Annual Summary of Vital Statistics—1986

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CONTRIBUTOR’S

SECTION

VOLUME 80. DECEMBER 1987. NUMBER 6

PEDIATRICS

Vol. 80 No. 6 December

1987

817

Pediatrics

Annual

Summary

of Vital Statistics-1986

Myron

E. Wegman,

MD

From the School of Public Health, University of Michigan, Ann Arbor

Data from this article, as in previous po5 are drawn principally from Monthly Vital Statistics Report, pub-lished by the National Center for Health Statistics (NCHS).26 The international data come from the Demo-graphic Yearbook7 and the quarterly Population and Vital Statistics Report,8 both published by the Statistical Office of the United Nations, which has also been kind enough to provide directly more recent data. Except for mortality data by cause and age, which are based on a 10% sample, all the US data for 1986 are estimates by place of occur-rence, based upon a count of certificates received in state offices between two dates, 1 month apart, regardless of when the event occurred. Experience has shown that for the country as a whole the estimates, with few exceptions, are close to the subsequent final figures. There are consid-erable variations in some states, however, particularly in comparing provisional figures by place of occurrence and final data by pkzce of residence. State information should be interpreted cautiously.

Careful attention should be paid to the denominator when studying rates presented in this article. For overall rates, like the birth rate or death rate, the standard de-nominator is 1,000 total population. In instances where more refined analysis is possible, the denominator may be 100,000 and the character of the population specified. The particular denominator is indicated in the table or in the context.

previously (Table 1). Both the number of births

and the birth rate declined for the first time in

many years, reflecting the effect of the lowest

fer-tility rate in US history. Marriages and divorces

were also lower in 1986 than in 1985, both in

numbers and the corresponding rates.

In contrast to the above declines, the total

num-ber of deaths in 1986 increased over 1985, to the highest number ever recorded. However, the

popu-lation also increased; therefore, the crude death rate

actually decreased by about 1%. Because the

in-creased number of deaths was largely related to the increasing proportion of older persons in our pop-ulation, the age-adjusted death rate, which

compen-sates for changing age distribution, decreased to the lowest level in US history.

In Table 1 all data for 1986 are provisional, and, except for marriages and divorces, 1985 figures are final. In comparing the situation in 1986 with 1985,

one should remember that, in general, the final

1985 figures were slightly higher than the

compa-rable provisional ones published last year.

BIRTHS

Infant mortality in the United States continued

to edge lower in 1986 but at a slower rate than

Received and accepted for publication Aug 31, 1987.

Reprint requests to (M.E.W.) School of Public Health, Univer-sity of Michigan, Ann Arbor, MI 48109-2029.

Live Births and Fertility

Since 1975, with the one exception of 1982, the

number of births each year has been higher than

the year before (Fig 1). This has been primarily due to the increase in number of women in the child-bearing period, as the baby boom generation has come of age. This increase continued into 1986, the

estimated number of women in the childbearing

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180

160

140

4

“3

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=

0

70

65

0

120

100

0

80

0

60

40

20

1’

‘1,

C

E

0

0 0

0. a,

t

Fig 2. Seasonally adjusted fertility rate, United States, by month and four-month moving average, 1983 to 1987.

.-.-. ‘O

1920 1930 i940 1950 1960 1970 iaeo

1925 1935 1945 1955 1965 1975 19B5

VAR

0

Fig 1. Live births and fertility rates, United States, 1920 to 1986.

1983 1984 1985 1986 1987

TABLE 1. Vital Statistics of the United States*

Item No. Rate

1986t 1985 1986t 1985 1980 1950 1915

Live births 3,731,000 3,760,561 15.5 15.8 15.9 24.1 29.5

Deaths 2,099,000 2,086,440 8.7 8.7 8.8 9.6 13.2

Age-adjusted rate 5.4 5.5 5.9 8.4 14.4

Natural increase 1,632,000 1,674,121 6.8 7.0 7.1 14.5 16.3

Marriages 2,400,000 2,425,000t 10.0 10.2t 10.6 11.1 10.0

Divorces 1,159,000 1,187,000t 4.8 5.Ot 5.2 2.6 1.0

Infant deaths 38,600 40,030 10.4 10.6 12.6 29.2 99.9

Population base (in 241.1 238.3 227.1 150.7 100.5

millions)

* Data fromNationalCenter for Health Statistics2 and US Bureau of the Census.9”#{176}

Rates per 1,000 population except for infant mortality, which is per 1,000 live births.

t Provisional data.

:1:Birth rate adjusted to include states not in Birth registration area. Death rate is for death registration area. Infant death rate is for Birth registration area.

§ Midyear estimates based on April 1, 1980, census.

period being 1% higher than for 1985. Despite this increase, however, the number ofbirths in 1986 was approximately 0.5% lower than in 1985, because

the fertility rate was even lower in 1986 than the low levels that have prevailed throughout this dec-ade. In fact, the estimated 1986 fertility rate, 64.9

births per 1,000 women in the age range 15 to 44 years, was the lowest in our country’s history (Fig 1).

The Census Bureau predicts relatively little fur-ther change in the total childbearing population through 1990 but expects the number of women in the age group 15 to 24 years, the source of most

first births, to decline. When this prediction is

combined with the relatively low fertility rate in early 1987,” the monthly variation of which is shown in Fig 2 along with a 4-month moving aver-age, it seems likely that the total of 1987 births will be even lower than in 1986. There are obvious

portents for the future size of the child population.

Total Fertility Rate

Data on important details about birth statistics lag behind estimates based on provisional data, but final data are now available for 1985 for key

mdi-cators, such as the total fertility rate, an estimate of completed family size based on specific fertility

rates at various maternal ages. To reach a

station-ary population, a society must have, in the long run, an average of slightly more than two children

per woman. Specifically, the total fertility rate

would need to be 2,110 per 1,000 female population. The rate in the United States has been less than this level for some years; the 1985 total fertility rate was 1,842.5, an increase of 2% over 1984 but still less than replacement level. The rate for white women was 1,754 and the rate for black women was 2,196, both rates representing a 2% increase over

1984. Even the present black rate is only slightly more than replacement level.

The 1986 general fertility estimates suggest that

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CONTRIBUTOR’S SECTION 819 remain at present levels, the United States will

eventually reach zero population growth, assuming, of course, no major change in the immigration!

emigration balance.

Maternal Age

Since 1976 there was been an increase in birth rates for older women, amounting to more than 25% in the age group 30 to 39 years. Between 1984 and 1985 the increase for mothers between 35 and

39 years was almost 5% and only a bit less in the 30- to 34-year group, continuing evidence that more women are postponing having a family.

There was also, however, some increase in birth rate in every age group except those younger than

18 years. Since 1972 there has been a relatively steady decline in the birth rate for those 15 to 17 years of age, from 39 per 1,000 to 31.1 in both 1984

and 1985. On the other hand, little change has taken place in births to women younger than 15 years of age; there were 10,220 births among this group in 1985, 2.6% more than in 1984.

Births to all women younger than 20 years of age decreased by about 2,000, constituting in 1985

12.7% of all births, compared with 13.1% in 1984.

This decrease was clearly due to the smaller number

of women in the age group; the age-specific birth

rate for women younger than 20 years of age ac-tually increased from 50.9 to 51.3.

Births

to Unmarried Women

In general, the care an infant receives is closely related to the stability of the home, and that is usually adversely affected when the mother is

un-married. There is ample evidence that, overall, in-fants of unmarried mothers more often show evi-dence of poor health-low birth weight is a notable example-and poorer use of prenatal care than when the mother is married. Thus, it is of some concern that nonmarital births constituted 22% of all births in 1985; the total of 828,174, an 8% increase over 1984, was the highest in the 45-year period that national statistics have been available on this subject. The rate of births per 1,000 unmar-ned women aged 15 to 44 years increased 6%, from 31.0 to 32.8. Since 1980, the increase in the non-marital birth rate has been 12%; in contrast, the

marital rate decreased 3%.

Childbearing by unmarried women has, in the past, been much higher for black than for white women, the ratio of the respective rates having been about 7 to 1 in 1970. The difference has narrowed in the past 15 years as the white rate has increased and the black rate has decreased. In 1985 the ratio was 3.6 to 1, decreased slightly from 1984. Among white teenagers, 45% ofall births were to unmarried

mothers, in contrast to 90% among black teenagers. Another point of interest in nonmarital births

has been the increase among older women. The

birth rate to unmarried women between the ages of 25 and 39 years increased almost 20% from 1980 to

1985, much more, relatively, than the increase to

unmarried teenagers. In 1985, 30% of all nonmarital

births took place to women older than 25 years as

against 18% in 1970.

A related observation is that during this period

substantial shifts have taken place in the propor-tion of women in their 20s who are unmarried. Among white women 20 to 24 years of age, the proportion unmarried increased from 34% in 1965 to 51% in 1980, and for those 25 to 29 years the increase was from 12% to 27%. This is reflected in

the increasing median age at first marriage, which

will be discussed later.

A special study by Ventura’2 looked into marital

status at conception, information obviously not ob-tamable from the birth certificate. In her study she used data from national natality surveys conducted in 1964 to 1966, 1972, and 1980 by the National Center for Health Statistics. In 1980, the survey dealt with a probability sample of the 1,445,000

first births that occurred that year to unmarried or

once-married women. Of this group, 63% of the mothers were married at the time of conception. Of

the other 37%, those unmarried at conception,

ap-proximately #{189},12% of all first births, were married

before the actual birth took place. Previously, in

the 1964 to 1966 survey, the proportion unmarried at conception was slightly less, 33%, but more of

them, 57%, 19% of all mothers, were married at the time of the child’s birth. Put in another way, in 1964 to 1966, almost 3/5 of mothers unmarried at conception were married before the child’s birth, whereas in 1980 that proportion decreased to ‘/3.

Doubtless, some of the weddings that took place between conception and birth of the child had long been planned. It is a fair inference, however, that

many had not and that marriage before birth to

ensure legitimacy of the child seems not to be the imperative it once was.

Among the states there was considerable varia-tion in births to unmarried women. The national figure was 220 nonmarital births for every 1,000 total births; most of the states had between 150 and 250 nonmarital births. The highest ratio of non-marital to all births was in the District of Columbia, with 567 (56.7%), whereas the lowest rate was in

Utah, with 87 per 1,000.

A mother’s marital status is reported on the birth

certificate in 41 states and the District of Columbia. Until 1980, the National Center for Health Statis-tics estimated the national total by assuming that the situation in the other nine states (California,

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Connecticut, Massachusetts, Michigan, Missouri, Nevada, New York, Ohio, and Texas), which

to-gether have about 39% of all births in the country, was parallel to the 41 states that did report. In 1980, the method of estimation in the nine states not reporting specifically was changed; and marital

5th-tus is not inferred by comparing the surnames of the child, the father and the mother, both her

present and her maiden names. Although there are certainly some exceptions and uncertainties in doing the estimates this way, various tests of the validity of the inferences indicate that they yield a higher degree of accuracy than the previous method.

Place of Birth and Attendant at Birth

For some years approximately 99% of all births have occurred in hospitals. Recently, this

propor-tion has been even higher for black births than for

white, in striking contrast to the situation not too

many years ago. Proportionally, twice as many white births as black births took place outside a hospital in 1985.

The recent trend toward more deliveries by mid-wives has continued, both in and out of hospitals. Midwives attended approximately 3% of all black

births and 2% of white births in hospitals in 1985;

10% more than in 1984. Outside the hospital the situation was different, midwives having attended 2% more white births in 1984, but 8% fewer black births. Furthermore, midwives attended 47% of all white births that took place outside of a hospital and only 15% of black births.

There is a great deal ofvariation among the states in the use of midwives. In nine states they attended 0.1% or less of all hospital births, whereas in 14

states and the District of Columbia, midwives

de-livered 4% or more of all births.

Weight at Birth

Overall, the percentage of infants weighing less than 2,500 g at birth was little changed: 6.8% in

1985 v 6.7% in 1984. The median birth weight was 3,370 g (7 lb 7 oz), essentially the same as the

previous year. A substantial difference was ob-served in the proportion of low birth weight by race, the level for black babies having been 12.4% and white 5.6%. Variation among the other races was much narrower, with the lowest rate, that among

Chinese babies, 5.0%, and the highest, 6.9%, among

Filipino babies.

There was a curious lack of close correlation between these percentages and the median birth weight. For the black population, the high percent-age of babies weighing less than 2,500 g was asso-ciated with a low median birth weight, 3,180 g. On the other hand, Chinese babies, only 5% of whom

weighed less than 2,500 g, also had a relatively low median weight, 3,290 g, as did Japanese babies. In contrast, American Indian and Filipino babies had high median weights, 3,400 and 3,460 g,

respec-tively, but 5.9% and 6.9% of the babies,

respec-tively, weighed less than 2,500 g. Because the latter two racial groups tend to have relatively high infant mortality, which is usually associated with a high incidence of prematurity, one wonders whether, given the relatively high median birth weight, a

figure of 2,500 g may be too low as a dividing line for providing special care to these babies.

Prenatal

Care

No improvement has occurred with regard to

timeliness of prenatal care. In 1985, 21% of white

mothers and 38% of black mothers still did not have prenatal care in the first trimester of preg-nancy, the desirable time to begin preventive care. Furthermore, as in the previous 3 years, 5% of white

mothers and 10% of black mothers either had no

prenatal care at all or had too little, too late. In 29 states and the District of Columbia, the proportion of mothers receiving delayed or no

pre-natal care increased and in only 1 1 states was any

improvement reported. With so tried and true a preventive technique as prenatal care there seems

little justification for not further reducing the

pro-portion of failures.

Geographic Variation

Between 1985 and 1986, the national decline in

birth rate was paralleled in eight of the nine

geo-graphic divisions of the country (Table 2). Only in

the Middle Atlantic region was a small increase reported and that was accounted for by an increase

in the New York State rate from 14.4 to 14.9, still

well below the national figure. Between 1984 and 1985, however, almost the reverse was true; the

number of births had increased in all nine divisions and the birth rate in six.

Variations among the individual states continues, with the highest 1986 birth rates in Alaska and

Utah (23.2 and 22.4, respectively) and the lowest in

West Virginia (12.6). Fertility rates in 1985 showed similar variation, with Alaska and Utah at 98.0 and West Virginia at 54.0.

Natural Increase

As might be expected from the decline in births and birth rates, the natural increase was less (Table

1). The rate of increase declined 2%, from 7.0 per

1,000 in 1985 to 6.8 in 1986. If the total fertility

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TABLE 2. Live births and Infant and Neonatal Mortality: Each State and Regions

State and Region Live Births (No.) Deaths of Infants <1 yr Mortality

ofAge RateI

1986t 1985t 1986t 1985t 1985 <lyr <28d

(1985) (1985)

New England 170,440 173,127 1,427 1,605 1,654 9.2 6.7

Maine 16,022 16,211 123 144 154 9.1 6.5

New Hampshire 16,361 15,724 118 106 144 9.3 6.3

Vermont 7,529 7,925 62 58 68 8.5 5.4

Massachusetts 75,998 82,872 604 755 743 9.1 6.5

Rhode Island 13,935 13,517 138 128 107 8.2 6.0

Connecticut 40,595 36,878 382 414 438 10.0 7.8

Middle Atlantic 529,790 521,643 5,486 5,658 5,676 10.8 7.4

New York 264,844 256,049 2,840 2,810 2,791 10.8 7.4

NewJersey 104,506 103,308 876 1,033 1,119 10.6 7.2

Pennsylvania 160,440 162,286 1,770 1,815 1,766 11.0 7.6

East North Central 618,696 626,650 6,640 6,595 6,912 10.9 7.3

Ohio 158,277 160,898 1,554 1,656 1,660 10.3 6.7

Indiana 79,630 80,774 862 837 883 10.9 7.5

Illinois 172,321 177,803 2,033 1,993 2,123 11.7 8.0

Michigan 136,198 134,090 1,549 1,474 1,572 11.4 7.8

Wisconsin 72,270 73,085 642 635 674 9.1 5.6

West North Central 265,986 275,155 2,599 2,639 2,609 9.5 5.9

Minnesota 64,819 66,270 605 634 594 8.8 5.4

Iowa 38,794 42,084 308 356 391 9.5 5.9

Missouri 76,224 77,186 872 811 789 10.2 6.5

NorthDakota 11,900 12,717 113 126 100 8.5 5.4

SouthDakota 11,714 12,253 136 103 120 9.9 5.4

Nebraska 24,433 25,688 248 271 246 9.6 6.2

Kansas 38,102 38,957 317 338 369 9.3 6.0

South Atlantic 606,735 601,687 7,099 7,055 7,261 12.1 8.2

Delaware 9,768 9,843 109 130 142 14.8 10.6

Maryland 61,953 60,019 637 574 808 11.9 8.2

District of Columbia 20,368 20,541 400 454 205 20.8 15.9

Virginia 84,209 83,184 881 926 989 11.5 8.1

West Virginia 24,195 25,589 253 268 259 10.7 7.3

North Carolina 90,597 89,859 1,058 1,086 1,051 11.8 7.8

South Carolina 49,604 49,300 649 691 738 14.2 10.0

Georgia 98,786 99,792 1,220 1,074 1,222 12.7 8.6

Florida 167,255 163,560 1,892 1,852 1,847 11.3 7.4

East South Central 221,525 223,449 2,561 2,757 2,701 12.1 7.9

Kentucky 51,682 51,710 477 555 594 11.2 7.5

Tennessee 71,890 70,547 820 876 759 11.4 7.5

Alabama 56,417 58,807 786 763 752 12.6 8.3

Mississippi 41,536 42,385 478 563 596 13.7 8.4

West South Central 474,837 483,106 4,948 5,051 4,968 10.4 6.6

Arkansas 34,063 35,079 326 380 409 11.6 7.1

Louisiana 77,953 81,136 943 967 968 11.9 7.7

Oklahoma 48,061 51,910 508 605 577 10.9 6.8

Texas 314,760 314,981 3,171 3,099 3,014 9.8 6.2

Mountain 229,868 236,406 2,210 2,268 2,317 9.8 5.7

Montana 12,372 13,236 86 109 139 10.3 5.0

Idaho 16,329 17,492 177 134 183 10.4 6.3

Wyoming 8,011 8,838 55 70 114 12.2 6.4

Colorado 55,724 55,319 529 588 519 9.4 5.5

New Mexico 23,952 28,904 256 280 295 10.6 6.3

Arizona 60,890 58,829 595 562 577 9.7 5.9

Utah 37,368 38,431 365 394 360 9.6 5.4

Nevada 15,222 15,357 147 131 130 8.5 4.8

Pacific 600,906 618,184 5,555 5,956 5,932 9.7 5.9

Washington 68,754 76,205 694 778 752 10.7 6.2

Oregon 40,356 40,448 360 409 389 9.9 5.3

California 461,162 470,733 4,205 4,479 4,490 9.5 6.0

Alaska 12,371 12,570 124 125 139 10.8 5.1

Hawaii 18,263 18,228 172 165 162 8.8 5.8

* Data from National Center for Health Statistics.2’8

t Provisional data, by state of occurrence.

:1:Rates per 1,000 live births. Final 1985 data (columns 5, 6, and 7) are by state of residence.

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0 Ii iii, II11 1iii ii iiiiI iiii iiiii Ii I II I I! IIIi ii i ii ii i 0

19 30 1940 1950 960 1970 iseo i 990

Fig 3. Marriage and divorce rates, United States, 1930 to 1986.

increase will continue to shrink but is not expected to reach zero for several decades.

MARRIAGES

The number of marriages decreased about 1% (2,400,000 v 2,425,000) in 1985. As may be seen in Fig 3 the increase and decrease of the marriage rate since 1977 seems to be repeating, in a general way,

the pattern of the preceding decade. Although lower than previously, the 1986 rate was well above the all time low of 7.9 observed in 1932 and has not even dipped to the levels of the late 1950s or early

1960s.

As in any other measure in which the denomi-nator is the total population, one must look also at what proportion of that population, or denomina-tor, has any real likelihood of being married, ie, how many are in the “marriageable” years, older than 15 years of age, and not already married. From the middle 1970s to 1984, an unusually large pro-portion of the population consisted of unmarried persons in the most marriageable ages, taken arbi-trarily as 15 to 44 years of age. In 1985 and 1986, however, as the population has grown, the high proportion disappeared and the marriage rate per

1,000 total population decreased.

Both the total marriage rate and the total first marriage rate, discussed at greater length in last year’s article,’ were slightly higher for men and women in 1984 than in i983, but there appears to

be no particular long-term trend. On the other hand, the trend toward higher age at marriage continued between 1983 and 1984, for both men and women and for both first marriage and remar-riages. The median age at first marriage in 1984 was 22.8 for brides and 24.6 for grooms, in both

instances the highest levels reported since national

figures were first published in 1963. Nevertheless, in those marriages that took place in 1984, 15% of the brides were younger than 20 years of age, as

were 6% of the grooms.

DIVORCES

There was a 2% decrease in the number of di-vorces in 1986, 1,159,000 in comparison with

1,187,000 in 1985, with a 4% decline in the divorce rate between the 2 years. The 1986 rate of 4.8 is

the lowest since 1975 but is still greater than the level of 2.0 recorded in 1940.

In 1984, divorces affected 1,181,000 children younger than 18 years, a decline of 10,000 from

1983. An average of 0.92 children were involved per

decree, the same as in 1955. The proportion of all children younger than 18 years that were in families that divorced in 1984 was 1.72%, a decrease of almost 9% from 1983.

DEATHS

Again, there was an increase in number of deaths, to an estimated 2,099,000 in 1986. The population

increased relatively more, however, so the crude death rate declined slightly, to 870.8 per 100,000.

What is more significant from a health standpoint is the trend of the age-adjusted rate, a hypothetical

rate that takes into account the changing age dis-tribution of the population. The age-adjusted rate declined from 545.9 deaths per 100,000 in 1985 to 540.2 in 1986, the lowest rate ever recorded in the United States. An indication of the trend in both crude and age-adjusted rates per 1,000 population

may be seen in Table 1.

One important use of age-adjusted rates is to

compare differences by race and sex. In 1986 the rate for white females was 387.0, black females 585.0, white males 680.7, and black males 1003.4. Three of those rates were the lowest ever recorded but the rate for black females had been as low as 581.4 in 1982.

Life Expectancy

Another way to examine differences in death

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expec-I

I-ck

>-0 z

0

w

a->(

w

h

55

-J

-.-‘-4-’-’-*-’-a

75

65 ...-‘ *

60

#{163}-6White Female

o-oWhjte Male

A- -Black/NW Female

.- -.Black/NW Male

1950 1 955 1 960 1965 1970 1 975 1980 1985

YEAR

Fig 4. Life expectancy at birth, by sex and race, United

States, 1950 to 1986. Years for which rates are for

nonwhite (NW).

CONTRIBUTOR’S SECTION 823

tation oflife. Life tables, like many other statistical analyses, are hypothetical estimates of what would happen if the age-specific death rates that prevail in a given year were to continue throughout one’s lifetime; thus, the trend in life expectancy parallels that of the age-adjusted death rate. The provisional abridged life table for the total population of the

United States for 1986 is given in Table 3; it is “abridged” because the data are for 5-year groups rather than individual years.

Basically, a life table follows a hypothetical co-hort of 100,000 persons from birth through their lifetimes. The various columns in Table 3 are ex-plained in the headings; eg, column 2 is the proba-bility of dying expressed as a proportion; thus, the rate for age 0 to 1 year translates into 10.3 per 1,000. This rate is not identical with the infant mortality rate because of a difference in the method of calculation. Columns 3, 4, and 5 are

self-explan-atory. Column 6, although more difficult to com-prehend, is a figure needed for some of the calcu-lations. Column 7, commonly called life expectancy, shows the average remaining lifetime at the

begin-ning age for each age group.

This life table inter cilia demonstrates the striking increase in numbers of persons reaching the older age groups. For example, column 3 shows that more than 45% of the cohort would be expected to live to the age of 80 years and almost 30% to 85 years.

In the past, increase in life expectancy was due

chiefly to a decline in infant mortality, but recently

decline in mortality among older age groups, partic-ularly males, has had a substantial effect.

There are manifest differences in average ex-pected lifetime at birth for each sex and race, and

trends of these data are shown in Fig 4, at 5-year

intervals for 1950 to 1980 and yearly thereafter. Because data were not available for just the black

population before 1970, the figures on the relevant

curves before that date represent the total nonwhite

population. This shift in base may help explain at

least part of the apparent sharp decrease in life expectancy in black males in 1970. In fact, the nonwhite life expectancy subsequent to 1970 was

consistently greater than the black alone, for both

TABLE 3. Provisional Abridged Life Table, United States, 1986* Period of Life

Between 2 Exact Ages

(yr) (x to x + n)

Proportion of Persons Alive at Beginning of

Age Interval Dying During

Interval (q)

Of 100,000 Born Alive Station ary Population No. of yr of Life Remaining at Beginning of Age

Intea1 () No. Living

at Beginning of Age Interval

(Ii)

No. Dying During Age

Interval

(d)

In the Age Interval

(,,L,,)

In This and All Subsequent Age Intervals

(Ti)

0-1 0.0103 100,000 1,030 99,113 7,485,374 74.9

1-5 0.0020 98,970 197 395,418 7,386,261 74.6

5-10 0.0013 98,773 125 493,525 6,990,843 70.8

10-15 0.0014 98,648 135 492,978 6,497,318 65.9

15-20 0.0043 98,513 421 491,610 6,004,340 60.9

20-25 0.0059 98,092 578 489,044 5,512,730 56.2

25-30 0.0059 97,514 579 486,121 5,023,686 51.5

30-35 0.0071 96,935 686 483,001 4,537,565 46.8

35-40 0.0089 96,249 857 479,224 4,054,564 42.1

40-45 0.0129 95,392 1,229 474,107 3,575,340 37.5

45-50 0.0190 94,163 1,786 466,677 3,101,233 32.9

50-55 0.0313 82,377 2,896 455,100 2,634,556 28.5

55-60 0.0480 89,481 4,299 437,275 2,179,456 24.4

60-65 0.0747 85,182 6,360 410,871 1,742,181 20.5

65-70 0.1073 78,822 8,458 373,878 1,331,310 16.9

70-75 0.1601 70,364 11,268 324,630 957,432 13.6

75-80 0.2307 59,096 13,633 262,229 632,802 10.7

80-85 0.3420 45,463 15,549 188,653 370,573 8.2

85 1.0000 29,914 29,914 181,920 181,920 6.1

8 Data from the National Center for Health Statistics2 and based on a 10% sample of deaths.

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TABLE 4. Death Rates, Crude and Age-adjusted, With Sex and Race Ratios, for Leading Causes of Death, United

States, 1986 and 1985*

1986t ₁₉₈₅

Age-Adjusted

Ratio

M/F B/W

% of Crude Age-Adjusted

All Death Death Death

Deaths Rate Rate Rate

All causes 100 870.8 540.2 546.1 1.75 1.49

Major cardiovascular diseases 46.1 401.5 214.4 224.0 1.80 1.41

Malignant neoplasms 22.2 193.3 132.5 133.6 1.48 1.32

Respiratory diseases 7.0 60.7 32.3 32.2 2.04 1.05

(Pneumonia and influenza) (3.2) (29.2) (13.6) (13.4) 1.80 1.45

(Chronic obstructive diseases) (3.6) (31.3) (18.5) (18.7) 2.23 0.78

Accidents 4.6 39.7 35.5 34.7 2.78 1.16

(Motor vehicle) (2.3) (20.1) (19.8) (18.8) 2.60 0.91

(Other) (2.2) (19.5) (15.7) (16.0) 2.98 1.49

Diabetes mellitus 1.7 15.1 9.4 9.6 1.05 2.29

Perinatal conditions and congenital anomalies 1.4 12.6

Suicide 1.5 13.1 12.0 11.5 3.84 0.96

Chronic liver disease and cirrhosis 1.2 10.9 9.2 9.6 2.23 1.81

Homicide and legal intervention 1.0 8.9 8.8 8.3 3.28 4.52 8 Data from National Center for Health Statistics.2’6 Parentheses indicate inclusion in category above. Percentages shown total 86.8% of all causes. Rates per 100,000 population.

t Provisional data.

:1:Because almost all deaths occur in infancy, no age-adjusted rates are shown for these causes.

*Data from National Center for Health Statistics.6

males and females. In any event, one should use

data on the nonwhite population before 1970 only

as an “order of magnitude” comparison.

Since 1970, life expectancy for black females has

exceeded that for white males but was still 5.3 years less in 1985 than for white females. The racial

difference among males was greater-white males had a life expectancy 6.5 years longer than black

males. Nevertheless, since 1970 the increase in life

expectancy for black males, 9.2%, has exceeded the other three groups: white males 5.9%, black females 7.8%, and white females 4.4%. White females

con-tinue to have the longest life expectancy of any of the race-sex groups.

Some international comparisons are discussed later, in connection with infant mortality.

Causes of Death

Death rates for the major cause groups are shown

in Table 4, making up 87% of all causes of death.

Major cardiovascular diseases appear to have de-dined, consistent with the long-term trend, and the

1986 age-adjusted rate was 4% lower than that for

1985. Malignant neoplasms also showed a decrease

(close to 1%). Motor vehicle accidents increased more than 5% but other forms of accidents declined

slightly. Little change was observed in the other causes.

The differences between the sexes and races in the various causes of death were approximately

similar to previous years. Homicide and legal

inter-vention was five times as frequent in the black population as in the white and three times as fre-quent in men as in women. On the other hand, blacks had half the suicide rates of whites, and men

TABLE 5. Infant Mortality by Age and Race, Selected

Years

1985 1984 1980 1970 1950 % Decline 1950-1985

Total 10.6 10.8 12.6 20.0 29.2 63.7

White 9.3 9.4 11.0 17.8 26.8 65.3

Black 18.2 18.4 21.4 32.6 43.9 58.5

B/W ratio 2.0 2.0 1.9 1.8 1.6

<28 d 7.0 7.0 8.5 15.1 20.5 65.9

White 6.9 6.2 7.5 13.8 19.4 64.4

Black 12.1 11.8 14.1 22.8 27.8 56.5

B/W ratio 1.8 1.9 1.9 1.7 1.4

Postneonatal 3.7 3.8 4.1 4.9 8.7 57.5

White 3.2 3.3 3.5 4.0 7.4 56.8

Black 6.1 6.5 7.3 9.9 16.1 62.1 B/W ratio 1.9 2.0 2.1 2.5 2.2

had more than three times the suicide rate of women. Blacks were less likely than whites to die

of chronic obstructive pulmonary disease.

INFANT MORTALITY

Age and Race

Little change has appeared in the differences between the races in infant mortality, as shown in

Table 5 and Fig 5. Both white and black infant mortality rates declined but the black rate con-tinued to be twice the white rate. The white neo-natal rate increased between 1984 and 1985, unlike

the decline observed between 1983 and 1984. The

black postneonatal rate has decreased to less than the white neonatal rate, as it was before 1983.

At least part of the explanation for the difference

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100

U,

§

1950 1955 1960 1965 1970 1975 1980 1995

YEAR

Fig 5. Infant mortality rates by race and sex, United States, 1950 to 1985.

CONTRIBUTOR’S

SECTION

825

related to the observation earlier about the

differ-ence between the races with respect to prenatal care. Recently, Berman and colleagues13 reported a

sharp increase in infant mortality in Jersey City in 1981 and 1982. One of the differences they were

able to identify was a deterioration in prenatal care. In the population group in which the increase in

infant mortality rate was most pronounced, the

percentage of mothers who had fewer than three prenatal care visits increased from 5.6% in 1979 to

11.6% in 1982. More of these mothers also failed to obtain prenatal care during the first trimester. The authors believe that their data justify intensified efforts to increase the availability of prenatal care,

a lesson that almost surely can be extended else-where in the country.

Causes of Infant Death

Some of the problems in trying to analyze cause of death from provisional figures are demonstrated in Table 6. Last year it appeared that there had

10

--- Block N#{149}enotol WPflts N#{149}onotol

.Block Po.tn.onotol Whit. Po.tn.onotol

been a decrease in deaths from “certain perinatal conditions,” but final 1985 figures show rates al-most identical with those in 1984. On the other

hand, the final figures for congenital anomalies

were less than the provisional data.

There were fairly large discrepancies between the

races in the various causes of death, with the

strik-ing exception of congenital anomalies; here, the ratio was essentially 1.0, ie, no real difference be-tween blacks and whites. As pointed out last year, observations in Japan and other areas suggest that the incidence of congenital anomalies may not vary much among the races of mankind.

The black to white ratio with regard to short

gestation and low birth weight was even more

strik-ing than in the 1984 figures. The problem of the

high incidence of low birth weight in black infants,

much greater than in other racial groups, was

dis-cussed earlier in the section on births. This is a subject crying out for intensified research.

Final data for 1985 show that sudden infant death syndrome (SIDS) accounted for more than 12% of

all infant deaths. A similar proportion was observed among black infants, despite the fact that black infant mortality is so much higher. SIDS is a serious problem, but it appears possible that this diagnosis,

which essentially must be made by exclusion, is

being overused, perhaps because of insufficient ef-fort to find more specific causes. Bass et al’4 carried out detailed death-scene investigations of deaths reported as SIDS and found that a significant num-ber probably were due to other causes. To develop preventive measures for this most distressing

con-dition it seems important to concentrate on clear

cases rather than an inflated number.

Geographic Variations

In last year’s paper I discussed at some length

TABLE 6. Infant Mortality Rates and Black to White Ratios for Major Cause Groups*

lCD Codest Provisional

1986 1985

Fin a! 1985

Total White Black B/W Ratio

All causes 1,039.2 1,057.0 1,064.5 931.5 1,819.0 1.95

Certain perinatal conditions 760-4, 766, 770-9 266.2 264.5 282.7 232.1 567.5 2.45

Congenital anomalies 740-759 218.9 236.7 227.7 230.6 233.3 1.01

Sudden infant death syndrome 798.0 130.4 129.6 141.3 125.6 223.1 1.78

Respiratory distress syndrome 769 94.4 100.7 98.2 90.5 149.8 1.66

Short gestation & low birth 765 87.9 83.3 86.6 62.3 217.9 3.50

weight

Intrauterine hypoxia-birth as- 768 24.2 28.4 30.8 26.1 58.2 2.23

phyxia

Pneumonia & influenza 480-487 18.0 17.9 18.7 14.8 39.0 2.64

Birth trauma 767 8.6 7.5 8.7 7.4 16.3 2.20

Certain gastrointestinal diseases 008-9, 535, 555-8 5.9 4.8 5.4 3.5 14.9 4.26

All other causes Residual 184.7 183.9 164.4 138.6 299.0 2.16

* Data from National Center for Health Statistics.2’6 Rates per 100,000 live births.

t International Classification of Diseases (lCD), ninth revision.

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TABLE 7. Births, Infant Mortality, and Life Expectancy

Than 2,500,000*

at 1 Year of Age in 25 Countries With Populations Greater

Country Births for Infant Mortality Life Expectancy

(Listed in Order of 1986t

1985 Infant Mortality Rate)

No.

Rate

1986t 1985

at 1 y4

Rate Male Female

Japan 1,431,577 (1985) 11.9 5.5 74.0 79.6

Finland 60,799 12.4 6.3 70.0 78.2

Sweden 102,000 12.2 6.7t 73.4 79.3

Switzerland 76,000 11.7 6.9 72.3 79.1 (1981-1982)

Hong Kong 76,126 (1985) 14.0 7.5 72.3 78.1 (1983)

Canada 378,260 14.8 7.9 71.7 78.7 (1980-1982)

Denmark 53,370 10.8 7.9 71.2 77.1

Netherlands 185,000 12.7 8.1 7.9t 72.7 79.2

France 778,940 14.1 8.Ot 70.2 78.0

Norway 52,543 12.6 8.5 72.3 79.1 (1982-1983)

German Federal Republic 624,400 10.2 8.9 70.7 77.2 (1982-1984)

Ireland 61,425 17.4 8.7 8.9t 69.9 75.4 (1980-1982)

Singapore 39,400 15.5 9.1 9.3t 68.6 73.9 (1980)

United Kingdom 755,000 13.3 9.3t 71.4 77.3

Belgium 117,102 11.8 9.7 9.4t 70.0 76.6 (1979-1982)

German Democratic Republic 222,268 13.4 9.2 9.6t 69.4 75.1

Australia 239,004 15.0 9.8 10.Ot 72.4 78.7

Spain 465,709 (1984) 12.1 10.5 70.9 76.5 (1975)

United States of America 3,731,000 15.5 10.4 10.6 71.1 78.0

New Zealand 52,832 16.3 10.8t 71.1 77.4

Italy 576,165 (1985) 10.1 10.9t 70.9 77.3 (1977-1979)

Austraia 86,265 11.4 10.3 11.Ot 70.0 77.0

Israel 99,258 23.1 11.4 12.3t 73.0 76.6

Greece 112,250 11.3 12.3 14.Ot 72.2 75.3 (1980-1985)

Czechoslovakia 220,000 14.2 14.0 67.3 74.3

* Data from United Nations Statistical Office.7’8

t Provisional data. Infant mortality rate per 1,000 live births. :1:Data for 1984 or year(s) shown.

§ Data for 1983.

some of the possibilities and some of the pitfalls in

comparing rates among the states and localities.

This year, again, provisional infant mortality rates

are not presented for the states (Table 2), because

in some states there is so much change between the provisional and final figures. Anyone who is

partic-ularly interested in an individual state can, of

course, calculate the rate easily by dividing the provisional figures for infant deaths by the provi-sional figure for live births but, by the time this

appears in print, most state offices will be able to provide more reliable data based on residence.

Because they constitute larger groupings, data for the nine regions of the country are less likely to

be affected by differences between data by place of occurrence and by place of residence. In five of the

nine regions, East North Central, West North

Cen-tral, South Atlantic, West South Central, and Mountain, the infant mortality rate showed little

or no change between 1985 and 1986. Four regions showed declines, New England from 9.2 to 8.4, East South Central from 12.3 to 11.6, Middle Atlantic from 10.8 to 10.4, and Pacific from 9.6 to 9.2.

The lowest final rate reported for 1985 was 8.2

in Rhode Island. It is one of the smaller states and the rate is based on slightly more than 100 infant

deaths. Five other states, four also small, reported rates between 8.5 and 8.8.

The highest rate was reported again from the

District of Columbia which, as has been noted previously, is a metropolitan area, different from a

state. Among the states, the highest mortality was

observed in Delaware, one of the smallest states,

which had an increase from the 1984 rate of 10.8 to

14.8 in 1985. When one is dealing with small

num-bers, of course, small variations may bring relatively

large changes in rates; the provisional 1986 rate for Delaware, 11.2, decreased considerably from the

provisional 1985 rate of 13.2.

South Carolina and Mississippi, which had the highest rates in 1984, both showed improvement in 1985. Regionally, New England showed the lowest rate in 1985 (9.2) and the highest rate that year was

seen in South Atlantic and East South Central,

both showing 12.1. For neonatal deaths, the distri-bution was somewhat different, with the lowest rates in the Mountain, Pacific, and West North Central regions.

International Comparisons

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pedi-CONTRIBUTOR’S SECTION 827 atrics, Arvo Ylppo, acclaimed by his Finnish

col-leagues as Archiater. His long-term commitment to

reducing infant mortality everywhere helped stim-ulate me to do these international comparisons and made it particularly pleasurable to report to him that, by 1981, Finland led the way. Professor Ylppo

is still active and as dynamic as ever; it is an honor

to congratulate him on his 100th birthday, Oct 27,

1987.

Only minor changes have occurred in the list of

25 countries with populations greater than 2.5 mil-lion which had the lowest infant mortality rates in

1985. Despite the extraordinarily low levels previ-ously achieved, most of the rates declined still

fur-ther, and nine countries, with populations totaling approximately 200,000,000 people, had infant

mor-tality rates lower than the 1985 Rhode Island rate,

lowest of any state in the United States. Further-more, Japan achieved a rate of 5.5 and three other

countries had rates less than 7. Even the countries

with the highest rate on this list, Greece and Czech-oslovakia, are at 14.0/1,000, lower than our two

highest states.

Life expectancy, discussed earlier as another

ap-proximate measure of comparative health status,

is, of course, greatly affected by infant mortality. Thus, one of the first concomitants of a sharply decreasing infant mortality rate is a considerable extension of life expectancy. For example, the pop-ulation division of the United Nations has estimated7 that in China, where, even though com-plete data are not available, there have clearly been

drastic reductions in infant mortality, the life

ex-pectancy currently is about 67 years for men and 69 years for women.

It seemed useful, therefore, to examine United

Nations data on life expectancy among the coun-tries with the lowest infant mortality rates. For this purpose, life expectancy at 1 year of age (ie, for

those who have survived infancy and the risk of infant mortality) is shown in Table 7 for the coun-tries listed. Although there is a great deal of varia-tion from the order shown for infant mortality, there is a general parallelism. On the other hand, there are some discrepancies. Israel and Greece show life expectancy for men greater than what one

would have expected from the infant mortality rates

and, conversely, Finland had a lower male life ex-pectancy than one would have expected from its

low infant mortality rate. One explanation may

apply in the latter instance. Life expectancy is

affected by the age-specific mortality rates later in

life, and Finland has had the dubious distinction of higher death rates from coronary heart disease than

many other countries.

The variations that are apparent in Table 7

among the 25 countries included reinforce the con-cept that, although indices based on reported vital

statistics rates may be useful guideposts, they must

be interpreted in the light of many other

observa-tions and findings and in no instance should be used as sole scorecards.

A recent monograph by Miller’5 notes that ten European countries (Belgium, Denmark, France, Federal Republic of Germany, Ireland,

Nether-lands, Norway, Spain, Switzerland, and the United

Kingdom), most with fewer resources than the United States, have better records of child survival

(cf Table

7).

Miller reports that all ten countries have easily understood and readily available pro-vider systems, no economic or other barriers to the full range of services offered, and linkage of

pre-natal care to comprehensive social and financial benefits, enabling pregnant women and new moth-ers to protect their own health and nurture their

children. These are worthy goals for the United

States and they are achievable if we are serious

about substantial lowering of infant mortality.

REFERENCES

1. Wegman ME: Annual summary of vital statistics-1985. Pediatrics 1985;78:983-994 (see also similar summaries an-nually since 1950)

2. Annual summary of births, deaths, marriages and divorces, United States, 1986. Monthly Vital Statistics Report, Na-tional Center for Health Statistics, vol 35, No. 13, Aug 24, 1987

3. Final natality statistics, 1985, advance report. Monthly Vital Statistics Report, National Center for Health Statistics, vol 35, No. 4 (suppl), July 17, 1987

4. Final marriage statistics, 1984, advance report. Monthly Vital Statistics Report, National Center for Health Statis-tics, vol 36, No. 2 (suppi 2), June 3, 1987

5. Final divorce statistics, 1984, advance report. Monthly Vital

Statistics Report, National Center for Health Statistics, vol 35, No. 6 (suppi), Sept 25, 1986

6. Final mortality statistics, 1985, advance report. Monthly Vital Statistics Report, National Center for Health Statis-tics, vol 36, No. 5 (suppi), Aug 28, 1987

7. Demographic Yearbook 1985. New York, United Nations, 1986

8. Statistical Papers: Population and Vital Statistics Reports. New York, United Nations, 1987, series A, vol 39 9. Linder FE, Grove RD: Vital Statistws Rates in the United

States, 1900-1940, US Bureau of the Census. Government Printing Office, 1943

10. Grove RD, Hetzel AM: Vital Statistics Rates in the United States, 1940-1960, National Center for Health Statistics. Government Printing Office, 1968

11. Births, marriages, divorces and deaths for May, 1987. Monthly Vital Statistics Report, National Center for Health Statistics, vol 36, Aug 13, 1987

12. Ventura SJ: Trend in marital status of mothers at concep-tion and birth of first child. Monthly Vital Statistics Report, National Center for Health Statistics, vol 36, No. 2 (suppl), May 29, 1987

13. Berman SM, Shapiro E, Hogue CJR, et al: Increased infant mortality in Jersey City. Public Health Rep 1987;102:404 14. Bass M, Kravath RE, Glass L: Death-scene investigation in

sudden infant death. N EngI J Med 1986;315:100-105 15. Miller CA: Maternal Health and Infant Survival.

Washing-ton, DC, National Center for Clinical Infant Programs, 1987

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1987;80;817

Pediatrics

Myron E. Wegman

1986

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