Search

Recently, the functioning of State-level expert review committees, operating under the auspices of professional medical societies, has become problematic. In particular, an increased number of State maternal mortality review committees have become inactive or disbanded primarily because of concern over liability of committee members and committee proceedings being used in litigation. A study was conducted of legal protection of the expert review process at the State level. The relevant immunity and privilege statutes of each State and the protection afforded by State law were analyzed. Findings show that, in all but a few States, the legal risk of participating in expert review is negligible. Most States have statutes that protect information involved in the review process from disclosure or use in subsequent litigation. Laws in most States also protect participants in the review process (both members of committees and providers of information) from civil liability.

To describe underlying causes of infant death by birth weight, we used data from the 1980 National Infant Mortality Surveillance project and aggregated International Classification of Diseases codes into seven categories: perinatal conditions, infections, congenital anomalies, injuries, sudden infant death syndrome (SIDS), other known causes, and nonspecific or unknown causes. Compared with heavier infants, infants with birth weights of 500-2,499 grams (g) are at increased risk of both neonatal and postneonatal death for virtually all causes. Sixty-two percent of neonatal deaths (under 28 days of life) were attributed to "conditions arising in the perinatal period," as defined using codes from the International Classification of Diseases. Prematurity-low birth weight and respiratory distress syndrome (RDS) were the leading causes of such deaths among infants with birth weights of 500-2,499 g, while birth trauma-hypoxia-asphyxia and other perinatal respiratory conditions were the leading causes among heavier infants. For all birth weight groups, congenital anomalies were the second leading cause, representing 27 percent of neonatal deaths. Although perinatal conditions caused nearly one-third of postneonatal deaths (28 days to under 1 year of life) among infants with birth weights of 500-1,499 g, for the other birth weight groups these conditions were much less important; predominant causes of postneonatal death were sudden infant death syndrome (SIDS), congenital anomalies, infections, and injuries. Black infants had a roughly twofold higher risk of neonatal and postneonatal death than did white infants for all causes except congenital anomalies, which occurred with almost equal frequency in blacks and whites. However, for infants with birth weights of 500-2,499 g, blacks had lower risks of neonatal death from RDS and congenital anomalies. Between 1960 (the latest year for which national birth weight-specific mortality statistics had been available) and 1980, SIDS emerged as a major diagnostic rubric. Otherwise, except for infections and congenital anomalies among infants with birth weights of 500-1,499 g, all causes of death declined in frequency among all birth weight groups.

Data from personal interviews with 705 Mexican American and 363 Anglo women during the 1979 U.S. Mexico Border Survey were analyzed to answer the question, To what extent do Mexican Americans and Anglos differ in having the number of children they want, when they want them? Mexican Americans had a significantly higher percentage of unwanted births than did Anglos. Much of this difference is related to the fact that Mexican Americans, when compared with Anglos, have completed fewer years of schooling and have incomes closer to the poverty threshold than do Anglos. Both Mexican Americans and Anglos had relatively moderate levels of planned births; thus, neither group is in full control of the number and timing of their births. Our results suggest that there is a substantial need for family planning services for Mexican Americans and Anglos in the Southwest.

In recent decades, neonatal and postneonatal mortality rates have declined overall in the United States. Yet, the mortality rates for black infants continue to be approximately twice those for white infants. With the use of data from 45 of the 53 vital statistics reporting areas that participated in the 1980 National Infant Mortality Surveillance project, we extended previous State analyses to describe differences, nationally, in neonatal and postneonatal mortality risks for black and white infants according to gestational age and birth weight. After restricting our analysis to single-delivery infants with known and plausible combinations of gestational age of 26 or more weeks and birth weights of 500 grams (g) or more, the neonatal mortality risk (NMR)--that is, the number of deaths to infants less than 28 days of life per 1,000 live births--for black infants was 1.6 times higher than the NMR for whites. This difference was largely explained by two findings: First, although the NMR was lower for black than for white infants with gestational ages of less than 38 weeks and birth weights less than 3,000 g, that advantage was heavily outweighed by the higher percentage of such births among blacks, accounting for roughly two-thirds of the overall difference in NMR between blacks and whites. Second, most of the remaining difference in NMR was accounted for by higher NMRs among black infants with gestational ages of 38 or more weeks and birth weights of 3,000 g or more. A comparison of the lowest mortality risk for any combination of birth weight and gestational age showed that the black NMR was 1.89 times higher than the white NMR. The postneonatal mortality risk (PNMR)--PNMR equals the number of deaths to infants 28 days to less than 1 year of life per 1,000 neonatal survivors--for black infants was 2.09 times the PNMR for white infants. Black infants had higher PNMRs than white infants for nearly all combinations of birth weight and gestational age. Higher PNMRs among infants with gestational ages of 38 or more weeks and birth weights of 2,500 g or more accounted for 43 percent of the difference in PNMR between black infants and white infants. Eliminating the U.S. black-white infant mortality disparity will require not only reducing the higher frequency of prematurity and low birth weight among black infants, but also improving the survival during both the neonatal and postneonatal periods of term black infants with normal birth weights.

Data from the National Infant Mortality Surveillance project were used to examine the State-specific variations in infant, neonatal, and postneonatal mortality and to examine some of the factors affecting the risks of death. The infant mortality risk, defined as the risk of death before 1 year of age to an infant born in the 1980 birth cohort, in the highest risk State was nearly three times that in the lowest risk State. Mortality risk ratios of two or greater were found when comparing high and low States for overall black infant mortality risks, overall neonatal mortality, neonatal mortality risks for black and white infants examined separately, neonatal mortality risks for low birth weight infants regardless of race, and overall postneonatal mortality and postneonatal mortality for white infants. The lowest State-specific black mortality risks were higher than the highest white risks for overall infant mortality and neonatal mortality. The differences between State extremes in mortality risks are greater than the differences between the United States and the Scandinavian countries with the lowest infant mortality.

Control of stress and violent behavior is 1 of the 15 priority areas addressed in the 1990 health objectives for the nation. For control of stress, improved awareness of appropriate community service agencies and increased scientific knowledge of stress effects are the main objectives. For control of violent behavior, the objectives focus on three major problems: (a) deaths from homicide among young black males, (b) adolescent suicide, and (c) child abuse. Since the last progress report, published in 1984, more than 200 research projects directly related to these objectives have been funded, and a variety of implementation actions have been undertaken. During this period, baseline data on such critical concerns as homicides among blacks and Hispanics, suicide, family violence, and perceived stress have been obtained, thereby encouraging further study and facilitating achievement of the objectives. The mid-decade status report and recommendations that are presented in this article were initiated in a September 1985 review, by the Acting Assistant Secretary for Health, of progress toward achieving the 10 stress and violent behavior objectives selected for Federal implementation by the year 1990. The most recent available data have been used to update information on these 10 priority objectives.

The recent slowdown in the decline of infant mortality in the United States and the continued high risk of death among black infants (twice that of white infants) prompted a consortium of Public Health Service agencies to collaborate with all States in the development of a national data base from linked birth and infant death certificates. This National Infant Mortality Surveillance (NIMS) project for the 1980 U.S. birth cohort provides neonatal, postneonatal, and infant mortality risks for blacks, whites, and all races in 12 categories of birth weights. (Note: Neonatal mortality risk = number of deaths to infants less than 28 days of life per 1,000 live births; postneonatal mortality risk = number of deaths to infants 28 days to less than 1 year of life per 1,000 neonatal survivors; and infant mortality risk = number of deaths to infants less than 1 year of life per 1,000 live births.) Separate tabulations were requested for infants born in single and multiple deliveries. For single-delivery births, tabulations included birth weight, age at death, race of infant, and each of these characteristics: infant's live-birth order, sex, gestation, type of delivery, and cause of death; and mother's age, education, prenatal care history, and number of prior fetal losses at 20 weeks' or more gestation. An estimated 95 percent of eligible deaths were included in the NIMS tabulations. The analyses focus on three components of infant mortality: birth weight distribution of live births, neonatal mortality, and postneonatal mortality. The most important predictor for infant survival was birth weight, with an exponential improvement in survival by increasing birth weight to its optimum level. The nearly twofold higher risk of infant mortality among blacks was related to a higher prevalence of low birth weights and to higher mortality risks in the neonatal period for infants weighing 3,000 grams or more, and in the postneonatal period for all infants, regardless of birth weight. Regardless of other infant or maternal risk factors, the black-white gap persisted for infants weighing 2,500 grams or more.

A study of suicide and homicide among Hispanics of Mexican origin (Mexican Americans) focused on five southwestern States--Arizona, California, Colorado, New Mexico, and Texas--where more than 60 percent of all Hispanics in the United States reside. And 85 percent of them are Mexican Americans. Data were obtained on all suicides and homicides among Hispanics and Anglos (white non-Hispanics), using Anglos as a comparison group. Results for suicide showed the suicide rate for Hispanics (9.0 per 100,000) to be less than the national rate for whites (13.2) and half that of the Anglos residing in the same area (19.2). The lower suicide rate for Hispanics relative to Anglos is seen for both males and females. For homicide, the overall rate for Hispanics (20.5) was more than 2 1/2 times that of Anglos (7.9). The rate for Hispanic men (39.3) was more than three times the rate for Anglo men (11.4).

National statistics on the risk of infant mortality by birth weight were collected most recently in 1980 and 1960. (Infant mortality risk is the number of deaths of infants under 1 year of age per 1,000 live births.) In this 20-year period, the infant mortality risk (IMR) for single-delivery infants declined 53 percent, from 23.3 deaths per 1,000 live births to 11.0; 91 percent of this decline was due to lower IMRs within birth weight categories, and 9 percent was due to reduced frequency of low birth weight. The greatest reduction in neonatal mortality (under 28 days)--73 percent--occurred among infants of 1,500-1,999 grams (g) birth weight, whereas the greatest reductions in postneonatal mortality (28 days to under 1 year)--51 percent to 54 percent--occurred among infants of 3,500 g or more birth weight. Trends in IMR for black and white infants were similar, and the twofold gap between the races in IMR persisted from 1960 to 1980. For whites, reductions in the frequency of low birth weights contributed to the decline in the IMR. For blacks, the percentage of infants with birth weights of less than 1,500 g increased, and the total reduction in the IMR was attributable to lower birth weight-specific mortality risks. In some regions of the United States, failure to observe an increase in birth weight for blacks may be a reporting artifact, reflecting improved reporting of births of very small black infants in 1980. Examination of changes in perinatal mortality risks (from 20 weeks gestation to less than 28 days of life) did not suggest that infant mortality trends were substantially affected by changes in the distinction between fetal and neonatal deaths over the 20-year period. Reducing the number of low birth weight infants remains the greatest potential for future reductions in infant mortality.

The National Infant Mortality Surveillance (NIMS) project aggregated data provided by 53 vital statistics reporting areas--50 States, New York City, the District of Columbia, and Puerto Rico (subsequently called States)--from their files of linked birth and death certificates and compared individual States' total infant mortality experiences for the 1980 birth cohort by age at death, race, birth weight, and plurality. Therefore, it was essential to achieve maximum uniformity among the separate data sets and to specify when this uniformity could not be obtained. In working with these multiple sources, we identified five key issues that relate to data from linked birth and death certificates: Variations in definitions of variables are often embedded in data that have been gathered from several independent sources. (For NIMS, the sources were 53 reporting areas and the National Center for Health Statistics.) Variations in States' linking procedures--these are based on an individual State's primary purpose for linking the data--affect the completeness and comparability of the 1980 resident birth cohorts used for NIMS. Variations in the recording of some pregnancy outcomes as fetal deaths or live births are known to be a problem in vital statistics data that particularly affects data for events among infants weighing less than 500 g at birth. Ambiguities occur frequently in unknowns or zero values. For NIMS this effect was most pronounced for the pregnancy history variables. Examination of the values reported for unknown or zero categories helps in uncovering problems with and improving quality of data. (e) Analysis from a new perspective may reveal unexpected data problems. These problems tend to surface only during a reexamination of underlying data that is prompted by unusual findings.Continued alertness to these issues may improve further the quality of data in files of linked birth and death certificates and assure the integrity of analysis based on these data.The authors analyze the quality of data in the files of linked birth and death certificates from the U.S. National Infant Mortality Surveillance (NIMS) project. The project compared individual states' total infant mortality experiences for the 1980 cohort. Uniformity among the separate data sets is considered essential. Variations in definitions, variations in states' linking procedures, variations in the recording of some pregnancy outcomes, ambiguous treatment of unknowns or zero values, and unexpected data problems are discussed

To describe regional differences in birth weight-specific infant mortality in the United States, we used data from the National Infant Mortality Surveillance project. The infant mortality risk (IMR) for the nation was 11.0 deaths per 1,000 live births. The risk (with 95 percent confidence intervals [CI]) for the four U.S. Census regions were West 9.9 (9.7 to 10.1), Northeast 10.4 (10.1 to 10.6), North Central 10.8 (10.6 to 11.0), and South 12.1 (11.9 to 12.3). In all regions, the IMR for blacks was approximately twice that of whites. Seventy-two percent of the higher IMR in the South was due to a higher proportion of black births compared with the remainder of the nation, reflecting the higher mortality rates suffered by black infants, and 28 percent to higher mortality among southern whites. The IMR for whites in the South was significantly higher than in the remainder of the nation: 9.8 versus 9.1 (relative risk = 1.09, CI = 1.06 to 1.11). Thirty-six percent of this excess in IMR was due to a higher frequency of low birth weight (less than 2,500 grams), 18 percent was due to higher IMR in infants with birth weight less than 2,500 grams, and 46 percent due to higher IMR in infants with birth weights of 2,500 g or more. Black infants born in the West had a lower risk of death than black infants in the other regions. When compared with the Northeast and South, 36 percent of the lower risk in the West among black infants was due to a lower frequency of low birth weight, 38 percent due to lower IMR in infants w'ith birth weight less than 2,500 g, and 26 percent to lower IMR in infants with birth weight of 2,500 g or more.

The impact of mortality due to congenital anomalies in single-delivery births was compared in 1960 and 1980 birth cohorts; data were used from the 1960 National Center for Health Statistics national linkage of birth and death certificates and the 1980 National Infant Mortality Surveillance project. In 1960 there were 14,714 deaths due to congenital anomalies, compared with 8,674 in 1980, a 41 percent reduction. The infant mortality risk (IMR) due to congenital anomalies fell 31 percent. This is in contrast with the observed 54 percent decline in IMR due to all causes. This reduction in mortality due to congenital anomalies occurred for both whites and blacks in the postneonatal period and for whites only in the neonatal period. Changes ranged from a 1.8 percent increase for the black neonatal mortality risk to a 46.6 percent decrease for the white postneonatal mortality risk. In spite of these relative reductions, the absolute percentage of all infant deaths due to congenital anomalies had increased from 15.8 percent in 1960 to 24.1 percent in 1980. Two categories, cardiovascular and central nervous system anomalies, accounted for 72 percent of infant deaths due to congenital anomalies in 1960 and for 59 percent in 1980; cardiovascular anomalies accounted for 48 percent of all deaths due to congenital anomalies in 1960 and 40 percent in 1980. Infant mortality risks in the United States showed a 2:1 black to white ratio in both 1960 and 1980. However, for infant mortality due to congenital anomalies, the black and white mortality risks were approximately equal in both 1960 and 1980. For infants with birth weights of 500-2,499 g, the risk of neonatal mortality for blacks was less than half the risk for whites.

As with the delivery of any medical service, abortion has definite public health effects that should be evaluated. The Center for Disease Control (CDC) has monitored the impact of abortion in three ways: (a) conducting epidemiologic surveillance of legally induced abortion beginning in 1969. (b) funding a multicenter study of abortion morbidity beginning in 1971, and (c) undertaking surveillance of abortion-related mortality beginning in 1972. These activities are intended to identify health problems related to abortion, to assess the magnitude of these problems, and to make recommendations directed at eliminating the problems. In addition to the Programmatic uses of abortion data, the CDC statistics have also provided a basis for both legislative and judicial decisions that have had national and local impact. The CDC and the National Center for Health Statistics are currently working collectively to strengthen the reporting of national abortion statistics so that the public health need for abortion statistics can be met.