CURRENT PROBLEMS IN DEATHS OF PERSONS UNDER 20 YEARS OF AGE

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CURRENT

PROBLEMS

IN

DEATHS

OF

PERSONS

UNDER

20

YEARS

OF

AGE

As Evidenced

by a Study

of the Situation

in the Past

Decade

in New

York

City

By LEONA BAUMGARTNER, M.D., AND VIVIAN PEssiN, M.A.

New York City

M

ORTALITY rates for children in New York City, as elsewhere in this country,

are on the decline. Such declines, however, are often taken for granted, which

leitds to a neglect of continuing studies of mortality. A periodic study of the problem, to

discover changing trends and to point to problems demanding greater attention, seems

definitely worth while.

For several reasons, analysis of New York City data is of more than local interest.

The numbers are large ; the deaths are, for all practical purposes, completely reported ; and

the cause of death as reported by the physician on the death certificate is verified by

autopsy in a relatively large percentage of cases. It is of course always true that analysis

of mortality trends as reflected in death certificates compares unfavorably in some respects

with studies based on medical and hospital records. However, they are the only records

which yield a picture of all the deaths occurring in a community.

The following data were secured by analyzing the confidential medical data on the

death certificatel of every person .under 20 years old who died in New York City in the

10 years from 1937 to 1946.*

MORTALITY BY AGE GROUP

The general downward trend in mortality is illustrated in Chart 1. This decline was

only temporarily interrupted by the war, during which there was a small increase in the

death rates of all age groups.

It is noteworthy that deaths of infants under 1 month of age have not declined as

rapidly as those among children from 1 to 12 months of age. In the past 10 years, for

example, there has been a reduction of 36% in infant mortality (deaths under 1 year)

and only 19% in neonatal mortality (deaths under 1 month) .

The over-all rate of decline in mortality is less than it was. For example, in the period

from 1937 to 1946 there was a decline of 13% for all ages under 20, in contrast to the

47% decline for the same age groups from 1920 to 1930.

The medical and public health professions can well be satisfied with this record but

From the Department of Health of the City of New York, and from the New York Hospital and

the Department of Pediatrics, Cornell University Medical College, New York, N.Y.

Presented at a meeting of the Pediatric Section of the New York Academy of Medicine, Feb. 13,

1948.

(Received for publication May 13, 1949.)

* In 1938 a revision was made in the International List of Causes of Deaths. Corrections for the

minor changes in coding of the causes of death necessitated by this revision have been made in the

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1938 939 1940 1941 942 943 $937

$0000

-8000

8000

4000

$944 $945 946

-RE YEAR

MONTHS

‘947

- 10000 8000

6000 4000

DER ONE MONTH

2.000

$000 800

600

400

200

100

80

60

40

20

:c:izb::A;$±:AS

10-14 YE

...-H--2000

000 $00 600

400

200

100 SO 60

40

20

‘0

938 939 940 1941 942 943 1944

- - 10

945 1,46 947

CITY

OF

NEW

YORK

MORTALITY

AMONG

CHILDREN

RATES

PER

100,000

POPULATION

*

BY AGE

GROUPS,

I937I946

* RATES UNDER 1 YEAR. UNDER I MONTH, AND I-Il MONTHS, AE PER 100,000 LIVE #{149}IRTHS.

CHART 1

such satisfaction does not lead to further gains. To accomplish these, certain questions

must be answered. What causes these deaths ? Where is progress being made ? What

problems remain unsolved?

MORTALITY UNDER ONE YEAR OF AGE

For infants under 1 year of age, the mortality picture is clearly visualized in Chart 2.

In this age group, prematurity, congenital malformation and birth injury stand out as

today’s chief problems. Ten years ago pneumonia, influenza and diarrheal diseases took

a much greater toll than they do now. In 1946, these caused only 10% and 5%,

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flATES PER 1,000 LIVE BIRTHS CITY OF NEW YORK

LEADING CAUSES OF DEATH

MORTALITY RATES PER 1,000 LIVE BIRTHS

UNDER I YEAR

OF

AGE

1937AND 946

PER CENT

CAUSE OF DEATH OPTOTAL

__________________

DEATHS

PREMATURE 29

BIRTH 42

PNEUMONIA AND $9

INFLUENZA 0

INJURY AT II

BIRTH II

DIARRHEA 1$

CONGENITAL II

MALFORMATIONS $7

ASPHYXIA

8

is also evident from the chart that little progress has been made in reducing deaths

at-tributed to premature birth and to congenital malformations. The decline in deaths due

to injury at birth is probably attributable to better obstetric practice, though this has

remained through the years the third leading cause of death. Deaths due to pertussis,

though always small in number, have decreased markedly, with only five deaths in 1946

in infants under 1 year of age and 11 in those from 0 to 4 years of age.

It has often been pointed out that the notation “prematurity” on a death certificate

does not necessarily reveal the true cause of death. However, the cause of death was

verified by an autopsy in 40% of the infant deaths in this series-a higher percentage

CHART 2

than prevails in many cities. It must be recognized, moreover, that many of the autopsies

performed on infants are not satisfactory. When more careful autopsies are performed, it

is revealed that many of the deaths now attributed to asphyxia, prematurity, etc., are due

to more specific and often preventable causes, with infections playing a prominent part.2

All this, however, does not negate the fact that deaths associated with premature birth

still constitute the major problem. As seen in Chart 2, prematurity increases in

im-portance as a cause of death in infants as deaths from other causes are prevented, which

is another way of saying that there has been least progress in fighting this particular

cause of infant mortality. Moreover, about 50% of all deaths occur in so-called premature

infants (i.e., those weighing less than 2500 gm. at birth) although the death may actually

occur from other complications.

A large number of infant deaths occur in the neonatal stage. Of the 4,200 infant deaths

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month of life. It is evident, therefore, that measures to reduce infant mortality must center

mainly around the hospital and the care given the pregnant woman and the newly born,

particularly the prematurely born, infant.

Further study of the prematurely born infant reveals several other points of interest.

It is only since 1939 that birth weight has been recorded on birth certificates in New

York City. The incidence of premature births in the period on record has run from 7.1

to 8.3%. Approximately 8.3% of all babies born alive weighed less than 2500 gm. in

194S. The total mortality rate among premature babies in the first year of life has varied

from 18.4% in 1939 to 15.1% in 1946.* It has not been possible to compare this figure

with statistics from other large urban areas or population groups which, because they

usually do not keep figures according to weight groups and color, do not provide a

satisfactory basis for comparison.

TABLE I

Cnv OF NEW YORK: PREMATURE BIRTHS AND DEATHS, BY BIRTH WEIGHT, 1946

Births Deaths tinder 1 Yr. of Age

Birth \Vt. _Per _Cent _of

(gm.) No. Premature No. Rate/l00

Births Births

Under 1,000

1,000-1,499

I,5C0-l,999

2,000-2,499

593

827

2,173

9,051

4.7

6.5

17.2

71.6

549

470

425

467

92.6

56.8

19.6

5.2

Totalunder2,500 12,644 100.0 1 ,911 15.1

Other wts. 140,092 2,328 1.7

Bain and her associates3 have recorded a hospital fatality rate of 21.5 for 32,000

in-fants weighing less than 2,500 gm. in 323 American hospitals in 1945 and 1946. The

New York City figures, as seen in Table I, include a larger percentage of babies in the

upper weight groups in which mortality rates are usually low. This probably accounts for

the lower mortality rate in New York City-though obviously the figures are not

com-parable anyway because one is based on deaths occurring during hospitalization and the

other on deaths within the first year of life.

A comparison of mortality rates of prematurely born infants in different hospitals, or

of the over-all city rate with an individual hospital, would obviously be of some interest;

but such procedures are, for the most part, unsatisfactory from the statistical point of

view. Allowance must be made, for example, for difference in econothic status, in

dis-tribution of nonwhite and white babies, or in distribution of small and larger babies.

The groups are usually too small to compare, and the comparative figures one often sees

* On a certain number of birth certificates, birth weight is not recorded. However, the period of gestation is stated. A method of distributing these ‘‘weight not stated” babies to weight groups by using the period of gestation has been devised. When these babies are included the incidence of pre-maturity is raised about 1% and the mortality figure in 1946, for example, to 19%. However, since

figures are probably more easily compared when only the babies of known weight are included. these

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are not statistically significant. The best we have been able to do is to compare the over-all

city rate for 1946 with the rate for 1945 and 1946 in one rather large hospital which

cares for white and Negro premature infants born in its own maternity service as well as

some born elsewhere. If the mortality rate achieved by this hospital had applied to all

infants prematurely born in the city in 1946, there would have been about 1,500 deaths

instead of 1,900, a saving of about 400 infant lives.

About half of all neonatal deaths occur in the first 24 hours, and an additional third

in the next six days. This is also true for the prematurely born infant. Some of these

deaths are not preventable, but others are. It is certain that prolonging the life of the

infant past the first 24 hours increases enormously its chances for survival.

CITY OF NEW YORK

REPORTED

FETAL

AND

INFANT

LOSS

IN

946

AVERAGE MONTHLY RATES PER 00,000 PREGNANCIES

BY AGE

2000L

800 Before ond during delivery Afler delivery

600

-400 -200

000 /// 800

600

400

// 200

_

---

-C UNDER 20 20- 24 28 32- 36 40 Isv 2nd 3,4 4th 5th 6th 7th SIP, 9th th 11111 12th

23 27 3’ 35 39 6

OVER

WEEKS GESTATION MONTH OF AGE

CHART 3

MORTALITY IN FETAL LIFE

If discussion of the possibility of saving additional lives is limited to the deaths of

live-born infants, an important part of the problem as indicated in Chart 3 (showing

deaths before and after delivery) is neglected. In 1946, about three times as many fetal

deaths were reported as deaths of infants under one year of age. How much greater the

pregnancy wastage is through unreported and illegal abortions cannot be known. Actually,

whether a viable fetus dies a few minutes before or after delivery, there is still loss of

life. The problem of the fetus that is not carried into the viable stage is similarly

im-portant to those interested in reducing infant mortality.

Certainly too little is known of the factors contributing to fetal deaths and to the deaths

attributed to prematurity, congenital malformation and birth injury. Certain of the deaths

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CHART 4

fundamental causes and effective methods of prevention. Such research is imperative if

our general death rate is to continue downward. It is little realized that today deaths

associated with childbirth (maternal, fetal and neonatal deaths) constitute a leading

cause of death. In New York City, for example, fetal and neonatal deaths, numbering

16,259 in 1946, were the second largest cause of death for all ages, including those over

20. Only heart disease claimed a larger number (30,348).

MORTALITY FROM ONE TO FOUR

Decrease in the mortality rate for this age group has been somewhat more rapid than

in the infant group (see Chart 1), but the actual number of deaths involved is, of course,

much smaller-only 663 in 1946, for example, compared to 4,200 for infants.

The leading cause of death is now accidents (see Chart 4), accidents in the home

taking the majority of lives. This chart illustrates strikingly, as do the charts for other

age groups, the rapid progress that has been made in the control of pneumonia and

influenza. There is reason for satisfaction, too, in the 73% decline in mortality due to

appendicitis and the 60% decline in tuberculosis and contagious diseases. The slight

increases in death rates due to congenital malformations are related, of course, to an

in-creasing ability to keep these children alive through the first year of life.

MORTALITY FROM FIVE TO NINE

In this age group, too, accidents are the leading cause of death, as they were 10 years

ago (see Chart 5). Children are now out on their own, and this is reflected in the number

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CITY OF NEW YORK

MORTALITY RATES PER 00,000 POPULATION

5 TO 9 YEARS OF AGE

1937 AND 946

PER CENT RATES PER /00,000 POPULATION CAUSE OF DEATH OP TOTAL

______________

DEATHS fl 10 $6 20 23 30

$8

ACCIDENTS

______

33

PNEUMONIA AND 4

______

INFLUENZA 4

13

________

HEART DISEASES

7

_________

CONTAGIOUS 8 ____________

DISEASES 9

_________

8 _________________

APPENDICITIS

3

5

____________

__________________

TUBERCULOSIS

4

_______

3

________

CANCER

6

#{189} 7 7

LEGEND

::

1.4#{189}q

1$;w%

E:8:zl;/A

;!;

---RATES PER 100,000 POPULATION

CITY OF NEW YORK

LEADING

CAUSES

OF

DEATH

MORTALITY RATES PER 100.000 POPULATION

10 TO

14 YEARS OF AGE

1937 AND 1946

PER CENT

CAUSE OF DEATH #{176}TOTAL

_________________ DEATHS

HEART DISEASES

ACCIDENTS $3

24

APPENDICITIS

PNEUMONIA AND 0

INFLUENZA 6

TUBERCULOSIS

CONTAGIOUS 4

DISEASES 6

CANCER 3

CHART 6

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CITY OF NEW YORK

MORTALITY RATES PER 100,000 POPULATION

15 TO 19 YEARS OF AGE

1937 AND 1946

RATES PER /00,000 POPULATION

I 10 IS 20 25 30 35

PER CENT CAUSE OF DEATH DEAThS

TUBERCULOSIS 20

I9

HEART DISEASES I5

PNEUMONIA AND I I

INFLUENZA 4

ACCIDENTS 10

IS

APPENDICITIS 5

2

CANCER 3

6

CHART 7

accidents occur in the home. After 5, only one third to one fourth of these accidents

occur in the home, the remainder occurring outside the home and including those due

to motor vehicles.

In the 5 to 9 age group, heart disease takes its place for the first time in the age cycle

as one of the leading causes of death, and cancer jumps to fourth place with an actual

increase in the number of children involved. On the credit side, pneumonia has dropped

from second to fifth place as a cause of death and important declines are also evident in

deaths due to appendicitis and tuberculosis.

MORTALITY FROM 10 TO 14

This is the golden age of childhood if measured by mortality, for it is the age of the

lowest mortality rates (see Chart 6) . Large gains have been made in saving lives formerly

lost through pneumonia and influenza, tuberculosis, appendicitis and heart disease. The

declines in deaths due to heart disease are of the same magnitude if rheumatic fever is

also included in this category.

MORTALITY FROM 15 TO 19

It is well known that during adolescence death rates begin to climb again. In 1946

the jump is one of 76% as one goes from the 10 to 14 year old group to this 15 to 19

year old group (see Chart 7) . Deaths due to tuberculosis increase sufficiently in this period

of later adolescence to become, with accidents, the leading cause of death. In 10 years,

of course, gains have also been made in saving the lives of those 15 to 19 years old.

There are fewer deaths due to appendicitis, pneumonia, tuberculosis and heart disease in

#{189}44yzJ

,

1

7

c

7A

a

LEGEND

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1946 than in 1937-even as in the younger children. The relatively insignificant change,

through the years, in the rate due to accidents is, however, discouraging. Gains in saving

lives lost through accidents in the younger age groups were greater, during the 10 years,

than they were in this group of 1 5 to 19 year olds.

%

of the deaths of individuals

up to 20 years of age. In 1900 they caused 14% of the deaths and by 1920 this figure

had dropped to only 12%. This indeed is a battle that has been won.

What lies ahead ? Four facts seem quite clear.

1. The greatest loss of children’s lives occurs at or near birth. In fact the numbers are

so large that, if compared to all causes of death at all ages in New York City, these

rank second. In other words, the loss of life of viable fetuses and in early infancy is

exceeded only by deaths due to diseases of the circulatory system.

2. There is insufficient scientific knowledge to prevent a considerable number of these

infant deaths. Research as to the fundamental causes of death and the means of

pre-venting them is more or less sporadic, is only meagerly supported financially, and needs

to be greatly intensified.

3. Despite these lacks, much that is known about preventing deaths, particularly in

newly born and prematurely born infants, is not put into practice in New York City

today. If all newly born babies and mothers got the care that modern medicine is able

to give, a large number of infant lives could be saved now. There is also sufficient

knowl-edge to prevent a considerable number of deaths due to tuberculosis, pneumonia, influenza

and appendicitis.

4. Accidents and heart disease emerge as leading causes of death after infancy. Gains

are still to be made in preventing these deaths. There has been little study of the

acci-dent problem, and much research needs to be done before satisfactory measures can be

found for the control of rheumatic fever.

CONCLUSION

In the past 10 years mortality rates for persons under 20 have declined less rapidly

than in that of the previous decades. Nevertheless, the application of new and well

recog-nized procedures in the prevention of deaths due to pneumonia, influenza, appendicitis,

diarrhea and contagious diseases, and tuberculosis have led to striking reductions in

deaths due to these causes. Because of these reductions, other causes of death have assumed

new importance. Thus, in children over one year of age accidents are today the leading

cause of death. Heart disease, tuberculosis and cancer claim a high percentage among

those from 10 to 20, while contagious and respiratory diseases are still important in

chil-dren under 10.

In infants, the deaths occurring before, at or near birth are of chief importance, with

those associated with premature birth assuming an importance that demands active and

immediate attention. Despite the gains made, deaths associated with childbirth (i.e., fetal

and neonatal deaths) stand second today in claiming lives of all ages in New York City.

Only heart disease has a larger mortality. The time has come for physicians to take

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good pediatricians and obstetricians know can be given. In addition, there is a pressing

need for an intensified research program to the end that deaths in infancy and those due

to accidents and heart disease can more effectively be prevented.

REFERENCES

1. Duffield, T. J., Parker, Sylvia L., and Baumgartner, Leona, Birth weight and its relation to

neonatal mortality, Child 5:123, 1940.

2. Potter, Edith L., and Adair, F. L., Fetal and Neonatal Death, Chicago, University of Chicago

Press, 1940.

3. Bain, Katherine, Hubbard, J. P., and Pennell, Maryland P., Hospital fatality rates for premature

infants, PEDIATRICS 4:454, 1949.

SPANISH ABSTRACT

Problemas Corrientes en Muertes de Personas Bajo 20 A#{241}os de Edaci

Como se Han Visto Mediante un Estudio de la Situaci#{243}n en la Decada Pasada en la Ciudad de Nueva York

Se hizo un estudio comparativo de Ia reducci#{243}n en las proporciones de mortalidad para ni#{241}osen Ia

Ciudad de Nueva York de 1937 a 1946. Los certificados de muerte, archivados por los medicos allI,

contienen ciertos informes m#{233}didos confidenciales y son estos informes los que se han usado como

base para este estudio. Las proporciones de mortalidad para los siguientes grupos de edades son

analizados: Menos de 1, 1-4, 5-9, 10-4 y 15-19 aflos. El ntimero de muertes fetales queda incluldo.

Se indican las causas de muerte principales en cada grupo lo mismo que los cambios en su importancia relativa durante los aflos. Los autores concluyen:

En los #{252}ltimos diez a#{241}oslas proporciones de mortalidad para personas de menos de 20 a#{241}oshan

bajados menos rapidamente que las de las d#{233}cadas anteriores. Sin embargo, Ia aplicaci#{243}n de procedi.

mientos neuvos y bien reconocidos en la prevenci#{243}n de muertes debidas a neumonia, influenza, apendicitis, diarrea y enfermedades ccntagio;as, y tuberculosis han ayudado a reducir notablemente las muertes debidas a estas causas. A causa de estas reducciones, otras causas de muerte han asumido nueva importancia. Asi, en niflos de m#{225}sde un a#{241}ode edad los accidentes son hoy Ia causa de

muerte que va a Ia cabeza. Enfermedad del coraz#{243}n, tuberculosis y cancer reclaman un alto

por-centaje entre #{233}stosde 10-20 aflos, mientras que enfermedades contagiosas y respiratorias son a#{252}n importantes en ni#{241}osde menos de 10 aflos.

En infantes, las muertes que ocurren antes, durante o cerca del parto son de primordial

impor-tancia, con aquellas asociadas con parto prematuro que asumen una importancia que pide atenci#{243}n activa e inmediata. A pesar de las ganancias hechas, las muertes asociadas con el parto (i.e., muertes

fetales y neonatales) ocupan segundo lugar hoy en reclamar las vidas de todas las edades en los

ciudadanos de Ia Ciudad de Nueva York. Solamente Ia enfermedad del coraz#{243}n tiene una mortalidad

mayor. El tiempo ha Ilegado para que los medicos se den cuenta de estos hechos y vean que todas

las madres y beb#{233}sreciban Ia clase de cuidado que los buenos pedi#{225}tricos y obst#{233}tricos puedan

darles. Ademfls, hay una gran necesidad para un programa de investigaci#{243}n intensificado con el

objeto de que las muertes en infancia y aquellas debidas a accidentes y enfermedades del coraz#{243}n

sean evitadas m#{225}seficazmente.

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1950;5;257

Pediatrics

LEONA BAUMGARTNER and VIVIAN PESSIN

As Evidenced by a Study of the Situation in the Past Decade in New York City

CURRENT PROBLEMS IN DEATHS OF PERSONS UNDER 20 YEARS OF AGE:

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