Child Health

USA 2004

Maternal and Child Health Bureau

Child Health USA 2004
Child Health USA 2004
Child Health USA 2004

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Child Health USA 2004
Suggested Citation:

U.S. Department of Health and Human Services, 

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

Child Health USA 2004. Rockville, Maryland: U.S. Department of Health and Human Services, 2004.

This publication is available online at http://www.mchb.hrsa.gov. 

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

HRSA Information Center

2070 Chain Bridge Road, Suite 450

Vienna, VA 22182-2536

703- 442-9051 or 1-888- ASK-HRSA 

Please note that Child Health USA 2004 is not copyrighted. Readers arefree to duplicate 

and use all or part of the information contained in this publication.

Child Health USA 2004
CONTENTS 3

PREFACE . . . . . . . . . . . . . . . . . . . . . . . . .5

INTRODUCTION . . . . . . . . . . . . . . . . . .6

POPULATION

CHARACTERISTICS . . . . . . . . . . . . . . .10

Population of Children . . . . . . . . . . . . . .11

Children of Foreign-born Parents . . . . . .12

Children with Special Health Care Needs . .13

Children in Poverty . . . . . . . . . . . . . . . . .14

School Dropouts . . . . . . . . . . . . . . . . . . .15

Working Mothers and Child Care . . . . . .16

Expenditures for CSHCN . . . . . . . . . . . .18

Maternal Age . . . . . . . . . . . . . . . . . . . . . .19

HEALTH STATUS . . . . . . . . . . . . . . . . . .20

Infants

Breastfeeding . . . . . . . . . . . . . . . . . . . . . .21

Low Birth Weight . . . . . . . . . . . . . . . . . .22

Very Low Birth Weight . . . . . . . . . . . . . .23

International Infant Mortality Rates . . . .24

Infant Mortality . . . . . . . . . . . . . . . . . . . .25

Neonatal and Postneonatal Mortality . . .26

Maternal Mortality . . . . . . . . . . . . . . . . .27

Children

Vaccine-Preventable Diseases . . . . . . . . . .28

Child Abuse and Neglect . . . . . . . . . . . . .30

Pediatric AIDS . . . . . . . . . . . . . . . . . . . .31

Hospitalization . . . . . . . . . . . . . . . . . . . .32

Hospital Discharge Trends . . . . . . . . . . . .33

Child Mortality . . . . . . . . . . . . . . . . . . . .34

Childhood Deaths Due to Injury . . . . . .35

Adolescents

Adolescents . . . . . . . . . . . . . . . . . . . . . . .36

Adolescent Childbearing . . . . . . . . . . . . .37

Sexual Activity . . . . . . . . . . . . . . . . . . . . .38 

Sexually Transmitted Diseases . . . . . . . . .39

Adolescent HIV Infection . . . . . . . . . . . .40

Adolescent AIDS . . . . . . . . . . . . . . . . . . .41

Mental Health . . . . . . . . . . . . . . . . . . . . .42

Violence . . . . . . . . . . . . . . . . . . . . . . . . .43

Physical Activity and Overweight . . . . . .44

Cigarette Smoking . . . . . . . . . . . . . . . . . .46

Substance Abuse . . . . . . . . . . . . . . . . . . .47

Adolescent Mortality . . . . . . . . . . . . . . . .48

Adolescent Deaths Due to Injury . . . . . .49

HEALTH SERVICES FINANCING 

AND UTILIZATION . . . . . . . . . . . . . . .50

Health Care Financing . . . . . . . . . . . . . .51

Health Care Financing for CSHCN . . . .52

Vaccination Coverage . . . . . . . . . . . . . . .54

Immunization Schedule . . . . . . . . . . . . . .55

Dental Care . . . . . . . . . . . . . . . . . . . . . . .56

Physician Visits . . . . . . . . . . . . . . . . . . . .58

Place of Physician Contact . . . . . . . . . . .60

Family-centered Care for CSHCN . . . . .61

Hospital Utilization . . . . . . . . . . . . . . . . .62

Prenatal Care . . . . . . . . . . . . . . . . . . . . . .64

STATE-SPECIFIC DATA . . . . . . . . . . . . .66

Prenatal Care, Low Birth Weight, 

and Births to Women Under 18 . . . . . . .67

Medicaid Recipients, Expenditures

and EPSDT Services . . . . . . . . . . . . . . . .68

SCHIP Enrollees . . . . . . . . . . . . . . . . . . .69

Health Insurance Status . . . . . . . . . . . . . .70

Uninsured Children (Map) . . . . . . . . . . .71

Infant and Neonatal Mortality . . . . . . . .72

CITY DATA . . . . . . . . . . . . . . . . . . . . . . .73

Low and Very Low Birth Weight . . . . . . .74

Infant Mortality . . . . . . . . . . . . . . . . . . . .75

Prenatal Care . . . . . . . . . . . . . . . . . . . . . .76

References . . . . . . . . . . . . . . . . . . . . . . . .77

Contributors . . . . . . . . . . . . . . . . . . . . . .80

Child Health USA 2004
4

Child Health USA 2004
PREFACE

PREFACE

The Health Resources and Services

Administration’s Maternal and Child Health

Bureau (MCHB) is pleased to present Child

Health USA 2004, the fifteenth annual report

on the health status and service needs of America’s

children. To assess the Bureau’s progress toward

achieving its vision for a nation where all individuals enjoy equal access to quality health care

in a supportive, culturally competent, family

and community setting, MCHB has compiled

this book of secondary data for 55 health and

health care indicators. It provides both graphical

and textual summaries of data and addresses

long-term trends where applicable.

All of the data discussed here came from the

same sources as the information in the graphs

(unless noted otherwise). Data are presented for

the target populations of Title V funding:

infants, children, adolescents, children with

special health care needs, and women of childbearing age. In addition to population characteristics, this book also addresses health status

and health services utilization. Child Health

USA 2004 also provides insight into the

nation’s progress toward the goals set out in the

MCHB’s strategic plan — to assure quality of

care, to eliminate barriers and health disparities,

and to improve the health infrastructure 

and system.

Child Health USA is published to provide

the most current data available for public health

professionals and other individuals in the private

and public sectors. The book’s succinct format is

intended to facilitate the use of the information

as a snapshot of measures of children’s health in

the United States.

The first section, Population Characteristics,

presents statistics on factors that influence the

well-being of children. The second section,

entitled Health Status, contains vital statistics

and health behavior information for infants,

children, adolescents, and women of childbearing

age. The third section, Health Services Financing

and Utilization, contains data regarding health

care financing and newly implemented health

policies. The fourth and fifth sections contain

information on selected indicators at the state

and city levels.

Please note that Child Health USA 2004 is

not copyrighted. Readers are free to duplicate and

use all or part of the information contained in

this publication.The book is available online at:

http://www.mchb.hrsa.gov.

Single copies of this publication are also 

available at no charge from:

HRSA Information Center

2070 Chain Bridge Road

Suite 450, Vienna, VA 22182-2536

703-442-9051 or 1-888-ASK-HRSA

5

Child Health USA 2004
6 INTRODUCTION

INTRODUCTION

The effectiveness of a health care system is

measured not only in how it treats sickness or

disease, but in how it utilizes prevention to

maintain a population’s health. Through services

such as prenatal care and immunization, as well

as promotion of healthy choices in life, prevention

is critical in assuring that children are born

healthy and that they maintain good health as

they grow older. These choices affect both 

children and their families, beginning early 

in pregnancy and continuing throughout 

childhood, adolescence, and young adulthood,

and require the continuing effort of individuals,

communities, and health care providers.

As of July 2003, there were 81.2 million

children ages 19 and under in the United

States, and another 20.7 million young adults

ages 20 to 24. The indicators in this book

demonstrate that we have thus far achieved

mixed success in promoting the health of these

children and their families. For instance,

although rates of maternal and infant mortality

have dropped dramatically in the past century,

the United States still has one of the highest

rates of infant death in the industrialized world.

In 2002, of every 1,000 live births, 7 babies 

died in their first year of life, and in some 

communities the rate of infant mortality is much

higher. In 2000 the U.S. infant mortality rate

Child Health USA 2004
INTRODUCTION

was 27th among industrialized nations.

One important means of preventing infant

mortality is improving the health of infants at

birth. The rate of low birth weight (LBW) — a

weight of less than 2500 grams (5.8 pounds) at

birth — has been steadily increasing since 1985,

when LBW babies represented 6.8 percent of

live births; in 2002, 7.8 percent of all live births

were of low weight. Very low birth weight

(VLBW) babies — those weighing less than

1500 grams — represented 1.5 percent of births.

VLBW babies are particularly likely to have

long-term health and developmental problems.

Good health care during pregnancy is a 

preventive strategy that assures the health of

both mother and child. Overall, early entry into

prenatal care (in the first 3 months of pregnancy)

has been improving, reaching 83.7 percent of

pregnant women in 2002. Unfortunately, this

rate is lower for younger women as well as Black

and Hispanic women. Some pregnant women

(3.6 percent in 2002) go without prenatal care

entirely or forgo these services until the third

trimester of their pregnancy.

Good breastfeeding habits are another

important step that parents can take to assure

the health of their babies. Breast milk has a

number of preventive health benefits for both

mother and child. The benefits of breastfeeding

include prevention of diarrhea and infections in

infants, as well as long-term preventive effects

for the mother, including earlier return to 

pre-pregnancy weight and reduced risk of 

premenopausal breast cancer and osteoporosis.

In 2002, 70.1 percent of mothers breastfed in the

hospital, the highest rate yet recorded. However,

rates of breastfeeding decline dramatically after

the initial months of life, and only 33.2 percent

of mothers report that they are still breastfeeding

their infants at 6 months of age. These rates are

lowest among Black mothers, with 53.9 percent

reporting breastfeeding in the hospital, and

only 19.2 breastfeeding at 6 months.

As children grow older, prevention efforts

are aimed at avoiding injuries and adopting

healthy habits for adulthood. Unintentional

injuries — most of which are preventable —

are the leading cause of death for children aged

1-14, causing the deaths of 4,359 children in

2002. The leading causes of death due to all

injuries for this age group were motor vehicle

crashes, drowning, firearms, and fires. This varies

by age group, as fire is a major cause of injury

death among young children, while firearms

more often affect older children.

Prevention efforts appear to be succeeding

in reducing rates of pediatric Acquired Immune

Deficiency Syndrome (AIDS). Only 158 new

cases of AIDS in children under age 13 were

reported in 2002, which represents a drastic

reduction over the past decade. Much of this

reduction is due to prevention efforts, including

an increase in treatment for pregnant women

before, during, and after birth to reduce perinatal

HIV transmission. A 1994 recommendation by

the U.S. Public Health Service that all pregnant

women receive such treatments, and a 1995 

recommendation for HIV counseling and 

voluntary testing among all pregnant women,

have helped to reduce transmission rates.

Immunization is probably the preventive

health service that is most recognized among

the public. Vaccines are available for such public

health threats as measles, mumps, rubella

(German measles), polio, diphtheria, tetanus,

pertussis (whooping cough), and H. Influenzae

type b (the bacterium that causes meningitis). A

2002-2003 survey released by the Centers for

Disease Control and Prevention shows that

77.9 percent of children aged 19-35 months

have been immunized with the recommended

series of vaccines. Although this is a huge public

health success, significant progress is still needed

to reach the 2010 goal of immunizing at least

90 percent of children by 35 months of age.

Dental care is another important preventive

service, one that too few children receive 

regularly. Overall, 70.6 percent of children 

visited a dentist within the past year, but among

children from low-income families, this 

7

Child Health USA 2004
8 INTRODUCTION

proportion was only 61.7 percent. According to

the U.S. Surgeon General, dental caries is the

single most common chronic disease among

children, and it can be prevented with regular

dental care.

Adolescence is a time of risk-taking, but it is

also the time when life-long health habits are

formed. The indicators in this book show

improvement in some areas of adolescent

health, but teens are still exposed to a number

of risks that threaten both their health and their

potential for independence and success in life,

such as unplanned childbearing. Childbearing

among adolescents has been declining in recent

years, and in 2002 rates reached an historic low

of 43 births per 1,000 teens ages 15 to 19. This

represents a 30 percent decrease in adolescent

childbearing since 1991. The greatest decrease

in adolescent childbearing has been among

Black youth, with a 42 percent decline from

1991 to 2002. Although there has been a decline

among all racial and ethnic groups, Hispanic

youth have experienced the least dramatic

decline; the rate among Hispanics has dropped

only 20 percent, leaving them with the highest

rate — 83.4 births per 1,000 teens in 2002.

Although smoking remains a major threat

to the health of adolescents, prevention efforts

have resulted in a large decline in cigarette use

among teens. Among 8th graders, reports of 

cigarette use over a 30-day period declined 51.4

percent between 1996-97 and 2003. There were

smaller, although still significant, drops in 

cigarette smoking among 10th and 12th graders, as

well (45 percent and 33 percent, respectively).

Regular, vigorous exercise is another health

habit with benefits that can last a lifetime.

Overall, almost two-thirds of high school 

students regularly participated in sufficient 

vigorous physical activity in 2003, and nearly

one-quarter participated in sufficient moderate

activity. These proportions have declined slightly

since 2001, but more students report playing

on one or more sports teams and being enrolled

in physical education classes.

Treatment for mental, emotional, and

behavioral problems can be a critical component

of adolescent health care. Nationally, nearly 

20 percent of teens received mental health

treatment or counseling in 2002, primarily for

feelings of depression, breaking rules or acting

out, suicidal thoughts or attempts, and feeling

very afraid or tense. The most common sources

of this treatment were private therapists, 

followed by school counselors or psychologists.

As many of the statistics here reveal, mental

health and well-being is a critical component of

children’s overall health. Mental disorders are

the leading cause of hospitalizations for children

aged 10 to 14 and the second leading cause of

hospitalizations for adolescents. Suicide is the

third leading cause of death for adolescents and

is the fifth leading cause of death for 5- to 14-

year-olds. Certain high-risk factors, such as

poverty and maternal depression, also affect a

child’s well-being and overall health. Screening

for mental health and substance abuse problems,

as appropriate, intervening early, and providing

access and linkages to services and supports can

help to prevent the tragic consequences of mental

health and/or substance abuse problems and

mental and/or addictive disorders for children

and their families.

Health insurance is critical in assuring that

children receive both the preventive and treatment

services they need. In 2002, 12 percent (8.5

million) children under 18 were without health

coverage. Over one-fourth (26.8 percent) were

covered under public insurance. The State

Children’s Health Insurance Program (SCHIP),

created under the Balanced Budget Act of

1997, allows States to extend comprehensive

insurance to children in low-income families

who are not eligible for the Medicaid program.

As of the end of Federal Fiscal Year 2003, 5.8

million children had been enrolled in SCHIP

since its inception. As of 2002, children in families

at 200% of the Federal poverty level were eligible for insurance through Medicaid or SCHIP

in 26 states. In another 12 states, the eligibility

Child Health USA 2004
9

level exceeded 235% of the poverty level.

The statistics presented in Child Health

USA 2004 are essential for both appreciating

America’s numerous public health achievements

and recognizing the challenges that we still face.

Prevention and health promotion include a range

of public health strategies including providing

access to knowledge, skills, and tools; providing

drug-free activities for youth; identifying risk

factors and linking people to services and 

supports; building community processes, such

as coalitions; and environmental approaches that

promote policy changes. These prevention efforts

are vital if we are to continue the improvements

that we are making in the health and well-being

of America’s children and families.

Child Health USA 2004
10 POPULATION CHARACTERISTICS

POPULATION

CHARACTERISTICS

Socio-demographic characteristics provide a

comprehensive picture of the country’s diverse

maternal and child population. The population

of children ages 21 and below comprises roughly

one-third of the U.S. population.

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

and children. By carefully analyzing and 

comparing data, health workers can often isolate

high-risk populations that require specific

interventions. Policy-makers can then tailor

programs to meet the needs of those populations. The following section presents data on

several population characteristics that have an

impact on maternal and child health program

development and evaluation. These include

age, poverty status, race and ethnicity, living

arrangements, child care trends, and school

dropout rates. Also presented in this section are

descriptions of specific target populations,

including the foreign-born population and

children with special health care needs.

Child Health USA 2004
POPULATION OF CHILDREN

Age

In 2003, the 73 million children under the

age of 18 in the United States represented 25

percent of the total population. Young adults

aged 20-24 represented 7.1 percent, adults aged

25-64 represented nearly 53 percent, and persons

ages 65 and over represented 12 percent of the

total population. The median age in the U.S.

for all races was 35.9 years.

In the last decade, the number of children

under 5 years of age has increased by 0.2 percent,

while the number of children ages 5-19 has

increased by 12 percent. In the same period, the

number of persons aged 65 and over has

increased by 9 percent.

Race and Ethnicity

Reflecting the trends in the general population, the population of children has become

increasingly diverse over the past several

decades. Since 1980, the percentage of children

who are Hispanic or Asian/Pacific Islander has

doubled, as the percentage who are nonHispanic White has declined. Hispanic children represented 9 percent of children in 1980

and 18 percent in 2003; likewise, Asian/Pacific

Islander children represented 2 percent in 1980

and 4 percent in 2003. In the same period, the

percentage of children who are White dropped

by 18 percent to represent 59 percent of the

child population in 2003, while the percentage

who are Black remained stable. In addition,

nearly 3 percent of children were of more than

one racial group in 2003.

POPULATION CHARACTERISTICS 11

Percent Distribution of Children 

Under 18, by Race/Ethnicity: 2003 

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

Two or

More Races

2.7% Asian/Pacific

Islander

3.9%

Hispanic

18.3%

Black*

15.3%

American Indian/

Alaskan Native

1.2%

White

(Non-Hispanic)

58.6%

* Includes Hispanic

U.S. Resident Population 

by Age Group: 2003

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

20-24 Years

7.1%

15-19 Years

7.0%

10-14 Years

7.3%

5-9 Years 

6.8%

Under 5 Years 

6.8%

Elderly

65+ Years

12.4%

25-64 Years

52.6%

Children

27.9%

Child Health USA 2004
12 POPULATION CHARACTERISTICS

CHILDREN OF

FOREIGN-BORN PARENTS

The foreign-born population in the United

States has increased substantially since 1970,

largely due to immigration from Asia and Latin

America. In 2002, nearly 20 percent of children

in the U.S. or 14 million children, had at least

one foreign-born parent: 15.9 percent were born

in the U.S., and 3.7 percent were themselves

foreign-born. Most children (76.2 percent)

were native-born living in households with

native-born parents.1

Compared to native-born children living

with native parents, children living with 

foreign-born parents were more likely to live

below 200 percent of the Federal poverty level,

more likely to live in cities, and more likely to

live in two-parent families. They were also more

likely to have parents with less than a high school

education, although educational attainment

varied by region of birth. Those born in Asia and

Europe had the highest percentages of high

school graduates (86.8 percent and 84 percent,

respectively) compared to those born in Latin

America, with only 49.1 percent having graduated from high school. Immigrant children and

children of foreign-born parents face the 

challenges of acculturation and have health and

psychosocial risks at home and at school.2

1 The term “native-born parents” indicates that both parents 

who live with the child are native-born, while “foreign-born”

means that one or both of the child’s parents are foreign-born.

2 Schmidley, Dianne (2003). The Foreign-born Population 

in the United States: March 2002. Current Population Reports,

P20-539. Washington, D.C.: U.S. Census Bureau.

Percent Distribution of Children Under 18, 

by Nativity of Child and Parents: 2002

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

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

Native Child

and Parent

76.2%

Other*

Foreign-born 4.2%

Child and Parent

3.7%

Native Child/

Foreign-born Parent

15.9%

Includes children living in households with no parent present and foreign-born children with native parents.

Percent Distribution of Children Under 18, 

by Income and Nativity of Child and Parents: 2002

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

Federal Poverty Level

10

20

30

40

50

60

70

80

Foreign-born Child,

Foreign-born Parent

Native Child,

Foreign-born Parent

Native Child and Parent

At or Above

200% FPL*

100 to 199%

FPL*

Below 100%

FPL*

14.2

20.0

26.8

19.6

29.0

33.2

66.2

51.1

39.9

Percent

Child Health USA 2004
POPULATION CHARACTERISTICS

CHILDREN WITH SPECIAL

HEALTH CARE NEEDS

Based on the 2001 National Survey of

Children with Special Health Care Needs, it is

estimated that 12.8 percent of children have

special health care needs. Children with special

health care needs (CSHCN) are defined by the

Maternal and Child Health Bureau as 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. Based on

this definition, the survey estimated that 

9.4 million children in the U.S. have special

health care needs.

The conditions of CSHCN vary in their

impact on children’s ability to function. The

parents of 23.2 percent of CSHCN report that

their children’s conditions affect their abilities

usually, always, or a great deal; 37.4 percent

report that their children’s conditions sometimes

affect their abilities; and 39.4 percent report

that their children’s conditions never affect 

their activities.

State-level data on the prevalence of CSHCN

can be found in the National Survey of CSHCN

Chartbook.

13

Prevalence of Children with Special Health Care Needs, 2001

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

National Center for Health Statistics, National Survey of CSHCN

Labels: Arialregular6/7

Children with 

Special Health 

Care Needs

12.8%

Children without

Special Health

Care Needs

87.2%

Impact on Child's Condition on Functional Ability, 2001

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

National Center for Health Statistics, National Survey of CSHCN

Never 

Affects 

Activities 

39.4%

Affects 

Activities 

Usually/Always 

or a Great Deal 

23.2%

Sometimes 

Affects 

Activities 

37.4%

Child Health USA 2004
14 POPULATION CHARACTERISTICS

CHILDREN IN POVERTY

In 2002, 12.1 million children under 18 years

of age lived in families with income below the

Federal poverty threshold (e.g., $18,392 for a

family of four).1 Children living below the

poverty level represented 16.7 percent of children

in the U.S., a rate that did not change from the

previous year. Children represented 35 percent

of people in poverty but only 25 percent of the

population as a whole.

Poverty affects living conditions and access to

health care and nutrition, all of which contribute

to health status. Black and Hispanic children

were particularly vulnerable. A much higher

proportion of Black (32.1 percent) and Hispanic

(28.2 percent) related* children under age 18

were poor than were related White children

(13.1 percent).

Children in single-parent families are particularly likely to be poor: of children under age

6 living with a single mother, 48.6 percent were

in poverty, compared to 9.7 percent of children

of the same age in married-couple families.

1 Based on the U.S. Census Bureau’s poverty threshold, which is 

calculated using the Consumer Price Index from the previous year.

Related Children Under 18 Living in Families* 

Below 100% of Poverty Level, by Race/Ethnicity:** 1970-2002

Source (I.4): U.S. Census Bureau, Current Population Survey

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

Hispanic

White (Including Hispanic)

Black (Including Hispanic)

1970*** 980 990 2002

32.1

13.1

37.7

44.2

33.0

10.5

41.5

13.4

42.1

15.1

28.2

P t

Year

50

10

20

30

40

Related children are those under 18 who are related to the householder by birth, marriage, or adoption.

** The 2003 CPS allowed respondents to choose more than one race. For 2001 and earlier years, only one race was allowed.

*** Hispanic ethnicity not reported prior to 1979.

Families Below 100% of Poverty Level, 

by Household Status: 2002

Source (I.4): U.S. Census Bureau, Current Population Survey

Male Head

of Household

7.8%

Female Head

of Household

50.0%

Married Head

of Household

42.2%

Child Health USA 2004
POPULATION CHARACTERISTICS

SCHOOL DROPOUTS

As of October 2001, the latest year for which

data are available, there were approximately

3,774,000 high school dropouts

1 between the

ages of 16 and 24 in the United States. This

translates into a total dropout rate of 10.7 percent

for youth in this age group, a rate that has

remained fairly stable since 1992.

Since 1970, Hispanic students have had the

highest dropout rates, representing well over a

quarter of Hispanic young adults. The high

Hispanic dropout rate (27 percent) is partly

driven by the significantly higher dropout rate

among foreign-born Hispanics of 43.4 percent

in 2001. The corresponding rates for White

and Black students were 7.3 percent and 10.9

percent, respectively. Although the gap in the

dropout rate between Blacks and Whites 

narrowed between the 1970’s and 1980’s, the

gap has remained constant since 1990.

According to the National Center for

Education Statistics, students who drop out of

high school are more likely to be unemployed

and earn less when employed, compared to 

students who complete high school. 1 This term refers to status dropouts, which represents 16- to 

24-year-olds who are not enrolled in school and have not earned a high school credential (diploma or equivalent).

15

Status School Dropout Rates for Ages 16-24 by Race/Ethnicity: 1991-2001

Source (I.5): U.S. Department of Education, National Center for Education Statistics

** Because of changes in data collection procedures begining in 1992, data may not be comparable with figures for earlier years. 

15

20

25

30

35

40

10

991 993** 994 995 996 997 998 999 000 2001

Hispanic

Black* 

White*

27.0

10.9

7.3 P t

Year * Non-Hispanic

Child Health USA 2004
16 POPULATION CHARACTERISTICS

WORKING MOTHERS 

AND CHILD CARE

In 2003, 63 percent of mothers with preschool-aged children (younger than 6 years)

were in the labor force (either employed or

looking for work), and 58 percent were actually

employed. Of those mothers, 70 percent

worked full-time and 30 percent worked parttime. Of women with children ages 6-17, 78

percent were in the labor force in 2003 and

nearly all of those were actually employed. Among

these employed mothers, 77 percent worked

full-time and 23 percent worked part-time.

Child Care Arrangements for Children Under Age 5

with Employed Mothers, by Family Income: 2002

Source (I.7): Urban Institute, National Survey of America's Families

Low income is defined as below 200 percent of the federal poverty level; higher-income is 200 percent and above.

 ** Care by a non-relative in the child's home.

*** Care by a non-relative in the provider's home.

10

15

20

25

30

35

Higher-Income*

Low-Income*

amily Center-Based Relative Parent/Other

Child Care***

Nanny/

Babysitter**

P t g f Child

3.5

5.3

10.7

14.2

31.2

24.9 23.9

29.5

25.4

31.3

Percent of Mothers in the Work Force: 1975-2003

Source (I.6): U.S. Department of Labor

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

40

50

60

70

80

< 6 years

6-17Years

975 980 985 990 995* 000 2003

77.8%

62.8%

Mothers with

Children Ages 6-17

Mothers with Preschool

Children Under Age 6

Year

Percent of Mothers Data for 1995 and later are not strictly comparable with data for earlier years due to changes 

in the survey and estimation process.

Child Health USA 2004
POPULATION CHARACTERISTICS 17

Child Health USA 2004
18 POPULATION CHARACTERISTICS

EXPENDITURES FOR CSHCN

Out-of-Pocket Expenditures

Payment for services not covered by a health

plan — such as therapies, home health care, 

prescription drugs, and dental services — may

be a particular burden for families of children

with special health care needs, who may need a

wide variety of services and who may use more

services than other children. Families of nearly 

half of CSHCN report spending $250 or more

a year for the care of their child with special

health care needs. Thirteen percent reported

spending between $501 and $1,000, and 

11 percent spent more than $1,000 a year. 

Financial Burden

Both the out-of-pocket expenses associated

with their children’s care and the need of some

parents to cut down their work hours to care for

their children can create financial burdens for

families of CSHCN. The parents of just over

20 percent of CSHCN report financial problems

due to their children’s conditions. Financial

burdens are twice as common in low-income

families of CSHCN as in higher-income families.

Percent of CSHCN* Whose Families Experience 

Financial Problems Due to Child's Condition

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

National Center for Health Statistics, National Survey of CSHCN

Experience

Financial

Problems

20.9%

Do Not

Experience

Financial

Problems

79.1%

CSHCN are defined as those who have 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.

Annual Out-of-Pocket Expenditures for Care of CSHCN*

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

National Center for Health Statistics, National Survey of CSHCN 

$250-$500

25.5%

$501-$1000

13.0%

More than $1000

11.2%

Less than $250

50.3%

Child Health USA 2004
MATERNAL AGE 

The general fertility rate declined to 64.8

births per 1,000 women in 2002. The birth rates

among older mothers ages 35-44 continued to

increase, while rates for women in their twenties

and early thirties declined or remained stable.

Birth rates for teenagers have fallen steadily in the

past decade and reached a record low in 2002.

Among 2002 births, almost 11 percent were

to women under 20, over half to women in their

twenties, one third to women in their thirties,

and about 2.5 percent to women in their forties

and early fifties. The average age of women 

having their first birth in 2002 was 25.1 years,

the highest yet recorded. The average age at first

birth has risen from 21.4 years in 1970.

Among both Black and White women, over

half of births in 2002 were to women in their

twenties. The proportion of births that were to

women under 20 years of age were higher

among Black (18.0 percent) than White 

(9.7 percent) women. White births were more

likely to be to women in their thirties, forties

and early fifties.

POPULATION CHARACTERISTICS 19

Percent Distribution of Births by Maternal Age and Race: 2002

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

National Center for Health Statistics, National Vital Statistics System

40-54 Years

2.0%

<15 Years

0.5%

15-17 Years

6.4%

Black*

30-39 Years

24.2%

20-29 Years

55.8%

18-19 Years

11.1%

Includes Hispanic

Percent Distribution of Births by Maternal Age and Race: 2002

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

National Center for Health Statistics, National Vital Statistics System

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

40-54 Years

2.6%

<15 Years

0.1%

15-17 Years

3.0%

White*

30-39 Years

36.2%

20-29 Years

51.5% 18-19 Years

6.6%

Includes Hispanic

Child Health USA 2004
20 HEALTH STATUS

HEALTH STATUS

The systematic assessment of the health 

status of children enables health professionals

to determine the impact of past and current

health intervention and prevention programs.

Program planners and policy-makers identify

trends by examining and comparing information from one data collection year to the next.

Although indicators are often assessed on an

annual basis, some surveillance systems may

only collect data every two, three, or five years.

In the following section, mortality, disease,

injury, and health behavior indicators are

presented by age groups. The health status indicators in this section are based on vital statistics

and national surveys. Population-based samples

are designed to yield data that are representative

of the maternal and child population that are

affected by, or in need of, specific health services.

Child Health USA 2004
HEALTH STATUS — Infants

BREASTFEEDING

The percentage of new mothers who began

to breastfeed their babies in the hospital has

increased steadily since 1990, reaching a high of

70.1 percent in 2002. Breastfeeding initiation

rates have increased among all racial and ethnic

groups, and especially among the populations

that have traditionally been least likely to

breastfeed, such as Black and Hispanic women.

These increases have contributed to a substantial

reduction in the gap in breastfeeding rates

between White and non-White women. 

Breastfeeding rates for all women decreased

substantially between delivery and 6 months

postpartum, the period recommended as most

critical for the infant’s health by the U.S.

Surgeon General. The percentage of women

who report that they are still breastfeeding at 

6 months postpartum reached a high of 33.2

percent in 2002. At six months postpartum,

36.0 percent, 19.2 percent, and 32.7 percent of

White, Black, and Hispanic women, respectively,

were still breastfeeding.

Average breastfeeding rates were highest

among women who are over 30 years of age,

college educated, and not participating in the

Women, Infants, and Children (WIC) supplementary food program. Overall breastfeeding

rates were lowest among women under 20 years

of age, Black, low-income, those with less than

a high school education, and women living in

the southeastern United States.

21

Breastfeeding* Rates, by Race/Ethnicity: 2002

Source (II.1): Mothers' Survey, Ross Products Division, Abbott Laboratories

Includes exclusive and supplemental breastfeeding.

Labels: Arial, regular, 6/7

Chart x & Y bars: .5 pt

Chart bar outlines: .25 pt

0

10

20

30

40

50

60

70

80

6 Months

In Hospital

Black White Hispanic

50% 6 MONTH POSTPARTUM 2010 TARGET

53.9

19.2

73.4

36.0

70.7

32.7

75% IN HOSPITAL 2010 TARGET

Percent

In-Hospital Breastfeeding* Rates, by Race/Ethnicity: 1990-2002

Source (II.1): Mothers' Survey, Ross Products Division, Abbott Laboratories

Includes exclusive and supplemental breastfeeding.

10

20

50

60

70

80

30

40

All Races

Black

Hispanic

White

990 991 992 993 994 995 996 997 998 999 000 001 2002

73.4

70.7

70.1

53.9

Percent

Year

Child Health USA 2004
22 HEALTH STATUS — Infants

LOW BIRTH WEIGHT

In 2002, 314,077 babies (7.8 percent of all

live births) were of low birth weight, weighing

less than 2,500 grams, or 5 pounds 8 ounces, at

birth. This rate represented a slight increase

from the previous year. The percentage of newborns born at low birth weight has risen steadily

from a low of 6.7 percent in 1984 and is 

currently at the highest level recorded in the

past three decades. 

The highest rates of delivering a low birth

weight infant are among mothers younger than

15 years and older than 45. Much of the incidence of low birth weight among older mothers

(older than 44) is due to an increase in the proportion of multiple births, as the use of assisted

reproductive technologies increases. Multiple

births accounted for 24 percent of low birth

weight infants in 2002 compared to only 

15 percent in 1980. However, the low birth

weight rate among singleton infants increased

as well.

Although the non-Hispanic Black low birth

weight has declined slightly from a high of 

13.6 percent in 1991, it remains considerably

higher than the rate for non-Hispanic White

(6.9 percent) and Hispanic (6.5 percent)

infants. In 2002, the percent of low birth

weight infants born to smokers (12.2 percent)

was substantially higher than among nonsmokers

(7.5 percent). This significant differential has

been consistently observed among both nonHispanic Black and non-Hispanic White

infants. Other factors associated with increased

risk of low birth weight include maternal poverty

and low levels of educational attainment.

Low birth weight is one of the leading causes

of neonatal mortality. Low birth weight infants

are more likely to experience long-term disability

or to die during the first year of life than are

infants of normal weight.

Low Birth Weight Among Infants, by Race/Ethnicity: 1985-2002*

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

National Center for Health Statistics, National Vital Statistics System

 * 1985 -1988 data based on race of child; 1989-2002 data based on race of mother.

** Non-Hispanic

12

15

White** Hispanic

American Indian/

Alaska Native

Asian/Pacific Islander

Black**

985 990 995 000 2002

13.4

6.5

6.9

7.2

7.8

Child Health USA 2004
VERY LOW BIRTH WEIGHT

In 2002, the rate of very low birth weight

(less than 1500 grams or 3 pounds 4 ounces)

newborns was 1.5 percent of live births, a rate

that has been relatively stable since 1997.

Because chance for survival increases as birth

weight increases, infants born at a very low birth

weight have the lowest survival rates. Infants born

at such low birth weights are approximately

100 times more likely to die by age one than are

infants of normal birth weight. Very low birth

weight infants who survive are at a significantly

increased risk of severe problems, including

physical and visual difficulties, developmental

delays and cognitive impairment requiring

increased levels of medical, educational and

parental care.

The overall rate of very low birth weight

among non-Hispanic Black newborns is two

and a half times greater than that among 

non-Hispanic Whites and is twice the rate of

the population as a whole. This disparity is a

major contributor to the disparity in infant

mortality rates between non-Hispanic Black and

non-Hispanic White infants.

HEALTH STATUS — Infants 23

Very Low Birth Weight Among Infants, by Race/Ethnicity: 1985-2002

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

National Center for Health Statistics, National Vital Statistics System

Non-Hispanic 

0.0

0.5

1.5

2.0

2.5

3.0

3.5

1.0

985 990 995 000 2002

3.1

1.1

1.2

1.2

1.3

Black*

American Indian/Alaska Native

Asian/Pacific Islander

Hispanic White*

Child Health USA 2004
24 HEALTH STATUS — Infants

INTERNATIONAL INFANT

MORTALITY RATES

Differences in the infant mortality rates

among industrialized nations reflect disparities

in the health status of women before and during

pregnancy, as well as the quality and accessibility

of primary care for pregnant women and their

infants. Although the United States has greatly

reduced its infant mortality rate since 1965, the

nation ranked 27th among industrialized

nations in 2000.

This graph comparing international infant

mortality rates includes countries, territories,

cities, or geographic areas with a population of

at least 1 million that have complete counts of

live births and infant deaths. In 2000, four of

these jurisdictions had infant mortality rates

less than half that of the United States.

Comparison of International Infant Mortality Rates: 2000

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

012345678

New Zealand

Greece

Scotland

England and Wales

Portugal

Israel*

Canada

Denmark

Australia

Northern Ireland

Netherlands

Switzerland

Belgium

Austria

France

Italy

Germany

Czech Republic

Spain

Finland

Norway

Sweden

Japan

Hong Kong

Singapore 2.5

3.0

3.8

3.2

3.4

4.1

4.4

3.8

3.9

4.8

4.5

4.8

4.5

4.9

5.5

5.3

5.1

5.4

5.3

5.2

6.9

6.1

6.3

6.2

7.2

Deaths per 1,000 Live Births

5.6

Ireland

5.1

5.7

Cuba

United States

Includes data for East Jerusalem and Israeli residents in certain other territories under occupation by Israel military forces since June 1967.

Child Health USA 2004
INFANT MORTALITY

In 2002, 27,970 infants died before their

first birthday. The infant mortality rate was 

7.0 deaths per 1,000 live births, representing a

small but significant increase from the previous

year, the first such increase in 40 years. The

leading causes of infant mortality include 

birth defects, low birth weight and prematurity,

and pregnancy complications. Approximately

25 percent of the increase in infant mortality is

due to multiple births.1

The rapid decline in infant mortality, which

began in the mid-1960’s, slowed among both

Blacks and Whites during the 1980’s. Major

advances, including the approval of synthetic

surfactants and the recommendation that infants

be placed on their backs when sleeping, 

may have contributed to a renewed decline 

during the 1990’s. In 2002, the leading cause 

of infant mortality was congenital malformations, deformations and chromosomal abnormalities, which accounted for 20.2 percent of

infant deaths.

Based on preliminary data, mortality among

non-Hispanic Black infants remained stable at

13.9 deaths per 1,000 live births in 2002. The

rate of 5.8 deaths per 1,000 live births among 

non-Hispanic White infants represented a

slight increase over the rate in 2001. The infant 

mortality rate for non-Hispanic Black infants

continues to be 2.5 times that of non-Hispanic

White infants. Although the trend in infant

mortality rates among non-Hispanic Blacks

and non-Hispanic Whites has generally

declined throughout the 20th century, the 

proportional discrepancy between the 

non-Hispanic Black and non-Hispanic White

rates remains largely unchanged.

The Maternal and Child Health Block

Grant and the MCHB’s Healthy Start Program

provide health and support services to pregnant

women and infants with the goal of reducing

infant mortality rates.

1 MacDorman MF et al. Explaining the 2001-02 Infant 

Mortality Increase: Data from the Linked Birth/Infant Death Set.

NVSR 2005; 53(12).

HEALTH STATUS — Infants 25

U.S. Mortality Rates Among Infants, by Race/Ethnicity of Mother, 1997-2002

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

National Vital Statistics System

 * Non-Hispanic

12

15

Hispanic

White*

All Races

Black*

1997 1998 1999 2000 2001 2002

Year

13.9

5.8

7.0

D ht p 1 000 Li Bi ht

5.6

Child Health USA 2004
26 HEALTH STATUS — Infants

NEONATAL AND

POSTNEONATAL MORTALITY

Neonatal

In 2002, 18,791 infants younger than 28 days

died, resulting in a neonatal mortality rate of

4.7 deaths per 1,000 live births. This neonatal

mortality rate represents a small increase from

the rate recorded in 2001.

Neonatal mortality is generally related to

congenital anomalies and disorders resulting

from preterm delivery and low birth weight.

Postneonatal

In 2002, 9,179 infants between 28 days and

1 year of age died; the postneonatal mortality

rate was 2.3 deaths per 1,000 live births. The

2002 rate is not different from the 2001 rate.

The leading causes of postneonatal mortality

in 2002 were Sudden Infant Death Syndrome

and congenital anomalies.

Neonatal Mortality Rates, by Race/Ethnicity of Mother: 2002

ource (II.2 Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System

Non-Hispanic 

10

A Races White* Black*

3.9 3.8

D ht p 1 000 Li Bi ht

9.3

4.7

Hispanic

Postneonatal Mortality Rates, by Race/Ethnicity of Mother: 2002

Source (II.2): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System

Non-Hispanic

10

2.3 1.9

4.6

All Races White* Black*

D th p 1 000 Li Bi th

Hispanic

1.8

Child Health USA 2004
HEALTH STATUS

—Infants

MATERNAL MORTALITY

During the past several decades, the rate of

maternal mortality in the United States has

declined dramatically. Since 1982, however, 

the maternal mortality rate has not declined

significantly. In 2002, 357 maternal deaths resulted from

complications during pregnancy, childbirth, or

up to 42 days postpartum. The maternal 

mortality rate of 8.9 per 100,000 live births was

not significantly different from those reported

in recent years.

The maternal mortality rate among nonHispanic Black women (24.9 per 100,000 live

births) is more than four times the rate among

non-Hispanic White women (5.6 per 100,000

live births). This disparity has widened 

since 2000.

According to the National Center for Health

Statistics, the risk of maternal death increases

for women over age 30, regardless of race.

Women aged 35-39 years have over three times

the risk of maternal death as women aged 

20-24 years.

1

1National Center for Health Statistics. Health, United States,

2004. Hyattsville, Maryland: 2004.

27

Maternal Mortality Rates, by Race/Ethnicity: 2002

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

10

15

20

25

otal White* lack* Hispanic

8.9

5.6

24.9 N b f D th p 100 000 Li Bi th

7.1

 * Non-Hispanic

Child Health USA 2004
28 HEALTH STATUS — Children

VACCINE-PREVENTABLE

DISEASES

The number of reported cases of vaccinepreventable diseases has decreased steadily over

the past decade. While the number of cases of

H. Influenzae, mumps, and pertussis increased

between 2001 and 2002, cases of rubella,

measles, Hepatitis B, and Hepatitis A all

decreased among children under 5. However,

since most Hepatitis B infections among

infants and young children are asymptomatic,

the reported number of cases likely underestimates the incidence of Hepatitis B in young

children. In 2002, the highest number of cases

of pertussis was reported since 1964. Of these

cases, 21 percent were among infants under 

6 months of age, too young to have received the

first three of the five doses of the vaccine.

Mumps and rubella were at record low levels

across all ages.

Although much progress has been made in

reducing the number of reported cases of vaccinepreventable diseases, several of these diseases are

still common. The number of cases of pertussis,

Hepatitis A, and H. Influenzae remain substantial and indicate a continuing need to promote

immunization efforts. Since childhood vaccination for Hepatitis A was recommended in highrisk areas, the number of cases has decreased; in

2002, the overall rate of Hepatitis A was the

lowest ever recorded at 3.1 per 100,000. Rates of

Hepatitis A have shown the greatest decline

among children in states where routine vaccination

was recommended, suggesting that immunization policies are having an effect.

Vaccine-Preventable Diseases Among Children Under 5: 2002

ource (II.4): Centers for Disease Control and Prevention

50 100 4000

Pertussis

Hepatitis A

H. Influenzae

Mumps

Hepatitis B

Measles

Rubella

Diptheria and Tetanus

3,700

331

55

16

20

297

Number of Cases

150

Child Health USA 2004
HEALTH STATUS — Children 29

Child Health USA 2004
30 HEALTH STATUS — Children

Child Abuse and Neglect Among Children Under 18, 

by Type of Maltreatment: 2002*

Source (II.5): National Child Abuse and Neglect Data System

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

0 10 20 30 40 50 60 70 80

Psychological/

Maltreatment

Sexual Abuse

Other

Physical Abuse

Neglect/

Medical Neglect 60.5%

6.5%

9.9 %

18.6 %

18.9% 

Percent of Abused/Neglected Children

Percentages total more than 100 because children may have been the victims of more than 

one type of maltreatment.

Sources of Maltreatment Reports: 2002*

Source (II.5): National Child Abuse and Neglect Data System

0 5 10 15 20

Perpetrators

Victims

Child Day Care/Substitute Care

Parents

Friends/Neighbors

Medical

Relatives (excluding parents)

Other

Anonymous

Social Services/Mental Health

Legal

Education

Percent

16.1

15.7

15.2

9.6

9.0

8.0

7.8

5.5

6.1

1.0

0.7

0.2

Based on 1,798,389 reports from 49 states.

CHILD ABUSE 

AND NEGLECT

State child protective services agencies

received reports alleging the maltreatment of

approximately 4.5 million children in 2002.

Over half of these reports were received from

community professionals, while the remainder

was received from family, friends, relatives, or

neighbors of these children.

In 2002, investigations by state child 

protective services agencies determined that an

estimated 896,000 children were victims of

abuse or neglect, equivalent to a rate of 12.3 per

1,000 children under 18 years of age.

Approximately 60 percent of all victims suffered

neglect, 19 percent physical abuse, 10 percent

sexual abuse, 7 percent psychological maltreatment, and 19 percent other forms of maltreatment. Some children suffered multiple types 

of maltreatment.

Victimization was highest among the

youngest children. In 2002, 16 percent of victims

were newborns to age 3, while 6 percent were

16 to 17 years old. Among the estimated 

1,400 children who died of abuse and neglect,

children under one year of age accounted for

41.2 percent of fatalities and children under 

7 years accounted for 87.9 percent. Of the child

fatalities that occurred in 2002, 79 percent

involved a parent as a perpetrator.

The data were obtained from the National

Child Abuse and Neglect Data System, the 

primary source of national information on

abused and neglected children known to state

child protective services agencies.

Child Health USA 2004
PEDIATRIC AIDS

As of December 31, 2002, 9,220 cases of

AIDS in children younger than 13 had been

reported in the United States. Pediatric AIDS

cases represented less than 2.1 percent of all

cases reported through 2002.

In 2002, 158 new AIDS cases in children were

reported, with 88 percent of them transmitted

before or during birth (perinatal transmission).

Since 1993, the number of new cases of pediatric

AIDS due to perinatal transmission has declined

substantially. A major factor in this decline is

the increasing use of treatment before, during

and after pregnancy to reduce perinatal HIV

transmission. In 1994, the U.S. Public Health

Service recommended this treatment for all

HIV-positive pregnant women, and in 1995,

routine HIV counseling and voluntary testing

for all pregnant women was recommended. It is

expected that the perinatal transmission rate

will continue to decline with increased use of

aggressive treatments and obstetric procedures,

such as elective cesarean section.

Racial and ethnic minorities are disproportionately represented among pediatric AIDS

cases. The number of pediatric AIDS cases ever

reported in Black non-Hispanic children is 

3.4 times that of White non-Hispanic children

and 2.6 times that of Hispanic children.

HEALTH STATUS — Children 31

14

AIDS Cases Among Children Under 13, 

by Exposure Category and Race/Ethnicity: 1981- 2002*

ource (II.6): Centers for Disease Control and Prevention, HIV/AIDS Surveillance System

0 100 200 300 400 500

Risk Not Reported/Identified

Receipt of Blood/Blood Components**

Perinatal Transmission

American Indian/

Alaska Native

31

Asian/Pacific

Islander

58

Hispanic

2,087

Black

(Non-Hispanic)

5,433

White

(Non-Hispanic)

1,601

1,216

352

33

5,208

122

103

1,924

130

33

39

29

Number of Cases

Graph does not include 13 children of unkown race/ethnicit

** Receipt of blood/blood components includes: receipt of clotting factor for hemophilia coagulation disorder or receipt of blood transfusions, 

blood components, or tissue.

Child Health USA 2004
32 HEALTH STATUS — Children

HOSPITALIZATION

In 2002, there were 3.7 million hospital 

discharges among children ages 1 to 21, or 4.4

discharges per 100 children. This represents a

slight increase from 2001. Hospital discharge

rates generally decrease until about age 8 and

increase during later adolescence.

Diseases of the respiratory system were the

major cause of hospitalization for children 1-9

years of age and accounted for 33 percent of

their discharges.

While injuries are the leading cause of death

among children older than 1 year, this category

accounted for only 8 percent of the hospital

discharges of children aged 10-14 in 2002.

Pregnancy and childbirth accounted for 64 

percent of discharges among young women

ages 15-21. Mental disorders were the second

leading cause of hospitalization for adolescents.

Major Causes of Hospitalization by Age: 2002

ource (II.7): Centers for Disease Control and Prevention, National Center for Health Statistics, 

National Hospital Discharge Survey

100 200 300 400 500 600

Ages 20-21

Ages 15-19

Ages 10-14

Ages 5-9

Ages 1-4

Diseases of the Respiratory System

Infectious and Parasitic Diseases

Endocrine, Nutritional, and Metaboli Diseases and Immunity Disorders

Diseases of the Digestive System

Injury

285

93

444

207

92

85

41

32

21

85

76

48

46

54

115

70

63

46

58

41

40

33

33

44

Diseases of the Respiratory System

Diseases of the Respiratory System

Diseases of Skin and Subcutaneous Tissue

Endocrine, Nutritional, and Metaboli Diseases and Immunity Disorders

Diseases of the Digestive System

Injury

Diseases of the Respiratory System

Endocrine, Nutritional, and Metaboli Diseases and Immunity Disorders

Diseases of the Digestive System

Injury

Mental Disorders

Diseases of the Digestive System

Injury

Mental Disorders

Pregnancy/Childbir

Diseases of the Digestive System

Mental Disorders

Pregnancy/Childbir

Injury

Disease of the Genitourinary System

Number of Hospital Discharges (In Thousands)

Diseases of the Genitourinary System 45

Child Health USA 2004
HEALTH STATUS

— Children

HOSPITAL 

DISCHARGE TRENDS

Since 1985, overall hospital discharge rates

for children ages 1-14 years have declined by 

33 percent.

Between 1985 and 2002, hospital discharge

rates for diseases of the respiratory systems

declined 42 percent for children in this age group.

Three diagnostic categories (respiratory 

diseases, injury, and digestive diseases) accounted

for 44 percent of discharges among children

ages 1-14 years in 2002.

33

Discharge Rates Among Children Ages 1-14 by Selected Diagnoses: 1985-2002

ource (II.7): Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey 

50

100

150

200

Diseases of the Digestive System

Injury

Diseases of the Respiratory System

985 990 995 2000 2002

77.8

30.2

25.2 H pit l Di h g R t p 10 000 Child Year

Child Health USA 2004
34 HEALTH STATUS — Children

CHILD MORTALITY 

Childhood death rates have generally

declined over the past several decades. In 2002,

a total of 12,008 children ages 1-14 died.

Unintentional injury continues to be the primary

cause of death for this age group. Among children

ages 1-4, unintentional injuries accounted for

33.8 percent of all deaths, followed by deaths

due to congenital malformations (birth defects),

malignant neoplasms (cancer), homicide, and 

diseases of the heart. Unintentional injuries

comprised 38.0 percent of all deaths among

children 5 to 14, followed by malignant neoplasms, congenital malformations, homicides,

suicides, and diseases of the heart.

Leading Causes of Death Among Children Ages 1-14: 2002

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

National Vital Statistics System

Ages 5-14

Unintentional Injury

Unintentional Injury

Congenital Malformations

Malignant Neoplasms

Malignant Neoplasms

Congenital Malformations

Diseases of the Heart

Diseases of the Heart

Suicide

Chronic Lower Respiratory Diseases

Septicemia

Homicide

Homicide

Pneumonia and Influenza

3.4

10.5

2.6

2.7

1.1

0.7

0.5

6.6

2.6

1.0

0.9

0.6

0.6

0.3

Death Rate per 100,000 Population in Specified Age Group

Ages 1-4

12

Child Health USA 2004
CHILDHOOD DEATHS 

DUE TO INJURY

In 2002, unintentional injuries caused the

deaths of 1,641 children ages 1-4 and 2,718

children ages 5-14. Among children ages 1-4,

motor vehicle crashes, drowning, and fire were

the most common causes of unintentional

injury death. Motor vehicle crashes were the

most common cause of unintentional injury

death among children ages 5-14, followed by

deaths due to drowning, fire, and suffocation. In addition, 423 children ages 1-4 were the

victims of homicide and 620 children ages 5-14 were the victims of homicide or suicide.

HEALTH STATUS — Children 35

0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Ages 5-14

Ages 1-4

Motor Vehicle Crashes

Drowning

Fires and Burns

Su focation

Motor Vehicle Crashes

Su focation

Drowning

Fires and Burns

Death Rate per 100,000 Population in Specified Age Group

Deaths Due to Unintentional Injury Among Children Ages 1-14: 2002

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

3.6

3.4

0.3

0.8

0.6

2.9

1.5

0.9

Child Health USA 2004
36 HEALTH STATUS — Adolescents

ADOLESCENTS

In 2002, individuals ages 13-19 accounted

for roughly 10 percent of the U.S. population.

(Adolescence may be defined differently by 

different health programs or for different health

issues.) Generally, adolescents are a healthy

population. Adolescence is a period during

which many lifelong health habits are formed,

such as diet, exercise, and the use of health care

services. National data related to physical activity

and overweight are presented in this section.

Adolescence is also a time of physical and

emotional growth and exploration. As a result,

many adolescents engage in risk-taking behaviors

that may result in acute illnesses and infections,

poor long-term health outcomes, and even 

disability and death. For example, adolescents

may experiment with cigarettes and drugs,

engage in sex, or be involved in motor vehicle

crashes. This section features many health status

indicators related to cigarette smoking, use of

illicit drugs, adolescent mortality, injury, sexual

intercourse, sexually transmitted diseases, and

pregnancy. Many of these data are presented by

age, gender, race and ethnicity. 

Child Health USA 2004
HEALTH STATUS — Adolescents

ADOLESCENT

CHILDBEARING 

Between 2001 and 2002, the birth rate among

adolescents ages 15-19 dropped 5 percent to

43.0 per 1,000 teenagers. This represents a historic low and a decrease of 30 percent since

1991. The birth rate among adolescents ages

10-14 also fell, to 0.7 per 1,000 teenagers. Birth

rates were highest among the oldest adolescents,

those ages 18-19, at 72.8 births per 1,000.

Birth rates among adolescents varied considerably by race and ethnicity. In 2002, birth

rates for adolescents 15-19 were 18.3 per 1,000

Asian/Pacific Islanders, 28.5 per 1,000 nonHispanic Whites, 53.8 per 1,000 American

Indians, 68.3 per 1,000 non-Hispanic Blacks,

and highest at 83.4 per 1,000 Hispanics.

Although all racial and ethnic groups saw a

decline in adolescent births in the past decade,

the steepest declines have occurred among nonHispanic Black adolescents. Between 1991 and

2002, the birth rate among Black adolescents

ages 15-19 decreased by 42 percent. In the same

time period, the birth rate among Hispanic

adolescents fell the least, by just 20 percent,

leaving Hispanic teens with the highest birth

rate among the five racial and ethnic groups.

37

Birth Rates Among Adolescents Ages 10-19, by Age

and Race/Ethnicity of Mother: 2002

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

National Center for Health Statistics, National Vital Statistics System

Non-Hispanic

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

30

60

90

120

150

Hispanic

Black*

White*

Total

10-14 15-17 18-19

0.7

133.0

110.3

51.9

72.8

50.7

41.0

13.1

23.2

0.2 1.9 1.4

Live Births per 1 000 Adolescents

Birth Rates Among Adolescents Ages 15-19, 

by Race/Ethnicity of Mother: 1990-2002

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

National Center for Health Statistics, National Vital Statistics System

Non-Hispanic

20

40

60

80

100

120

Hispanic

Asian or Pacific Islander

American Indian/

Alaska Native

Black*

White*

990 995 000 2002

28.5

53.8

68.3

83.4

18.3

Year

Live Births per 1 000 Adolescents

Child Health USA 2004
38 HEALTH STATUS — Adolescents

SEXUAL ACTIVITY

In 2003, 46.7 percent of high school students

reported ever having sexual intercourse, representing a slight increase since 2001. Although nonHispanic Black students were most likely to report

ever having sexual intercourse (67.3 percent),

they were also most likely to report condom use

during their last sexual encounter (72.8 percent

of sexually active students). Hispanic students

were second most likely to report ever having

intercourse (51.4 percent), followed by nonHispanic White students (41.8 percent).

Almost half of all 12th grade students reported

having sexual intercourse in the three months

preceding the survey. Among 9th grade students,

more males were currently sexually active 

(24 percent) than females (18.3 percent). By

12th grade, however, females were more likely to

be currently sexually active (51 percent) than

males (46.5 percent). More than half of all high

school students reported that they have never

had sexual intercourse. The Maternal and Child

Health Bureau’s Abstinence Education Program

provides funding for education, mentoring,

counseling, and adult supervision to promote

abstinence from sexual activity.

In 2003, 63 percent of sexually active students

reported using a condom during their last sexual

intercourse. Condom use by male students is

reportedly higher than condom use by females

in every grade, and younger students reported

more condom use during their last sexual intercourse (69 percent of 9th and 10th graders) than

older students (57.4 percent of 12th graders).

Sexual Activity Among High School Students: 2003

Source (III.1): Centers for Disease Control and Prevention, Youth Risk Behavior Survey

Have never had intercourse

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

Abstinent*

53.3%

Intercourse

in past 3 months,

no condom

at last intercourse

12.7%

Intercourse

in past 3 months,

used condom

at last intercourse

21.6%

No intercourse

in past 3 months

12.4%

Sexual Activity and Condom Use 

Among High School Students by Grade: 2003

Source (III.1): Centers for Disease Control and Prevention, Youth Risk Behavior Survey

 * Sexual intercourse during the 3 months preceding the survey

** Percent of students who are sexually active and used a condom at last sexual intercourse

10

20

30

40

50

9th 10th 11th 12th

21.2

14.6

30.6

21.1

41.1

25.0

48.9

28.1

Sexually

Active*

Condom

Use**

Percent of Students

Grade

Child Health USA 2004
HEALTH STATUS — Adolescents

SEXUALLY TRANSMITTED

DISEASES

Adolescents (ages 15-19) and young adults

(ages 20-24) are at much higher risk of contracting sexually transmitted diseases (STDs)

than are older adults. Within these age groups,

reported rates of chlamydia, gonorrhea, and

syphilis are significantly higher among nonHispanic Black youth than youth of all other

reported racial/ethnic categories. Rates of STDs

among Hispanic adolescents and young adults

are about twice those of non-Hispanic Whites.

Chlamydia continues to be the most common

STD in adolescents and young adults, with a

rate of 1,488 cases per 100,000 adolescents and

1,619 per 100,000 young adults. Gonorrhea

followed in prevalence with an overall rate of

476 cases per 100,000 adolescents and 593

cases per 100,000 young adults. Syphilis is less

common among young people, with only 1.7

cases per 100,000 adolescents and 4.4 cases per

100,000 young adults in 2002. For each of

these diseases, rates are slightly higher among

20- to 24-year-olds than among adolescents.

Although these conditions are treatable with

antibiotics, STDs can have serious health consequences. Active infections can increase the

likelihood of contracting HIV and untreated

STDs can lead to pelvic inflammatory disease

and infertility in women.

39

Sexually Transmitted Diseases Among Adolescents 

and Young Adults, by Age and Race: 2002

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

1000

2000

3000

4000

5000

6000

5-19 Years 20-24 Years

713.2 819.2

5321.1

5032.2

Chlamydia

1320.8 1356.8

Non-Hispanic

500

1000

1500

2000

2500

3000

3500

5-19 Years 20-24 Years

115.0 152.0

3197.6

2484.9

Black*

White*

Gonorrhea

Hispanic

216.6 249.4

20

25

5-19 Years 20-24 Years

0.3 1.1

20.7

8.6

Syphilis

1.6

2.8

Child Health USA 2004
40 HEALTH STATUS — Adolescents

ADOLESCENT HIV

INFECTION

Of the 7,446 cases of HIV infection ever

reported among adolescents (ages 13-19), males

made up close to 44 percent and represented

the same proportion of the new HIV infection

cases reported in 2002 among adolescents.

Over half of these new cases were transmitted

by men having sex with men. In 33 percent of

new adolescent male cases, the risk category was

not reported. From 1981 through 2002, Black

males were more likely to report HIV infection

and comprised almost 60 percent of the infected

male adolescent population.

More than half of adolescent HIV infection

cases ever reported, 56 percent, were among

females. The percentage of new HIV infection

cases in adolescent females has been decreasing

in recent years. Of the new cases in 2002, about

40 percent acquired HIV infection through

heterosexual contact and 5.2 percent were

injecting drug users. The risk category was not

reported for 54 percent of new adolescent female

cases in 2002. Similar to the trend among 

adolescent males, Black females are significantly

more likely to contract HIV and comprised 

60 percent of female adolescents living with 

HIV infection.

HIV Infection Among Adolescents Ages 13-19,

by Sex and Race/Ethnicity: 1981-2002*

ource (II.6): Centers for Disease Control and Prevention, HIV/AIDS Surveillance System

 * Includes persons reported with HIV infection who have not developed AIDS in the 39 areas with confidential HIV infection reporting.

** Total includes 35 persons of unknown race/ethnicity.

1000 2000 3000 4000 5000 6000 7000 8000

Asian/Pacific Islander (12)

American Indian/

Alaska Native (25)

Hispanic (347)

Black (non-Hispanic)

White (non-Hispanic)

otal**

7,446

Females

4,193

Males

3,253

948

828

1,907

1,776 4,886

2,978

Asian/Pacific Islander (14)

American Indian/

Alaska Native (19)

Asian/Pacific Islander (26)

American Indian/

Alaska Native (44)

Number of Cases

Hispanic (333)

Hispanic (680)

Child Health USA 2004
HEALTH STATUS — Adolescents

ADOLESCENT AIDS

An adult or adolescent with HIV is defined

as having AIDS if he or she has a CD4 count of

less than 200 cells/uL or a CD4 percentage of

less than 14 or if he or she is diagnosed with

pulmonary tuberculosis, recurrent pneumonia,

or invasive cervical cancer. Males comprised

about 57 percent of the 4,819 AIDS cases ever

reported among adolescents ages 13-19 years

old, and represented 50 percent of the new

AIDS cases reported among adolescents in

2002. Of the 204 new cases reported in 2002

among adolescent males, the largest exposure

category (47 percent) was identified as men

who have sex with men. In 38.7 percent of new

cases, a risk category was not reported or identified. Approximately 43 percent of adolescent

AIDS cases ever reported were among females.

Females comprised of 50% percent of new

AIDS cases reported in 2002 among adolescents,

which is a 4 percent decrease from 54 percent

in 2000. Among adolescent females, there were

704 new AIDS cases. In 34.8 percent of these

new cases, heterosexual contact was reported as

the risk category, but in most cases (59.3 percent), a risk category was not reported or identified.

41

AIDS Cases Among Adolescents Ages 13-19, 

by Sex and Exposure Category, 1981-2002

ource (II.6): Centers for Disease Control and Prevention, HIV/AIDS Surveillance System

Receipt of blood/blood components includes: receipt of clotting factor for hemophilia coagulation disorder or receipt of blood transfusions, 

blood components, or tissue. Heterosexual contact includes sex with: an injecting drug user; a person with hemophilia; a transfusion recipient 

infected with HIV; an HIV-infected person, risk not specific; a bisexual male (females only). The category "Men Having Sex with Men" also 

includes men who have sex with men and inject drugs. 

0 1000 2000 3000 4000 5000

otal

4,819

Females

2,072

Males

2,747

462

648

1,110 987 418 1,178 1,126

117 259 1,048

870 159 130 1,126

Risk Not

Reported/

Identified

Receipt of

Blood/Blood

Components*

Heterosexual Contact*

Men Having Sex with Men*

Injecting Drug Use

Number of Cases

Child Health USA 2004
42 HEALTH STATUS — Adolescents

MENTAL HEALTH

TREATMENT

In 2002, 19.3 percent of youth 12 to 17

years of age received mental health treatment or

counseling. Non-Hispanic White and nonHispanic Black youths were most likely to

receive treatment, at 20.1 and 19.3 percent,

respectively. Among Hispanic youth, 17.5 percent

received treatment, followed by 13.4 percent 

of Asian youth. The most commonly reported

reasons for seeking counseling were feeling

depressed (49.5 percent), breaking rules or 

“acting out” (26.7 percent), suicidal thoughts

or attempts (19.5 percent), and feeling very

afraid or tense (19.5 percent).

Among youth receiving mental health treatment/counseling, 47.6 percent went to a private

therapist, psychologist, psychiatrist, social worker,

or counselor. The second most common source

of treatment was school counselors, school 

psychologists, or regular meetings with teachers,

at 44.6 percent. Only 4.7 percent of youths

received treatment through an overnight or

longer stay in a residential treatment center. In

some instances, source of treatment varied

greatly by age group. For example, 40.8 percent

of 12- to 13- year-olds who received treatment

used private therapists, compared to 50.6 percent

of 16- to 17-year-olds. The percentage of youth

using school counselors or regular teacher

meetings as a source of counseling drops from

48.5 percent among 12- to 13-year-olds to only

37.9 percent of 16- to 17-year-olds. A number

of other options were also reported, and

respondents could choose more than one

source of treatment.

Reasons for Mental Health Treatment/Counseling*

Among Persons Aged 12-17 Who Received Treatment: 2002

Source (III.3): Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health

Mental health treatment/counseling for youths is defined as having received treatment or counseling from any of 10 specific sources 

for emotional or behavioral problems not caused by alcohol or drug use.

** Respondents could indicate multiple reasons; therefore, response categories total more than 100%.

0 10 20 30 40 50

Other reason(s)

Other diagnosed mental/

neurological disorder

Social/friend problems

Eating problems

School-related issues

Family/home problems

Felt very afraid or tense

Suicidal thoughts or attempts

Breaking rules or "acting out"

Felt depressed 49.5

22.3

2.8

8.0

9.1

9.8

13.8

19.5

19.5

26.7

Child Health USA 2004
HEALTH STATUS — Adolescents

High School Students Who Carried a Weapon 

in the Past 30 Days, by Sex and Race: 1993-2003

Source (III.1): Centers for Disease Control and Prevention, Youth Risk Behavior Survey

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

10

15

20

25

30

35

40

993 995 997 999 001 2003

White Male*

Black Male*

Hispanic Male

27.1

5.5

8.5

9.8

24.3

24.9

Hispanic Female

White Female*

Black Female*

Percentage of Students Non-Hispanic

High School Students Who Were Threatened or Injured 

with a Weapon on School Property in Past 12 Months, 

by Race: 1993-2003

Source (III.1): Centers for Disease Control and Prevention, Youth Risk Behavior Survey

12

Year

Percent

10.9

9.4

7.8

1993 1995 997 1999 2001 2003

White*

Black*

Hispanic

Non-Hispanic

VIOLENCE

Violence among adolescents is a critical public

health issue in the United States: homicide was

the second leading cause of death among 

persons ages 15-24 in 2002.

Results from the 2003 Youth Risk Behavior

Surveillance reveal that 17.1 percent of students

had carried a weapon, such as a gun, knife, or

club, on at least one of the preceding 30 days;

just over 6 percent had carried a gun. Males

were significantly more likely to carry a weapon

(26.9 percent) than females (6.7 percent). The

percentage of students that carry weapons

steadily decreased from 1991 to 1999, then

began to level off at around 17 percent. 

Some high school students also reported

carrying weapons to school. In 2003, 6.1 percent

of students reported carrying a weapon on school

property in the past 30 days—nearly a 50 percent

decrease since 1993. Despite this decline, more

than 9 percent of students were threatened or

injured with a weapon on school property at

some point during the 12 months before the

survey. In addition, over 5 percent of students

did not go to school in the preceding 30 days

because they felt unsafe at school or while traveling before or after school. Younger students

and non-Hispanic Black and Hispanic students

expressed the most concern for their safety.

43

Child Health USA 2004
44 HEALTH STATUS — Adolescents

PHYSICAL ACTIVITY 

AND OVERWEIGHT

Results from the 2003 National Youth Risk

Behavior Survey show that almost two-thirds

(62.6 percent) of high school students regularly

participated in sufficient vigorous physical

activity, and almost one-quarter (24.7 percent)

participated in sufficient moderate physical

activity. Just over half (51.9 percent) performed

regular strengthening exercises, while 57.6 

percent played on one or more sports teams.

Nationwide, 55.7 percent of students were

enrolled in a physical education class, although

the percentage is far higher in the younger

grades (71 percent of 9th graders) than in the

older grades (39.5 percent of 12th graders). The

percentage of students attending daily physical

education classes has dropped from 42 percent

in 1991 to 28.4 percent in 2003.

While 29.6 percent of high school students

described themselves as overweight in 2003,

43.8 percent of students were trying to lose

weight. Among all racial and ethnic groups,

males were more likely to be overweight, while

females were more likely to perceive themselves

as such. Among high-school males, 17.4 percent

were overweight compared to 9.4 percent of

females, while 36.1 percent of females

described themselves as overweight compared

to 23.5 percent of males. 

In an attempt to lose weight or to prevent

themselves from gaining weight, 42.2 percent

of students engaged in healthy behaviors such

as eating less food, fewer calories, or foods lower

in fat. In addition, 57.1 percent of students

exercised for the same purpose. Females were

more likely to engage in such weight control

behaviors than males; 56.2 percent of females

used food as a way to control weight compared

to 28.9 percent of males, and 65.7 percent used

exercise compared to 49 percent of males. In

contrast to these healthy behaviors, 13.3 percent

of students went without eating for more than

24 hours in an attempt to lose weight, 9.2 percent

took diet pills, powders, or liquids without the

advice of a doctor, and 6.0 percent vomited or

took laxatives. Again, such behaviors are more

common among female students than males.

The HealthierUS Initiative (www.healthier

us.gov) provides credible, accurate information

about physical fitness, nutrition, and prevention to help Americans of all ages to make

healthy choices.

Physical Activity Among High School Students, by Race/Ethnicity: 2003

Source (III.1): Centers for Disease Control and Prevention, Youth Risk Behavior Survey

10

20

30

40

50

60

70

80

Hispanic

Black (Non-Hispanic)

White (Non-Hispanic)

Vigorous* Moderate** Strength***

65.2

54.8

59.3

26.2

21.7 22.0

53.6

45.4

51.5

P t Activities that caused sweating and hard breathing for at least 20 minutes on 3 of the 7 preceding days.

 ** Activities that did not cause sweating or hard breathing for at least 30 minutes on 5 of the 7 preceding days.

*** Activities such as push-ups, sit-ups, or weight-lifting on 3 of the 7 preceding days.

Child Health USA 2004
HEALTH STATUS — Adolescents 45

Child Health USA 2004
46 HEALTH STATUS — Adolescents

CIGARETTE SMOKING

Cigarette smoking declined significantly

among 8th, 10th, 12th graders in 2003 from 2002,

as reported by the University of Michigan’s

Monitoring the Future Study. In 2003, 10.2

percent, 16.7 percent, and 24.4 percent of 8th,

10th, and 12th graders, respectively, reported

smoking in the 30 days preceding the survey,

compared to 10.7, 17.7, and 26.7 percent in

2002. These figures represent a 51.4 percent,

45 percent, and 33 percent decline in smoking

for 8th, 10th, and 12th graders, respectively, since

these levels peaked in 1996 and 1997. The

younger age groups have shown the largest

improvement over this time period. Researchers

speculate that these declines resulted from an

increase in the perceived risk and disapproval of

smoking, an increase in cigarette price, and a

decline in access to cigarettes.

The prevalence of smoking among teens

increased substantially between 1991 and

1996. These increases occurred in virtually

every socio-demographic group: both sexes,

those planning on attending college and not,

those living in all four regions of the country,

those living in rural or urban areas, and among

Whites, Blacks, and Hispanics. Since 1996,

rates have consistently declined across all demographic groups. Although absolute rates of

smoking have declined among adolescents, 

certain subgroups are less likely to smoke than

others. Students who are not college-bound are

more likely to smoke than college-bound high

school students and Black adolescents are less

likely to smoke cigarettes than White adolescents.

The decline in rates of cigarette smoking since

1996 is likely to have important long-term health

consequences for this generation of adolescents.

Cigarette Use Among High School Students in the Past 30 Days, 

by Grade: 1975-2003

Source (III.4): The Monitoring the Future Study, University of Michigan

15

20

25

30

35

40

10

1975 980 1985 1990 1995 2000

12th Grade

 8th Grade

10th Grade

24.4

16.7

10.2

P t g f St d t

Year

2003

Child Health USA 2004
HEALTH STATUS — Adolescents

SUBSTANCE ABUSE

Prevalence and Incidence

In 2002, 11.6 percent of adolescents ages

12-17 reported using illicit drugs in the previous month. The use of illicit drugs within the

past month increased with age: 4.2 percent of

12- to 13-year-olds reported drug use, compared to 11.2 percent of 14- to 15-year-olds

and 19.8 percent of 16- to 17-year-olds. 

Alcohol, used by 17.6 percent of teens aged

12 to 17, is the most commonly used drug

among adolescents, and marijuana is the most 

commonly used illicit drug. The next most

common is nonmedical use of prescription

drugs, such as pain relievers, tranquilizers, or

stimulants; this was reported by 4 percent of

adolescents. Marijuana use is more common

among males, with 9.1 percent reporting use in

the past month compared to 7.2 percent of

females, while prescription drug abuse is more

likely to be reported by females (4.3 percent,

compared to 3.6 percent of males).

Data also indicate that other habits, such as

cigarette smoking, influence adolescents’ use of

illicit drugs. In 2002, 48.1 percent of youths

who smoked cigarettes currently used illicit

drugs, while only 6.2 percent of nonsmokers

used illicit drugs.

Perception of Risk and Access to Drugs

The National Survey on Drug Use and Health

(NSDUH) included questions about perceived

risk and access to illicit drugs among youths

aged 12-17. According to the 2002 survey results,

32.4 percent of youths perceive smoking marijuana as a great risk while 50.5 percent believed

that using cocaine once a month was a great

risk. In the same year, 63.1 percent of youths

believed that smoking at least one pack of 

cigarettes a day was a great risk. Among those

youths that believed smoking marijuana was a

great risk, 1.9 percent admitted to using the

drug within the past month. But for youths that

perceived smoking marijuana as a moderate,

slight, or nonexistent risk, 11.3 percent reported

using marijuana in the past 30 days.

In 2002, 55 percent of youths aged 12-17

reported that marijuana would be fairly or very

easy to obtain, 25 percent reported the same for

cocaine, 19.4 percent for LSD and 15.8 percent

for heroin. Little variation existed between

youths from large metropolitan areas, small

metropolitan areas, and non-metropolitan areas

in the proportion that reported that marijuana

was fairly or easily obtainable.

47

Drug Use Among Adolescents, 

Ages 12-17, in the Past 30 Days: 2002 

Source (III.3): Substance Abuse and Mental Health Services 

Administration, National Survey on Drug Use and Health 

0

5

10

15

20

Alcohol Marijuana Cocaine

17.6

0.6

8.2

Percent

Child Health USA 2004
48 HEALTH STATUS — Adolescents

Deaths Due to Injury 

Among Adolescents Ages 15-19: 2002

Source (II.3): Centers for Disease Control and Prevention, 

National Center for Health Statistics, National Vital Statistics System

5 10 15 20 25 30 35

Death Rate per 100,000 Population in Specified Age Group

27.1

1.7

3.4

12.2

Motor Vehicle

Traffic

Firearms

Poisoning

Drowning

Leading Causes of Death 

Among Adolescents Ages 15-19: 2002

Source (II.3): Centers for Disease Control and Prevention, 

National Center for Health Statistics, National Vital Statistics System

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

5 10 15 20 25 30 35

Unintentional

Injury

Malignant

Neoplasms

Diseases

of the Heart

Death Rate per 100,000 Population in Specified Age Group

35.0

7.4

9.3

3.5

2.0

Homicide

Suicide

ADOLESCENT MORTALITY

In 2002, 13,812 deaths were reported of

adolescents aged 15-19 years. After a moderate

increase in death rates for this age group in the

early 1980’s, there has been a gradual decrease

since that time. Unintentional injury remains

the leading cause of death and accounted for

approximately 52 percent of all deaths among

adolescents 15-19 years of age in 2002. Homicide

and suicide were the next leading causes of

death, accounting for 14 and 11 percent,

respectively, of all deaths within this age group.

Deaths Due to Injury

Within the classification of deaths due to

injury or other external causes, motor vehicle

crashes were the leading cause of mortality

among 15- to 19-year-olds in 2002, and

accounted for 52 percent of injury-related

deaths among adolescents. Alcohol is a significant

contributor to these deaths; nearly one-third of

adolescent drivers killed in crashes had been

drinking. Firearms were the next leading cause

of injury death, accounting for 23 percent of 

injury-related deaths in this age group.

Adolescent death rates due to motor vehicle

injuries and firearms were similar in the early

1990’s until 1994, when they began to diverge.

The rate of adolescent firearm deaths decreased

much faster and was recorded at a rate of 12.2

per 100,000 population in 2002, less than half

the rate of motor vehicle injury deaths, which

was 27.1 per 100,000.

Child Health USA 2004
HEALTH STATUS — Adolescents

ADOLESCENT DEATHS 

DUE TO INJURY

The two leading causes of death due to

injuries among adolescents are motor vehicle

crashes and firearms. In 2002, motor vehicle

traffic caused the deaths of 5,522 adolescents

15-19 years of age. The vast majority of those

killed were in motor vehicle accidents either as a passenger or driver. Deaths of pedestrians,

motorcyclists, and others accounted for the

remainder of motor vehicle mortality among

adolescents.

Results of the 2003 Youth Risk Behavior

Survey revealed that 18.2 percent of high

school students had rarely or never worn seat

belts when riding in a car driven by someone

else. Additionally, 30.2 percent of students had

ridden on one or more occasions with a driver

who had been drinking alcohol in the 30 days

preceding the survey.

In 2002, 2,474 adolescents ages 15-19 were

killed by firearms. Of these, homicide accounted

for 63 percent of firearm deaths, suicide

accounted for 30 percent, and 4 percent were

considered to be unintentional.

49 Traffic and Firearm Mortality Among Adolescents Ages 15-19: 2002

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

6 9 12 15 18

Firearms Mortality 

by Intent 

raffic Mortality 

by Person Injured

Motor Vehicle Occupant

Pedestrian

Motorcyclist

Pedal Cyclist

Homicide

Suicide

Unintentional

Unknown

15.4

0.8

1.4

0.2

3.7

0.5

0.2

7.7

Death Rate per 100,000 Population in Specified Age Group

Child Health USA 2004
50 HEALTH SERVICES FINANCING AND UTILIZATION

HEALTH SERVICES

FINANCING 

AND UTILIZATION

The availability of, and access to, quality

health care directly affects the health of mothers

and children, especially those at high risk due

to chronic medical conditions or low socioeconomic status.

Children may receive health coverage through

private insurance purchased by their parents or

their parents’ employers; or public programs,

such as Medicaid or the State Children’s Health

Insurance Program (SCHIP). Eligibility for these

programs is based on a family’s income 

compared to the Federal Poverty Level, which

was $18,100 for a family of four in 2002. Every

state has implemented a SCHIP program,

expanding coverage to many uninsured children.

Outreach and consumer education are key

components of the expansion in health insurance for children. Despite the progress achieved

through public programs such as Medicaid and

SCHIP, approximately 8.5 million children

remain uninsured in the United States.

The following section presents data on the

utilization of health services within the maternal and child population. The most recent data

are summarized by source of payment, type of

care, and place of service delivery. Data are 

presented by age, income, race and ethnicity.

Child Health USA 2004
HEALTH SERVICES FINANCING AND UTILIZATION

HEALTH CARE FINANCING

Nearly 12 percent (8.5 million) of children

younger than 18 years of age had no insurance

coverage in 2002, a proportion that has remained

relatively stable since 2000.

In 2002, just over one quarter of all children

(26.8 percent) were publicly insured, primarily

through Medicaid, and two-thirds were covered

by private insurance. By comparison, children

living in families with incomes below the

Federal poverty level were more likely to have

public insurance (63.8 percent) or be uninsured

(20.7 percent). Only 21.6 percent of low-income

children had private coverage.

In 2002, most uninsured children (64.7

percent) lived in families whose head was

employed year-round, on a full-time basis.

Even when parents are employed, coverage 

may not be offered or may be prohibitively

expensive. Most privately insured children

(88.7 percent) received insurance through a

parent’s employer.

Created in response to the growing number

of uninsured children in low-income working

families, the State Children’s Health Insurance

Program (SCHIP) has enrolled 5.8 million

children through the end of Federal Fiscal Year

2003. As of 2002, children with family incomes

up to 200% of the Federal poverty level were

eligible for coverage through SCHIP or

Medicaid in 26 states. Twelve states implemented

eligibility levels exceeding 235 percent of the

Federal poverty level.

51

Health Insurance Coverage* Among Children Under 18: 2002

Source (IV.1): U.S. Census Bureau, Current Population Study

Children may have more than one source of coverage.

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

10

30

40

50

60

70

80

20

67.5

Private

Coverage

No

Coverage

Public

Coverage

11.6

26.8

Percent

Health Insurance Coverage* Among Children

Living in Families Below 100% of Poverty Level: 2002

Source (IV.2): Employee Benefit Research Institute, Analysis of Current Population Survey

Children may have more than one source of coverage.

10

30

40

50

60

70

80

20

21.6 20.7

63.8

Private

Coverage

No

Coverage

Public

Coverage

Percent

Child Health USA 2004
52 HEALTH SERVICES FINANCING AND UTILIZATION

HEALTH CARE FINANCING:

CHILDREN WITH SPECIAL

HEALTH CARE NEEDS

According to the 2001 National Survey of

Children with Special Health Care Needs

(CSHCN), nearly two-thirds (64.7 percent) of

CSHCN have private or employment-based

coverage, 21.7 percent had public coverage, 

8.1 percent had both, and 5.2 percent reported

having no insurance at the time of the interview.

However, many of the families interviewed

reported that their children’s coverage was not

adequate to meet their needs. Twelve percent

said that their plan did not usually or always

allow their children to see the providers they

needed; 14.5 percent said their benefits did not

meet their children’s needs; and 28.4 percent

reported that the costs not covered by the plan

were not reasonable. In all, one-third of parents

of CSHCN reported that their coverage did not

usually or always meet at least one of these criteria.

Health Insurance Coverage for Children 

with Special Health Care Needs: 2001

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

National Center for Health Statistics, National Survey of CSHCN

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: 5 pt

Private or

EmploymentBased

Insurance

64.7%

Medicaid, SCHIP, or

Other Public Insurance 

21.7%

Private and

Public Insurance

8.1%

Other Comprehensive

Insurance

0.4%

Uninsured

5.2%

Percent of CSHCN Whose Insurance 

Does Not Meet Each Criterion for Adequacy

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

National Center for Health Statistics, National Survey of CSHCN

Percent whose insurance does not usually or always meet this criterion.

10

15

20

25

30

Charges are

Not Reasonable*

Benefits Do Not

Meet Child's Needs*

CSHCN Not Allowed to

See Needed Providers*

12.3

28.4

14.5

Percent

Child Health USA 2004
HEALTH SERVICES FINANCING AND UTILIZATION 53

Child Health USA 2004
VACCINATION COVERAGE

The Healthy People 2010 objective for the

complete series of routinely recommended

childhood vaccinations is immunization of at

least 90 percent of 19- to 35-month-olds with

the full series of vaccines. Data released from

CDC’s 2002-2003 National Immunization

Survey revealed that 77.9 percent of children

ages 19-35 months have received the recommended 4:3:1:3:3 series of vaccines (4 DTaP, 3

polio, 1 MCV, 3 Hib, 3 hepatitis B). In the past

5 years, the greatest increases in vaccination

rates have occurred with the hepatitis B vaccine

and the varicella (chicken pox) vaccine, which

was added to the schedule in 1996. Since 1997,

the vaccination rate for hepatitis B has

increased by almost 9 percent to 91.9 percent

in 2002. The varicella vaccination rate rose to

82.5 percent, which represents a more than 

2-fold increase since 1997. Despite this

progress, approximately 900,000 children

under two years of age have not received the

recommended immunization series to be fully

protected.1 Among children aged 19-35

months, non-Hispanic Black children have the

lowest immunization rates of any racial/ethnic

group and they are consistently below the

national average for each of the major vaccines.

In April 2004, the CDC published an

updated immunization schedule (see facing page).

The 2004 schedule continues to encourage the

routine use of hepatitis B vaccine for all infants

before hospital discharge and also recommends

the expansion of routine influenza immunization

to include all children 6 to 23 months of age.

1 American Academy of Pediatrics. (2003). Vaccination 

Fact Sheets from the Childhood Immunization Support Program

(CISP). Elk Grove Village, Illinois: AAP.

54 HEALTH SERVICES FINANCING AND UTILIZATION

Estimated Vaccination Rates Among Children Ages 19-35 Months,

by Race/Ethnicity: 2002-2003

ource (IV.3): Centers for Disease Control and Prevention, National Immunization Survey

60

70

80

90

100

Hispanic

Black*

White*

1+

Varicella

3+

HepB

3+

Hib

1+

MMR

3+

Polio

4+

DTP

Vaccines

P t f Chi dl 19 35 M ht

85.7 81.2

78.1

91.6

93.0

91.4

88.9 92.8

91.1

92.4

91.7

94.6 93.6

91.6

90.6

84.5

81.3

81.9

Non-Hispanic

Child Health USA 2004
HEALTH SERVICES FINANCING AND UTILIZATION 55

1 Hepatitis B Vaccine (HepB). All infants should receive the first dose of HepB vaccine soon

after birth and before hospital discharge; the first dose may also be given by age 2 months

if the infant’s mother is HbsAg-negative. Only monovalent HepB vaccine can be used 

for the birth dose. Monovalent or combination vaccine containing HepB may be used to

complete the series. Four doses of vaccine may be administered when a birth dose is

given. The second dose should be given at least 4 weeks after the first dose, except for

combination vaccines, which cannot be administered before age 6 weeks. The third dose

should be given at least 16 weeks after the first dose and at least 8 weeks after the second

dose. The last dose in the vaccination series (third or fourth dose) should not be administered before age 6 months.

Infants born to HbsAg-positive mothers should receive HepB and 0.5 mL hepatitis B

immune globulin (HBIG) within 12 hours of birth at separate sites. The second dose is 

recommended at age 1-2 months. The last dose in the vaccination series should not 

be administered before age 6 months. These infants should be tested for HbsAg and 

anti-HBs at 9-15 months of age.

Infants born to mothers whose HbsAg status is unknown should receive the first dose 

of the HepB series within 12 hours of birth. Maternal blood should be drawn as soon as

possible to determine the mother’s HbsAg status; if the HbsAg test is positive, the infant

should receive HBIG as soon as possible (no later than age 1 week). The second dose 

is recommended at age 1-2 months. The last dose in the vaccination series should not 

be administered before age 6 months.

2 Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). The fourth dose 

of DTaP may be administered at age 12 months, provided 6 months have elapsed since

the third dose and the child is unlikely to return at age 15-18 months. The final dose 

in the series should be given at age ≥ 4 years. Tetanus and diphtheria toxoids (Td) is 

recommended at age 11-12 years if at least 5 years have elapsed since the last dose 

of tetanus and diphtheria toxoid-containing vaccine. Subsequent routine Td boosters 

are recommended every 10 years.

3 Haemophilus Influenzae type b (Hib) conjugate vaccine. Three Hib conjugate vaccines are

licensed for infant use. If PRP-OMP (PedvaxHIB ® or ComVax ® [Merck]) is administered

at ages 2 and 4 months, a dose at age 6 months is not required. DTaP/Hib combination

products should not be used for primary vaccination in infants at ages 2, 4 or 6 months, 

but can be used as boosters following any Hib vaccine.

4 Measles, mumps, and rubella vaccine (MMR). The second dose of MMR is recommended

routinely at age 4-6 years but may be administered during any visit, provided at least 

4 weeks have elapsed since the first dose and that both doses are administered beginning 

at or after age 12 months. Those who have not previously received the second dose

should complete the schedule by the visit at age 11-12 years.

5 Varicella vaccine (VAR). Varicella vaccine is recommended at any visit at or after age 

12 months for susceptible children (i.e. those who lack a reliable history of chickenpox).

Susceptible persons aged ≥13 years should receive two doses, given at least 4 weeks apart.

6 Pneumococcal vaccine. The heptavalent pneumococcal conjugate vaccine (PCV) is 

recommended for all children age 2-23 months and for certain children aged 24-59 months.

Pneumococcal polysaccharide vaccine (PPV) is recommended in addition to PCV for 

certain high-risk groups. See MMWR 2000;49(RR-9):1-35.

7 Hepatitis A vaccine. Hepatitis A vaccine is recommended for children and adolescents 

in selected states and regions, and for certain high-risk groups; consult your local public

health authority and MMWR 1999;48(RR-12):1-37. Children and adolescents in these

states, regions, and high-risk groups who have not been immunized against hepatitis A

can begin in the hepatitis A vaccination series during any visit. The two doses in the series

should be administered at least 6 months apart.

8 Influenza vaccine. Influenza vaccine is recommended annually for children age ≥ 6 months

with certain risk factors (including but not limited to asthma, cardiac disease, sickle cell 

disease, HIV, diabetes), health care workers, and other persons (including household

members) in close contact with persons in groups at high risk (see MMWR 2004;53;[RR]

[in press]) and can be administered to all others wishing to obtain immunity. In addition,

healthy children age 6-23 and close contacts of healthy children aged 0-23 months are 

recommended to receive influenza vaccine, because children in this age group are at 

substantially increased risk for influenza-related hospitalizations. For healthy persons aged

5-49 years, the intranasally administered live, attenuated influenza vaccine (LAIV) is an

acceptable alternative to the intramuscular trivalent inactivated influenza vaccine (TIV). 

See MMWR 2003;52(RR-13):1-8. Children receiving TIV should be administered a dosage

appropriate for their age (0.25 mL if 6-35 months of 0.5 mL if ≥ 3 years). Children aged 

≤ 8 years who are receiving influenza vaccine for the first time should receive 2 doses

(separated by at least 4 weeks for TIV and at least 6 weeks for LAIV).

For additional information about vaccines, including precautions and contraindications for

immunization and vaccine shortages, please visit the National Immunization Program Website

at www.cdc.gov/nip or call the National Immunization Hotline at (800) 232-2522 (English) 

or (800) 232-0233 (Spanish).

Included above the text is the July-December 2004 recommended immunization schedule

from MMWR 2004;53(16):2.

This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of April 1, 2004, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible.

Graphic Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and

the vaccine’s other components are not contraindicated. Providers should consult the manufacturers’ package inserts for detailed recommendations. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting Systems (VAERS).

Guidance about how to obtain and complete a VAERS form is available at http://www.vaers.org or by telephone, 800-822-7967.

AGE

Hepatitis B1

Diphtheria,Tetanus,

Pertussis2

H. influenzae type b3

Inactivated Poliovirus

Measles, Mumps, Rubella4

Varicella5

Pneumococcal 6

Influenza7

Range of recommended ages

Hib

Hep B #1

Hep B #2 Hep B #3

DTaP

MMR#1

Varicella

IPV

Birth 1 mo. 2 mos. 4 mos. 6 mos. 12 mos. 15 mos. 18 mos. 24 mos. 4-6 yrs. 11-12 yrs.

DTaP

Hib

IPV

PCV

DTaP DTaP DTaP

Hib Hib

PCV PCV PCV

MMR #2

IPV IPV

13-18 yrs.

Td Td

only if mother HBsAg(-) Hep B series

MMR #2

Varicella

PCV PPV

Hepatitis A Hepatitis A series 8

Preadolescent assessment

Influenza (yearly)

Vaccines below this line are for selected populations

Recommended Childhood Immunization Schedule, United States, 2004

Source (IV.4): Centers for Disease Control and Prevention

Catch-up vaccination

Influenza (yearly)

VACCINE

Child Health USA 2004
DENTAL CARE

According to the Surgeon General’s Report

on Oral Health, dental caries (tooth decay) is

the single most common chronic disease among

children in the U.S., and is twice as common

among poor children as those with higher family

incomes. This is a preventable health problem

that can significantly affect children’s health,

ability to concentrate in school, and quality of

life. With half of children experiencing tooth

decay by the age of 8, beginning dental checkups

early in life is essential. Some professional associations recommend that a child have his or her

first dental visit by age 1.

Preventive services such as regular dental

health screenings may not always be available to

those children who need them most; twice as

many children lack dental insurance as lack

medical insurance. In Federal Fiscal Year 2001,

only 21 percent of children eligible for dental

services under the Medicaid Early and Periodic

Screening, Diagnosis, and Treatment (EPSDT)

program received a preventive dental service.

Problems related to oral health are more

common among particular populations,

including Black and Hispanic children, as well

as children from low-income families. Analysis

of the 2002 National Health Interview Survey

found that 76 percent of children with family

incomes at or above 200 percent of the Federal

Poverty Level saw a dentist in the past year,

compared to 62 percent of low-income children.

56 HEALTH SERVICES FINANCING AND UTILIZATION

Children Receiving Dental Care 

in the Past 12 Months, by Income: 2002

Source (IV.5): Centers for Disease Control and Prevention, 

National Center for Health Statistics, National Health Interview Survey 

Federal Poverty Level

10

20

30

40

50

60

70

80

More than 

Year Ago 

or Never

Within Past Year

Children in Families

 with Income 

at or Above 

200% FPL*

Children in Families

with Income

Below 200% FPL*

All Children

70.6

29.4

61.7

38.4

76.0

24.0

Percent

Children Receiving an EPSDT 

Preventive Dental Service: 1990-2001

Source (IV.5) Center for Medicare and Medicaid Services

Includes data from 47 states.

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

20

25

30

990 991 992 993 994 995 996 997 998 999 000 2001*

21.0%

Year

Percent

Child Health USA 2004
HEALTH SERVICES FINANCING AND UTILIZATION 57

Child Health USA 2004
PHYSICIAN VISITS

Based on data from the 2002 National Health

Interview Survey, approximately 11.4 percent

of children under the age of 18 had not seen a

physician or other health care professional in

the prior year. Older children were more likely

than younger children to go without a physician

visit. Nearly 16 percent of children ages 15-17

had not had a physician visit in the prior year,

compared to only 5.9 percent of children under 5.

Across all age groups, Hispanic children

were the least likely to have seen a physician in

the prior year, compared to non-Hispanic White

and non-Hispanic Black children. At every age

group, Hispanic children were at least 50 percent

more likely than non-Hispanic White children

to have had no physician visits. 

The American Academy of Pediatrics recommends that children have eight health care 

visits in their first year, three in their second

year, and one a year, generally, from middle

childhood through adolescence.

58 HEALTH SERVICES FINANCING AND UTILIZATION

Children Reported Not to Have Seen a Physician or Other Health Professional 

in the Past 12 Months, by Age and Race/Ethnicity: 2002*

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

National Health Interview Survey

 * Percent answering "zero" to the question: "During the past 12 months, how many times has [the child] seen a doctor or other health care 

professional about his or her health at a doctor's office, a clinic, or some other place?"

** Non-Hispanic

10

15

20

25

Hispanic

Black**

White**

-9 0-14 15-17

4.9 5.0

9.4 9.6

8.0

17.2

11.3

17.8

24.8

12.9

17.6

23.1

P t

Age

Child Health USA 2004
HEALTH SERVICES FINANCING AND UTILIZATION 59

Child Health USA 2004
Place of Physician Contact, by Age and Poverty Status: 2002

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

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

20

40

60

80

100

elow Poverty Above Poverty

15.9

82.9

59.0

34.7

2.3 3.8

0.3 0.9

Under 5 Years

P t 60 HEALTH SERVICES FINANCING AND UTILIZATION

PLACE OF 

PHYSICIAN CONTACT

Regardless of age or family income, most

children with a usual source of health care

received care at either a physician’s office or an

HMO in 2002. Across all age groups, 31.4 percent of children living in poverty used a clinic

or health center as their usual source of acute

care, compared to 15.4 percent of children not

living in poverty. Children with family incomes

above poverty were less likely to obtain care at a

hospital emergency department than children

in poverty.

0

20

40

60

80

100

Below Poverty Above Poverty

16.3

81.9

67.7

28.5

2.2 1.4 0.6 0.9

13-17 Years

Percent

0

20

40

60

80

100

Below Poverty Above Poverty

14.7

83.6

64.6

30.7

2.3 2.3 0.8 0.7

5-12 Years

Percent

Clinic or Health Center

Doctor's Office or HMO

Hospital Emergency Room

Hospital Outpatient Department

Child Health USA 2004
HEALTH SERVICES FINANCING AND UTILIZATION

FAMILY-CENTERED 

CARE FOR CHILDREN 

WITH SPECIAL 

HEALTH CARE NEEDS

The National Survey of Children With

Special Health Care Needs measured families’

satisfaction with their children’s care using five

indicators: whether or not the child’s provider

spends enough time with the family, listens

carefully to the parents, makes the parent feel

like a partner in the child’s care, is sensitive to

the family’s values and customs, and provides

the specific information that the parent needs.

Taken together, these questions provide an

indication of how family-centered the care that

CSHCN receive is.

Approximately one-third of families reported

that their children’s care did not meet at least

one of these five criteria. The one most commonly reported missing is the provision of

information: over 19 percent of CSHCN see

providers who do not usually provide their 

families with the information they need. Over

16 percent said that their children’s providers

did not spend enough time with the family, and

14 percent said that their children’s providers

did not usually make them feel like a partner in

their children’s care.

61

Percent of CSHCN Not Receiving Family-Centered Care

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

National Center for Health Statistics, National Survey of CSHCN

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

10

15

20

Does Not

Usually

Listen to

Family's Concerns

Does Not

Usually

Spend

Enough Time

Is Not

Usually

Sensitive to

Values/Customs

Does Not

Usually

Make Parent Feel

Like a Partner

Does Not

Usually

Provide Enough

Information

19.1

12.0

16.5

13.1

14.2

Receipt of Family-Centered Care by CSHCN

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

National Center for Health Statistics, National Survey of CSHCN

Lacks One or More

Components of

Family-Centered Care

33.5%

Receives

Family-Centered Care

66.5%

Child Health USA 2004
62 HEALTH SERVICES FINANCING AND UTILIZATION

HOSPITAL UTILIZATION

In 2002, the vast majority of children were

not admitted to a hospital overnight. However,

children in low-income families (those with

family incomes below the Federal Poverty

Level) were more likely to spend at least one

night in the hospital than children in higherincome families: 7.2 percent of low-income 

children had hospital stays of at least one night,

compared to 5.9 percent of children in 

higher-income families. In addition, hospital

stays lasting four nights or longer were more

common among children in low-income families

than children in higher-income families. The

proportion of children staying between 1 and 3

nights was similar in the two income groups.

20

100

15

10

FPL = Federal Poverty Level

100% FPL or more

Under 100% FPL

one One wo hree Four or More

Number of Nights

1.7 2.2

1.2 1.1

2.0 2.4

1.1 1.4

94.1

92.8

Number of Nights in the Hospital, by Poverty Level: 2002

Source (IV.5): Centers for Disease Control and Prevention, 

National Center for Health Statistics, National Health Interview Survey

P t f Child

Child Health USA 2004
HEALTH SERVICES FINANCING AND UTILIZATION 63

Child Health USA 2004
64 HEALTH SERVICES FINANCING AND UTILIZATION

PRENATAL CARE

Timely Prenatal Care

Receiving early and continuous prenatal

care throughout pregnancy has been linked to

improved pregnancy and health outcomes for

mother and child. The proportion of mothers

beginning prenatal care in the first trimester

improved again to 83.7 percent in 2002. 

In the last decade, the rate of women beginning prenatal care in the first trimester has risen

steadily (by 10 percent) overall and substantially

among racial and ethnic minorities. The proportion of non-Hispanic Black, Hispanic, and

American Indian women receiving early prenatal

care increased by 20 percent or more between

1990 and 2000. Although gains have occurred

across all racial groups, racial disparities persist.

On average, 88.6 percent of non-Hispanic

White women, compared to 76.7 percent of

Hispanic women and 75.2 percent of nonHispanic Black women, began prenatal care in

the first trimester in 2002.

A woman’s age is also related to prenatal care

initiation. Women younger than 20 years of age

were much less likely than older women to begin

prenatal care in the first trimester, although

rates of early entry into care have increased in

this age group.

Late or No Prenatal Care

The percentage of pregnant women beginning

prenatal care in the third trimester or going

without prenatal care decreased slightly to 3.6

percent in 2002. Regardless of age, Black and

Hispanic women were over twice as likely as

White women to receive late or no prenatal care.

Other risk factors for not using prenatal care

included being younger than 20 years old,

being unmarried, and having low educational

attainment.

Mothers Beginning Prenatal Care in the First Trimester, 

by Age and Race: 2002

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

National Center for Health Statistics, National Vital Statistics System

Labels: Arial, regular, 6/7

Chart x & Y bars: 1 pt

Chart bar outlines: .5 pt

Age of Mother

Percent

20

40

60

80

100 Black*

White*

15 5-19 0-24 5-29 0-34 5-39 40+

56.1

42.4

75.8

64.6

83.2

73.6

90.6

79.4

93.1

81.9

92.3

80.6

89.5

77.5

Non-Hispanic

Mothers Receiving Late or No Prenatal Care, 

by Age and Race: 2002

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

National Center for Health Statistics, National Vital Statistics System

Age of Mother 

10

15

20

15 5-19 0-24 5-29 0-34 5-39 40+

12.4

17.1

4.6

8.1

3.2

6.2

1.8

5.2

1.4

5.1

1.6 2.3

7.0

White*

Black*

6.1 Percent Non-Hispanic Child Health USA 2004
HEALTH SERVICES FINANCING AND UTILIZATION 65

Child Health USA 2004
66 STATE-SPECIFIC DATA

STATE DATA

While the indicators presented in the previous sections of this book are representative of

the U.S. as a whole, the next section presents

state-level health and health care indicators;

specifically, data on infant, neonatal, and perinatal mortality, low birth weight, early prenatal

care, births to women under 18, health care

financing for children, Medicaid enrollment

and expenditures, and SCHIP enrollment.

The following pages reveal stark differences

across states. Women living in the District of

Columbia and Delaware, and the southern

states of Alabama, Louisiana, Mississippi, and

South Carolina were more likely to give birth to

low birth weight babies (less than 2,500 grams

or 5 pounds 8 ounces) than women in other

regions of the country. These states, in addition

to New Mexico and Texas, were among those

with the highest rates of births to women under

18 years of age.

Poverty in the U.S. has risen over the past

three years. Poverty affects living conditions and

access to health care and nutrition, all of which

contribute to health status. Title XIX of the

Social Security Act (Medicaid) and the State

Children’s Health Insurance Program (SCHIP)

were designed to assure that children living in

low-income families have access to insurance

coverage and receive adequate health care 

services. In 2002, New Mexico and the District

of Columbia had the greatest proportion of

children with Medicaid/SCHIP coverage (over

40 percent), followed closely by Vermont (39.9

percent), while Maryland and Nevada had the

smallest proportion (12.5 percent). Wisconsin

had the lowest proportion of uninsured children

(4.9 percent) while Texas led the nation with

the highest proportion of uninsured children

(23.0 percent).

Child Health USA 2004
STATE-SPECIFIC DATA

Low Early Births 

Birthweight Prenatal Care Under 18

non-Hispanic non-Hispanic

State All** White Black All** White Black All** White† Black† Hispanic

United States 7.8 6.9 13.4 83.7 88.6 75.2 3.6 3.1 6.9 5.6

Alabama 9.9 7.9 14.3 83.3 90.0 73.6 5.2 3.8 8.4 5.6

Alaska 5.8 4.6 10.1 80.3 83.5 84.6 3.4 2.2 * 5.1

Arizona 6.8 6.7 12.2 76.5 87.2 77.4 4.8 4.7 5.9 7.3

Arkansas 8.6 7.5 13.6 79.6 83.7 70.4 5.1 4.1 9.0 5.6

California 6.4 6.0 11.6 86.4 90.4 83.0 3.3 3.5 4.7 4.9

Colorado 8.9 8.6 14.6 79.1 86.2 70.7 3.7 3.6 6.4 7.4

Connecticut 7.8 6.7 12.7 88.3 92.2 82.1 2.5 2.1 5.4 7.2

Delaware 9.9 8.3 15.0 87.1 91.1 82.3 3.7 2.5 7.7 5.5

DC 11.6 6.1 14.5 76.4 90.8 70.6 4.9 1.8 6.9 4.2

Florida 8.4 7.3 12.8 85.4 89.8 77.0 3.8 3.1 6.6 4.0

Georgia 8.9 7.0 13.3 84.7 90.5 78.9 4.4 3.4 6.8 4.9

Hawaii 8.3 6.9 10.9 83.9 89.1 94.7 2.5 0.7 * 3.9

Idaho 6.1 6.0 * 82.1 84.3 81.3 2.9 2.8 * 6.1

Illinois 8.2 7.0 14.3 84.9 90.8 74.2 3.5 2.6 8.7 4.8

Indiana 7.6 7.0 13.0 81.4 84.5 69.7 3.6 3.1 7.8 4.8

Iowa 6.6 6.5 10.2 88.8 90.4 78.3 2.8 2.5 8.9 5.6

Kansas 7.0 6.7 12.4 86.8 90.0 79.6 3.4 3.1 7.1 6.9

Kentucky 8.6 8.0 14.4 86.8 88.0 80.7 4.0 3.8 6.6 4.2

Louisiana 10.4 7.6 14.6 83.8 90.7 74.7 5.4 3.2 8.6 3.7

Maine 6.3 6.3 * 87.9 88.3 72.5 2.4 2.4 * *

Maryland 9.0 7.0 13.2 84.1 90.8 76.5 3.3 2.1 5.9 3.8

Massachusetts 7.5 6.7 12.1 89.9 92.7 79.2 1.9 1.7 3.9 6.4

Michigan 8.0 6.7 14.0 85.6 89.4 71.2 3.1 2.4 6.9 5.7

Minnesota 6.3 5.7 10.8 85.5 89.8 70.1 2.4 1.8 6.3 6.0

Mississippi 11.2 8.2 15.2 83.8 90.7 76.1 6.2 4.0 9.0 5.3

Missouri 8.0 7.0 13.9 87.8 89.9 79.7 3.7 3.0 8.2 5.3

Montana 6.8 6.7 * 83.7 86.4 68.8 3.4 2.7 * 6.5

Nebraska 7.2 6.8 13.7 83.4 87.0 70.4 2.9 2.4 9.3 6.1

Low Early Births 

Birthweight Prenatal Care Under 18

non-Hispanic non-Hispanic

State All** White Black All** White Black All** White† Black† Hispanic

Nevada 7.5 7.0 14.6 75.9 85.3 70.5 3.8 3.6 6.8 5.6

New Hampshire 6.3 6.5 * 91.5 92.2 79.7 1.5 1.6 * *

New Jersey 8.0 6.9 13.3 80.3 89.0 63.8 2.3 1.7 5.7 4.4

New Mexico 8.0 7.8 14.3 69.0 76.8 68.6 6.2 6.4 5.1 8.6

New York 7.9 6.5 12.3 81.6 88.2 71.9 2.5 2.1 4.6 4.4

North Carolina 9.0 7.6 14.1 84.3 90.9 75.5 4.2 3.2 7.3 5.4

North Dakota 6.3 6.0 * 86.1 88.9 81.6 2.2 1.5 * *

Ohio 8.3 7.3 13.9 87.8 89.8 78.9 3.4 2.7 7.8 5.8

Oklahoma 8.0 7.5 13.8 76.8 80.8 69.3 4.7 4.1 7.3 6.9

Oregon 5.8 5.7 9.8 81.6 84.6 75.8 3.0 2.9 7.1 5.5

Pennsylvania 8.2 7.0 14.1 84.6 88.0 71.1 3.2 2.3 8.6 8.0

Rhode Island 7.9 7.4 11.1 89.6 92.4 79.2 3.2 2.9 5.0 7.1

South Carolina 10.0 7.6 14.8 78.4 84.7 70.3 4.6 3.3 7.4 4.9

South Dakota 7.2 7.0 * 77.7 82.4 61.2 2.9 1.9 * *

Tennessee 9.2 7.9 14.5 82.8 87.8 72.3 4.4 3.5 7.9 5.4

Texas 7.7 7.1 12.8 80.5 87.8 76.7 5.3 5.2 7.2 7.1

Utah 6.4 6.3 15.7 79.5 83.6 58.4 2.1 2.0 * 5.0

Vermont 6.4 6.6 * 88.9 89.2 71.1 2.1 2.1 * *

Virginia 7.9 6.5 12.6 85.2 90.7 76.6 2.9 2.1 6.2 3.2

Washington 5.9 5.5 10.4 83.4 86.0 77.8 2.8 2.8 4.0 6.0

West Virginia 9.0 8.7 14.2 85.9 86.4 75.5 3.7 3.6 7.1 *

Wisconsin 6.6 5.9 13.3 84.3 88.2 71.4 2.9 2.0 10.2 6.1

Wyoming 8.4 8.3 * 84.9 86.0 78.8 3.4 3.1 * 4.8

* Figure does not meet standards of reliability or precision.

** Includes races other than White and Black.

† Includes Hispanic.

Percentage of Infants Born at Low Birth Weight, Women Receiving First Trimester Prenatal Care, 

and Births to Women Under 18, by State and Race of Mother: 2002

Source (I.8 and V.1): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System

67

Child Health USA 2004
68 STATE-SPECIFIC DATA

Medicaid Per Enrollee Participation 

State Enrollees* Expenditure** Ratio***

Alabama 422,948 $1,618.85 47.7%

Alaska 80,927 $3,042.18 50.0%

Arizona 411,152 $2,002.40 56.0%

Arkansas 267,003 $1,861.04 25.3%

California 3,160,766 $1,274.44 36.0%

Colorado 229,944 $2,114.55 50.0%

Connecticut 244,083 $1,243.96 54.2%

Delaware 67,836 $2,608.09 51.0%

District of Columbia 86,075 $2,594.56 64.0%

Florida 1,378,135 $1,564.00 47.0%

Georgia 1,058,369 $1,434.91 37.0%

Hawaii 105,769 N/R 70.0%

Idaho 122,526 $1,703.09 N/R

Illinois 1,082,020 $1,594.03 67.1%

Indiana 500,916 $2,459.44 51.0%

Iowa 182,821 $2,150.54 100.0%

Kansas 178,612 $1,668.93 69.7%

Kentucky 388,361 $2,186.76 40.0%

Louisiana 562,625 $1,276.80 55.0%

Maine N/R $4,162.36 N/R

Maryland 426,587 $2,699.68 46.0%

Massachusetts 468,854 $1,924.21 67.0%

Michigan 852,610 $1,231.46 43.0%

Minnesota 343,268 $2,400.49 55.0%

Mississippi 413,995 $1,358.76 28.0%

Missouri 584,003 $1,551.92 56.0%

Montana 56,968 $2,337.61 45.4%

Nebraska 148,676 $1,775.35 64.5%

Medicaid Per Enrollee Participation 

State Enrollees* Expenditure** Ratio***

Nevada 108,479 $1,899.87 75.4%

New Hampshire 68,064 $2,413.45 50.0%

New Jersey 490,064 $1,929.16 39.0%

New Mexico 283,234 $1,920.11 49.0%

New York 1,627,851 $2,602.05 85.0%

North Carolina 750,563 $1,777.88 N/R

North Dakota 36,575 $1,782.38 44.0%

Ohio 982,881 $1,592.83 39.0%

Oklahoma 413,302 $1,359.09 36.4%

Oregon 265,599 $1,758.23 50.0%

Pennsylvania 866,718 $2,373.01 65.0%

Rhode Island N/R $2,612.23 N/R

South Carolina 534,374 $1,520.70 33.0%

South Dakota 69,837 $1,754.71 42.2%

Tennessee 555,961 $1,340.79 36.0%

Texas 1,816,774 $1,773.88 52.0%

Utah 123,679 $2,102.06 58.0%

Vermont 71,548 $2,242.46 36.0%

Virginia 419,840 $1,534.19 54.0%

Washington N/R $1,187.85 N/R

West Virginia N/R $1,791.15 N/R

Wisconsin 357,339 $1,580.25 52.0%

Wyoming 30,021 $1,706.71 35.0%

* Unduplicated number of individuals determined to be eligible for EPSDT services 

(FY 2001 416 Report).

** Represents total Medicaid vendor payments divided by Medicaid eligibles under age 21 

(FY 2001 MSIS Report).

*** This ratio indicates the extent to which Medicaid eligibles received any initial and 

periodic screening services during FY 2001 (416 Report).

Medicaid Enrollees, Expenditures, and Reported EPDST Utilization for Children Under 21: FY 2001

Source (V.2 and V.3): Centers for Medicare and Medicaid Services

Child Health USA 2004
STATE-SPECIFIC DATA

Type of SCHIP Date Upper Total SCHIP

State Program* Implemented Eligibility Enrollment

Alabama SEPARATE 02/01/98 200% 78,554

Alaska MEDICAID 03/01/99 200% 22,934

Arizona SEPARATE 11/01/98 200% 90,468

Arkansas MEDICAID 10/01/98 200% NR

California COMBO 03/01/98 250% 955,152

Colorado SEPARATE 04/22/98 185% 74,144

Connecticut SEPARATE 07/01/98 300% 21,471

Delaware SEPARATE 02/01/99 200% 9,744

District of Columbia MEDICAID 10/01/98 200% 5,875

Florida COMBO 04/01/98 200% 443,177

Georgia SEPARATE 11/01/98 235% 251,711

Hawaii MEDICAID 07/01/00 200% 12,022

Idaho MEDICAID 10/01/97 150% 16,877

Illinois COMBO 01/05/98 185% 126,855

Indiana COMBO 10/01/97 200% 73,762

Iowa COMBO 07/01/98 200% 37,060

Kansas SEPARATE 01/01/99 200% 45,662

Kentucky COMBO 07/01/98 200% 94,053

Louisiana MEDICAID 11/01/98 200% 104,763

Maine COMBO 07/01/98 200% 29,474

Maryland COMBO 07/01/98 300% 130,161

Massachusetts COMBO 10/01/97 200% 125,177

Michigan COMBO 05/01/98 200% 77,467

Minnesota SEPARATE 10/01/98 275% NR

Mississippi SEPARATE 07/01/98 200% 75,010

Missouri MEDICAID 09/01/98 300% 150,292

Montana SEPARATE 01/01/99 150% 13,084

Nebraska MEDICAID 05/01/98 185% 45,490

Type of SCHIP Date Upper Total SCHIP

State Program* Implemented Eligibility Enrollment

Nevada SEPARATE 10/01/98 200% 47,183

New Hampshire COMBO 05/01/98 300% 9,893

New Jersey COMBO 03/01/98 350% 119,272

New Mexico MEDICAID 03/31/99 235% 18,841

New York COMBO 04/15/98 250% 795,111

North Carolina SEPARATE 10/01/98 200% 149,979

North Dakota COMBO 10/01/98 140% 4,955

Ohio MEDICAID 01/01/98 200% 204,114

Oklahoma MEDICAID 12/01/97 185% 91,914

Oregon SEPARATE 07/01/98 185% 44,752

Pennsylvania SEPARATE 05/28/98 200% 160,015

Rhode Island COMBO 10/01/97 250% 24,505

South Carolina MEDICAID 10/01/97 150% 76,128

South Dakota COMBO 07/01/98 200% 11,361

Tennessee MEDICAID 10/01/97 100% NR

Texas SEPARATE 07/01/98 200% 726,428

Utah SEPARATE 08/03/98 200% 37,766

Vermont SEPARATE 10/01/98 300% 6,467

Virginia COMBO 10/22/98 200% 83,716

Washington SEPARATE 02/01/00 250% 9,571

West Virginia SEPARATE 07/01/98 200% 35,320

Wisconsin MEDICAID 04/01/99 185% 68,332

Wyoming SEPARATE 12/01/99 133% 5,241

* Program type as of January 30,2004

** Reflects upper eligibility level approved as of April 2003

NR - State did not report data

State Children’s Health Insurance Program (SCHIP) Aggregate Enrollment Statistics: FY 2003

Source (V.4): Centers for Medicare and Medicaid Services

69

Child Health USA 2004
70 STATE-SPECIFIC DATA

Percent with 

Private/Employer- Percent Enrolled Percent

State Based Insurance in Medicaid/SCHIP** Uninsured***

Alabama 68.3 20.8 10.9

Alaska 51.4 38.8 9.8

Arizona 60.5 25.0 14.5

Arkansas 52.4 36.9 10.8

California 59.2 26.5 14.3

Colorado 72.1 12.9 15.1

Connecticut 74.0 17.9 8.1

Delaware 69.2 20.8 10.0

District of Columbia 45.9 44.9 9.2

Florida 62.1 22.8 15.1

Georgia 63.5 23.8 12.7

Hawaii 72.5 19.8 7.6

Idaho 64.2 21.9 14.0

Illinois 69.5 19.0 11.6

Indiana 74.2 15.8 9.9

Iowa 73.1 21.1 5.8

Kansas 75.1 16.8 8.0

Kentucky 61.0 26.4 12.6

Louisiana 51.2 36.4 12.4

Maine 60.6 31.2 8.2

Maryland 77.4 12.5 10.2

Massachusetts 72.9 21.0 6.1

Michigan 68.0 24.7 7.3

Minnesota 77.8 16.2 6.0

Mississippi 50.5 38.0 11.5

Missouri 69.5 24.9 5.7

Montana 59.3 29.0 11.7

Nebraska 69.2 24.9 5.8

Percent with 

Private/Employer- Percent Enrolled Percent

State Based Insurance in Medicaid/SCHIP** Uninsured***

Nevada 68.2 12.5 19.3

New Hampshire 78.9 16.1 5.0

New Jersey 72.1 17.8 10.1

New Mexico 45.3 40.2 14.6

New York 59.8 29.7 10.4

North Carolina 60.0 27.0 13.1

North Dakota 74.1 20.6 5.3

Ohio 72.5 19.2 8.3

Oklahoma 59.3 30.1 10.6

Oregon 63.7 24.2 12.1

Pennsylvania 70.1 19.7 10.2

Rhode Island 64.0 30.7 5.3

South Carolina 57.5 34.9 7.5

South Dakota 68.2 25.5 6.4

Tennessee 58.4 34.4 7.2

Texas 50.8 26.2 23.0

Utah 73.3 18.0 8.7

Vermont 54.3 39.9 5.8

Virginia 73.2 14.1 12.7

Washington 62.0 27.1 10.9

West Virginia 50.4 39.2 10.4

Wisconsin 74.2 20.9 4.9

Wyoming 64.5 21.8 13.7

* Estimates for 2002 should not be compared directly to estimates prior to 2000 

due to changes in survey design.

** Includes children covered by Medicare and Indian Health Services.

*** See map on facing page.

Health Insurance Status of Children Through Age 18: 2002*

Source (V.5): Analysis of 2003 Current Population Survey by the American Academy of Pediatrics

Child Health USA 2004
STATE-SPECIFIC DATA

Alaska

Hawaii

Washington

Oregon

California

Kansas

Nevada

New Mexico

Texas

M N

WI

MO

AR

LA

TN

MS AL GA

FL

SC

NC

K Y

M I

OH

PA

NY

VT

N H

ME

MA

C T

R I

N J

MD

DE

DC (9.2%)

Nebraska

VA WV

Oklahoma

Montana North

Dakota

South

Dakota Wyoming

Idaho

Arizona

Utah

Colorado

7.5% 7.5 – 10% 10.1 – 12% 12.1 – 23%

Percentage of Children Under the Age of 19 Who Are Uninsured: 2002

Source (V.5): Analysis of 2003 Current Population Survey by the American Academy of Pediatrics

71

Child Health USA 2004
Infant and Neonatal Mortality Rates, by Race of Mother and State: 2002

Source (V.6): Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System (2004)

Infant Neonatal 

Mortality*** Mortality 

State All**  White† Black† All** White† Black†

Alabama 9.1 7.1 13.9 5.9 4.6 8.9

Alaska 5.5 4.2 * 2.0 * *

Arizona 6.4 6.2 13.0 4.1 4.1 *

Arkansas 8.3 6.9 13.9 5.1 4.2 8.3

California 5.5 5.2 12.9 3.7 3.5 8.0

Colorado 6.1 5.5 21.1 4.0 3.6 13.6

Connecticut 6.5 5.5 14.2 4.7 4.2 9.0

Delaware 8.7 7.3 12.9 7.0 6.1 10.3

District of Columbia 11.3 * 14.5 7.6 * 9.3

Florida 7.5 5.8 13.6 5.0 3.9 9.1

Georgia 8.9 6.6 13.7 5.9 4.2 9.4

Hawaii 7.3 * * 4.7 * *

Idaho 6.1 6.1 * 4.0 4.1 *

Illinois 7.4 5.6 16.3 5.0 4.0 10.2

Indiana 7.7 6.8 15.3 5.3 4.7 9.6

Iowa 5.3 5.1 * 3.6 3.5 *

Kansas 7.1 6.5 15.2 4.8 4.4 10.0

Kentucky 7.2 6.6 14.2 4.2 4.0 6.7

Louisiana 10.3 6.9 15.0 6.6 4.4 9.7

Maine 4.4 4.3 * 3.2 3.1 *

Maryland 7.5 5.3 12.3 5.4 3.9 8.5

Massachusetts 4.9 4.5 9.1 3.7 3.5 6.1

Michigan 8.1 6.0 18.5 5.5 4.2 12.1

Minnesota 5.4 5.0 10.3 3.5 3.5 4.9

Mississippi 10.3 6.9 14.8 6.8 4.4 9.8

Missouri 8.5 7.1 17.1 5.5 4.7 11.0

Montana 7.5 7.1 * 4.9 4.7 *

Nebraska 7.0 6.1 20.8 4.8 4.2 15.3

Infant Neonatal 

Mortality*** Mortality 

State All**  White† Black† All** White† Black†

Nevada 6.0 5.1 18.4 3.9 3.3 10.7

New Hampshire 5.0 5.3 * 3.5 3.7 *

New Jersey 5.7 4.5 12.8 4.1 3.2 9.2

New Mexico 6.3 5.7 * 4.3 4.0 *

New York 6.0 5.4 9.9 4.3 3.9 6.7

North Carolina 8.2 5.9 15.6 5.6 3.8 11.5

North Dakota 6.3 5.6 * 4.1 3.7 *

Ohio 7.9 6.2 17.7 5.4 4.2 12.1

Oklahoma 8.1 7.1 17.2 5.1 4.4 11.1

Oregon 5.8 5.6 * 3.8 3.8 *

Pennsylvania 7.6 6.6 15.1 5.6 4.9 10.2

Rhode Island 7.0 6.4 * 4.8 4.3 *

South Carolina 9.3 6.0 15.8 6.3 3.9 11.2

South Dakota 6.5 4.9 * 3.6 2.9 *

Tennessee 9.4 7.0 18.3 5.9 4.2 12.5

Texas 6.4 5.6 13.5 3.9 3.4 8.3

Utah 5.6 5.5 * 3.8 3.8 *

Vermont 4.4 4.5 * * * *

Virginia 7.4 5.5 14.6 5.1 3.6 10.8

Washington 5.8 5.5 12.7 3.7 3.5 8.8

West Virginia 9.1 8.5 * 5.3 5.0 *

Wisconsin 6.9 5.6 18.9 4.8 4.0 12.9

Wyoming 6.7 6.8 * 3.8 3.9 *

* Figure does not meet standards of reliability or precision.

** Includes races other than White or Black.

*** Rates are deaths less than one year per 1,000 live births in specified group.

**** Rates are deaths under 28 days per 1,000 live births in specified group.

† Includes Hispanic.

72 STATE-SPECIFIC DATA

Child Health USA 2004
CIT

Y-SPECIFIC DATA

CITY DATA

How does the health of infants and children

in America’s cities compare to that of children

nationwide? This section presents data on

infant mortality, low birth weight, and health

care for children and pregnant women who

reside in the nation’s cities with populations

over 100,000 residents.

As the following data indicate, the health

status of children living in large U.S. cities is

generally inferior to that of children in the

nation as a whole. In 2002, the percentage of

infants born at low birth weight was 9 percent

higher for residents of U.S. cities compared to

the national average (8.5 percent versus 7.8 percent). While the infant mortality rate has

decreased in both cities and the nation as a

whole, a difference in rates remains. Higher

rates of low birth weight contributed to the city

infant mortality rate of 7.4 deaths per 1,000

live births in 2001; the national rate for 2001

was 6.9 per 1,000. The percentage of pregnant

women receiving first trimester prenatal care is

lower in cities (80.8 percent) than it is nationwide

(83.7 percent).

73

Child Health USA 2004
BIRTHWEIGHT

Low Birth Weight

Disorders related to short gestation and low

birth weight are the second leading cause of

neonatal mortality in the United States.1 In 2002,

103,932 babies (8.5 percent) born to residents

of U.S. cities with populations over 100,000

were of low birth weight (weighing less than

2,500 grams, or 5.5 pounds). The 2002 percentage of urban infants born at low birth

weight was 9 percent higher than the national

rate of 7.8 percent.

Very Low Birth Weight

Infants born at very low birth weight (less

than 1,500 grams, or 3 pounds and 4 ounces)

are at highest risk for poor health outcomes. 

In 2002, 1.7 percent of live births in cities with

populations over 100,000 were of very low

birth weight. This rate exceeded the national

very low birth weight rate by 13 percent.

1 The leading cause of neonatal mortality is congenital anomalies.

74 CITY-SPECIFIC DATA

Infants Born at Low Birth Weight in U.S. Cities 

with Populations Over 100,000: 1990-2002

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

National Vital Statistics System

10

Total U.S.

Cities

990 991 992 993 994 995 996 997 998 999 000 001 2002

8.5

7.8

Year

P t

Infants Born at Very Low Birth Weight in U.S. Cities 

with Populations Over 100,000: 1990-2002

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

National Vital Statistics System

0.0

0.5

1.0

1.5

2.0

2.5

otal U.S.

Cities

990 991 992 993 994 995 996 997 998 999 000 001 2002

P t

Year

1.7

1.5

Child Health USA 2004
INFANT MORTALITY

In 2001, 9,139 infants born to residents of

U.S. cities with populations over 100,000 died

in the first year of life. The city infant mortality

rate was 7.4 deaths per 1,000 live births, which

was higher than the rate of 6.9 for the nation as a whole. Although the infant mortality rate in

cities has routinely been higher than the rate

nationwide, it has steadily declined over the

past decade. Between 1990 and 2000, infant

mortality in cities declined by roughly 

one-third; the decline nationwide in the same

period was 25 percent.

CITY-SPECIFIC DATA 75

Infant Mortality Rates in U.S. Cities with Populations Over 100,000: 1990-2001

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

National Vital Statistics System 

10

12

Total U.S.

Cities

990 991 992 993 994 995 996 997 998 999 000 2001

7.4

6.9 P t

Year

Child Health USA 2004
76 CITY-SPECIFIC DATA

PRENATAL CARE

Early Prenatal Care

Women living in U.S. cities with a population

of over 100,000 are less likely to begin prenatal

care in the first three months of pregnancy than

women nationwide. The gap in early entry into

prenatal care between urban women and the

nation as a whole has narrowed since 1991.

In 2002, 80.8 percent of pregnant women

living in U.S. cities began prenatal care in the

first trimester of pregnancy, compared to 83.7

percent nationwide. The percentage of women

receiving prenatal care has increased steadily in

the past decade at both the city and nationwide

levels. The Healthy People 2010 objective is for

90 percent of pregnant women to begin prenatal

care in the first trimester.

Late or No Prenatal Care

In 2002, 4.6 percent of pregnant women

living in U.S. cities with a population over

100,000 either began prenatal care in the 3rd

trimester or received no prenatal care. The percentage of women receiving late or no prenatal

care is 28 percent higher among women living

in cities than among the overall U.S. population.

Pregnant Women Receiving Late or No Prenatal Care 

in U.S. Cities with Populations Over 100,000: 1990-2002

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

National Vital Statistics System

10

15

Total U.S.

Cities

990 991 992 993 994 995 996 997 998 999 000 001 2002

4.6

3.6

Year

P t Pregnant Women Receiving First Trimester Prenatal Care 

in U.S. Cities with Populations Over 100,000: 1990-2002

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

National Vital Statistics System

70

80

90

Cities

Total U.S.

990 991 992 993 994 995 996 997 998 999 000 001 2002

Year

P t

83.7

80.8

Child Health USA 2004
REFERENCES 77

REFERENCES

Population Characteristics

(I.1) Population Division (2004). Table NC-EST2003-01, National Population Estimates, Characteristics. Washington, DC: U.S. Census Bureau.

(I.2) Fields, J (2003). Children’s Living Arrangements and Characteristics: March 2002. Current Population Reports, P20-547. Washington, DC: U.S. Census Bureau.

(I.3) Health Resources and Services Administration, Maternal and Child Health Bureau (2004). The National Survey of Children with Special Health Care Needs Chartbook.

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

(I.4) Population Division (2003). Current Population Survey, 2003. Washington, DC: U.S. Census Bureau.

(I.5) National Center for Education Statistics (2003). The Condition of Education 2003. Washington, DC: U.S. Department of Education.

(I.6) Bureau of Labor Statistics (2004). Employment Characteristics of Families in 2003. Washington, DC: U.S. Department of Labor.

(I.7) Capizzano J, Adams G. Snapshots of America’s Families, No. 16 — Children in Low-Income Families are Less Likely to Be in Center-Based Child Care. 

Washington, DC: Urban Institute.

(I.8) Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: Final Data for 2002. 

National Vital Statistics Reports, Vol. 52, No. 10. Hyattsville, MD: National Center for Health Statistics.

Child Health USA 2004
78 REFERENCES

Health Status

(II.1) Ross Products Division (2003). Mothers Survey. Columbus, OH: Abbott Laboratories.

(II.2) National Center for Health Statistics. Health, United States, 2004. Hyattsville, MD: 2004.

(II.3) Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: Final Data for 2002. National Vital Statistics Reports 2004: 53(5).

(II.4) Center for Disease Control and Prevention (30 April, 2004). MMWR, Vol. 51, No. 53. Atlanta, GA: U.S. Department of Health and Human Services.

(II.5) Administration on Children, Youth, and Families (2004). Child Maltreatment 2002. Washington, DC: U.S. Department of Health and Human Services.

(II.6) Centers for Disease Control and Prevention (2002). HIV/AIDS Surveillance Report 2001, Vol. 13, No. 2. Atlanta, GA: U.S. Department of Health and Human Services.

(II.7) National Center for Health Statistics (2003). National Hospital Discharge Survey. Unpublished data.

(III.1) Centers for Disease Control and Prevention (21 May, 2004). MMWR, Vol. 53, No. SS-2: Youth Risk Behavior Surveillance — United States, 2003. 

Atlanta, GA: U.S. Department of Health and Human Services.

(III.2) Centers for Disease Control and Prevention (2003). STD Surveillance 2002. Atlanta, GA: U.S. Department of Health and Human Services. 

(III.3) Substance Abuse and Mental Health Services Administration (2003). Overview of Findings from the 2002 National Survey on Drug Use and Health. 

Rockville, MD: U.S. Department of Health and Human Services. Page 42, mental health; Page 47, substance abuse.

(III.4) Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE (2004). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2003. 

(NIH Publication No. 04-5506). Bethesda, MD: National Institute on Drug Abuse.

Child Health USA 2004
REFERENCES

Health Services

(IV.1) Mills RJ, Bandahari S (2003). Health Insurance Coverage in the United States: 2002. Current Population Reports P60-223. Washington, DC: U.S. Census Bureau.

(IV.2) Fronstin, P (2003). Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2003 Current Population Survey. 

EBRI Issue Brief No. 264. Washington, DC: Employee Benefit Research Institute.

(IV.3) Centers for Disease Control and Prevention, National Immunization Program (2004). National Immunization Survey, July 2002-June 2003. 

Atlanta, GA: U.S. Department of Health and Human Services.

(IV.4) Centers for Disease Control and Prevention (2004). Recommended Childhood and Adolescent Immunization Schedule. Atlanta, GA: U.S. 

Department of Health and Human Services.

(IV.5) National Center for Health Statistics. National Health Interview Survey, 2002. Analysis conducted by the Maternal and Child Health Information Resource Center.

State Data

(V.1) National Center for Health Statistics (2004). Unpublished data.

(V.2) Centers for Medicare and Medicaid Services. Annual EPSDT Participation Report FY 2001, Form 416. Baltimore, MD: The Centers.

(V.3) Centers for Medicare and Medicaid Services. Medicaid Program Statistics FY 2001, MSIS. Baltimore, MD: The Centers.

(V.4) Centers for Medicare and Medicaid Services. The State Children’s Health Insurance Program: Preliminary Annual Report for FY 2003. Baltimore, MD: The Centers.

(V.5) American Academy of Pediatrics, Division of Health Policy Research (2003). Analysis of 2003 Current Population Survey. Elk Grove Village, IL: The Academy.

(V.6) Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: Final Data for 2002. National Vital Statistics Reports 2004: 53(5).

City Data

(VI.1) National Center for Health Statistics (2003). Unpublished data.

79

Child Health USA 2004
80 CONTRIBUTORS

CONTRIBUTORS

This publication was prepared for the

Health Resources and Services Administration’s

Maternal and Child Health Bureau (MCHB),

and was produced by MCHB’s Maternal and

Child Health Information Resource Center.

Federal Contributors with the U.S.

Department of Health and Human Services

Health Resources and Services 

Administration

Substance Abuse and 

Mental Health Services Administration

Administration on Children and Families

Centers for Medicare and Medicaid Services

National Institute on Drug Abuse

Centers for Disease Control and 

Prevention (including the National 

Center for Health Statistics)

Other Federal and Non-governmental

Contributors

U.S. Census Bureau

U.S. Department of Education’s 

National Center for Education Statistics

U.S. Department of Labor’s

Bureau of Labor Statistics

Urban Institute

American Academy of Pediatrics

Employee Benefit Research Institute

Abbott Laboratories

Photography copyright: Jupiter Images (pp. 10, 17, 36, 45, 57, 59, 63, 65, 66), LaLeche League (p. 20), and Getty Images (p. 29). Other photos contributed 

by Lynda Honberg, Margaret Hansen, Renee Schwalberg, Julia Gage, Florence Sterla, Beth Lowe, JoLane Thomas, Elizabeth Watson, and Maureen Roihl.

Child Health USA 2004
Child Health USA 2004
U.S. Department of Health and Human Services

Health Resources and Services Administration

Maternal and Child Health Bureau

5600 Fishers Lane • Room 18-05

Rockville, MD 20857

Tel: 301- 443-2170

Fax: 301- 443-1797

www.hrsa.gov

Child Health USA 2004