percent of Infants

7.2

Asian/Pacific Islander**

American Indian/

Alaska Native

All Races

*Data for 2009 are preliminary. **Separate estimates for Asians and Native Hawaiians and Other Pacific Islanders were not available.

5

6

7

8

9

10

11

12

13

14

15

1990 19921991 19941993 19961995 19981997 20001999 20022001 20042003 20062005 200920082007

Hispanic
 CHILD HEALTH USA 2011 HEALTH STATUS-INFANTS 23

VERY LOW BIRTH WEIGHT

According to preliminary data, 1.5 percent of 

infants were born very low birth weight (less than 

1,500 grams, or 3 pounds 4 ounces) in 2009. The 

proportion of very low birth weight infants has 

slowly climbed from just over 1 percent in 1980.

Infants born at such low weight are more than 

100 times more likely to die in the first year of life 

than are infants of normal birth weight (above 5 

pounds 8 ounces).1 Very low birth weight infants 

who survive are at a significantly increased risk 

of severe health and developmental problems, 

including physical and sensory difficulties, developmental delays, and cognitive impairment, 

which may require increased levels of medical, 

educational, and parental care.2

Infants born to non-Hispanic Black women 

are over two times more likely than infants born 

to mothers of other racial/ethnic groups to be 

very low birth weight. Among infants born to 

non-Hispanic Black women, 3.1 percent were 

very low birth weight in 2009, compared to 1.2 

percent of infants born to non-Hispanic White 

and Hispanic women, 1.3 percent born to American Indian/Alaska Native women, and 1.1 percent born to Asian/Pacific Islander women. This 

difference is a major contributor to the disparity 

in infant mortality rates between non-Hispanic 

Black infants and infants of other racial/ethnic 

groups.3

 Although, overall, the rate of very low 

birth weight was not statistically different from 

2008, rates for non-Hispanic White and nonHispanic Black newborns were down 2-3 percent 

from 2006.4

In 2008 (the latest year for which data are 

available), the rate of very low birth weight was 

highest among babies born to mothers aged 45-

54 years (3.6 percent). Mothers under 15 years of 

age also had high rates of very low birth weight 

(3.0 percent.) The rate was lowest among mothers 

aged 25-29 years (1.3 percent; data not shown).

1 Matthews TJ, MacDorman MF. Infant mortality statistics 

from the 2006 period linked birth/infant death data set. 

National vital statistics reports; vol 58 no 17. Hyattsville, 

MD: National Center for Health Statistics. 2010.

2 Eichenwald EC, Stark AR. Management and outcomes of 

very low birth weight. N Engl J Med 2008;358:1700-1711.

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

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

4 Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary 

data for 2009. National vital statistics reports web release; 

vol 59 no 3. Hyattsville, MD: National Center for Health 

Statistics. 2010.

Very Low Birth Weight Among Infants, by Maternal Race/Ethnicity, 1990–2009*

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

Statistics System

3.1

1.2

1.1

1.3

1.5

Non-Hispanic

 White

Non-Hispanic Black

Hispanic Asian/Pacific Islander

Percent of Infants

American Indian/

Alaska Native

0.5

1.0

1.5

2.0

2.5

3.0

3.5

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2009

All Races

*Data for 2009 are preliminary. **Separate estimates for Asians and Native Hawaiians and Other Pacific Islanders were not available.
24 HEALTH STATUS – INFANTS CHILD HEALTH USA 2011

PRETERM BIRTH

Babies born preterm, before 37 completed 

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

mortality. Complications that can occur during 

the newborn period include respiratory distress, 

jaundice, anemia, and infection, while longterm complications can include learning and 

behavioral problems, cerebral palsy, lung problems, and vision and hearing loss. 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 these types of problems.1

According to preliminary data, 12.2 percent 

of infants were born preterm in 2009. Overall, 8.7 percent of babies were born at 34 to 

36 weeks’ gestation, 1.6 percent were born at

32-33 weeks, and 2.0 percent were “very preterm” (less than 32 weeks). The preterm birth 

rate increased more than 20 percent from 1990 

to 2006, but has declined in the three years 

since (data not shown).

The preterm birth rate varies by race/ethnicity. In 2009, 17.5 percent of babies born to 

non-Hispanic Black women were born preterm, 

compared to 10.8 percent of babies born to 

Asian/Pacific Islander women. Among babies 

born to non-Hispanic White women, 10.9 

percent were born preterm, while the same was 

true of 12.0 percent of babies born to Hispanic

women and 13.5 percent of babies born to 

American Indian/Alaska native women.

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 March 2011.

Preterm Birth Among Infants, by Completed Weeks of

Gestation, 2009*

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

Statistics, National Vital Statistics System

Preterm Birth Among Infants, by Maternal Race/Ethnicity, 2009*

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

National Vital Statistics System

*Data for 2009 are preliminary

*Data for 2009 are preliminary. **Includes Hispanics. †

Separate data for Asians and Native Hawaiians and

Other Pacific Islanders not available. Percent of Infants

10.9

17.5

12.0 10.8

13.5

5

10

15

20

25

30

Asian/

Pacific Islander**†

American Indian/

Alaska Native**

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Percent of IInfants

12.2

2.0

8.7

1.6

5

10

15

20

25

30

Total Less than 32 Weeks 32-33 Weeks 34-36 Weeks
BREASTFEEDING

Breastfeeding has been shown to promote 

the health and development of infants, including their immunity to disease. It also confers a 

number of maternal benefits, such as a decreased 

risk of breast and ovarian cancers.1 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.2

Breastfeeding practices vary considerably by a 

number of factors including maternal age, maternal education, household income, and race/

ethnicity. In 2007, the parents of 75.5 percent of 

children from birth to 5 years of age reported that 

the child had ever been breastfed or fed breast 

milk. While this represents a substantial increase 

in breastfeeding initiation over the past 25 years, 

the overall prevalence of any breastfeeding for 6 

months and the prevalence of exclusive breastfeeding for 6 months remain below national objectives.3

 Parents of 45.0 percent of children aged 

6 months to 5 years reported that the child was 

breastfed for 6 months. Exclusive breastfeeding 

for 6 months was reported for 12.4 percent of 

children aged 6 months to 5 years.

Children born to mothers aged 30 years or 

older are the most likely to be breastfed (79.8 

percent), while children born to mothers aged 

20 years or younger are the least likely (58.5 percent). A similar trend exists for exclusive breastfeeding; 14.1 percent of children born to mothers aged 30 years or older are exclusively breastfed 

for 6 months compared to 4.6 percent of children born to mothers aged 20 years or younger. 

Mothers with more than a high school education 

are more likely to both initiate breastfeeding and 

to breastfeed for 6 months exclusively than those 

with less than a high school education. 

1 Ip S, Chung M, Raman G, Chew P, Magula N, DeVine 

D, et al. Breastfeeding and maternal and infant health 

outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007(153):1-186. 

2 Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare 

D, Schanler RJ, et al. Breastfeeding and the use of human 

milk. Pediatrics. 2005;115(2):496-506.

3 U.S. Department of Health and Human Services. Healthy 

People 2020. Available at: www.healthypeople.gov.

Accessed March 2011.

 CHILD HEALTH USA 2011 HEALTH STATUS-INFANTS 25

Breastfeeding Among Children Aged 0-5 Years, by Maternal Age

and Duration, 2007

Source (II.2): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health Percent of Infants 20

40

60

80

100

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

20

40

60

80

100

More than

High School

Less than High School

High School

Total

*Ever fed breast milk. **Exclusive breastfeeding is defined as only human breastmilk—no solids, water, or

other liquids. †

Data is for infants aged 6 months to 5 years. Those less than 6 months of age were excluded.

Breastfeeding Among Children Aged 0-5 Years, by Maternal

Education and Duration, 2007

Source (II.2): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health Percent of Infants

*Ever fed breast milk **Exclusive breastfeeding is defined as only human breastmilk—no solids, water, or

other liquids. †

Data is for infants aged 6 months to 5 years. Those less than 6 months of age were excluded.

75.5

45.0

12.4

68.1

10.4

37.8

67.9

9.2

33.4

81.7

14.4

52.3

75.5

22.2

4.6

58.5

12.4

45.0

76.5

12.3

44.4

79.8

14.1

51.2

Ever Breastfed* Exclusively at 6 Months** Any at 6 Months† † Ever Breastfed* Exclusively at 6 Months** Any at 6 Months† †
26 HEALTH STATUS – INFANTS CHILD HEALTH USA 2011

INFANT MORTALITY

Based on preliminary data, in 2009, 26,531 

infants died before their first birthday, representing an infant mortality rate of 6.42 deaths 

per 1,000 live births. This represents a decrease 

of 2.6 percent from the preliminary estimate in 

2008 (6.59 deaths per 1,000 live births). The 

leading causes of infant mortality were congenital 

malformations, followed by disorders related to 

short gestation and low birth weight, and Sudden Infant Death Syndrome (data not shown). 

Although overall there were no changes in the 

ranking of leading causes of infant death, the infant mortality rate decreased for 2 of 10 leading 

causes of infant death between 2008 and 2009: 

maternal complications of pregnancy and unintentional injuries. The infant mortality rates associated with each of these causes declined by 7.5 

and 8.5 percent, respectively.

The infant mortality declined substantially 

during the 20th century resulting in a 93 percent decrease in the overall infant mortality rate 

between 1915 and 1998.1

 Some factors which 

contributed to this decline included economic 

growth, improved nutrition, and new sanitary 

measures, as well as advances in clinical medicine 

and access to care.2 More recent declines in birthweight-specific infant mortality rates in the latter 

part of the 20th century have been attributed, 

in part, to the approval of synthetic surfactants 

to reduce the severity of respiratory distress syndrome3

 and the recommendation that infants be 

placed on their backs to sleep to prevent Sudden 

Infant Death Syndrome.4

In 2009, the mortality rate among infants 

born to Black women (including Hispanics) was 

12.71 deaths per 1,000 live births, compared to 

12.68 per 1,000 live births in 2008; this difference was not statistically significant. Despite the 

overall decrease in the infant mortality rate, in 

2009 the rate for Blacks (including Hispanics) 

was still 2.4 times the rate among infants born 

to non-Hispanic White women (5.32 per 1,000 

births). The 2009 rate for infants born to nonHispanic white women reflects a 4.0 percent decrease since the previous year (5.54 infant deaths 

per 1,000 live births).

The Maternal and Child Health Block Grant 

and MCHB’s Healthy Start program provide 

health and support services to pregnant women 

and infants with the goal of improving children’s 

health outcomes and reducing infant and child 

mortality.

1 Guyer B, Freedman MA, Strobino DM, and Sondik EJ. Annual summary of vital statistics: trends in the health of Americans during the 20th century. Pediatrics. 2000;106:1307-17.

2 Centers for Disease Control and Prevention. Advancements 

in public health, 1900-1999: healthier mothers and babies. 

MMWR. 1999; 48:849-58.

3 Schoendorf KC and JL Kiely. Birth weight and age-specific 

analysis of the 1990 US infant mortality drop: was it surfactant? Arch Pediatr Adolesc Med. 1997;151:129-134

4 American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics. 

1992;87:1120-6.

2

4

6

8

10

12

14

16

18

20

1985 1990 1995 2000 2005 2009

6.4

5.3

5.4

12.7

Non-Hispanic White

Hispanic

Black†

All Races

Deaths per 1,000 Live Births

*Under 1 year of age. **Data for 2009 are preliminary. †Including Hispanics who identify themselves as Black.

Infant Mortality Rates,* by Maternal Race/Ethnicity, 1985-2009**

Source (II.3): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System
 CHILD HEALTH USA 2011 HEALTH STATUS-INFANTS 27

NEONATAL AND

POSTNEONATAL MORTALITY

Neonatal. According to preliminary data, in 

2009, 17,298 infants died before reaching 28 

days of age, representing a neonatal mortality 

rate of 4.19 deaths per 1,000 live births. Although this represents a 1.9 percent decrease 

from 4.27 per 1,000 live births in 2008, this 

change was not statistically significant.

Neonatal mortality is generally related to 

short gestation and low birth weight, congenital 

malformations, and conditions originating in 

the perinatal period, such as maternal complications related to pregnancy or complications experienced by the newborn resulting from birth.1

Neonatal mortality rates vary by race and 

ethnicity. Based on preliminary data for 2009, 

the neonatal mortality rate among infants born 

to Black women (including Hispanics) was 8.20 

per 1,000 live births, more than twice the rate 

among infants born to non-Hispanic White and 

Hispanic women (3.43 and 3.62 per 1,000, respectively).

Postneonatal. In 2009, 9,233 infants died 

between the ages of 28 days and 1 year, representing a postneonatal mortality rate of 2.24 

deaths per 1,000 live births. This represents a 

3.4 percent decrease since 2008, when the postneonatal mortality rate was 2.32 deaths per 

1,000 live births.

Postneonatal mortality is generally related 

to Sudden Infant Death Syndrome (SIDS), 

congenital malformations, and unintentional 

injuries.1

 Postneonatal mortality varies by 

race and ethnicity. According to preliminary 

data in 2009, the highest rate of postneonatal 

mortality was reported among infants born to 

Black (including Hispanic) women (4.51 deaths 

per 1,000 live births). Rates for infants born 

to non-Hispanic White and Hispanic women 

were 1.84 and 1.82 deaths per 1,000 live births, 

respectively.

1 Centers for Disease Control and Prevention. Quick Stats: 

Leading Causes of Neonatal and Postneonatal Deaths — 

United States, 2002. MMWR. 2005; 54(38):966. 

Neonatal and Post Neonatal Mortality Rates, by Maternal Race/Ethnicity, 2009*

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

Statistics System

Deaths per 1,000 Live Births

*Data for 2009 are preliminary.

4 8 12 16 20

Hispanic

Black

Non-Hispanic

White

All Races

Under 1 Year

Less Than 28 Days

28 Days to 11 Months

6.42

5.27

3.43

1.84

4.19

2.24

12.71

8.20

4.51

5.44

3.62

1.82
28 HEALTH STATUS – INFANTS CHILD HEALTH USA 2011

INTERNATIONAL INFANT

MORTALITY

In 2007, the U.S. infant mortality rate (6.8 

infant deaths per 1,000 live births) was higher 

than that of many other industrialized nations. 

Differences in infant mortality rates among 

industrialized nations may reflect variation in the 

definition, measurement, and reporting of fetal 

and infant deaths. However, recent analyses of 

the differences in gestational age-specific infant 

mortality indicate that this disparity is most 

likely related to the high rate of preterm birth in 

the U.S.1

 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).2 Although the United States 

compares favorably with European countries 

with respect to the survival of infants born 

preterm, the higher rate of preterm birth in the 

U.S. overall has a significant impact on the infant 

mortality rate. 

In 2007, the U.S. infant mortality rate was 

more than twice that of nine other industrialized 

countries (Luxembourg, Iceland, Sweden, Japan, 

Finland, Czech Republic, Ireland, Norway, and 

Portugal). Luxemburg had the lowest rate (1.8 

per 1,000), followed by Iceland and Sweden (2.0 

and 2.5 deaths per 1,000 live births, respectively).

2 MacDorman, MF, and Mathews, TJ. Recent Trends in 

Infant Mortality in the United States. NCHS Data 

Brief No. 9. National Center for health Statistics, Hyattsville, MD, 2008.

5 10 15 20 25

Turkey 

Mexico 

United States

Slovak Republic

Poland 

Hungary 

United Kingdom

New Zealand

Australia

Netherlands

Denmark 

Belgium 

Switzerland

Germany 

Spain 

Italy 

Austria 

Greece 

Portugal 

Norway 

Ireland 

Czech Republic

Finland 

Japan 

Sweden 

Iceland 

Luxembourg 

International Infant Mortality Rates, Selected Countries,* 2007

Source (II.4): e Organization for Economic Co-operation and Development (OECD)

Deaths per 1,000 Live Births

*2007 data were not available for all Organization for Economic Co-operation and Development (OECD) countries. 

1.8

2.0

2.5

2.6

2.7

3.1

3.1

3.1

3.4

3.6

3.7

3.7

3.7

3.9

3.9

4.0

4.0

4.1

4.2

4.8

4.8

5.9

6.0

6.1

6.8

15.7

20.7

1 MacDorman MF and Mathews TJ. Behind international 

rankings of infant mortality: how the US compares with 

Europe. Int J Health Serv. 2010;40(4):577-88.
MATERNAL MORTALITY

Maternal mortality, or death due to maternal 

causes, includes deaths due to causes related to or 

aggravated by pregnancy or pregnancy management, and excludes deaths occurring more than 

42 days after the end of the pregnancy and deaths 

of pregnant women due to external causes (such 

as injury).1 The rate of maternal mortality in the 

United States declined dramatically over the last 

century; however, this trend has reversed somewhat in the last several decades and racial and 

ethnic disparities persist.2

 

In 2007, the latest year for which data are 

available, the maternal mortality rate was 12.7 

deaths per 100,000 live births, compared to a 

low of 6.6 per 100,000 in 1987. This represents 

a total of 548 women who died due to maternal 

causes in 2007. Some of this increase observed 

over the past decades may be due to changes in 

the coding and classification of maternal deaths. 

The maternal mortality rate among non-Hispanic Black women was approximately 2.7 times 

the rate for non-Hispanic White women (28.4 

versus 10.5 per 100,000), while the maternal 

mortality rate among Hispanic women was 8.9 

deaths per 100,000 live births. 

Causes of maternal death are classified as direct, indirect, or unspecified. Some of the most 

common direct causes are complications related 

to the puerperium, or period immediately after 

delivery (2.2 per 100,000), eclampsia and pre-eclampsia (1.5 per 100,000), hemorrhage of pregnancy, childbirth, and placenta previa (0.9 per 

100,000), and pregnancy with abortive outcome 

(0.7 per 100,000). Indirect causes occurred at a 

rate of 3.1 per 100,000, and comprised deaths 

from pre-existing conditions complicated by 

pregnancy. The rate of maternal deaths from unspecified causes was 0.5 per 100,000.

For more information on maternal morbidity, 

please see Women’s Health USA 2011 available at: 

http://www.mchb.hrsa.gov/publications/index.html. 

1 Xu J, Kochanek K, Murphy S, Tejada-Vera B. Deaths: 

Final data for 2007. National vital statistics reports; vol 

58, no 19. Hyattsville, MD: National Center for Health 

Statistics. May 2010.

2 Chang J, Elam-Evans LD, Berg CJ et al. Pregnancy-Related Mortality Surveillance --- United States, 1991—

1999. MMWR. 2003; 52(SS02);1-8.4 

 CHILD HEALTH USA 2011 HEALTH STATUS – INFANTS 29

Maternal Mortality Rates, by Race/Ethnicity, 2007

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

for Health Statistics, National Vital Statistics System Maternal Deaths per 100,000 Live Births

12.7

10.5

28.4

8.9

Leading Causes of Maternal Mortality, 2007

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

National Vital Statistics System

Maternal Deaths per 100,000 Live Births

2.2

0.5

3.1

3.8

0.7

5

10

15

20

25

30

35

Non-Hispanic Hispanic 

 Black

Non-Hispanic

 White

Total 12345

Unspecified Cause

Indirect Causes**

Other direct causes

Pregnancy with abortive outcome

Hemorrhage of pregnancy, childbirth,

 and placenta previa

Eclampsia and pre-eclampsia

Complications related to the puerperium*

0.9

1.5

Direct Causes

*Deaths occurring in the period immediately after delivery. **Deaths from pre-existing conditions complicated by pregnancy. 
30 HEALTH STATUS –CHILDREN CHILD HEALTH USA 2011

HEALTH STATUS - CHILDREN
VACCINE-PREVENTABLE

DISEASES

The number of reported cases of vaccinepreventable diseases among children has 

generally decreased over the past several 

decades. In 2008, there were no reported cases 

of diphtheria, polio, or smallpox in the United 

States, and no cases of tetanus among children 

under 5 years of age. There were 5 cases of 

rubella (German measles) among children aged 

0-4 years. 

From 2007 to 2008, the number of reported 

cases of hepatitis A, mumps, and meningococcal 

disease decreased among children under 5 

years of age. The overall incidence of hepatitis 

A began dropping dramatically once routine 

vaccination for children living in high-risk 

areas was recommended beginning in 1996. 

Furthermore, in 2005, the Centers for Disease 

Control and Prevention (CDC) instituted 

the recommendation that all children be 

immunized for hepatitis A starting at 1 year 

of age. The latter recommendation was made 

because two-thirds of cases were occurring 

in States where the vaccine was not currently 

recommended. With regard to pertussis (or 

whooping cough), the number of cases among 

children aged 0-4 years increased from 2,746 

in 2007 to 3,468 in 2008. According to the 

CDC, pertussis occurs cyclically and decreases 

 CHILD HEALTH USA 2011 HEALTH STATUS–CHILDREN 31

in the incidence of the disease may not be due 

to increases in immunization rates. The highest 

reported rate occurred among infants under 6 

months of age, a population that is too young to 

be fully vaccinated. In 2006, the United States 

experienced a multi-state outbreak of mumps, 

primarily in Midwestern states. In the following 

two years, the number of reported cases returned 

to usual levels; however, beginning in July 2009, 

another outbreak was documented primarily in 

New York and New Jersey.1 Reported cases of 

hepatitis B and H. influenzae remained relatively 

unchanged from 2007 to 2008.

1 Centers for Disease Control and Prevention. Mumps 

Outbreaks. Available at: http://www.cdc.gov/mumps/outbreaks.html#b. Accessed March 2011.

Reported Cases of Selected Vaccine-Preventable Diseases Among Children Aged

0-4 Years, 2008

Source (II.6): Centers for Disease Control and Prevention, National Notiable Diseases Surveillance System

Number of Reported Cases

0

0

0

3

5

48

60

66

284

437

3468

100 200 300 400 500 600 700 800 900 1000 3400 3600 3800 4000

Pertussis

H. Influenzae

Meningococcal Disease

Hepatitis A

Mumps

Measles

Rubella

Hepatitis B

Tetanus

Polio

Diphtheria
32 HEALTH STATUS –CHILDREN CHILD HEALTH USA 2011

PEDIATRIC HIV AND AIDS

Human immunodeficiency virus (HIV) is a 

disease that destroys cells that are critical to a 

healthy immune system. Acquired immunodeficiency syndrome (AIDS) is diagnosed when 

HIV has weakened the immune system enough 

that the body has difficulty fighting disease and 

infections. In 2009, an estimated 166 children 

younger than 13 years of age were diagnosed 

with HIV, and 13 were reported to have AIDS. 

Racial and ethnic minorities are disproportionately affected by HIV. In 2009, non-Hispanic 

Black children accounted for over three-quarters of diagnosed cases, but represented only 

15 percent of the total U.S. population in this

age group.

The number of pediatric AIDS cases has declined substantially since 1992, when an estimated 911 cases were reported. A major factor 

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

and the promotion of universal prenatal HIV 

testing. Perinatal transmission accounts for 91 

percent of all AIDS cases among children in 

the United States. Antiretroviral therapy during 

pregnancy can reduce the transmission rate to 

2 percent or less, while without treatment the 

transmission rate is 25 percent.1

 At the end of 2008, 660,062 adults and adolescents and 3,022 children under age 13 years 

were living with HIV while 479,161 adults and 

adolescents, and 707 children under age 13 

years were living with AIDS. Of the 1,108,611 

AIDS cases cumulatively diagnosed through 

2009, 9,448 were among children under age 13 

years (data not shown).

1 Centers for Disease Control and Prevention. One Test 

Two Lives. Available at: http://www.cdc.gov/hiv/topics/

perinatal/1test2lives/default.htm. Accessed April 2011.

Estimated Numbers of Diagnoses of HIV Infection* Reported in

Children Under Age 13, by Race/Ethnicity, 2009

Source (II.7): Centers for Disease Control and Prevention, HIV/AIDS Surveillance System

Number of Diagnoses

166

127

*Includes persons with a diagnosis of HIV infection regardless of stage of disease at the time of diagnosis.

**The total was estimated independently of values for each subpopulation; therefore, the sum of all

races/ethnicities does not equal the overall total.

Estimated Numbers of AIDS Diagnoses in Children Under Age 13,

by Year of Diagnosis, 1992–2009 

Source (II.7): Centers for Disease Control and Prevention, HIV/AIDS Surveillance System Number of Diagnoses

11

23

4

0

0

3

112 75 59 39 31

257

133

684

911

203

522

897

139

347

821

57 40

50 100 150 200

Non-Hispanic

Multiple Races

Non-Hispanic American

Indian/Alaska Native

Non-Hispanic Native Hawaiian/

Other Pacific Islander

Non-Hispanic Asian

Hispanic

Non-Hispanic Black

Non-Hispanic White 

Total**

200

400

600

800

1000

1992 1994 1996 1998 2000 2002 2004 2006 20092008

13
 CHILD HEALTH USA 2011 HEALTH STATUS–CHILDREN 33

HOSPITALIZATION

In 2009, there were over 3.1 million 

hospital discharges among people aged 1‒21 

years, equaling 3.6 hospital discharges per 100 

children, adolescents and young adults. While 

injuries are the leading cause of death among 

this age group, they were not the most common 

cause of hospitalization. In 2009, diseases of 

the respiratory system, including asthma and 

pneumonia, were the most common causes of 

hospitalization among children aged 1‒4 and 5‒9 

years. Among children aged 1-4 years, diseases of 

the respiratory system accounted for nearly 40 

percent of discharges; the same was true for about 

one-quarter of 5-9 year-olds. Mental disorders 

were the most common cause of hospitalization 

among children aged 10‒14 years (22.5 percent 

of discharges) and the second most common 

cause among adolescents aged 15-19 years (15.7 

percent of discharges) and young adults aged 

20‒21 years (8.4 percent). Among adolescents 

aged 15-19 years and young adults aged 20‒21 

years, labor and delivery (among females) was the 

most common cause of hospitalization resulting 

49.6 and 62.3 percent of discharges, respectively.

Between 1990 and 2009, overall hospital 

discharge rates for children aged 1‒14 years 

did not change significantly. However, there 

was a change in the rates for some of the most 

common individual categories of discharges: the 

rate of discharges for diseases of the respiratory 

system increased by 19.6 percent between 1990 

and 2009, while discharges related to injury and 

poisoning decreased by 31.5 percent during the 

same period. 

Major Causes of Hospitalization, by Age Group, 2009

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

175

340

48

287

221

53

50

37

89

45

32

24

99

102

67

55

55

415

41

53

54

759

418

354

Number of Hospital Discharges (in thousands)

80 160 240 320 400 480 560 640 720 800

Injury and Poisoning

Complications of Pregnancy/Childbirth

Mental Disorders

Pregnancy/Childbirth

20-21 Years

Diseases of the Digestive System

Injury and Poisoning

Mental Disorders

Pregnancy/Childbirth

15-19 Years

Diseases of the Respiratory System

Diseases of the Digestive System

Injury and Poisoning

Mental Disorders

10-14 Years

Disease of the Nervous System and Sense Organs

Injury and Poisoning

Diseases of the Digestive System

Diseases of the Respiratory System

5-9 Years

Disease of the Nervous System and Sense Organs

Injury and Poisoning

Endocrine, Metabolic, and

Immunity Diseases and Disorders

Diseases of the Respiratory System

1-4 Years

Injury and Poisoning

Mental Disorders

Diseases of the Respiratory System

Pregnancy/Childbirth

Total
34 HEALTH STATUS–CHILDREN CHILD HEALTH USA 2011

CHRONIC HEALTH CONDITIONS

In 2007, the parents of 22.3 percent of 

children reported that their child had one or 

more of 16 chronic physical or mental health 

conditions. The five most commonly reported 

conditions were asthma, learning disabilities, 

attention deficit or attention deficit hyperactivity 

disorder (ADD/ADHD), speech problems, and 

oppositional defiant or conduct disorder. The 

least commonly reported conditions addressed in 

the survey were brain injury or concussion and 

Tourette syndrome.

The proportion of children with one or more 

conditions varied by race/ethnicity. Nearly 30 

percent of non-Hispanic Black children had one 

or more chronic conditions while the same was 

true for 18.3 percent of Hispanic children and 

22.5 percent of non-Hispanic White children. 

The proportion of children with chronic conditions was also greater among those living in 

households with incomes less than 100 percent 

or between 100-199 percent of the Federal poverty level ($20,650 for a family of four in 2007), 

with 27.0 and 24.2 percent of poor and nearpoor children, respectively, having at least one 

reported condition compared to 18.9 percent of 

children living in families with incomes of 400 

percent or more of the Federal poverty level (data 

not shown). 

Among children with at least one of these 

16 health conditions, 47.8 percent were reported to have one or more moderate or severe 

conditions. Of the 9.0 percent of children with

asthma, the majority (71.3 percent) had parents 

who reported the condition to be mild, while

23.1 percent had a condition reported to be

moderate and 5.6 percent had a condition

reported to be severe. Parent-reported severity 

of asthma varied by race/ethnicity: 10.3 percent 

of non-Hispanic Black children were severely affected by their asthma, followed by 6.5 percent 

of Hispanic children and 3.1 percent of nonHispanic White children.

Five Most Common Chronic Conditions* Among Children Aged

0-17 Years, 2007 

Source (II.2): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health

Children Aged 0-17 Years with Asthma, by Condition Severity* and

Race/Ethnicity, 2007

Source (II.2): Health Resources and Services Administration, Maternal and Child Health

Bureau and Centers for Disease Control and Prevention, National Center for Health Statistics,

National Survey of Children’s Health

*Based on parent-report that a doctor or other health care provider ever told them that their child had

a particular condition. *Based on parent-report. Percent of Children

71.3

76.6

64.3 64.0

23.1 25.5 29.6

20.4

5.6 10.3 6.5 3.1 10

20

30

40

50

60

70

80

Mild Moderate Severe

Percent of Children

9.0 7.8

3.7 3.3

6.4

4

8

12

16

20

Oppositional

Defiant or

Conduct Disorder

Speech

Problems

Learning ADD/ADHD

Disabilities

Asthma

Total

Non-Hispanic White

Non-Hispanic Black

Hispanic
ABUSE AND NEGLECT

State child protective services (CPS) 

agencies received approximately 3.3 million 

referrals, involving an estimated 6.0 million 

children, alleging abuse or neglect in 2009. 

More than 58.3 percent of these reports were 

made by professionals, including teachers, 

police officers, lawyers, and social services staff. 

Nonprofessionals, including parents, neighbors, 

friends, other relatives, and anonymous reporters 

made 28.1 percent of the reports; other and 

unknown sources submitted the remainder of 

reports (13.6 percent; data not shown).

CPS investigations determined that an estimated 702,000 individual children were victims 

of abuse or neglect in 2009, equaling a victimization rate of 9.3 per 1,000 children in the population (data not shown). Neglect was the most 

common type of maltreatment (experienced by 

78.3 percent of victims), followed by physical 

abuse (17.8 percent), sexual abuse (9.5 percent), 

psychological maltreatment (7.6 percent), and 

medical neglect (2.4 percent). About 10 percent 

of victims experienced other types of maltreatment including abandonment, threats of harm, 

or congenital drug addiction. A child may have 

suffered from multiple forms of maltreatment 

and was counted once for each maltreatment 

type. 

In 2009, children aged 0-3 years accounted for 

33.4 percent of all victims. Approximately onequarter of victims were between the ages of 4 and 

7 years, 18.8 percent were aged 8-11 years, 17.8 

percent were aged 12-15 years, and 6.3 percent 

were aged 16-17 years. Victimization was split 

between the sexes with males accounting for 48.2 

percent and females accounting for 51.1 percent 

(the remainder were unknown; data not shown). 

Overall, 80.9 percent of perpetrators of abuse 

or neglect were parents of the victim (either alone 

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

relatives (6.3 percent), unmarried partners of 

parents (4.3 percent), and professionals such as 

childcare workers and residential facility staff (0.8 

percent). Other types of perpetrators included 

foster parents, friends and neighbors, and legal 

guardians (data not shown).

 CHILD HEALTH USA 2011 HEALTH STATUS–CHILDREN 35

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

Maltreatment,* 2009

Source (II.9): Administration for Children and Families, National Child Abuse and Neglect

Data System

Percent of Victims

78.3

9.5

7.6

17.8

2.4

9.6

Child Abuse and Neglect Victims, by Age, 2009

Source (II.9): Administration for Children and Families, National Child Abuse

and Neglect Data System

Unknown

10 20 30 40 50 60 70 80

Other

Medical Neglect

Psychological

Maltreatment

Sexual Abuse

Physical Abuse

Neglect

*A child may have suffered from multiple forms of maltreatment and was counted once for each 

maltreatment type. 

< 1 Year

12.6% 1-3 Years

20.8%

4-7 Years

23.3%

8-11 Years

18.8%

12-15 Years

17.8%

16-17 Years

6.3%

Unknown

0.4%
36 HEALTH STATUS – CHILDREN CHILD HEALTH USA 2011

CHILD MORTALITY

According to preliminary data in 2009, 10,076 

children aged 1-14 years died of various causes, 

which was a decrease of 335 cases since the previous year. The overall mortality rate among 

children aged 1-4 years was 26.1 per 100,000 

children in that age group, and the rate among 

children aged 5-14 years was 13.9 per 100,000. 

Unintentional injury continued to be the 

leading cause of death among children in both 

age groups, accounting for 32.5 percent of all 

deaths among 1- to 4-year-olds and 29.6 percent of deaths among 5- to 14-year-olds. Among 

children aged 1-4 years, congenital anomalies 

(or birth defects) were the second most common cause of death (10.9 percent of deaths), 

while among children aged 5-14 years, cancer 

was the second leading cause of death (15.9 percent of deaths).

Between 1970 and 2008, the leading causes of 

child mortality shifted. The percentage of deaths 

due to homicide increased from 2 to 9 percent 

among 1- to 4-year-olds and from 2 to 6 percent 

among 5- to 14-year-olds. Conversely, the proportion of deaths due to pneumonia and influenza declined from 9 to 3 percent among 1- to 

4-year-olds and from 4 to 2 percent among 5- to 

14-year-olds during the same time period (data 

not shown).1

 

In 2009, mortality rates were higher among 

males than females in both age groups. Among 

children aged 1-4 years, the mortality rate for 

males was 28.8 per 100,000 compared to 23.4 

per 100,000 among females of the same age; rates 

among 5- to 14-year-old children were 15.6 per 

100,000 and 12.1 per 100,000 for males and 

females, respectively (data not shown). There 

are also racial/ethnic disparities in child mortality, with non-Hispanic Black children experiencing higher mortality rates than children of other 

racial/ethnic groups. Among children aged 1-4 

years, the rate was 41.2 per 100,000 for nonHispanic Blacks, compared to rates of 23.2 and 

23.9 per 100,000 for Hispanics and non-Hispanic Whites, respectively. Among children aged 

5-14 years, rates were 21.0 per 100,000 for nonHispanic Blacks, 13.1 per 100,000 for Hispanics, 

12.2 for non-Hispanic Whites, 10.9 for Asian or 

Pacific Islanders,2

 and 20.2 for American Indian/

Alaskan Native children (data not shown). 

1 Singh GK. Child Mortality in the United States, 1935-

2007: Large Racial and Socioeconomic Disparities Have 

Persisted Over Time. A 75th Anniversary Publication. 

Health Resources and Services Administration, Maternal 

and Child Health Bureau. Rockville, MD: US Department of Health and Human Services; 2010.

2 Separate estimates for Asians and Native Hawaiian or 

Other Pacific Islanders not available.

2468 10

In situ, Benign or Other Neoplasms

Influenza and Pneumonia

Cerebrovascular Diseases

Chronic Lower Respiratory Diseases

Heart Disease

Suicide

Homicide

Congenital Anomalies

Malignant Neoplasms (cancer)

Unintentional Injury

In situ, Benign or Other Neoplasms

Conditions Originating in the Perinatal Period

Cerebrovascular Diseases

Septicemia

Influenza and Pneumonia

Heart Disease

Malignant Neoplasms (cancer)

Homicide

Congenital Anomalies

Unintentional Injury

Leading Causes of Death Among Children Aged 1-14 Years, 2009*

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

Statistics System 1–4 Years

5–14 Years

*Data are preliminary. Death Rate per 100,000 Population in Specified Age Group

8.5

2.8

2.3

2.0

0.3

0.3

0.4

0.4

0.8

0.9

4.1

2.2

0.9

0.8

0.2

0.2

0.2

0.3

0.5

0.7
 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS 37

HEALTH STATUS - ADOLESCENTS
38 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2011

SEXUAL ACTIVITY AND

EDUCATION

In 2009, 46.0 percent of high school students reported having had sexual intercourse 

at least once, while the remaining 54.0 percent 

were abstinent. Sexual activity increased with 

grade level: 31.6 percent of 9th grade students 

reported having had sexual intercourse, compared to 40.9 percent of 10th graders, 53.0 

percent 11th graders, and 62.3 percent of 12th 

graders. No significant difference was observed 

between males and females with respect to the 

proportion who reported sexual activity within 

each grade level. However, males are significantly more likely to report having had sexual 

intercourse for the first time before age 13 than 

females (data not shown).

Contraceptive use also varies significantly 

by sex. Overall, 68.6 percent of males and 53.9 

percent of females reported condom use at 

last intercourse. Use of a hormonal contraceptive (by self or partner) was less common than 

condom use and was reported by 18.3 percent 

of males and 27.4 percent of females. Overall, 

fewer than 9 percent of adolescents used both a 

condom and a form of hormonal contraception 

during last sexual intercourse. 

According to data from the National Survey 

of Family Growth, 96 percent of females and 

97 percent of males received some form of formal sex education before the age of 18 (data not 

shown).1

 This includes information on topics 

such as how to say no to sex, methods of birth 

control, sexually transmitted diseases, and/or 

how to prevent HIV/AIDS. By individual topic, formal sex education on sexually transmitted 

diseases was the most prevalent (92 percent of 

males and 93 percent of females), while methods of birth control was the least common (62 

percent of males and 70 percent of females).

1 Martinez G, Abma J, Copen C. Educating teenagers about 

sex in the United States. NCHS data brief, no 44. Hyattsville, MD: National Center for Health Statistics. 2010.

Contraceptive Method Used* Among Currently Sexually Active,

High School Students, by Sex and Type of Method, 2009

Source (II.10): Centers for Disease Control and Prevention, Youth Risk Behavior Surveillance

System

High School Students Who Have Ever Had Sexual Intercourse,

by Grade Level and Sex, 2009 

Source (II.10): Centers for Disease Control and Prevention, Youth Risk Behavior

Surveillance System

*Used during last sexual intercourse by student or their partner. **Hormonal contraceptives refers to either

birth control pills or Depo-Provera. Percent of Students 10

20

30

40

50

60

70

Both a Condom and

Hormonal Contraceptive**

Condom Hormonal Contraceptive **

Female Male

Total 61.1

22.9

53.9

68.6

7.8 9.8

18.3

27.4

8.9

Percent of Students 10

20

30

40

50

60

70

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

Female

Male

Total

46.0 45.7

29.3

33.6

46.1

31.6

65.0 62.3 59.6

40.9 41.9 39.6

53.0 52.5 53.4
 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS 39

ADOLESCENT CHILDBEARING

According to preliminary data, the birth rate 

among adolescent females aged 15–19 years 

decreased to 39.1 per 1,000 females in 2009. 

This continues the general decline in teen 

birth rates since the most recent peak in 1991, 

when the rate was 61.8 per 1,000 females, and 

represents a decline of nearly 37 percent over 

that period. The birth rate among adolescents 

aged 10–14 years was 0.5 births per 1,000 

females, the lowest rate ever reported. Teenage 

birth rates were highest among adolescents aged 

18-19 years (66.2 per 1,000), and this age group 

experienced the smallest decline since 1991 (30 

percent; data not shown).

Among adolescents aged 10–14 years, nonHispanic Black and Hispanic females had the 

highest birth rates in 2009 (1.2 and 1.0 per 

1,000 population, respectively). Non-Hispanic 

White and Asian/Pacific Islander females had 

the lowest birth rates among those aged 10–14 

years (both 0.2 per 1,000). The birth rate among 

American Indian/Alaskan Native adolescents 

aged 10-14 years was 0.8 per 1,000.

Among adolescents aged 15–19 years, Asian/

Pacific Islander females had the lowest birth 

rate in 2009 (14.6 per 1,000), followed by 

non-Hispanic White females (25.6 per 1,000). 

Hispanic females had the highest birth rate in this 

age group (70.1 per 1,000) in 2009. However, 

this estimate represents a 10 percent decline since 

2008 and the lowest rate ever reported for this 

group in the two decades for which rates for 

Hispanic teenagers are available. Non-Hispanic 

Black females had the second highest birth rate 

among those aged 15–19 years (59.0 per 1,000), 

followed by American Indian/Alaska Native 

teens (55.5 per 1,000).

Birth Rates Among Adolescent Females Aged 10-19 Years, by Age

and Race/Ethnicity, 2009*

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

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

20.1

66.2

0.5

11.0

46.1

0.2

32.1

97.5

1.0

41.0

114.0 

1.2 7.1

25.7

0.2

30.6

90.5

0.8

Birth Rates Among Adolescent Females Aged 15-19,

by Race/Ethnicity, 1990-2009 *

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

Health Statistics, National Vital Statistics System

20

40

60

80

100

120

140

American Indian/

Alaska Native**

Asian/

Pacific Islander**†

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total

*Data for 2009 are preliminary. **May include Hispanics. †

Separate estimates for Asians and Native

Hawaiians and Other Pacific Islanders were not available.

*Data for 2009 are preliminary. **May include Hispanics. †Separate estimates for Asians and Native

Hawaiians and Other Pacific Islanders were not available.

10-14 Years

15-17 Years

18-19 Years

25.6

59.0

70.1 Non-Hispanic Black

Non-Hispanic White

Hispanic

Live Births per 1,000 Females

14.6

55.5

American Indian/

Alaska Native**

Asian/Pacific Islander**†

20

40

60

80

100

120

140

1990 1992 1994 1996 1998 2000 2002 2004 2006 20092008
40 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2011

SEXUALLY TRANSMITTED

INFECTIONS

In general, adolescents and young adults are at 

much higher risk than older adults of contracting sexually transmitted infections (STIs), such 

as chlamydia, gonorrhea, and genital human 

papillomavirus (HPV). Although young people 

aged 15–24 years represent only one-quarter of 

the sexually experienced population, they acquire 

nearly half of all new STIs.1

Chlamydia continues to be the most common 

reportable STI among adolescents and young 

adults. There were 2,000 chlamydial infections 

per 100,000 adolescents aged 15-19 years and 

2,165 per 100,000 young adults aged 20-24 

years in 2009. Gonorrhea was less common, with 

rates of 405 and 479 per 100,000 in these age 

groups, respectively. Rates vary by race/ethnicity: 

among adolescents aged 15-19 years, the highest rates of chlamydia was reported among nonHispanic Blacks (6,765 per 100,000), followed 

by American Indian/Alaska Natives (2,718 per 

100,000). Rates of gonorrhea were also highest 

among these two groups.

Unlike chlamydia and gonorrhea, HPV is not 

required to be reported to the CDC. However, 

a recent study indicated that approximately onequarter of females aged 14–19 years and nearly 

45 percent of those aged 20–24 years are infected 

with HPV.2

 A vaccine for certain types of HPV 

was approved in 2006 for use in females aged 

9–26 years.3 In 2009, 44.3 percent of females 

aged 13–17 years had received at least one dose 

of the three-dose series.4

1 Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and 

prevalence estimates, 2000. Perspect Sex Reprod Health. 

2004:36(1):6-10.

2 Dunne EF, Unger ER, Sternberg M, McQuillan G, Swan 

DC, Patel SS, Markowitz LE. Prevalence of HPV infection among females in the United States. JAMA. 2007 

Feb;297(8):876-8.

3 Centers for Disease Control and Prevention, Division of 

STD Prevention. HPV and HPV vaccines: information 

for healthcare providers. June 2006. Available at: http://

www.cdc.gov/std/hpv/STDFact-HPV-vaccine-hcp.htm. 

Accessed August 2011.

4 Centers for Disease Control and Prevention. National, 

state, and local area vaccination coverage among adolescents aged 13–17 years—United States, 2009. MMWR 

2010;59: 1018-23.

1,000

2,000

3,000

4,000

5,000

6,000

7,000

American Indian/

Alaska Native†

Asian/

Pacific Islanders*†

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total

Reported Gonorrhea Infections Among Adolescents and Young

Adults, by Age and Race/Ethnicity, 2009

Source (II.11): Centers for Disease Control and Prevention, STD Surveillance System

*Separate estimates for Asians and Native Hawaiian and Other Pacific Islanders not available.

†

May include Hispanics.

*Separate estimates for Asians and Native Hawaiian and Other Pacific Islanders not available.

†

May include Hispanics.

Reported Chlamydia Infections Among Adolescents and Young

Adults, by Age and Race/Ethnicity, 2009

Source (II.11): Centers for Disease Control and Prevention, STD Surveillance System

5.3

Rate Per 100,000 Population

Rate Per 100,000 Population

20-24 Years

15-19 Years 10.8

11.8

14.7

28.2

4.4

5.9

32.9 33.9

39.3 21.6

42.6 16.2

40.1 31.8

40.8 13.1

22.6 62.4

33.6 40.1

28.1 15.0 2,165 2,000 1,866

2,229

484

877 1,094

6,765 6,802

785

2,718

3,205

1,000

2,000

3,000

4,000

5,000

6,000

7,000

American Indian/

Alaska Native†

Asian/

Pacific Islanders*†

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total

20-24 Years

15-19 Years

405 94

1,956

2,351

479

132 181 244 59 79 317 404
 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS 41

ADOLESCENT AND YOUNG 

ADULT HIV AND AIDS

Human immunodeficiency virus (HIV) is 

a disease that destroys cells that are critical to a 

healthy immune system. Acquired immunodeficiency syndrome (AIDS) is diagnosed when 

HIV has weakened the immune system enough 

that the body has difficulty fighting disease 

and infections. In 2009, an estimated 8,294 

people aged 13–24 years were diagnosed with 

HIV,representing 19.7 percent of all cases. Between 2006 and 2009, the rate of diagnosed HIV 

infection decreased for younger adolescents (aged 

13-14 years) while increasing for those aged 15-

24 years. In 2009, the rates of diagnosed HIV infection among adolescents aged 13-14 years and 

15-19 years were 0.3 and 12.0 per 100,000 population, respectively. Among young adults aged 

20-24 years the rate was 36.9 per 100,000 – the 

highest rate of any age group (data not shown).

By 2009, an estimated 51,455 adolescents and 

young adults had been diagnosed with AIDS, 

representing 4.6 percent of AIDS diagnoses. In 

2008, the death rates for adolescents and young 

adults with AIDS remained stable with an estimated 205 deaths reported for individuals with 

an AIDS diagnosis in this population. Since the 

beginning of the epidemic through 2008, an estimated 10,682 persons aged 13–24 years have 

died with the disease. 

Death rates among adolescents and young 

adults with a diagnosis of HIV infection or AIDS 

remained stable between 2006-2008.1

 In 2008, 

an estimated 29,056 people aged 13–24 years 

were living with HIV, representing 4.4 percent of 

all cases. Overall, the number of adolescents and 

young adults living with HIV increased nearly 17 

percent between 2006 and 2008.

1 Centers for Disease Control and Prevention. HIV Surveillance Report, 2009; vol. 21. February 2011. Available 

at: http://www.cdc.gov/hiv/topics/surveillance/resources/

reports/. Accessed April 2011.

1000 2000 3000 4000 5000 6000 7000 8000 18000 19000 20000 21000 22000

Died with

AIDS

Diagnosis

Living

with AIDS

Living with

Diagnosed HIV Infection**

Diagnosed

with HIV

Infection**

1,996

13–14 Years

15–19 Years

37

5,662 20–24 Years

1,258

6,601

21,197

607

2,781

6,501

0

40

165

Selected Data on HIV* and AIDS Among Adolescents and Young Adults, by Age, 2008

Source (II.7): Centers for Disease Control and Prevention, HIV/AIDS Surveillance System

Number of Persons

58

480

1869

Diagnosed

with AIDS

*All HIV estimates reflect diagnoses. **Data from 40 states with confidential name-based HIV infection reporting. Includes persons with a

diagnosis of HIV infection regardless of stage of disease at the time of diagnosis.
42 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2011

PHYSICAL ACTIVITY

Data from the 2009 Youth Risk Behavior 

Surveillance System showed that 18.4 percent 

of high school students were physically active 

for at least 60 minutes on each of the 7 

previous days. This is consistent with the U.S. 

Department of Health and Human Services’ 

recommendation that children and adolescents 

get one hour or more of physical activity every 

day, most of which should be moderate- to 

vigorous-intensity aerobic activity. 

Overall, 23.1 percent of students did not 

participate in 60 or more minutes of physical 

activity on any day in the preceding week. The 

rate was higher for females than males (29.9 

versus 17.0 percent) and for non-Hispanic Black 

and Asian children (32.1 and 31.1 percent, 

respectively) than non-Hispanic Whites (20.3 

percent; data not shown).

Participation in recommended levels of 

physical activity varied by sex and grade level. 

Among high school students in all grades, 

a smaller proportion of females reported 

60 minutes of physical activity on each of 

the previous seven days than males. Among 

9th graders, 13.6 percent of females met 

recommended levels of physical activity 

compared to 28.0 percent of their male 

counterparts. By 12th grade, only 8.6 percent of 

females met the recommended levels compared 

to 21.9 percent of males in the same grade.

Nationwide, 56.4 percent of high school students attended physical education (PE) classes at 

least one day per week in 2009. The rate drops 

dramatically with increasing grade: 72.4 percent 

of 9th grade students attended PE class, compared to 43.8 percent of 12th grade students. 

Overall, only 33.3 percent of students attended 

daily PE classes in 2009 (data not shown). 

In 2009, 58.3 percent of high school students 

reported playing on at least one sports team in 

the past year. This was more common among 

younger children than older children (61.6 

percent of 9th graders compared to 51.1 percent of 12th graders). Sex differences were also 

observed in sports participation. Overall, just 

over half of high-school females reported playing on at least one sports team in the past year, 

compared to 63.8 percent of high school males. 

These differences increased with age: while 56.6 

percent of 9th grade females reported sports 

participation in 2009, only 44.1 percent of 12th 

grade females did so. Among males, the rates 

of past-year sports team participation declined 

from 65.9 percent among 9th graders to 57.9 

percent among 12th graders (data not shown).

Physical Activity* Among High School Students, by Grade Level and Sex, 2009

Source (II.10): Centers for Disease Control and Prevention, Youth Risk Behavior Surveillance System Percent of High School Students

*Met recommended levels of physical activity, which is one hour or more of physical activity every day, most of which should be moderateto vigorous-intensity aerobic activity.

Total Male Female

18.4

15.6

11.4

24.8

21.3

13.6

28.0

19.3

12.7

25.3

17.0

10.3

23.3

15.3

8.6

21.9

6

12

18

24

30

Total 9th Grade 10th Grade 11th Grade 12th Grade
 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS 43
44 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2011

SEDENTARY BEHAVIORS

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

to 1-2 hours per day.1 This includes time spent 

watching TV or videos as well as time spent 

playing video games. In 2007, 7.9 percent of 

children aged 1-5 years did not watch any TV 

or videos on an average weekday while 37.7 percent watched 1 hour or less, and 54.4 percent 

watched more than 1 hour. Among school-aged 

children (6-17 years), 5.8 percent of children 

did not spend any time on an average weekday 

watching TV or videos or playing video games 

while 44.1 percent spent 1 hour or less, and 

50.1 percent spent more than 1 hour.

Among preschool aged children, the amount 

of weekday media use varied by poverty.

Children living in households with incomes 

of less than 100 percent of the Federal poverty 

level($20,650 for a family of four in 2007) 

were most likely to engage in 4 or more 

hours of media use per day (19.1 percent) 

while only 6.6 percent of children living 

in households with incomes 400 percent 

or greater of the poverty level reported 4 

or more hours of media use per weekday.

A similar pattern was observed for school-aged 

children (data not shown).

Media use among school-aged children varied by age and sex. While the proportions of 

males and females engaged in each level of media use were similar among children aged 6-11 

years, females aged 12-17 were more likely to 

report lower levels of weekday media use than 

their male counterparts. Nearly 8 percent of 12-

17 year old girls did not engage in any weekday 

media use compared to 4.7 percent of boys of 

the same age, and males in this age group were 

more likely than their female counterparts to 

engage in 4 or more hours of media use (14.7 

percent and 10.1 percent, respectively).

1 Committee on Public Education. Children, Adolescents, and Television. Pediatrics. February 1, 2001 

2001;107(2):423-426.

Media Use* Among Children Aged 6-17, by Age and Sex, 2007

Source (II.2): Health Resources and Services Administration, Maternal and Child Health Bureau

and Centers for Disease Control and Prevention, National Center for Health Statistics, National

Survey of Children’s Health

Media Use* Among Children 1-5 and 6-17 Years of Age, 2007

Source (II.2): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health

*This is the number of hours spent watching TV or videos or playing video games on an average weekday.

Children Aged 1-5 Years Children Aged 6-17 Years

None

7.9%

1 Hour or Less

37.7%

1-4 Hours

41.6%

4 or

More Hours

12.8%

None

5.8%

1 Hour or Less

44.1%

1-4 Hours

39.3%

4 or

More Hours

10.8%

*For children 1-5 years of age, this is the number of hours spent watching TV or videos on an average

weekday; for children 6-17 years, this is the number of hours spent watching TV or videos or playing

video games on an average weekday. 

10

20

30

40

50

None 1 Hour or Less 1-4 Hours 4 or More Hours

Percent of Children

Males

6-11 Years

Females

6-11 Years

Males

12-17 Years

Females

12-17 Years

5.6 5.0 4.7

7.9 9.8 8.5

14.7

10.1

45.1 47.6

39.3

44.7

39.5 38.9 41.2

37.3
 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS 45

OVERWEIGHT AND OBESITY

Body mass index (BMI) is the ratio of weight 

to height, which is used to define weight status. 

In children, BMI is used in conjunction with 

age and sex, since both of these factors affect 

body composition. Children who fall between 

the 85th and 94th percentile of BMI-for-age are 

considered overweight, while children who are 

in the 95th percentile or above are considered 

obese; those who fall below the 5th percentile are 

considered underweight. Those between the 5th 

and 84th percentile are considered to be normal 

weight. In 2007, 15.3 percent of children aged 

10-17 years were overweight and 16.4 percent 

were obese based on parent-reported height and 

weight. Obesity is a serious health concern for 

children—obese children are more likely to have 

risk factors for cardiovascular disease, such as 

high blood pressure, high cholesterol, and Type 2 

diabetes. Obese children are also at increased risk 

of obesity in adulthood, which is associated with 

a host of serious health consequences.1

Weight status among children varies by a 

number of factors including household poverty.2 

In 2007, 27.4 percent of children living with 

household incomes below 100 percent of the 

Federal poverty level ($20,650 for a family of 

four in 2007) were obese, compared to only 10.0 

percent of children living in households with 

incomes of 400 percent or more of the Federal 

poverty level. 

The prevalence of obesity among children 

increased sharply between 1976 and 2008. The 

obesity prevalence for male children nearly quadrupled from 5.5 percent in 1976-1980 to 21.0 

percent in 2007-2008. For female children, the 

obesity prevalence tripled from 5.8 percent in 

1976-1980 to 17.3 percent in 2007-2008.3

1 Centers for Disease Control and Prevention. Childhood 

overweight and obesity. Available at: http://www.cdc.gov/

obesity/childhood/index.html. Accessed February 2011.

2 Gopal SK and Kogan MD. Childhood Obesity in the 

United States, 1976-2008. A 75th Anniversary Publication. Health Resources and Services Administration, 

Maternal and CHild Health Bureau. Rockville, MD: US 

Department of Health and Human Services; 2010.

3 Federal Interagency Forum on Child and Family Statistics. America’s Children in Brief: Key National Indicators 

of Well-Being, 2010. Available at: http://childstats.gov/

americaschildren/index.asp. Accessed June 2011.

Weight Status* Among Children Aged 10-17 Years, by Poverty,** 2007

Source (II.2): Health Resources and Services Administration, Maternal and Child Health Bureau

and Centers for Disease Control and Prevention, National Center for Health Statistics,

National Survey of Children’s Health Percent of Children

Obesity* Among US Children Aged 6-17, by Sex, 1976-2008 

Source (II.12): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Health and Nutrition Examination Survey

10

20

30

40

50

60

70

80

400% or more

of Poverty

200-399%

of Poverty

100-199%

of Poverty

<100%

of Poverty

Total

Percent of Children

17.3

19.2

21.0

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

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

BMI-for-age in the 95th percentile or above; based on parent-reported height and weight. **The U.S.

Department of Health and Human Services poverty level for a family of four was $20,650 in 2007. *Obesity is a BMI-for-age in the 95th percentile or above; based on parent-reported height and weight.

5.2

63.2

15.3 16.4

49.8

5.1

17.7

27.4

57.5

4.6

21.1 16.8

64.6

5.1

15.914.5

71.9

5.7 10.0 12.4

Obese

Overweight

Normal Weight

Underweight

6

12

18

24

30

1976-1980 1988-1994 1999-2000 2001-2002 2003-2004 2005-2006 2007-2008

Male

Female

Both Sexes
46 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2011

MENTAL HEALTH

In 2009, 8.1 percent or 2.0 million adolescents 

aged 12–17 years experienced at least one major 

depressive episode (MDE), which is defined as 

having at least 2 weeks of depressed mood or loss 

of interest or pleasure in daily activities, plus a 

majority of specific depression symptoms, such 

as altered sleeping patterns, fatigue, and feelings 

of worthlessness.1 Females were more likely than 

males to experience MDE (11.7 percent versus 

4.7 percent). Occurrence of MDE increased 

with age, from 3.6 percent among children age 

12 years to 10.9 percent among children age 17 

(data not shown). 

Among adolescents experiencing MDE in 

2009, over one-half (1.4 million) also experienced severe impairment defined by the degree 

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

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

common among older adolescents and females 

(data not shown).

In 2009, adolescents aged 12 to 17 with pastyear MDE were more likely than those without 

MDE to have used illicit drugs in the past year 

(35.7 compared to 18.0 percent). Adolescents 

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

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

MDE who used illicit drugs, nearly one-quarter 

(24.2 percent) reported using marijuana or hashish and nearly one-fifth (19.2 percent) reported 

non-medical use of psychotherapeutics, including pain relievers, tranquilizers, stimulants and 

sedatives. Among adolescents who did not experience past-year MDE, the proportion who reported using these substances was 12.6 percent 

and 6.6 percent, respectively (data not shown).

1 Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on 

Drug Use and Health: Mental Health Findings (Office of 

Applied Studies, NSDUH Series H-39, HHS Publication 

No. SMA 10-4609). Rockville, MD.

*MDE is defined as a period of at least two weeks when a person experienced a depressed mood or

loss of pleasure in daily activities and had a majority of specific depression symptoms.

**Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants,

or prescription-type psychotherapeutics used non-medically. ***Heavy Alcohol Use is defined as

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

*MDE is defined as a period of at least two weeks when a person experienced a depressed mood or loss

of pleasure in daily activities and had a majority of specific depression symptoms.

Percent of Adolescents

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

Among Adolescents Aged 12-17 Years, by Age and Sex, 2009

Source (II.13): Substance Abuse and Mental Health Service Administration, National

Survey of Drug Use and Health Percent of Adolescents

Substance Use among Adolescents Aged 12-17, by Past-Year

Major Depressive Episode (MDE)*, 2009

Source (II.13): Substance Abuse and Mental Health Service Administration, National Survey

of Drug Use and Health

18.0

3.6 1.9 4.2 1.9

Female 35.7

Male

5

10

15

20

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

14.9 14.6

1.8

4.7 5.4

3.6

6.4 5.8

10.6

2.4

8.5

7.0

14.8

11.7

8

16

24

32

40

No Past Year MDE

Past Year MDE

Past Year Illicit Drug Use** Past Month Daily Cigarette Use Past Month Heavy Alcohol Use***
 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS 47

SUICIDE

In 2007, the latest year for which mortality 

data were available, suicide was the third leading 

cause of death among persons aged 15-24 years, 

9.7 deaths per 100,000 population.1 Suicide 

mortality among this age group increased by over 

70 percent between 1969 and 1994; however, 

there was a downward trend between the years of 

1994 and 2007. The overall rise in suicide rates 

between 1969 and 2007 occurred disproportionately, with a larger increase among White youth 

aged 15-24 years than among Black youth.2

In 2009, data from the Youth Risk Behavior 

Surveillance System showed that 13.8 percent of 

all high school students had considered attempting suicide during the 12 months prior to the 

survey. Female students in the 9th grade were 

the most likely to consider suicide (20.3 percent) while 9th- and 10th-grade males were the 

least likely (10.0 percent). Female students were 

significantly more likely to consider suicide as 

compared to males within each grade level; 13.6 

percent of 12th grade females had considered suicide in the prior year. No significant difference by 

grade level was found among male students. 

In 2009, 6.3 percent of high school students 

reported having attempted suicide in the past 12 

months. Overall, females (8.1 percent) were more 

likely to report at least one suicide attempt than 

males (4.6 percent; data not shown).The proportion of students who reported having attempted 

suicide also varied by race/ethnicity. Non-Hispanic Asian and White students were least likely 

to report attempting suicide (4.0 percent and 5.0 

percent, respectively) while non-Hispanic Native 

Hawaiian/Other Pacific Islander students and 

non-Hispanic students of more than one race 

were the most likely to report at least one attempt 

in the past year (11.9 percent and 12.4 percent, 

respectively). Female students were significantly 

more likely to report attempted suicide among 

non-Hispanic Black, White, and Hispanic students; no sex differences were observed for other 

racial/ethnic groups (data not shown). 

1 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Available at: http://

www.cdc.gov/ncipc/wisqars. Accessed March, 2011.

2 Singh GK. Youth Mortality in the United States, 1935-

2007; Over Seven Decades of Progress and Disparities. 

A 75th Anniversary Publication. Health Resources and Services Administration, Maternal and Child Health Bureau. 

Rockville, Maryland: U.S. Department of Health and Human Services; 2010.

High School Students Who Attempted Suicide in the Past 12 Months,

by Race/Ethnicity and Sex*, 2009

Source (II.10): Centers for Disease Control and Prevention, Youth Risk Behavior Surveillance

System

High School Students Who Considered Attempting Suicide in

the Past 12 Months, by Grade Level and Sex, 2009

Source (II.10): Centers for Disease Control and Prevention, Youth Risk Behavior

Surveillance System Percent of Students

Percent of Students

6

12

18

24

30

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

Male

Female

Total

13.8

10.5 10.0

20.3

17.4

14.8

10.5 12.1 13.4 13.6

17.2

10.0

14.5

17.8

11.4

4

8

12

16

20

Non-Hispanic

Multiple

Races

NonHispanic

Native Hawaiian/

Pacific Islander

Non-Hispanic

American

Indian/

Alaska Native

NonHispanic

 Asian

Non- Hispanic

Hispanic

Black

NonHispanic

 White

Total

6.3

7.9 8.1

5.0 4.0

10.0

11.9 12.4
48 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2011

VIOLENCE

Physical violence among adolescents occurs 

in multiple forms and is a critical public health 

issue in the United States. Instances of violence 

include homicide, which was the second leading cause of death among all persons aged 15–24 

years in 2007 (the latest year for which data are 

available).1

Results from the Youth Risk Behavior Surveillance System show that, in 2009, 11.1 percent of high school students reported being in 

a physical fight on school property during the 

preceding 12 months. Males were more than 

twice as likely as females to report having been 

in a fight (15.1 percent versus 6.7 percent). 

This disparity was most pronounced among 

non-Hispanic Whites, where males were almost 

three times as likely as females to have been in a 

fight (12.4 percent versus 4.3 percent), although 

significant sex differences were observed across 

all racial/ethnic groups. Overall, non-Hispanic 

White and Asian students were least likely to 

report having been in a fight (8.6 percent and 

7.7 percent, respectively) while over one-fifth 

of non-Hispanic American Indian/Alaska Native students reported having been in a physical 

fight on school property in the past year. 

Approximately 1 out of every 10 high school 

students reported that they were hit, slapped, or 

physically hurt on purpose by their boyfriend or 

girlfriend at least once in the past 12 months. 

The prevalence of dating violence was similar 

across grade levels and among males and females, 

with one execption. Males in the 11th grade 

were slightly more likely to report having been 

victims of dating violence (11.5 percent) than females in the same grade level (9.1 percent; data 

not shown).

1 Centers for Disease Control and Prevention, National 

Center for Injury Prevention and Control. Available at: 

http://www.cdc.gov/ncipc/wisqars. Accessed July 2011.

High School Students Experiencing Dating Violence* in

the Past 12 Months, by Grade and Sex, 2009

Source (II.10): Centers for Disease Control and Prevention, Youth Risk Behavior

Surveillance System

High School Students in a Physical Fight on School Property in

the Past 12 Months, by Sex and Race/Ethnicity*, 2009

Source (II.10): Centers for Disease Control and Prevention, Youth Risk Behavior Surveillance System

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

boyfriend or girlfriend.

Percent of Students

*Data for American Indian/Alaska Natives and Native Hawaiian/Other Pacific Islanders do not meet standards for

reliability or precision.

6

12

18

24

30

NonHispanic

Multiple

Races

NonHispanic

Native Hawaiian/

Other Pacific

Islander

NonHispanic

American

Indian/

Alaska Native

NonHispanic

Asian

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Male

Female

Total

11.1

15.1

12.4

4.3

6.7

8.6

11.4

4.1

7.7

17.4

12.5

22.2 20.7

14.8

* * * *

13.5

9.3

17.7

12.4

7.5

18.3

Percent of Students

9.8 9.2 9.2 10.4 10.4

6

12

18

24

30

Total 9th Grade 10th Grade 11th Grade 12th Grade
 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS 49

BULLYING

Bullying is defined as aggressive behavior that 

is intentional, repeated over time, and involves 

an imbalance of power or strength. Bullying 

may damage children’s self-esteem, cause higher 

rates of loneliness and depression, and affect 

academic success. Bullying can also have physical 

effects, such as an increase in headaches, sleeping 

problems, and stomach ailments. Children who 

engage in bullying may be more likely to get into 

physical altercations, use drugs and alcohol, and 

get into trouble with the law. Even children who 

witness bullying can be negatively affected.1

In 2009, 19.9 percent of high school students 

reported that they had been bullied on school 

property in the past year. The likelihood of a 

child being bullied varied by a number of factors 

including sex, race/ethnicity, and grade level. 

Females were more likely than males to have 

been bullied (21.2 percent versus 18.7 percent) 

while nearly one-quarter of 9th graders reported 

being bullied compared to 13.5 percent of 12th 

graders (data not shown). Overall, non-Hispanic 

American Indian/Alaska Native children were 

most likely to report having been bullied (33.8 

percent), while non-Hispanic Black children 

were least likely (13.7 percent). 

Violence, such as bullying, can prevent 

children from attending school for fear of their 

safety. In 2009, 5.0 percent of high school 

students reported that they did not go to school 

on at least one day during the past month because 

they felt unsafe at school or on their way to or 

from school. Non-Hispanic American Indian/

Alaska Native and Hispanic students were more 

than twice as likely to miss school because of 

safety concerns as non-Hispanic White children 

(8.7 and 8.1 percent, respectively, versus 3.5 

percent) while non-Hispanic Native Hawaiian or 

Other Pacific Islander children were more than 

three times as likely (10.6 percent). 

1 U.S. Department of Health and Human Services. Stop 

Bullying Now. Available at: http://www.stopbullying.gov/.

Accessed March 2011.

High School Students Who Felt Unsafe at School,* by

Race/Ethnicity, 2009

Source (II.10): Centers for Disease Control and Prevention, High School Youth Risk Behavior Survey

*Did not go to school on at least 1 day during the preceding 30 days

because he/she felt unsafe at school or on the way to or from school.

High School Students Who Were Bullied on School Property in the

Past Year, by Race/Ethnicity, 2009

Source (II.10): Centers for Disease Control and Prevention, High School Youth Risk Behavior

Survey

Percent of High School Students

33.9

2.9

5.5

10.6 8.1 6.3

3.5

8.7

5.0 8

16

24

32

40

NonHispanic

Multiple Race

NonHispanic

Native

Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Percent of High School Students

17.5

23.9

20.4 18.5

13.7

21.6

33.8

19.9

8

16

24

32

40

NonHispanic

Multiple Race

NonHispanic

Native

Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total
50 HEALTH STATUS – ADOLESCENTS CHILD HEALTH USA 2011

SOCIAL SKILLS

Cultivating social skills is a significant component of a child’s development and begins at an 

early age. Social skills include the ability to communicate and empathize with others and remain 

important throughout a child’s lifetime. 

Parents of children aged 6-17 years were 

asked if their child had never, rarely, sometimes, 

usually, or always exhibited each of the following behaviors in the past month: showed respect for teachers and neighbors; got along well 

with other children; tried to understand other 

people’s feelings; and tried to resolve conflict 

with classmates, family, or friends. The prevalence of individual social skills varied greatly. 

Parents of over 90 percent of children reported 

that they usually or always showed respect for 

teachers and neighbors, and got along well with 

other children. In comparison, 75.3 percent of 

children were reported to have tried to understand other people’s feelings, and 68.9 percent 

were reported to have tried to resolve conflict 

with classmates, family, or friends. While most 

children displayed positive social skills to some 

degree, children were considered to consistently 

display social skills if parents responded “usually” or “always” to two or more of these questions. Overall, 93.6 percent of children were 

reported as having consistently exhibited two or 

more positive social skills (data not shown). 

The display of specific social skills varied by 

the child’s sex. Among children aged 6-17 years, 

72.5 percent of females tried to resolve conflicts 

with classmates, family, or friends compared to 

65.4 percent of males; however, this behavior increased in both sexes with age.

Children Aged 6-17 Years Usually or Always Exhibiting Social

Skills, by Type of Social Skill, 2007

Source (II.14): Health Resources and Services Administration, Maternal and Child Health

Bureau and Centers for Disease Control and Prevention, National Center for Health Statistics,

National Survey of Children’s Health

Percent of Children

68.9

90.4

93.7

75.3

Children Aged 6-17 Years Who Usually or Always Try to Resolve

Conflicts,* by Age and Sex, 2007

Source (II.2): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health Percent of Children

65.4 64.0

72.5 68.9 67.8 71.6 66.8 70.0 73.4

20 40 60 80 100

Tries to Resolve Conflict with

Classmates, Family, or Friends

Tries to Understand

Other People's Feelings

Gets Along Well with

Other Children

Shows Respect for

Teachers and Neighbors

20

40

60

80

100 Total Male Female

Total 6-11 Years Age 12-17 Years of Age

*With classmates, family, or friends.
 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS 51

CIGARETTE SMOKING

In 2009, cigarette smoking among adolescents reached the lowest levels recorded in the 

past 34 years, according to the annual Monitoring the Future study. Between 2009 and 2010, 

there was a non-significant increase in the overall percentage of high school students to have 

smoked cigarettes in the past 30 days from 12.7 

percent in 2009 to 12.8 percent in 2010. This 

increase in current cigarette use occurred among 

both 8th and 10th graders, from 6.5 percent to 

7.1 percent and 13.1 percent to 13.6 percent, 

respectively. During this same period a small 

decline was observed among 12th graders (20.1 

percent to 19.2 percent).1

The percent of teens who report smoking in 

the past month began a rapid increase in the 

early 1990s, with the rates among 8th and 10th 

grade students reaching a peak in 1996 (at 21.0 

and 30.4 percent, respectively), and the rate 

among 12th grade students peaking a year later 

(36.5 percent). These increases occurred in virtually every sociodemographic group: male and 

female, those with and without plans for college attendance, those living in all four regions 

of the country, and those of different racial and 

ethnic groups. Since peaking in the mid-1990s, 

overall rates of smoking in the past month have 

dropped 66 percent among 8th grade students, 

55 percent among 10th grade students, and 47 

percent among 12th grade students.

Despite a population-wide decline, certain 

subgroups of adolescents were still more likely 

than others to smoke. In 2009-2010, non-Hispanic White students were the most likely to 

report smoking in the past month, followed by 

Hispanic students. Also, males were more likely 

than females to smoke, and adolescents without 

plans to attend a four-year college program are 

more likely to smoke than their college-bound 

peers (data not shown).

1 Johnston, LD, O’Malley, PM, Bachman, JG, & Schulenberg, JE (December 14, 2010). “Smoking stops declining and shows signs of increasing among younger teens.” 

University of Michigan News Service. 2010. Available at: 

http://www.monitoringthefuture.org. Accessed July 2011.

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

and Race/Ethnicity, 2009-2010*

Source (II.16): National Institutes of Health, National Institute on Drug Abuse, Monitoring the Future Study

*To derive percentages for each racial subgroup, data for 2009 and 2010 have been combined to

increase subgroup sample sizes and thus provide more stable estimates.

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

Level, 1991-2010

Source (II.15): National Institutes of Health, National Institute on Drug Abuse,

Monitoring the Future Study

10

20

30

40

7.1

13.6

19.2

Percent of StudentsPercent of Students

8th Grade

10th Grade

12th Grade

10

20

30

40

Non-Hispanic White Non-Hispanic Black Hispanic

7.6

14.7

22.9

4.3

6.7

10.1

6.7

12.2

15.0

8th Grade

10th Grade

12th Grade

1991 1993 1995 1997 1999 2001 2003 2005 2007 20102009
52 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS

SUBSTANCE ABUSE

In 2009, 10.0 percent of adolescents aged 12–

17 years reported using illicit drugs in the past 

month, representing a significant increase since 

the previous year. Illicit drug use varied by age, 

with 3.6 percent of youth aged 12–13 years reporting drug use in the past month, compared to 

9.0 percent of youth aged 14–15 years and 16.7 

percent of youth aged 16–17 years. There was 

also variation by race/ethnicity, with rates ranging from 5.5 percent among non-Hispanic Asian 

youth to 14.6 percent among non-Hispanic 

American Indian/Alaska Native youth. Rates for 

non-Hispanic White, non-Hispanic Black, and 

Hispanic youth were 9.6 percent, 10.8 percent, 

and 11.4 percent, respectively (data not shown). 

Marijuana is consistently the most commonly 

used illicit drug among adolescents, with 7.3 percent reporting past-month use in 2009. This was 

followed by nonmedical use of prescription-type 

psychotherapeutics, such as pain relievers, tranquilizers, stimulants, and sedatives (3.1 percent). 

Marijuana was the most commonly used drug 

among adolescents aged 14-15 and 16-17 years 

(6.3 percent and 14.0 percent, respectively) compared to less than 1 percent among adolescents 

aged 12-13 years (data not shown).

Illicit drug use is associated with other health 

risk behaviors. In 2009, 52.8 percent of adolescents who reported cigarette use in the past 

month also reported illicit drug use, compared to 

only 5.9 percent of adolescents who did not report smoking. Adolescents who reported alcohol 

use in the past month were also more likely to use 

illicit drugs than adolescents who did not report 

alcohol use: 70 percent of heavy drinkers (i.e., 

adolescents who consumed five or more drinks 

on the same occasion on each of 5 or more days 

in the past 30 days), also used illicit drugs (data 

not shown).

Alcohol continues to be the most commonly 

used drug among adolescents, with 14.7 percent 

reporting past-month use in 2009. Rates of past 

month alcohol use varied by race/ethnicity, with 

rates ranging from 6.5 percent among non-Hispanic Asian youth to 16.1 percent non-Hispanic 

White youth (data not shown).

In 2009, 30.7 percent of adolescents perceived 

smoking marijuana once a month to be a great 

risk, while 49.5 percent perceived the same risk 

regarding cocaine use. Smoking one or more 

packs of cigarettes a day was considered a great 

risk by 65.8 percent of adolescents. Drinking five 

or more drinks once or twice per week was considered a great risk by 39.9 percent of adolescents 

(data not shown).

While 14.3 percent of adolescents were 

approached by someone selling drugs in the 

past month, nearly 50 percent reported that 

marijuana would be fairly or very easy to obtain; 

22.1 percent reported the same for crack, 20.9 

percent for cocaine, 13.5 percent for LSD, and 

12.9 percent for heroin (data not shown).

Past Month Drug Use Among Adolescents Aged 12-17 Years, by Drug Type, 2009

Source (II.13): Substance Abuse and Mental Health Service Administration, National Survey of Drug Use and Health

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

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

10.0

14.7

7.3

1.0

3.1

0.9

4

8

12

16

20

Nonmedical Use Inhalants Hallucinogens**

of Psychotherapeutics*

Alcohol Any Illicit Drug Marijuana
 CHILD HEALTH USA 2011 HEALTH STATUS – ADOLESCENTS 53

ADOLESCENT MORTALITY

In 2007, the latest year for which data are 

available, 13,299 adolescents aged 15 to 19 years 

died of various causes, representing a rate of 61.9 

per 100,000. Unintentional injury was the leading cause of death, followed by homicide, suicide, cancer, and heart disease. Together, these 

causes account for 84.3 percent of deaths in this 

age group, although nearly half of all adolescent 

deaths are attributable to unintentional injury. 

The mortality rate of males in this age group 

was notably higher than that of females (86.9 

versus 35.7 per 100,000, respectively; data not 

shown). While unintentional injuries account 

for about half of deaths among both males and 

females, the proportion of deaths due to homicide, suicide, and cancer vary by sex. One-fifth of 

deaths among adolescent males were homicides, 

compared to 7.8 percent of deaths among females. Similarly, 12.8 percent of adolescent male 

deaths were attributed to suicide, compared to 

7.4 percent of adolescent female deaths. 

Racial and ethnic disparities also exist, with 

non-Hispanic Black adolescents experiencing a 

mortality rate of 85.7 per 100,000, compared to 

rates of 58.0 and 57.9 per 100,000 among nonHispanic Whites and Hispanics, respectively 

(data not shown). In 2007, unintentional injury 

was the leading cause of death among adolescents 

of all racial/ethnic groups, except non-Hispanic 

Blacks. Nearly 45 percent of adolescent deaths 

among non-Hispanic Blacks were homicides, 

compared to nearly one-quarter of deaths among 

Hispanic adolescents and 4.5 percent of deaths 

among non-Hispanic White adolescents (data 

not shown).

Of the 6,493 adolescent deaths in 2007 due 

to unintentional injuries, motor vehicle traffic 

was the leading cause death (70.7 percent), followed by poisoning (12.9 percent). However, of 

the 10,415 deaths due to both unintentional and 

intentional (or violence-related) injuries, motor vehicle traffic accounted for 44.1 percent of 

deaths, while homicide by firearm was the second leading cause of injury death, accounting for 

18.2 percent of adolescent deaths of this nature. 

Firearms accounted for 85.3 percent of homicide 

deaths and 42.5 percent of suicide deaths among 

adolescents (data not shown). 

Deaths Due to Unintentional and Intentional Injury Among

Adolescents Aged 15-19 Years, 2007

Source (II.17): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

Leading Causes of Death Among Adolescents Aged 15-19 Years,

by Sex, 2007

Source (II.17):Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

Percent of Deaths Among Adolescent Males Percent of Deaths Among Adolescent Females

Homicide

20.2%

Cancer

4.1%

Heart

Disease

2.4%

Heart Disease

3.1%

All Others*

12.9%

Suicide

12.8%

Unintentional Injury 47.5%

Suicide

7.4%

Unintentional Injury

52.2%

Percent of Deaths Due to Unintentional Injury Percent of Deaths Due to Injury*

Poisoning

12.9%

Fires/Burns

1.3%

Drowning

4.9%

Other Land Transport

2.0%

Homicide

(Firearm)

18.2%

Motor Vehicle Traffic 44.1%

Suicide

(Suffocation) 5.9%

*Includes congenital anomalies, cerebrovascular diseases, chronic lower respiratory disease (males),

pregnancy and childbirth (females), diabetes (males), influenza and pneumonia (females), septicemia,

and all other causes not specified.

Homicide

7.8%

Cancer

7.0%

All Others*

22.6%

Motor Vehicle Traffic

70.7%

Poisoning 8.0%

Suicide

(Firearm)

6.0%

*Includes unintentional injury, intentional injury, such as homicide and suicide, and injury deaths of

undetermined intent.
54 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2011

HEALTH SERVICES FINANCING 

AND UTILIZATION

The availability of and access to quality health 

care directly affects the health of the population. 

This is especially true of those at high risk due 

to low socioeconomic status or chronic medical 

conditions. 

Children may receive health coverage 

through a number of sources, including private 

insurance, either employer-based or purchased 

directly, and public programs, such as Medicaid 

or the Children’s Health Insurance Program 

(CHIP). Eligibility for public programs is 

based on a family’s income compared to the 

Federal poverty level. Nearly every state has 

CHIP programs that help to expand coverage 

to children who would otherwise be uninsured. 

Despite the progress achieved through public 

programs, approximately 7.5 million children 

remain uninsured in the United States. 

This section presents data on the health 

insurance status and utilization of health

services within the maternal and child 

population. Data are summarized by source 

of payment, type of care, and place of service 

delivery.
 CHILD HEALTH USA 2011 HEALTH SERVICES FINANCING AND UTILIZATION 55

HEALTH CARE FINANCING

In 2009, approximately 7.5 million U.S. 

children under 18 years of age had no health 

insurance coverage, representing 10.0 percent of 

the population. More than one-third of children 

were insured through public programs such as 

Medicaid and the Children’s Health Insurance 

Program (36.8 percent), and 60.4 percent were 

covered by private insurance.

Children’s insurance status varies by race and 

ethnicity. In 2009, 74.0 percent and 70.9 percent 

of non-Hispanic White and non-Hispanic Asian 

children, respectively, and 70.8 percent of Asian 

children had private coverage, while the same was 

true of only 47.1 percent of non-Hispanic Native 

Hawaiian and Other Pacific Islander children, 

43.7 percent of non-Hispanic Black children, 

41.8 percent of non-Hispanic American Indian 

and Alaska Native children, and 36.8 percent of 

Hispanic children. Over half of non-Hispanic 

Black, American Indian and Alaska Native, and 

Native Hawaiian and Other Pacific Islander 

children were publicly insured.

As family income increases, private health 

insurance coverage among children rises and the 

proportions of children with public coverage and 

no coverage decrease. In 2009, children living 

in households with incomes below 100 percent 

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

($21,954 for a family of four in 2009) were most 

likely to have public coverage (74.8 percent) 

while similar proportions of poor and nearpoor (incomes between 100-199 percent of the 

poverty threshold) children were uninsured (15.1 

percent and 14.8 percent, respectively. Children 

with family incomes of 300 percent or more of 

the poverty threshold were most likely to have 

private coverage (89.0 percent), and least likely 

to have public coverage (12.2 percent) or to be 

uninsured (4.7 percent).

In 1997, the Children’s Health Insurance 

Program (CHIP) was created in response to the 

growing number of uninsured children in lowincome working families. Although designed to 

cover children with family incomes below 200 

percent of the poverty level, many States have 

expanded eligibility to children with higher 

family incomes.

20

40

60

80

100

NonHispanic

Native Hawaiian/

Other Pacific Islander

NonHispanic

Asian

NonHispanic

American Indian/

Alaska Native

Non- Hispanic

Hispanic

Black

NonHispanic

White

Total

Health Insurance Coverage Among Children Under Age 18, by

Poverty Status* and Type of Coverage,** 2009

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

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

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

poverty threshold for a family of four was $21,954 in 2009. **Totals equal more than 100 percent

because children may have more than one source of coverage.

Health Insurance Coverage Among Children Under Age 18, by

Race/Ethnicity and Type of Coverage,* 2009

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

Rate Per 100,000 Population

Public Coverage

No Coverage

Private Coverage

32.9

33.9

16.3 15.1

74.8

9.9 4.7

89.0

26.5

71.9

41.0

53.5

12.2 14.8

74.0

36.8 43.7

26.2

7.0

53.8 60.4

10.0

16.8

41.8

52.0

36.8

18.1 11.3

51.1 47.1

10.0

51.2

70.9

10.2

25.0

20

40

60

80

100

300% or more

of Poverty

200-299%

of Poverty

100-199%

of Poverty

<100%

of Poverty

Public Coverage

No Coverage

Private Coverage
56 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2011

LEVELS OF INSURANCE

While most children have some type of 

health insurance, it may not always meet their 

needs. The 2007 National Survey of Children’s 

Health asked parents about their child’s health 

insurance coverage and related costs and benefits. 

Based on both insurance status and benefits, 

four levels of insurance were defined: full and 

adequate coverage; full and inadequate coverage 

(or underinsurance); gaps in coverage (child had 

periods of no insurance coverage in the past 

year); and uninsured (child was never insured in 

the past year).1

 Overall, 65.7 percent of children 

were fully insured in 2007, 19.3 percent were 

underinsured (i.e., covered but did not receive 

the level of benefits necessary to meet their 

needs), 10.4 percent had gaps in coverage, and 

4.7 percent were consistently uninsured during 

the past year. 

The proportion of children with different 

levels of insurance coverage varied by a number 

of factors. Children aged 0-5 years were most 

likely to have full and adequate insurance 

coverage (69.3 percent) compared to children 

aged 6-11 years (64.0 percent) and aged 12-17 

years (63.9 percent; data not shown). Hispanic 

children were most likely to be uninsured (12.1 

percent) and to have gaps in their past-year 

coverage (16.1 percent). Non-Hispanic White 

and multiracial children had the highest rates of 

full and adequate insurance coverage (69.8 and 

70.8 percent, respectively).

Underinsurance was most commonly reported 

among children living in households with 

incomes 200-399 percent of the Federal poverty 

level ($20,650 for a family of four in 2007) and 

least commonly reported among children living 

in households with incomes below the poverty 

line (22.8 versus 14.1 percent). Underinsurance 

was also more common among children in fair 

or poor health and those with special health care 

needs (data not shown).

1 Kogan MD, Newacheck PW, Blumberg SJ, Ghandour 

RM, Singh GK, Strickland BB, van Dyck PC. Underinsurance among children in the United States. N Engl J 

Med. 2010 Aug 26;363(9):841-51.

Levels of Insurance Among Children Aged 0-17 Years, by

Poverty*, 2007

Source (III.2): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health

*The U.S. Department of Health and Human Services establishes poverty guidelines for determining financial

eligibility for Federal programs; the poverty level for a family of four was $20,650 in 2007.

**Fully insured but did not receive the level of benefits necessary to meet their needs, based on parent report. 

*Fully insured but did not receive the level of benefits necessary to meet their needs, based on parent report. 

Levels of Insurance Among Children Aged 0-17 Years, by

Race/Ethnicity 2007 

Source (III.2): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health

20 40 60 80 100

Non-Hispanic

Multiracial

Hispanic

Non-Hispanic

Black

Non-Hispanic

White

Total 65.7 10.4

12.8

16.1

9.6

69.8 8.0

64.7

54.3

70.8

19.3 4.7

2.4

4.0

12.1

2.9

19.8

18.5

17.5

16.8

Fully Insured Underinsured* Gaps in Coverage Never Insured

Proportion of Children

20 40 60 80 100

400%

or More of Poverty

200-399%

of Poverty

100-199%

of Poverty

< 100%

of Poverty

Total 65.7 10.4

16.6

4.7

62.0 15.0

57.7

64.8

74.7

19.3 4.7

9.0

7.6

3.6

1.0

14.1

Fully Insured Underinsured** Gaps in Coverage Never Insured

Proportion of Children

8.8

18.2

22.8

19.7
 CHILD HEALTH USA 2011 HEALTH SERVICES FINANCING AND UTILIZATION 57

VACCINATION COVERAGE

The Healthy People 2020 objective for childhood immunization is to achieve 90 percent 

coverage for each of the universally recommended vaccines among young children. In 

2009, 70.5 percent of children 19–35 months 

of age received each of six vaccines in a modified 

series of recommended vaccines (4:3:1:3:1:4). 

This series includes four doses of diphtheria, tetanus, and pertussis vaccine (DTP/DT/DTaP); 

three doses of poliovirus vaccine; one dose of 

measles, mumps, and rubella vaccine (MMR); 

three doses of the Hepatitis B vaccine (HepB); 

one dose of the varicella (chicken pox) vaccine; 

and four doses of the pneumococcal conjugate 

vaccine (PCV). Estimates presented in previous 

editions of Child Health USA have focused on 

receipt of a 7-vaccine series which also included 

three doses of Haemophilus influenza type b 

vaccine (Hib). However, because of changes in 

measurement of the Hib vaccine and the vaccine shortage that occurred from December 

2007 to September 2009, coverage estimates 

included here are based on the modified series 

that excludes Hib. 

For some vaccines, the proportion of children covered varied by poverty status. Children 

living in households with family incomes below 

100 percent of the U.S. Census Bureau’s poverty threshold ($22,025 for a family of four in 

2008) had significantly lower rates of vaccine 

coverage for diphtheria, tetanus, and pertussis (80.1 percent compared to 85.7 percent of 

children living in households with family incomes above the poverty threshold) as well as 

for the four recommended doses of pneumococcal conjugate vaccine (74.8 percent versus 83.2 

percent). Although no difference was observed 

in the proportion of children receiving three 

doses of the Hepatitis B vaccine by poverty status, coverage for the Hepatitis B birth dose (one 

dose within the first three days of life) was higher among children living below poverty than for 

those living at or above poverty (63.2 percent 

versus 59.4 percent; data not shown). No statistically significant difference was observed in the 

proportion of children receiving the modified 

6-vaccine schedule by poverty status.

Vaccination Rates Among Children Aged 19-35 Months, by Poverty,* 2009

Source (III.3): Centers for Disease Control and Prevention, National Immunization Survey

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

$22,025 in 2008. **Excludes Hib, due to the 2007–2009 shortage. ***Depending on product type received

Vaccine Total < 100% Poverty ≥ 100% Poverty

4:3:1:3:x:1:4 Modified Series** 70.5 75.5 78.5

4+DTAP 83.9 80.1 85.7

3+Polio 92.8 92.0 93.3

1+MMR 90.0 88.8 90.6

2+ or 3+Hib*** 83.6 90.1 93.1

3+HepB 92.4 92.3 92.7

1+ Varicella 89.6 89.0 90.2

4+ PCV 80.4 74.8 83.2
58 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2011

Recommended Immunization Schedule for Children Aged 0-6 Years, United States, 2011

Source (III.4): Department of Health and Human Services, Centers for Disease Control and Prevention

Birth 1mo 2mo 4mo 6mo 12mo 15mo 18mo 19-23mo 2-3yr 4-6yr

Hepatitis B1 HepB HepB HepB

Rotavirus2 RV RV RV2

Diphtheria, Tetanus, Pertussis3 DTaP DTaP DTaP see footnote 3 DTaP DTaP

Haemophilus influenzae tybe b4 Hib Hib Hib4 Hib

Pneumococcal5 PCV PCV PCV PCV PPSV

Inactivated Poliovirus6 IPV IPV IPV IPV

Influenza7 Influenza (yearly)

Measles, Mumps, Rubella8 MMR see footnote 8 MMR

Varicella9 Varicella see footnote 9 Varicella

Hepatitis A10 HepA (2 doses) HepA Series

Meningococcal11 MCV

Range of recommended ages Certain high-risk groups

This schedule includes recommendations in effect as of December 21, 2010. Any dose not administered at the recommended age 

should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred 

over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. Providers should consult the relevant Advisory Committee on Immunization Practices 

statement for detailed recommendations: http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse

events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at

http://www.vaers.hhs.gov or by telephone, 800-822-7967. Use of trade names and commercial sources is for identification

only and does not imply endorsement by the U.S. Department of Health and Human Services.

1. Hepatitis B vaccine (HepB). (Minimum age: birth)

At birth:

• Administer monovalent HepB to all newborns before hospital discharge.

• If mother is hepatitis B surface antigen (HBsAg)-positive, administer HepB and 

0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth.

• If mother’s HBsAg status is unknown, administer HepB within 12 hours of birth. 

Determine mother’s HBsAg status as soon as possible and, if HBsAg-positive, 

administer HBIG (no later than age 1 week).

Doses following the birth dose:

• The second dose should be administered at age 1 or 2 months. Monovalent 

HepB should be used for doses administered before age 6 weeks.

• Infants born to HBsAg-positive mothers should be tested for HBsAg and antibody 

to HBsAg 1 to 2 months after completion of at least 3 doses of the HepB series, 

at age 9 through 18 months (generally at the next well-child visit).

• Administration of 4 doses of HepB to infants is permissible when a combination 

vaccine containing HepB is administered after the birth dose.

• Infants who did not receive a birth dose should receive 3 doses of HepB on a 

schedule of 0, 1, and 6 months.

• The final (3rd or 4th) dose in the HepB series should be administered no earlier 

than age 24 weeks.

2. Rotavirus vaccine (RV). (Minimum age: 6 weeks)

• Administer the first dose at age 6 through 14 weeks (maximum age: 14 weeks 

6 days). Vaccination should not be initiated for infants aged 15 weeks 0 days 

or older.

• The maximum age for the final dose in the series is 8 months 0 days

• If Rotarix is administered at ages 2 and 4 months, a dose at 6 months is not 

indicated.

3. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP).

(Minimum age: 6 weeks)

• The fourth dose may be administered as early as age 12 months, provided at 

least 6 months have elapsed since the third dose.

4. Haemophilus influenzae type b conjugate vaccine (Hib). (Minimum age:

6 weeks)

• If PRP-OMP (PedvaxHIB or Comvax [HepB-Hib]) is administered at ages

2 and 4 months, a dose at age 6 months is not indicated.

• Hiberix should not be used for doses at ages 2, 4, or 6 months for the primary series but can be used as the final dose in children aged 12 months through 4 years.

5. Pneumococcal vaccine. (Minimum age: 6 weeks for pneumococcal conjugate

vaccine [PCV]; 2 years for pneumococcal polysaccharide vaccine [PPSV])

• PCV is recommended for all children aged younger than 5 years. Administer 

1 dose of PCV to all healthy children aged 24 through 59 months who are not 

completely vaccinated for their age.

• A PCV series begun with 7-valent PCV (PCV7) should be completed with 

13-valent PCV (PCV13).

• A single supplemental dose of PCV13 is recommended for all children aged 14 

through 59 months who have received an age-appropriate series of PCV7.

• A single supplemental dose of PCV13 is recommended for all children aged 60 

through 71 months with underlying medical conditions who have received an 

age-appropriate series of PCV7.

• The supplemental dose of PCV13 should be administered at least 8 weeks after 

the previous dose of PCV7. See MMWR 2010:59(No. RR-11).

• Administer PPSV at least 8 weeks after last dose of PCV to children aged

2 years or older with certain underlying medical conditions, including a cochlear 

implant.

6. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks)

• If 4 or more doses are administered prior to age 4 years an additional dose

should be administered at age 4 through 6 years.

• The final dose in the series should be administered on or after the fourth birthday 

and at least 6 months following the previous dose.

7. Influenza vaccine (seasonal). (Minimum age: 6 months for trivalent 

inactivated influenza vaccine [TIV]; 2 years for live, attenuated influenza 

vaccine [LAIV])

• For healthy children aged 2 years and older (i.e., those who do not have underlying medical conditions that predispose them to influenza complications), either 

LAIV or TIV may be used, except LAIV should not be given to children aged 2 

through 4 years who have had wheezing in the past 12 months.

• Administer 2 doses (separated by at least 4 weeks) to children aged 6 months 

through 8 years who are receiving seasonal influenza vaccine for the first time or 

who were vaccinated for the first time during the previous influenza season but 

only received 1 dose.

• Children aged 6 months through 8 years who received no doses of monovalent 

2009 H1N1 vaccine should receive 2 doses of 2010–2011 seasonal influenza 

vaccine. See MMWR 2010;59(No. RR-8):33–34.

8. Measles, mumps, and rubella vaccine (MMR). (Minimum age: 12 months)

• The second dose may be administered before age 4 years, provided at least

4 weeks have elapsed since the first dose.

9. Varicella vaccine. (Minimum age: 12 months)

• The second dose may be administered before age 4 years, provided at least 3 

months have elapsed since the first dose.

• For children aged 12 months through 12 years the recommended minimum

interval between doses is 3 months. However, if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid.

10. Hepatitis A vaccine (HepA). (Minimum age: 12 months)

• Administer 2 doses at least 6 months apart.

• HepA is recommended for children aged older than 23 months who live in areas 

where vaccination programs target older children, who are at increased risk for 

infection, or for whom immunity against hepatitis A is desired.

11. Meningococcal conjugate vaccine, quadrivalent (MCV4). (Minimum age:

2 years)

• Administer 2 doses of MCV4 at least 8 weeks apart to children aged 2 through 

10 years with persistent complement component deficiency and anatomic or 

functional asplenia, and 1 dose every 5 years thereafter.

• Persons with human immunodeficiency virus (HIV) infection who are vaccinated 

with MCV4 should receive 2 doses at least 8 weeks apart.

• Administer 1 dose of MCV4 to children aged 2 through 10 years who travel to 

countries with highly endemic or epidemic disease and during outbreaks caused 

by a vaccine serogroup.

• Administer MCV4 to children at continued risk for meningococcal disease who 

were previously vaccinated with MCV4 or meningococcal polysaccharide vaccine 

after 3 years if the first dose was administered at age 2 through 6 years.
 CHILD HEALTH USA 2011 HEALTH SERVICES FINANCING AND UTILIZATION 59

CHILDREN WITH SPECIAL 

HEALTH CARE NEEDS

The National Survey of Children with Special Health Care Needs (CSHCN) asked the 

parents of CSHCN whether their child had insurance in the past 12 months and what kind 

of insurance they had. Overall, 91.2 percent of 

CSHCN were reported to have been insured for 

all of the previous 12 months, while the remaining 8.8 percent were uninsured for all or some 

part of the year. At the time of the interview, 

almost 97 percent of CSHCN were reported 

to have some type of insurance: 59.1 percent 

had private insurance provided through an employer or obtained directly from an insurance 

company and 28.1 percent had public insurance, such as Medicaid, the Children’s Health 

Insurance Program (CHIP), or military health 

care. Another 7.4 percent of CSHCN had both 

private and public insurance, and 3.5 percent 

were uninsured at the time of the interview 

(data not shown).

The percentage of CSHCN without insurance in 2005-06 varied by race/ethnicity and 

family income. Hispanic CSHCN were most 

likely to have been uninsured at some point 

during the prior year (15.1 percent), followed 

by non-Hispanic Black children (11.0 percent), non-Hispanic CSHCN of other races 

(8.9 percent) and non-Hispanic White children 

(7.1 percent). CSHCN living in poor and near 

poor families—or those with family incomes 

below 100 percent of the Federal poverty level 

($19,350 for a family of four in 2005) and between 100 and 199 percent of the Federal poverty level—were most likely to be uninsured 

at some point in the prior year (14.2 and 14.1 

percent, respectively). In contrast, the same was 

true for 7.1 percent of CSHCN living in families with incomes 200-399 percent of poverty 

and 2.9 percent of CSHCN living in households with family incomes of 400 percent or 

more of poverty.

Percent of CSHCN Ever Uninsured in the Past 12 Months, by

Race/Ethnicity, 2005-06

Source (III.5): Health Resources and Services Administration, Maternal and Child Health

Bureau and Centers for Disease Control and Prevention, National Center for Health Statistics,

National Survey of Children with Special Health Care Needs Percent of CSHCN

11.0

*The U.S. Department of Health and Human Services establishes poverty guidelines for determining

financial eligibility for Federal programs; the poverty level for a family of four was $19,350 in 2005.

8.9

15.1

4

8

12

16

20

Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic Other

Percent of CSHCN Ever Uninsured in the Past 12 Months, by

Poverty Level,* 2005-06

Source (III.5): Health Resources and Services Administration, Maternal and Child

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

Health Statistics, National Survey of Children with Special Health Care Needs Percent of CSHCN

14.2

2.9 4

8

12

16

20

0-99% FPL 100-199% FPL 200-399% FPL 400% or more FPL

14.1

7.1 7.1
60 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2011

MENTAL HEALTH TREATMENT

In 2009, 2.9 million, or 12.0 percent of adolescents aged 12 to 17 received past-year treatment or counseling for problems with emotions 

or behavior (not including problems caused by 

drug or alcohol use) in a specialty mental health 

setting, including both inpatient1 and outpatient2

care (data not shown). A similar proportion of 

adolescents received mental health services in an 

educational setting3 (12.1 percent) while 2.5 percent received services from a pediatrician or other 

family doctor in a medical setting, and less than 1 

percent received mental health services in a juvenile justice setting. About 5 percent of adolescents 

received mental health services in both a specialty 

mental health setting and either an educational or 

a medical setting.

A greater proportion of females received 

specialty mental health services (14.0 percent) 

than males (10.1 percent; data not shown). 

Few racial and ethnic differences in service site 

for past-year treatment were observed with 

two notable exceptions: Asians were less likely 

to receive services in a specialty mental health 

setting compared to non-Hispanic White and 

Black children (6.6 percent versus 12.8 and 12.2 

percent, respectively) and non-Hispanic Black 

children were more likely to receive services in an 

educational setting (16.4 percent) than children 

of other racial/ethnic groups (data not shown).

The most commonly reported reason for 

service use was feeling depressed. This was true for 

nearly half of adolescents who received services 

in either a specialty mental health or medical 

setting, and over one-third of those who received 

services in an educational setting. Overall, 

reasons for treatment or counseling varied by 

service site. For example, problems with home/

family was reported as the reason for seeking 

services by 27.8 percent of those seeking care in a 

specialty mental health setting compared to 17.8 

and 11.9 percent of those treated in educational 

and medical settings, respectively.

1 Includes treatment/counseling from an overnight or longer 

stay in a hospital, residential treatment center, or foster care 

or therapeutic foster care home.

2 Includes treatment/counseling from a private therapist, psychologist, psychiatrist, social worker, or counselor; mental 

health clinic or center; partial day hospital or day treatment 

program; or in-home therapist, counselor, or family preservation worker.

3 Includes treatment/counseling from a school social worker, 

school psychologist, or school counselor.

Selected Reasons* for Mental Health Service Use Among

Adolescents Aged 12-17,** by Service Site, 2009

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

of Drug Use and Health

Past-Year Mental Health Service Use Among Adolescents Aged

12-17, by Service Site, 2009

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

Survey of Drug Use and Health

*Inpatient or Outpatient services in addition to services received in either an educational or medical setting.

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

treatment or counseling.

Percent of Adolescents

Percent of Adolescents

International 25%

10

20

30

40

50

Problems

at School

Problems with

Friends

Problems with

Home/Family

Rule Breaking/

Acting Out

Suicidal Depressed

Thoughts/Actions

10

20

30

40

50

Outpatient Inpatient Educational Medical Multiple*

Specialty Mental Health

Education

Medical

9.4

15.0

36.2

48.0

20.7

46.0

26.1 27.8

14.0

24.9

11.9

17.8

12.1

2.5 4.9

10.8

2.3

13.2

7.5

21.0 19.1

13.6

21.2
 CHILD HEALTH USA 2011 HEALTH SERVICES FINANCING AND UTILIZATION 61

DENTAL CARE

According to the Centers for Disease Control 

and Prevention, dental caries (tooth decay) is the 

most common chronic disease among children in 

the United States. Untreated tooth decay causes 

pain and infections, which may affect children’s 

ability to eat, speak, play, and learn.1 Tooth decay, 

however, is preventable with proper dental care. 

For this reason, the American Dental Association 

recommends that children have their first dental checkup within 6 months of the eruption of 

the first tooth or at 12 months of age, whichever 

comes first.2

In 2009, 78.4 percent of children aged 2–17 

years received dental care in the past year while 

15.0 percent had not received such care in more 

than 2 years. Receipt of dental care varied by 

a number of factors, including insurance status 

and poverty. Over 80 percent of children with 

private health insurance coverage received pastyear dental care, as did 76.6 percent of children 

with public insurance, and only 51.6 percent of 

uninsured children. Poor and near poor children, 

or those living in households with incomes 

at or below 100 or 200 percent of the U.S. 

Census Bureau’s poverty threshold ($22,025 

for a family of four in 2008), were less likely 

than children living in households with incomes 

above 200 percent of the poverty threshold 

to have received past-year dental care (71.5 

and 75.6 percent, respectively, compared to

82.2 percent; data not shown).

Similar patterns were observed for unmet dental care needs. Overall, 7.1 percent of children 

had unmet dental care needs in 2009. However, 

the proportion of children with unmet needs was 

substantially higher among those who were uninsured (27.8 percent) compared to those with

either private (4.4 percent) or public (6.7 percent) insurance. Similar proportions of poor 

and near poor children, about 10 percent, had 

unmet dental needs compared to 4.5 percent of 

children living in households with incomes above 

200 percent of the poverty threshold (data not 

shown).

1 Centers for Disease Control and Prevention, Division 

of Oral Health. Children’s Oral Health. Available at:

http://www.cdc.gov/OralHealth/topics/child.htm.

Accessed April 2011.

2 American Dental Association. For the patient: baby’s first 

teeth. JADA 2002;133:255.

Unmet Dental Need* Among Children Aged 2-17 Years in Past 12

Months, by Insurance Status and Type, 2009

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

Statistics, National Health Interview Survey

Time Since Last Dental Contact Among Children Aged 2-17 Years,

by Insurance Status and Type, 2009

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

Statistics, National Health Interview Survey

*Based on parent report that services were needed but were not affordable.

Percent of Population

Percent of Population

International

25%

20

40

60

80

100

Total Private Insurance Public Insurance Uninsured

20

40

60

80

100

Total Private Insurance Public Insurance Uninsured

Less than 1 Year

Between 1 and 2 Years

More than 2 Years 78.4

6.6 5.1 11.6 15.0

82.6 76.6

15.5

7.0

51.6

33.9

14.0 6.7

27.9

7.1 4.4
62 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2011

WELL-CHILD VISITS

In 2009, 78.0 percent of children under 18 

years of age were reported by their parents to 

have had a preventive, or “well-child”, medical 

visit in the past year. The American Academy of 

Pediatrics recommends that children have eight 

preventive health care visits in their first year, 

three in their second year, and at least one per 

year from middle childhood through adolescence. Well-child visits offer an opportunity not 

only to monitor children’s health and provide 

immunizations, but also to assess a child’s behavior and development, discuss nutrition, and 

answer parents’ questions.

The proportion of children receiving wellchild visits declines with age. In 2009, 88.7 

percent of children 4 years of age and younger 

received a preventive visit in the past year, compared to 78.5 percent of children 5–9 years of 

age, 71.6 percent of children 10–14 years of age, 

and 69.0 percent of children 15–17 years of age.

Receipt of preventive medical care also varies 

by race and ethnicity. In 2009, non-Hispanic 

Black children were significantly more likely 

to have received a well-child visit in the past 

year (83.6 percent) than non-Hispanic White 

and Hispanic children (77.6 percent and 74.9 

percent, respectively). Non-Hispanic American 

Indian/Alaskan Native children had the lowest reported rate of preventive care in the past 

year (72.1 percent), but this was not statistically 

different than estimates for other racial/ethnic 

groups.

Receipt of Preventive Health Care in the Past Year Among

Children Under Age 18, by Age, 2009

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

Statistics, National Health Interview Survey Percent of Children

71.6

78.0 78.5

Receipt of Preventive Health Care in the Past Year Among

Children Under Age 18, by Race/Ethnicity, 2009

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

Statistics, National Health Interview Survey

88.7

69.0

20

40

60

80

100

Total 0-4 Years 5-9 Years 10-14 Years 15-17 Years

Percent of Children

74.9 72.1

79.2 77.9 77.6 77.6

83.6

20

40

60

80

100

Non-Hispanic

Multiple Race

Non-Hispanic

American

Indian/

Alaska Native

Non-Hispanic 

Asian

Non-Hispanic Hispanic

Black

Non-Hispanic

White

Total
 CHILD HEALTH USA 2011 HEALTH SERVICES FINANCING AND UTILIZATION 63

Child Reported to Have Not Seen a Physician or Other Health Care Professional* in

the Past 12 Months, by Age and Race/Ethnicity, 2009

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

Interview Survey

*Does not include overnight hospitalizations, emergency department visits, home health care, and dental care.

Total

0-4 Years

5-9 Years

10-14 Years

15-17 Years

10.1

13.3

14.4

4.7

9.7

8.5

11.7 11.6

3.6

8.1

10.3

11.7

15.8

5.2

10.7

13.6

18.4

21.5

7.5

12.8

5

10

15

20

25

30

Total Non-Hispanic White Non-Hispanic Black Hispanic

Percent of Children

HEALTH CARE VISITS

In 2009, 10.1 percent of children under 18 

years of age had not seen a physician or other 

health care professional in the past year for either 

sick or routine care (not including overnight 

hospitalization, emergency department visits, 

home health care, or dental care). Older children 

were more likely than younger children to go 12 

months without seeing a health care provider. 

Nearly 15 percent of children aged 15–17 

years had not seen a health care provider in the 

past year, compared to less than 5.0 percent of 

children under 5 years of age.

Health care visits also varied by race/

ethnicity. In 2009, 13.6 percent of Hispanic 

children had not seen a physician or other health 

professional in the past year, compared to 8.5 

percent of non-Hispanic White children and 

10.3 percent of non-Hispanic Black children. 

Across all age groups, Hispanic children were the 

least likely to have seen a health care provider, 

and non-Hispanic White children were the 

most likely to have seen one; however, not all 

observed differences were statistically significant. 

Differences were most pronounced among older 

children: Among children aged 15-17, 11.6 

percent of non-Hispanic White children had 

not seen a health professional in the past year 

compared to 21.5 percent of Hispanic children.

The proportion of children going without 

health care also varied by poverty level. In 2009, 

13.2 percent of children living in households 

with incomes below 100 percent of the U.S. 

Census Bureau’s poverty threshold ($21,954 

for a family of four in 2009) had not seen a 

physician or other health professional in the past 

year, compared to 5.4 percent of children living 

in households with incomes of 400 percent or 

more of the poverty threshold (data not shown).
64 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2011

USUAL PLACE FOR SICK CARE

In 2009, a doctor’s office or health maintenance organization (HMO) was the usual place 

for sick care (not including routine or preventive care) for 74.5 percent of children in the 

United States, a proportion that varies by poverty status and race/ethnicity. Children living in 

households with incomes above the U.S. Census Bureau’s poverty threshold ($21,954 for a 

family of four in 2009) were more likely to visit 

a doctor’s office or HMO for sick care than children living in households with incomes below 

the poverty threshold (78.6 percent versus 57.3 

percent). Children living in households with incomes below the poverty threshold were more 

likely than children living in households with 

higher incomes to go to a clinic or health center 

(39.4 percent versus 19.9 percent).

Among children living in poverty, 75.8 percent of non-Hispanic White children received 

sick care at a doctor’s office or HMO, compared 

to 59.0 percent of non-Hispanic Black children 

and 40.7 percent of Hispanic children. Regardless of income, Hispanic children were more 

likely than non-Hispanic children to receive 

sick care at a clinic or health center. Among 

Hispanic children living in poverty, 55.1 percent received care at a clinic or health center, 

compared to 36.8 percent of their non-Hispanic Black counterparts and 22.5 percent of their 

non-Hispanic White counterparts. Among children living in families with incomes above the 

poverty threshold, 32.3 percent of Hispanics, 

21.6 percent of non-Hispanic Blacks, and 16.3 

percent of non- Hispanic Whites received sick 

care at a clinic or health center.

Although only a small proportion of children 

used a hospital emergency room, hospital outpatient department, or other place as their primary 

source of sick care, it was more common among 

children living in families with incomes below 

the poverty threshold than among children with 

family incomes above the poverty threshold (3.2 

percent versus 1.4 percent). Regardless of income, this was generally more common among 

non-Hispanic Black and Hispanic children than 

among non-Hispanic Whites.

Place of Physician Contact,* by Poverty** and Race/Ethnicity, 2009

Source (III.8): Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey Percent of Children

*The place where the child usually goes when sick; does not include routine or preventive care visits. **The U.S. Census Bureau uses a set of money income thresholds to determine who is in poverty; the poverty

threshold for a family of four was $21,954 in 2009. ***Includes Hospital Emergency Room, Outpatient Department or some other place.

Doctor’s Office or HMO

78.6

66.0

75.9

82.5

40.7

59.0

75.8

57.3

20

40

60

80

100

Below Poverty Threshold Above Poverty Threshold

Clinic or Health Center

19.9 21.6

32.3

16.3

36.8

55.1

22.5

39.4

Total

Non-Hispanic White

Non-Hispanic Black

Hispanic

20

40

60

80

100

Below Poverty Threshold Above Poverty Threshold

Hospital or Other Place***

1.4 1.1 2.5 1.7 3.9 4.0 1.6 3.2

20

40

60

80

100

Below Poverty Threshold Above Poverty Threshold

Total

Non-Hispanic White

Non-Hispanic Black

Hispanic

Total

Non-Hispanic White

Non-Hispanic Black

Hispanic
 CHILD HEALTH USA 2011 HEALTH SERVICES FINANCING AND UTILIZATION 65

MEDICAL HOME

According to the American Academy of Pediatrics, children’s medical care should be accessible, continuous, comprehensive, family centered, 

coordinated, compassionate, and culturally effective.1

 Together, these characteristics of care 

form the medical home model. The 2007 National Survey of Children’s Health measured if a 

child’s health care met the standards of a medical 

home during the previous 12 months. For this 

purpose, the survey included questions on the 

following: 1) whether the child has a personal 

doctor or nurse and a usual source of sick care; 

2) whether the child has no problems gaining 

referrals to specialty care and access to therapies 

or other services or equipment; 3) whether the 

family is very satisfied with the level of communication among their child’s doctors and other 

programs; 4) whether the family usually or always gets sufficient help coordinating care when 

needed, and receives effective care coordination; 

5) whether the child’s providers usually or always 

spend enough time with the family, listen carefully to concerns, are sensitive to values and customs, provide needed information, and make the 

family feel like a partner in the child’s care; and

6) whether an interpreter is usually or always 

available when needed. If a child’s care met all of 

these criteria, according to the parent, then the 

child was defined as having a medical home.

In 2007, the care received by 57.5 percent of 

children met this medical home standard. This 

varied substantially by household income: 39.4 

percent of children in households with incomes 

at less than 100% of the Federal poverty level 

($20,650 for a family of four in 2007) had a 

medical home, compared to 69.3 percent of children in households at or above 400% of the of 

the Federal poverty level.

Receipt of care from a medical home also 

varied by parent-reported health status. Children 

in excellent or very good health were the most 

likely to receive care in a medical home (61.8 

percent), followed by children in good health 

(36.5 percent). Children in fair or poor health 

were the least likely to have a medical home (25.3 

percent). 

1 American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory 

Committee. The medical home. Pediatrics. 2002;110(1 

pt 1):184–186

Children with a Medical Home, by Poverty*, 2007

Source (III.9): Health Resources and Services Administration, Maternal and Child Health

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

Statistics, National Survey of Children’s Health Percent of Children 

39.4

*The U.S. Department of Health and Human Services establishes poverty guidelines for determining financial

eligibility for Federal programs; the poverty level for a family of four was $20,650 in 2007.

62.5

49.4

69.3

10

20

30

40

50

60

70

400% or more

of Poverty

200-399%

of Poverty

100-199%

of Poverty

<100%

of Poverty

Total

Children with a Medical Home, by Parent-Reported Health

Status, 2007

Source (III.10): Health Resources and Services Administration, Maternal and Child

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

Health Statistics, National Survey of Children’s Health Percent of Children 

57.5

25.3

10

20

30

40

50

60

70

Excellent or

Very Good

Total Fair or Poor Good

36.5

57.5 61.8
66 HEALTH SERVICES FINANCING AND UTILIZATION CHILD HEALTH USA 2011

EMERGENCY DEPARTMENT

UTILIZATION

In 2009, more than 20.8 percent of children 

had at least one visit to a hospital emergency department (ED). Children living in households 

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

poverty threshold ($21,954 for a family of four 

in 2009) were more likely than children living 

in households with incomes above the poverty 

threshold to have visited the ED in the past year. 

One-quarter of children living in poverty made 

1–3 ED visits during the year, compared to 18.5 

percent of children living in households with 

incomes above poverty. Similarly, 2.2 percent of 

children from low-income households made four 

or more visits to the ED, compared to 1.0 percent of children from higher-income households.

Emergency department utilization also 

varied by age: 24.5 percent of children under 5 

years of age made 1–3 visits to the ED in 2009, 

compared to 17.6 percent of children aged 

15–17 years. Children under 5 years of age were 

also the most likely to make four or more ED 

visits (2.3 percent). There were also racial/ethnic 

differences in ED utilization: 24.6 percent of 

non-Hispanic Black children made 1–3 visits 

to the ED in 2009 compared to 19.0 percent 

of Hispanic children and 18.8 percent of nonHispanic White children (data not shown).

According to the 2007 National Hospital 

Ambulatory Medical Care Survey, the most 

common reason for a visit to the emergency 

department among children under 15 years of 

age was fever (15.8 percent), followed by cough 

(6.1 percent), and vomiting (6.7 percent). The 

two most common primary diagnoses treated in 

ED visits among both males and females were 

acute upper respiratory infections (9.8 percent, 

combined), otitis media (middle ear infection) 

and Eustachian tube disorders (7.0 percent, 

combined), followed by unspecified viral and 

chlamydial infection among females (2.3 

percent) and open wound of head (2.9 percent) 

among males.1

1 Niska RW, Bhuiya F, Xu J. National Hospital Ambulatory 

Medical Care Survey: 2007 emergency department summary. National Health Statistics Reports, No. 26; 2010 Aug.

Visits to the Emergency Room Among Children Under Age 18,

by Poverty,* 2009

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

Statistics, National Health Interview Survey Percent of Children

Total 

Below Poverty Threshold

Above Poverty Threshold

18.5

2.2 1.2 1.0

19.6

25.0

79.2

72.8

80.5

Visits to the Emergency Department Among Children Under 

Age 18, by Age, 2008

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

Statistics, National Health Interview Survey Percent of Children

Under 5 Years

5–9 Years

10–14 Years

15–17 Years 81.2 82.1 81.5

73.2

2.3 0.9 0.6 0.9

17.9 17.3 17.6

24.5

20

40

60

80

100

No Visits 1-3 Visits 4 or More Visits

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

threshold for a family of four was $21,954 in 2009.

20

40

60

80

100

No Visits 1-3 Visits 4 or More Visits
 CHILD HEALTH USA 2011 HEALTH SERVICES FINANCING AND UTILIZATION 67

PRENATAL CARE

Prenatal care—especially care beginning in 

the first trimester—allows health care providers 

to identify and manage a woman’s risk factors 

and health conditions and to provide expectant 

parents with relevant health care advice. The 

reported rate of first trimester prenatal care 

utilization has been increasing fairly steadily 

since the early 1990s; however, changes made 

to the standard birth certificate in 2003, which 

are gradually being adopted by the states, 

make comparisons over time impossible. As of 

January 1, 2008, 27 states had implemented the 

revised birth certificate representing 65 percent 

of all U.S. births.1

In 2008, in the 27 reporting areas that used 

the revised birth certificate, 71.0 percent of 

women giving birth were determined to have 

received prenatal care in the first trimester, while 

7.0 percent of women began prenatal care in the 

third trimester or did not receive any prenatal 

care. Early prenatal care utilization differs by 

race/ethnicity. Non-Hispanic Asian and nonHispanic White women were most likely to 

receive prenatal care beginning in the first 

trimester (77.9 and 76.7 percent, respectively). 

Non-Hispanic American Indian/Alaska Native 

women and non-Hispanic Native Hawaiian 

and Other Pacific Islander women were least 

likely to receive first trimester care (53.3 and 

54.8 percent, respectively). 

Timing of prenatal care initiation also varied 

by maternal age. Teen-aged mothers were least 

likely to receive timely prenatal care, with less 

than one-third of those under the age of 15 and 

about half of those aged 15-19 years initiating 

prenatal care in the first trimester (32.9 percent 

and 54.3 percent, respectively). In comparison, 

over 70 percent of mothers-to-be aged 25 years 

and older received early prenatal care.

1 Martin JA, Hamilton BE, Sutton PD, et al. Births: Final 

data for 2008. National vital statistics reports; vol 59 no 

1. Hyattsville, MD: National Center for Health Statistics. 

2010.

Receipt of First Trimester Prenatal Care,* by Maternal Race/Ethnicity,

2008

Source (III.11): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System Percent of Mothers

77.9

53.3 54.8

71.0

60.3

Receipt of First Trimester Prenatal Care,* by Maternal Age, 2008

Source (III.11): Centers for Disease Control and Prevention, National Center for Health

Statistics, National Vital Statistics System

76.6

64.7

20

40

60

80

100

Non-Hispanic

Native

Hawaiian

and Other

Pacific Islander

NonHispanic

American Indian/

Alaska

Native

NonHispanic

Asian

Non- Hispanic

Hispanic

Black

NonHispanic

White 

Total

Percent of Mothers

79.1 76.3 74.7

54.3

63.2

71.0

32.9

79.2 73.9

20

40

60

80

100

45+

Years

40-44

Years

35-39

Years

30-34

Years

25-29

Years

20-24

Years

15-19

Years

Under

15 Years 

Total

*In the 27 reporting areas (States and territories) that used the revised birth certificate. *In the 27 reporting areas (States and territories) that used the revised birth certificate.
68 STATE DATA CHILD HEALTH USA 2011

STATE DATA

While the indicators presented in the previ-

ous sections are representative of the U.S. popu-

lation as a whole, the following section presents 

data at the State level. Geographic differences 

in health status and health care utilization play 

an important role in tailoring health programs 

and interventions to specific populations. In-

cluded are data on infant, neonatal, and peri-

natal mortality, low birth weight, preterm birth, 

health care financing, Medicaid enrollment and 

expenditures, and CHIP enrollment. 

The following pages reveal important dispari-

ties in these measures across States. For instance, 

the proportion of infants born low birth weight 

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

was highest in Mississippi, followed by Louisi-

ana and several other southern States. Births to 

unmarried women tended to be highest in these 

States, as well. 

All of the issues presented here have geo-

graphic program and policy implications. State 

and local leaders can use this information to 

better serve their maternal and child popula-

tions in need.
 CHILD HEALTH USA 2011 STATE DATA 69

Children’s Health Insurance Program (CHIP) Program Design and Aggregate Enrollment, 2009*

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

* Data on Program Type and Total Enrollment are from Federal Fiscal Year 2009 (October 2008-September 2009); data on eligibility are from calendar year 2009 (January 2009-December 2009).

**Programs may be an expansion of Medicaid, a separate CHIP program, or a combination of the two.

†

Presumptive eligibility provides immediate but temporary benefits for applicants who appear to meet eligibility requirements but have not yet been officially approved; in some States, this is only available for 

certain populations (e.g., infants). For States with a combination plan, information for the Medicaid plan is listed first, followed by information for the separate SCHIP plan.

State Type of CHIP 

Program**

Upper 

Eligibility

Total CHIP 

Enrollment

Presumptive 

Eligibility†

Alabama Separate 300% 110,158 N

Alaska Medicaid 175% 11,655 N

Arizona Separate 200% 66,275 N

Arkansas Combo 200% 101,312 N/N

California Combo 250% 1,748,135 Y/Y

Colorado Separate 205% 102,395 Y

Connecticut Separate 300% 21,874 N

Delaware Combo 200% 12,599 N/N

District of Columbia Medicaid 300% 9,260 N

Florida Combo 200% 417,414 N/N

Georgia Separate 235% 254,365 N

Hawaii Medicaid 300% 24,691 N

Idaho Combo 185% 44,319 N/N

Illinois Combo 200% 376,618 Y/Y

Indiana Combo 250% 142,665 N/N

Iowa Combo 300% 52,608 Y/Y

Kansas Separate 241% 48,090 Y

Kentucky Combo 200% 73,143 N/N

Louisiana Combo 250% 170,082 N/N

Maine Combo 200% 31,349 N/N

Maryland Medicaid 300% 124,622 N

Massachusetts Combo 300% 143,044 Y/Y

Michigan Combo 200% 72,035 Y/Y

Minnesota Combo 280% 5,470 N/N

Mississippi Separate 200% 86,839 N

Missouri Combo 300% 103,709 Y/N

State Type of CHIP 

Program**

Upper 

Eligibility

Total CHIP 

Enrollment

Presumptive 

Eligibility†

Montana Separate 250% 25,749 N

Nebraska Medicaid 200% 48,139 N

Nevada Separate 200% 33,981 N/N

New Hampshire Combo 300% 13,197 Y/N

New Jersey Combo 350% 167,009 Y/Y

New Mexico Medicaid 235% 11,169 Y

New York Separate 400% 532,635 Y

North Carolina Combo 200% 259,652 N/N

North Dakota Combo 160% 6,983 N/N

Ohio Medicaid 200% 265,680 N

Oklahoma Combo 185% 123,681 N/N

Oregon Separate 300% 51,835 N

Pennsylvania Separate 300% 264,847 N

Rhode Island Combo 250% 19,596 N/N

South Carolina Combo 200% 85,046 N/N

South Dakota Combo 200% 15,249 N/N

Tennessee Combo 250% 83,333 N/N

Texas Separate 200% 869,867 N

Utah Separate 200% 59,806 N

Vermont Separate 300% 7,092 N

Virginia Combo 200% 167,589 N/N

Washington Separate 300% 27,415 N

West Virginia Separate 250% 38,200 N

Wisconsin Combo 300% 153,917 Y/N

Wyoming Separate 200% 8,871 N
70 STATE DATA CHILD HEALTH USA 2011

Medicaid Enrollment and EPSDT◊ Utilization for Children Under 21, FY 2009

Source (IV.3): Centers for Medicare and Medicaid Services. Annual EPSDT Report and Medicaid Statistical Information System and Medicaid Statistical Information System

◊

Early and Periodic Screening, Diagnosis, and Treatment Program is the child health component of Medicaid. It is designed to improve the health of low-income children by financing appropriate and necessary

pediatric services.

*Unduplicated number of individuals under age 21 determined to be eligible for EPSDT services.

**The ratio of Medicaid eligibles receiving any EPSDT services to the number of eligibles who should have received such services. 

***Represents total Medicaid vendor payments divided by Medicaid eligibles under 21.

†

Enrollee and Participation data for Michigan and Oregon are from FY 2008. Expenditure data for Hawaii, Massachusetts, Missouri, Pennsylvania, Utah, and Wisconsin, are from FY 2008.

State Medicaid Enrollees*

EPSDT 

Participation 

Ratio** 

Medicaid 

Expenditures 

(per enrollee)***

Alabama 520,955 53% $2,473

Alaska 85,889 56% $5,136

Arizona 760,837 66% $3,532

Arkansas 421,494 38% $3,068

California 4,527,629 87% $1,834

Colorado 382,800 56% $2,374

Connecticut 300,731 65% $2,705

Delaware 95,766 61% $3,902

District of Columbia 96,552 68% $3,694

Florida 1,868,563 71% $2,265

Georgia 1,146,385 51% $2,311

Hawaii† 145,702 72% $2,183

Idaho 173,214 95% $2,956

Illinois 1,561,906 74% $1,697

Indiana 728,832 65% $2,026

Iowa 277,541 75% $2,813

Kansas 230,551 50% $2,926

Kentucky 519,259 58% $3,438

Louisiana 776,127 72% $2,200

Maine 140,884 61% $2,792

Maryland 556,206 61% $3,298

Massachusetts† 593,187 67% $3,647

Michigan† 1,126,951 54% $1,863

Minnesota 439,513 70% $4,225

Mississippi 409,443 41% $2,432

State Medicaid Enrollees*

EPSDT 

Participation 

Ratio** 

Medicaid 

Expenditures 

(per enrollee)***

Missouri† 665,577 71% $2,455

Montana 67,648 65% $3,267

Nebraska 170,714 54% $2,955

Nevada 192,778 70% $2,481

New Hampshire 98,747 71% $2,984

New Jersey 642,519 64% $2,833

New Mexico 359,515 70% $2,990

New York 2,068,245 65% $3,626

North Carolina 1,070,396 53% $3,067

North Dakota 46,075 49% $2,873

Ohio 1,323,868 52% $2,526

Oklahoma 538,449 58% $2,451

Oregon† 272,379 64% $2,459

Pennsylvania† 1,181,406 59% $3,422

Rhode Island 107,991 58% $3,956

South Carolina 555,486 60% $2,564

South Dakota 97,657 47% $2,831

Tennessee 854,062 62% $2,766

Texas 3,111,775 64% $2,764

Utah† 194,038 64% $2,486

Vermont 63,141 52% $4,232

Virginia 607,911 70% $3,061

Washington 714,210 65% $1,976

West Virginia 213,390 47% $2,718

Wisconsin† 575,755 71% $1,592

Wyoming 56,593 48% $3,329
 CHILD HEALTH USA 2011 STATE DATA 71

Health Insurance Status of Children Under 18,* 2009

Source (III.1): U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement

*Children may have more than one type of coverage.

**Includes children covered by Medicare, Medicaid, SCHIP, state-specific plans, military health insurance, and the Indian Health Service.

State Percent with 

Private Insurance

Percent with 

Public Insurance**

Percent 

Uninsured

Alabama 54.8% 46.7% 7.9%

Alaska 55.9% 46.1% 9.9%

Arizona 51.5% 41.7% 13.4%

Arkansas 50.1% 46.4% 11.5%

California 54.2% 40.8% 10.7%

Colorado 66.0% 30.4% 9.6%

Connecticut 76.4% 21.3% 7.7%

Delaware 65.9% 31.1% 8.8%

District of Columbia 45.1% 54.6% 8.0%

Florida 55.1% 34.2% 17.9%

Georgia 59.9% 36.0% 11.3%

Hawaii 66.3% 44.3% 3.5%

Idaho 66.6% 31.1% 10.2%

Illinois 59.4% 37.0% 9.1%

Indiana 59.3% 38.3% 8.6%

Iowa 72.0% 33.5% 5.9%

Kansas 64.9% 35.0% 8.1%

Kentucky 58.0% 40.3% 8.2%

Louisiana 58.2% 39.9% 8.4%

Maine 62.3% 43.4% 4.0%

Maryland 72.0% 27.4% 7.0%

Massachusetts 72.5% 33.1% 2.9%

Michigan 70.3% 32.5% 5.6%

Minnesota 71.6% 29.6% 5.5%

Mississippi 45.4% 51.6% 10.9%

Missouri 64.8% 35.0% 9.7%

State Percent with 

Private Insurance

Percent with 

Public Insurance**

Percent 

Uninsured

Montana 59.4% 35.8% 10.4%

Nebraska 70.1% 33.2% 6.7%

Nevada 65.2% 26.9% 13.4%

New Hampshire 78.7% 22.0% 3.8%

New Jersey 72.6% 23.7% 9.2%

New Mexico 42.2% 50.0% 14.0%

New York 58.5% 41.4% 7.5%

North Carolina 57.2% 38.7% 11.8%

North Dakota 74.8% 27.3% 5.9%

Ohio 66.3% 31.3% 8.7%

Oklahoma 52.2% 45.1% 12.6%

Oregon 63.7% 32.4% 11.9%

Pennsylvania 67.3% 32.4% 6.8%

Rhode Island 62.4% 39.9% 6.0%

South Carolina 63.1% 31.4% 12.3%

South Dakota 67.8% 36.4% 8.4%

Tennessee 58.5% 44.9% 6.6%

Texas 48.5% 40.2% 16.5%

Utah 73.9% 20.2% 11.3%

Vermont 59.1% 47.4% 5.6%

Virginia 70.1% 31.2% 7.5%

Washington 62.9% 46.1% 4.8%

West Virginia 59.3% 46.6% 6.2%

Wisconsin 73.7% 32.1% 4.7%

Wyoming 68.5% 32.1% 9.6%
72 STATE DATA CHILD HEALTH USA 2011

Health Insurance Status: Percent of Children Under 18 Who Are Uninsured, by State, 2009

Source (III.1): U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement

AK

HI

WA

KS

MN

WI

IA

MS AL

SC

KY

PA

NY

VT 

NH

ME

MA 

CT

RI

NJ

MD 

DE 

DC

NE

VA WV

ND

SD

≤ 6.4% 6.5 - 8.4% 8.5-10.8% 10.9-17.9%

LA

FL

OR

TN

CO

TX

GA

NV

AZ

CA

MT

NM

MI

IL IN OH

WY

AR OK

ID

UT

NC

MO
 CHILD HEALTH USA 2011 STATE DATA 73

Low Birth Weight, Preterm Birth, and Births to Unmarried Women (Percent), by State and Maternal Race/Ethnicity, 2008

Source (III.2): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System

State

Low Birth Weight* Preterm Birth** Births to Unmarried Women

Total Non-Hispanic 

White Black

Hispanic Total Non-Hispanic 

White Black

Hispanic Total Non-Hispanic 

White Black

Hispanic

United States 8.2 7.2 13.7 7.0 12.3 11.1 17.5 12.1 40.6 28.7 72.3 52.6

Alabama 10.6 8.4 15.8 6.9 15.7 13.6 20.5 14.2 39.9 25.6 72.9 24.1

Alaska 6.0 5.0 11.9 8.6 10.3 8.5 13.8 12.3 37.6 24.3 47.1 34.9

Arizona 7.1 6.8 11.8 6.7 12.9 11.8 18.3 13.3 45.3 29.7 62.8 56.5

Arkansas 9.2 8.0 15.1 6.4 13.5 12.2 18.9 12.1 44.6 33.8 80.3 50.1

California 6.8 6.4 12.1 6.1 10.5 9.6 14.8 10.6 40.2 24.1 68.0 51.6

Colorado 8.9 8.5 14.8 8.5 11.4 10.7 15.6 12.0 24.9 17.5 49.3 36.3

Connecticut 8.0 6.6 13.6 8.1 10.4 9.4 14.6 10.6 36.4 22.1 69.8 64.2

Delaware 8.5 7.0 12.6 7.0 12.9 11.1 16.4 13.8 48.0 34.3 72.7 64.7

District of Columbia 10.5 6.8 13.7 5.8 15.5 9.7 19.3 12.6 57.8 7.0 79.1 72.6

Florida 8.8 7.5 13.5 7.3 13.8 11.8 18.9 13.4 46.9 35.3 69.9 50.5

Georgia 9.6 7.6 13.8 6.8 13.4 12.0 16.8 10.9 45.4 26.9 70.2 50.9

Hawaii 8.1 6.4 1.07 7.6 12.8 10.1 14.5 12.5 37.9 25.9 29.7 49.5

Idaho 6.5 6.2 N/A 7.4 9.8 9.1 13.6 12.3 25.3 21.0 37.7 43.3

Illinois 8.4 7.3 13.8 6.6 12.7 11.6 17.7 11.9 40.7 25.9 79.8 52.1

Indiana 8.3 7.7 14.1 6.8 12.4 11.6 18.0 12.5 43.3 36.8 79.5 57.5

Iowa 6.6 6.3 11.9 7.0 11.5 11.0 17.5 12.8 35.2 31.6 77.1 50.8

Kansas 7.2 6.8 12.4 6.1 11.2 10.6 15.7 11.4 37.8 31.1 74.6 53.2

Kentucky 9.2 8.7 15.0 6.1 14.0 13.6 19.2 12.0 40.7 36.5 76.7 53.0

Louisiana 10.8 8.0 15.1 7.0 15.4 12.4 20.0 12.6 53.0 34.2 79.4 57.1

Maine 6.7 6.6 9.7 N/A 10.3 10.2 12.2 11.8 39.7 39.9 31.7 45.7

Maryland 9.2 7.2 13.1 7.0 13.0 10.8 16.7 12.5 42.4 26.7 64.2 57.1

Massachusetts 7.8 7.1 11.1 8.3 10.8 10.2 13.6 12.1 34.0 26.0 58.4 66.1

Michigan 8.6 7.2 14.5 6.8 12.7 11.4 18.1 12.2 40.2 30.2 78.9 49.8

Minnesota 6.4 5.7 10.8 6.0 10.0 9.6 12.4 9.6 33.3 26.0 60.9 57.9

Mississippi 11.8 8.6 16.1 6.5 18.0 14.8 22.3 12.8 54.5 31.8 80.5 59.0

State

Low Birth Weight* Preterm Birth** Births to Unmarried Women

Total Non-Hispanic 

White Black

Hispanic Total Non-Hispanic 

White Black

Hispanic Total Non-Hispanic 

White Black

Hispanic

Missouri 8.1 7.2 13.3 6.1 12.3 11.2 18.0 11.6 40.9 33.1 79.1 51.5

Montana 7.4 7.3 N/A 7.4 11.5 11.2 N/A 9.7 36.7 30.3 52.8 52.1

Nebraska 7.0 6.5 12.5 6.9 11.8 11.0 16.2 13.6 33.9 27.0 68.3 50.4

Nevada 8.0 8.0 13.1 6.9 13.5 12.6 19.1 12.9 42.5 30.4 71.0 50.9

New Hampshire 6.5 6.4 N/A 7.5 9.6 9.5 16.3 11.2 32.9 33.1 39.5 48.7

New Jersey 8.4 7.4 13.1 7.6 12.5 11.2 17.2 13.1 35.0 17.7 68.2 59.4

New Mexico 8.5 8.2 12.3 8.7 12.3 11.8 10.9 12.4 52.9 31.9 60.5 58.8

New York 8.2 6.8 12.8 7.9 12.0 10.2 16.7 13.0 41.4 24.6 69.5 65.7

North Carolina 9.1 7.7 14.4 6.2 12.9 11.1 17.9 12.1 42.0 26.7 72.4 53.2

North Dakota 6.8 6.7 N/A 7.5 11.1 10.7 N/A 10.4 33.6 26.9 37.2 45.9

Ohio 8.6 7.4 14.5 7.6 12.6 11.5 17.5 12.7 43.4 35.5 79.1 59.5

Oklahoma 8.3 7.8 15.1 6.7 13.4 12.9 18.0 12.5 42.3 34.4 75.7 49.0

Oregon 6.1 5.9 10.8 5.8 10.1 9.3 14.8 11.7 36.1 32.0 63.2 49.0

Pennsylvania 8.3 7.1 13.5 8.7 11.6 10.4 16.5 12.8 40.8 30.9 78.0 66.4

Rhode Island 7.9 6.8 11.0 8.3 11.2 9.6 14.0 13.5 43.9 33.8 68.0 65.8

South Carolina 9.9 7.7 14.5 6.4 14.3 11.9 18.7 13.0 47.8 30.1 78.0 49.8

South Dakota 6.5 6.2 9.8 8.9 11.9 10.7 14.0 15.2 38.4 27.9 52.1 51.5

Tennessee 9.2 8.1 13.9 6.2 13.5 12.1 18.7 11.9 44.1 32.8 78.2 53.7

Texas 8.4 7.7 14.0 7.6 13.3 12.2 17.4 13.3 41.7 26.7 66.5 49.0

Utah 6.8 6.5 13.0 7.4 11.0 10.5 16.6 12.7 20.4 13.6 47.7 45.8

Vermont 7.0 7.0 N/A N/A 9.5 9.6 N/A N/A 38.8 39.1 40.2 56.0

Virginia 8.3 7.0 13.0 6.6 11.3 10.1 15.0 11.6 35.8 23.9 66.8 51.4

Washington 6.3 6.0 9.0 6.0 10.7 10.0 12.8 11.5 34.0 28.6 54.2 50.9

West Virginia 9.5 9.4 14.5 N/A 13.7 13.6 18.4 10.4 42.0 40.8 75.0 45.0

Wisconsin 7.0 6.3 13.0 6.2 11.1 10.3 16.9 11.3 36.3 27.9 83.9 53.8

Wyoming 8.3 8.1 N/A 9.0 11.2 10.7 N/A 12.2 34.6 30.0 56.9 51.2

* Low birth weight is less than 2,500 grams or 5 pounds 8 ounces.

** Preterm birth is less than 37 completed weeks of gestation.

N/A: Figure does not meet standards of reliability or precision; based on fewer than 20 births in the numerator.
74 STATE DATA CHILD HEALTH USA 2011

Infant and Neonatal Mortality,* by State and Maternal Race, 2007

Source (II.5): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System

*Mortality figures are presented as number of deaths per 1,000 live births. Infant mortality is defined as death 

during the first year of life; neonatal mortality is death during the first 28 days of life.

**Includes all races. ***Includes Hispanics. N/A: Figure does not meet the standards of reliability or precision.

State Infant Deaths Neonatal Deaths

Total** White*** Black*** Total** White*** Black***

Alabama 9.89 7.98 14.35 6.27 4.90 9.50

Alaska 6.51 5.20 N/A 3.17 3.03 N/A

Arizona 6.83 6.49 14.95 4.69 4.53 10.12

Arkansas 7.66 6.47 13.17 4.33 3.38 8.61

California 5.20 4.89 12.35 3.55 3.34 7.98

Colorado 6.12 5.85 13.16 4.17 4.01 8.19

Connecticut 6.63 5.90 12.07 5.06 4.46 9.41

Delaware 7.48 6.12 11.84 5.34 4.32 8.80

District of Columbia 13.09 8.52 16.61 9.70 5.87 12.60

Florida 7.05 5.52 12.21 4.42 3.53 7.47

Georgia 7.98 5.56 12.77 5.07 3.58 7.90

Hawaii 6.48 6.11 N/A 4.23 3.59 N/A

Idaho 6.75 6.59 N/A 4.52 4.46 N/A

Illinois 6.73 5.22 14.16 4.78 3.84 9.46

Indiana 7.58 6.61 15.99 4.79 4.13 10.40

Iowa 5.50 5.34 11.58 3.30 3.27 N/A

Kansas 7.93 7.03 18.98 5.00 4.49 11.63

Kentucky 6.69 6.01 12.69 4.06 3.73 7.58

Louisiana 9.17 6.14 14.08 5.35 3.49 8.37

Maine 6.30 6.33 N/A 4.46 4.54 N/A

Maryland 8.00 4.79 13.63 5.80 3.54 9.67

Massachusetts 4.93 4.54 8.76 3.42 3.11 6.12

Michigan 7.94 6.11 16.39 5.56 4.37 11.12

Minnesota 5.55 4.69 11.70 3.80 3.28 7.13

Mississippi 10.04 6.65 13.87 5.89 3.83 8.37

Missouri 7.48 5.89 16.48 4.99 3.77 11.69

State Infant Deaths Neonatal Deaths

Total** White*** Black*** Total** White*** Black***

Montana 6.35 5.94 N/A 3.62 3.49 N/A

Nebraska 6.76 6.12 14.04 4.86 4.38 10.53

Nevada 6.36 6.03 12.35 4.03 3.81 8.15

New Hampshire 5.36 5.34 N/A 3.25 3.31 N/A

New Jersey 5.18 4.13 11.02 3.44 2.86 6.87

New Mexico 6.27 5.99 N/A 3.89 3.88 N/A

New York 5.57 4.95 8.82 3.70 3.27 5.95

North Carolina 8.49 6.35 15.14 5.70 4.24 10.28

North Dakota 7.47 6.80 N/A 4.86 5.07 N/A

Ohio 7.69 6.34 14.81 5.18 4.21 10.20

Oklahoma 8.52 7.25 18.03 4.78 4.16 10.82

Oregon 5.75 5.70 N/A 3.95 3.93 N/A

Pennsylvania 7.56 6.12 15.07 4.98 4.12 9.45

Rhode Island 7.35 6.52 16.00 5.41 4.79 N/A

South Carolina 8.57 6.03 13.69 5.66 3.93 9.13

South Dakota 6.44 5.55 N/A 4.16 4.01 N/A

Tennessee 8.31 6.44 15.74 5.19 3.91 10.19

Texas 6.29 5.68 11.51 3.86 3.43 7.37

Utah 5.08 4.98 N/A 3.39 3.35 N/A

Vermont 5.07 4.76 N/A 3.07 N/A N/A

Virginia 7.79 5.80 15.41 5.35 3.76 11.26

Washington 4.82 4.33 10.28 2.85 2.63 5.55

West Virginia 7.46 6.95 N/A 4.68 4.33 N/A

Wisconsin 6.46 5.37 15.18 4.03 3.56 8.34

Wyoming 7.35 6.65 N/A 3.67 3.66 N/A
 CHILD HEALTH USA 2011 CITY DATA 75

CITY DATA

The following section compares urban health 

to the national average for several indicators. 

Included are data on low and very low birth 

weight for infants born in U.S. cities with over 

100,000 residents, and infant mortality among 

infants born in cities with more than 250,000 

residents. 

These comparisons indicate that the health 

status of infants living in large U.S. cities is 

generally poorer than that of infants in the 

Nation as a whole. In 2008, 8.7 percent of 

infants living in cities were born at low birth 

weight, compared to a national average of 8.2 

percent. The infant mortality rate in 2006, 

the most recent year for which city-level data 

are available, showed a similar disparity, with a 

rate of 7.2 per 1,000 live births among infants 

in cities compared to 6.7 deaths per 1,000 live 

births for the Nation as a whole. 
76 CHILD HEALTH USA 2011

BIRTH WEIGHT

Low Birth Weight. Disorders related to 

short gestation and low birth weight are the second leading cause of neonatal mortality in the 

United States. In 2008, 118,712 babies born to 

residents of U.S. cities with populations over 

100,000 were low birth weight (weighing less 

than 2,500 grams, or 5 pounds 8 ounces); this 

represents 8.7 percent of infants in U.S. cities. 

The rate of low birth weight among urban infants was 6 percent higher than the rate nationwide (8.2 percent). Although this has been a 

persistent disparity, the gap has decreased somewhat since 1990. 

CITY DATA

Very Low Birth Weight. Infants born very 

low birth weight (less than 1,500 grams, or 3 

pounds 4 ounces) are at highest risk for poor 

health outcomes. In 2008, 1.6 percent of live 

births in cities with populations over 100,000 

were very low birth weight. This exceeded the 

rate of very low birth weight nationwide (1.5 

percent) by 7 percent.

Infants Born Very Low Birth Weight in U.S. Cities with 

Populations over 100,000, 1990−2008

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

Statistics, National Vital Statistics System

Total U.S. Population Total U.S. Cities

Percent of Infants

Infants Born Low Birth Weight in U.S. Cities with

Populations over 100,000, 1990−2008

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

Statistics, National Vital Statistics System Percent of Infants

8.2

8.7

1.6

1.5

Total U.S. Population Total U.S. Cities

1

2

3

4

5

6

7

8

9

10

1990 1995 2000 2005 2008

1

2

3

4

5

6

7

8

9

10

1990 1995 2000 2005 2008
 CHILD HEALTH USA 2011 77

INFANT MORTALITY

In 2007, 6,583 infants born to residents of 

cities in the United States with populations 

over 250,000 died in the first year of life. The 

infant mortality rate in U.S. cities was 7.2 

deaths per 1,000 live births, which was higher 

than the rate for the Nation as a whole (6.8 per 

1,000). Although the infant mortality rate in 

cities has consistently been higher than the rate 

nationwide, it declined over the past decade, and 

the disparity in infant mortality rates between 

infants in cities and the Nation as a whole 

decreased by 50 percent. Between 1990 and 

2007, the infant mortality rate in cities declined 

by one-third, while the nationwide decline 

during the same period was approximately 25 

percent. Declines in infant mortality rates since 

2000, however, have been relatively small for 

both cities and the population as a whole.

CITY DATA

Infant Mortality Rates in U.S. Cities,* 1990−2007

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

Statistics System

7.2

6.8

Total U.S. Cities

Rate per 1,000 Live Births

Total U.S. Population

*Data for 1990–2002 were for cities with populations over 100,000; data after 2002 reflect cities with populations over 250,000.

5

6

7

8

9

10

11

12

13

14

15

1990 1992 1994 1996 1998 2000 2002 2004 2006 2007
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80 CONTRIBUTORS CHILD HEALTH USA 2011

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). It was produced 

for MCHB by the Maternal and Child Health 

Information Resource Center under contract.

Federal Contributors within the U.S. 

Department of Health and Human Services

Administration for Children and Families

Centers for Disease Control and Prevention

Centers for Medicare and Medicaid Services

National Institutes of Health, National Institute on 

Drug Abuse

Substance Abuse and Mental Health Services 

Administration

Other Federal and Non-Governmental 

Contributors

Child and Adolescent Health Measurement 

Initiative, Data Resource Center for Child and 

Adolescent Health

Federal Interagency Forum on Child and Family 

Statistics

Kaiser Commission on Medicaid and the Uninsured

Organization for Economic Co-operation and 

Development

U.S. Census Bureau

U.S. Department of Education

U.S. Department of Housing and Urban 

Development

U.S. Department of Labor

Photography Credits

Cover and title page, clockwise from top left: first photo, Janice Lynch Schuster; second photo, Lanna Forrest; 

third photo, iStockPhoto; fourth photo, Jeff Groat; fifth and sixth photos, Altarum Institute; page 4, Lanna 

Forrest; page 21, top photo, Holly Korda, bottom photo, Altarum Institute; page 30, top photo, Gena Tuckerman, bottom photo, Altarum Institute; page 37, bottom photo, Jeff Groat; page 68, Sheryl Mathis; page 80, 

Altarum Institute; all other photos, iStockPhoto.