Several recent trends in the vital statistics of the United States continued in 1996, including an increase in life expectancy and declines in infant mortality, births to teenage mothers, age-adjusted death rates, and death rates for children and adolescents.
In 1996, there were an estimated 3 914 953 births in the United States. The preliminary birth rate remained unchanged at 14.8 births per 1000 population, and the fertility rate, births per 1000 women 15 to 44 years of age, was essentially the same at 65.7. Fertility rates rose slightly for most racial and ethnic groups except black women, for whom the rate hit a historic low of 70.8. Overall, fertility remains particularly high for Hispanic women, although there is considerable variation within this heterogenous group. For the fifth consecutive year, birth rates dropped for teenagers. Birth rates for women ≥30 years of age continued to increase. The birth rate for unmarried women declined 1% in 1996 to 44.6 births per 1000 unmarried women, continuing the decline noted in 1995 for the first time in 2 decades.
The percentage of women who began prenatal care in the first trimester rose in 1996 to 81.8%, whereas the percentage with late (third trimester) or no care dropped to 4.1%. The rise in timely prenatal care was greatest for black and Hispanic women.
The percentage of low birth weight (LBW) infants reached 7.4% in 1996, its highest level since 1975. The very low birth weight rate remained unchanged at 1.4%. The rise in LBW occurred primarily among white women, whereas the LBW rate for black women dropped to 13.0%, the lowest rate reported since 1987. The rise among white women is only partially a result of increases in multiple births, because LBW rates have also risen among white singleton births. The multiple birth ratio rose again in 1996 by 2%, as it has since 1980. The rise was particularly large for higher-order multiple births.
Infant mortality reached an all time low level of 7.2 deaths per 1000 births, based on preliminary 1996 data. Neonatal and postneonatal rates declined, as did rates for both black and white infants. National birth weight specific mortality rates are reported here for the first time. In 1995, 63% of infant deaths occurred to the 7.3% of the population that was born LBW. The four leading cause of infant death were congenital anomalies, disorders relating to short gestation and unspecified birth weight, sudden infant death syndrome, and respiratory distress syndrome, accounting for more than half of infant deaths in 1996. Despite the declines in infant mortality, the United States continues to rank poorly in international comparisons of infant mortality.
Expectation of life at birth reached a new high in 1996 of 76.1 years for all gender and race groups combined. Age-adjusted mortality rates declined in 1996 for diseases of the heart, malignant neoplasms, cerebrovascular diseases, accidents and adverse effects, chronic liver disease and cirrhosis, and suicide. They rose, as in the past several years, for chronic obstructive pulmonary diseases, diabetes mellitus, and pneumonia and influenza. For the first time since human immunodeficiency virus infection was created as a special cause-of-death category in 1987, death rates for human immunodeficiency virus infection declined from 15.6 in 1995 to 11.6 in 1996. The homicide rate also declined, as it has since 1991.
Death rates for children between 1 and 19 years of age declined in 1996, with an estimated 29 183 deaths to children. Unintentional injury mortality has dropped by ∼50% among children and adolescents since 1979, although it remains the leading cause of death for all age groups of children from 1 to 19 years. Homicide was the fourth leading cause of death for children 1 to 4 and 5 to 9 years of age, the third leading cause for children 10 to 14, and the second leading cause for 15 to 19 year olds.
Much of the information presented in this report of vital statistics for 1996 is good news. The infant mortality rate (IMR) for the United States continued to decline in 1996 to the lowest level ever recorded, life expectancy at birth reached an all time high, the rate of births to teen mothers has decreased for the fifth consecutive year, use of early prenatal care continued to increase for all groups of women, the birth rate for unmarried women declined slightly, the death rate from human immunodeficiency virus (HIV) infection decreased sharply, and deaths among children and adolescents from injuries including homicides decreased.
The sources of data for this report were discussed in last year's paper.1 Preliminary data shown for 1996 are based on a substantial sample of records that are weighted to independent control counts of births, infant deaths, and total deaths2 reported to the National Center for Health Statistics (NCHS). Final data are shown for 1995 and earlier years. Because more detailed data are available in the final files for 1995 than in the preliminary files for 1996, some of the detailed analyses of birth and death patterns that we present here focus on the 1995 data. Wherever possible, comparisons are made between final 1995 and preliminary 1996 data. Final data for 1996, based on complete birth and death files, may differ from preliminary estimates presented here, but we expect the differences to be small.
We include for the first time in this report information from NCHS's Linked Birth/Infant Death Data Set—1995 Period Data.3 In this dataset, the death certificate is linked with the corresponding birth certificate for each infant who died in 1995 in the United States. The purpose of this linkage is to use the many additional variables available from the birth certificate to better interpret infant mortality patterns. From this dataset, we present 1995 IMRs by detailed birth weight categories. As requested by some readers, more detailed information is being provided on the causes of childhood death from injuries, particularly those resulting from bicycle and pedestrian injury and from firearms.
Readers will note that we have eliminated the reports on marriages and divorces; readers who wish to obtain this information should consult the following publication: Births, Marriages, Divorces, and Deaths for 1996.4
An estimated 1 592 688 persons were added to the US population in 1996 as a result of natural increase, the excess of births over deaths (Table 1). The rate of natural increase was 6.0 per 1000 population, the same as the 1995 rate.
There were an estimated 3 914 953 births in the United States in 1996, a slight increase (<1%) over the number reported in 1995 (Table1). The preliminary birth rate in 1996 was unchanged at 14.8 births per 1000 total population. The fertility rate, defined as the number of births per 1000 women 15 to 44 years of age, was 65.7, nearly the same as the rate in 1995. The differences in these three measures of childbearing between 1995 and 1996 are the smallest recorded in almost 50 years and suggest an easing of the downward trend in childbearing observed since 1991.5
The preliminary number of births for 1996 increased in 28 states, declined in 21 states and the District of Columbia, and was the same in 1 state. Fertility rates rose in 26 states, declined in 22 states and the District of Columbia, and were unchanged in 2 states. Table2 shows the number of births for each state for 1996 by maternal race and Hispanic origin, and birth and fertility rates by state for 1995 and 1996.
Births to mothers of Hispanic, American Indian, and Asian or Pacific Islander origin tend to be highly concentrated geographically. In 1996, as in recent years, more than ¾ of all Hispanic births were to residents of six states (California, Texas, New York, Florida, Illinois, and Arizona). A total of 65% of Asian or Pacific Islander births were to residents of California, New York, Hawaii, Texas, Illinois, and Washington; and half of all births to American Indian women were to residents of five states (Arizona, Oklahoma, California, New Mexico, and Alaska).
Racial and Ethnic Composition
The fertility levels of all racial and ethnic groups have generally declined during the 1990s, but preliminary data for 1996 suggest a deviation in the downward trend for some groups. Fertility rates rose or were fairly level in 1996 compared with 1995 among white (64.7), American Indian (69.8), and Asian or Pacific Islander (66.6) women, but the rate continued to drop among black mothers to a historic low of 70.8. Fertility among black mothers has dropped 18% since 1990 (from 86.8). A slight decline (<1%) was also reported for Hispanic mothers (104.4).
Fertility rates differ among racial and ethnic groups and particularly among Hispanic subgroups (Table 3). Fertility among Hispanic women overall continues to be higher than that of the other racial or ethnic groups for whom rates can be computed. The category of Hispanic women, however, includes Mexican women with the highest reported fertility (117.0) and Cuban women with the lowest (55.1) rate. Primarily because of the higher fertility of Hispanic mothers compared with non-Hispanic mothers, and a rise in the proportion of Hispanic women in their childbearing years, the percentage of all births that are of Hispanic origin rose from 14.5% in 1990 to 17.8% in 1996.6,7
Trends in Age-specific Birth Rates
Preliminary 1996 data indicate that teenage childbearing fell 4% to 54.7 births per 1000 females 15 to 19 years of age, the fifth consecutive year of decline in the teen birth rate, with a total drop of 12% since 1991 (Table 4). A recent study of teen birth rates between 1991 and 1995 indicates that the decline is widespread throughout the United States, occurring in all 50 states and the District of Columbia.8 The 1996 teen birth rate is still higher, however, than rates reported between 1976 and 1988.
The preliminary 1996 birth rate for white teenagers 15 to 19 years of age decreased 3% to 48.4, with a larger decline among younger teens 15 to 17 years of age. The rate for black teens 15 to 19 years fell 5% to 91.7 and included a 7% drop for younger black women 15 to 17 years of age. Since 1991, the fertility rate for black teens 15 to 19 years of age has fallen 21% (from 115.5).
The rate for Hispanic teens 15 to 19 years of age also fell 5% between 1995 and 1996, from 106.7 to 101.6 per 1000. Unlike that of white and black teens however, childbearing among Hispanic teens has not declined consistently in recent years; and 1996 marks the first substantial decline since data for this group have been available.
Although the teenage population in the United States grew in 1996, the decline in the teen birth rate resulted in a slight drop in the total number of births to teen mothers (from 499 873 to 494 272 births to 15 to 19 year olds) and a decline in the proportion of all births that were to teen mothers (13.1% to 12.9%). This drop is noteworthy; had the teen birth rate not fallen from the 1991 level, there would have been at least an additional 67 000 births to teenage mothers in 1996.
Childbearing for Women ≥20 Years of Age
Birth rates for women 20 to 24 and 25 to 29 years of age, the principal childbearing years, had declined in the first half of the 1990s, but rose in 1996 by 1% and 2% to 111.1 and 113.9 per 1000, respectively.
Birth rates also rose among women 30 to 34 and 35 to 39 years of age by 2% and 3%, respectively, in 1996, to 84.5 and 35.4 per 1000. Rates among these age groups had been rising through the 1990s, although the pace of increase has slowed. Birth rates for women 30 to 34, and especially for those 35 to 39 years of age, have risen substantially since the late 1970s (by 46% and 86%, respectively, since 1978) and are the highest observed in 3 decades. The birth rate for women 40 to 44 years of age also continued to increase for 1996, rising from 6.6 to 6.8, and was higher than any year since 1971.
The preliminary birth rate in 1996 for unmarried women declined 1% to 44.6 births per 1000 unmarried women, reflecting the larger increase in the number of unmarried women relative to the number of births to unmarried women. This rate had declined for the first time in nearly 2 decades between 1994 and 1995 from 46.9 to 45.1. The percentage of all births to unmarried women rose slightly in 1996, however, to 32.4%, and the number of births to unmarried women increased 1% to 1 267 383. The percentage of births to unmarried women rose for whites, but it declined slightly for black women in 1996.
Smoking During Pregnancy
Smoking during pregnancy declined 5% to 13.9% of mothers who gave birth in 1995 (Table 5). (Data on tobacco use are not available for 1996.) Since information on tobacco use during pregnancy first became available from birth certificate data in 1989, the proportion of women who are reported to smoke during pregnancy has fallen 29% (from 19.5%), as has the number of cigarettes consumed by smokers. Smoking levels declined for mothers ≥20 years of age in 1995 but rose slightly for teenagers 15 to 19 years of age. The percentage of black teenagers who smoked rose 6% to 5.3% but remained much lower than that for white teenagers (21.9%). Smoking during pregnancy has long been linked to adverse pregnancy outcome and is considered as a major known modifiable risk factor for low birth weight (LBW) and infant death.9
The percentage of mothers who began care in the first trimester of pregnancy continued to rise based on preliminary 1996 data, climbing to 81.8% (Table 5). Prenatal care use improved rapidly during the 1970s, was generally unchanged during the 1980s, but has risen steadily during the 1990s (from 75.5% in 1989). Concurrently, the percentage of mothers with late care (beginning in the third trimester) or no care has dropped from 6.4% to 4.1% between 1989 and 1996. Early, comprehensive prenatal care can promote healthier pregnancies by detecting and managing preexisting medical conditions and providing health behavior advice.10
Between 1995 and 1996, increases in first trimester care were observed among white (from 83.6% to 83.9%), black (from 70.4% to 71.3%), and Hispanic mothers (from 70.8% to 71.9%). Since 1989, the percentage of black mothers with first trimester care has risen 19% (from 60.0%), and the level of late or no care has dropped from 11.9% to 7.4%. Improvement is even more marked among Hispanic mothers; timely care has climbed 21% (from 59.5%), and the percentage of mothers with late or no care plummeted from 13.0% to 6.8%. The gains for black and Hispanic mothers have occurred among all age groups.
Preliminary 1996 data indicate that the percentage of births delivered by cesarean delivery declined slightly to 20.6%, from 20.8% in 1995. This rate has fallen steadily from 22.8% in 1989 when information on the method of delivery first became available from birth certificate data (Table 5). Most of the current year decline is attributable to an increase in the rate of vaginal births after previous cesarean, which rose from 27.5% to 28.4% between 1995 and 1996. The primary cesarean rate (first cesarean per 100 live births to women who have not had a previous cesarean) declined only slightly from 14.7% to 14.6% in this period. Since 1989, the vaginal births after previous cesarean rate has risen 50% (from 18.9%), and the primary cesarean rate has declined 9% (from 16.1%). Results of a recent study indicate that most of the progress in reducing cesarean rates between 1991 and 1995 has been for non-Hispanic white mothers and, to a lesser extent, for Hispanic mothers.11
The multiple birth ratio rose again in 1995 by 2%, to 26.1 per 1000 births. (Preliminary 1996 data for multiple births are not available.) This ratio (defined as the number of births in multiple deliveries per 1000 live births) has risen by an average of 2% each year since 1980 (Table 5). The number of births in multiple deliveries increased only slightly to 101 709 from 101 658 for 1994. There was a small dip in the total number of twin births as a result of a 7% drop in the number of twins born to black mothers; the number of twins born to white mothers rose 1%. Since 1980, the number of twin births has risen by 42% (from 68 339), and the number of higher-order multiple births by 272% (from 1337).12,13 Births in higher-order multiple deliveries (triplets and higher-order multiple births) rose 8% to 4973 births for 1995, and included 4551 triplet, 365 quadruplet, and 57 quintuplet or greater multiples.
The higher-order multiple birth ratio climbed 10% between 1994 and 1995, from 116.2 to 127.5 per 100 000. This ratio has doubled since 1989, tripled since the early 1980s, and quadrupled since the early 1970s.13 To illustrate this growth in another way, 1 of every 785 births was a triplet in 1995 compared with only 1 of 3500 births in the early 1970s. About one third of the rise in the ratio since 1980 has been estimated to be the result of shifts in the maternal age distribution to older ages (multiple births are more common among older mothers) and the remaining two thirds, a result of increases in the use of fertility-enhancing therapies.13,14
Twins, triplets, and higher-order multiple births are much more vulnerable to early death and long-term disability than singletons, and risk rises with increasing plurality.15 More than 50% of all twins and 90% of triplets are LBW (<2500 g) compared with 6% of singleton births. Moreover, twins are 5 times, and triplets 13 times more likely to die within the first year of life.3
The percent of LBW infants (<2500 g) rose to 7.4% in 1996, the highest level reported since 1975. The LBW rate declined during the 1970s and early 1980s, but has risen 10% since 1984 (from 6.7%). The percent of very low birth weight (VLBW) infants (<1500 g) was essentially unchanged at 1.4% (Table 5).
LBW increased among births to white mothers for the fourth consecutive year, to 6.3% in 1996, and has risen from 5.7% since 1990. All of the current year rise was for mothers ≥20 years of age. The proportion of VLBW white births was 1.08%, the highest level reported since at least 1970. Some of this increase in LBW can be attributed to the rising proportion of multiple births among white mothers, but in more recent years, LBW for white singletons has also risen (from 4.7% in 1992 to 5.0% in 1995).
Among births to black mothers, LBW fell to the lowest rate reported since 1987 (13.0%), continuing the downward trend noted since 1992. The level of VLBW among black births has been essentially static at 3.0% since the late 1980s.
The LBW percent is highest for the youngest and oldest mothers, with a slightly elevated risk for mothers ≥40 years of age. When only singleton births for 1995 are examined, however, the LBW percent was 10% higher for mothers <20 years of age than for those ≥40 years of age (multiple births are more common among older mothers). Recent studies suggest that the elevated LBW rate of younger mothers may be related to the preponderance of teenage mothers who are from disadvantaged backgrounds.16,17
LBW percentages vary widely by state (Table6). For 1995, ratios for infants born to white mothers ranged from 5.1% for Alaska, North Dakota, and Wisconsin to 8.0% and 7.7% in Colorado and New Mexico. Among the reporting areas with 1000 or more black infants, LBW percents for black infants ranged from 10.4% for Massachusetts to 15.9% for the District of Columbia and Colorado.
In 1996, an estimated 28 237 infant deaths were reported in the United States (Table 1). The preliminary IMR was 7.2 per 1000 live births, 5% lower than the 1995 rate of 7.6, and the lowest ever recorded in the United States.18 Neonatal mortality rates (NMRs; infant deaths <28 days) and postneonatal mortality rates (PNMRs; infant deaths 28 days through 11 months) also declined, as did rates for both white and black infants.
Infant mortality in the United States has declined by >60% since 1970 (Table 7, Figure ). For the early part of this period, the NMR declined more rapidly than the PNMR, although the PNMR has declined more rapidly than the NMR since 1989. The decline in the perinatal mortality rate (number of fetal deaths at 28 weeks gestation or more plus number of infant deaths at <7 days of age per 1000 live births plus fetal deaths) has closely paralleled the decline in the NMR.19
Racial differences in the IMR remain a major national concern. Although all race groups have experienced declines in IMR, the relative difference in rates between black and white newborns has increased (Table 7). Higher neonatal mortality among black births largely reflects their higher percentage of LBW and VLBW births. Although various hypotheses have been advanced to explain these differences,20,21 the large race disparity in LBW and VLBW presents continued challenges for researchers and health care providers.
Birth Weight-Specific Infant Mortality
Birth weight is one of the important predictors of infant mortality. The IMR for a given population can be partitioned into two key components: the birth weight distribution and birth weight-specific mortality rates (the death rate for infants at a given weight). The IMR decreases when either the percentage of LBW births decreases or the birth weight-specific mortality rates decrease. The percentage of LBW and VLBW births declined slightly from the 1970s to the mid 1980s but has increased steadily since then (Figure)1. Thus, virtually all of the decline in infant mortality since 1970 has been attributable to declines in birth weight-specific IMR, and not to the prevention of LBW.22 These declines have been attributed primarily to improvements in obstetric and neonatal care. However, we have been unsuccessful in the United States in reducing the number of preterm and LBW deliveries, even though prevention efforts have the potential to save many more infant lives and reduce subsequent morbidity than additional improvements in neonatal care.23
In 1995, 63% of all infant deaths occurred to the 7.3% of infants born at LBW.3 More than 9 of 10 infants with birth weights <500 g die within the first year of life—most within the first few days of life (Table 8). An infant's chances of survival increase rapidly thereafter with increasing birth weight. At birth weights of 1250 to 1499 g, ∼95 of 100 babies now survive the first year of life. IMRs are lowest for white infants at birth weights of 4000 to 4499 g and for black infants at birth weights of 3500 to 3999 g, with small increases among the heaviest infants. IMRs are lower for black than for white infants for individual birth weight categories <2500 g, but are higher at birth weights of ≥2500 g. In contrast, IMRs are slightly higher for black infants for the broad birth weight categories of <1500 g and <2500 g. The birth weight distribution for black infants has a much higher proportion of births at extremely LBWs, and this has influenced the IMRs for these broad birth weight groupings.
From 1985 to 1995, IMRs declined by 50% to 56% for infants weighing 750 to 1499 g at birth and by 35% to 39% for infants with birth weights between 1500 and 2499 g. IMRs declined by 31% for infants at birth weights of 500 to 749 g, and coincidentally, for those weighing ≥2500 g. In contrast, mortality rates for infants born at <500 g declined by <2% during the decade, reflecting the limited success of intensive efforts made to save these very small infants. For the few infants who do survive at these LVBWs, many suffer lifetime disabilities such as blindness, mental retardation, and neurologic disorders, necessitating increased levels of medical and parental care.24-26
Leading Causes of Infant Death
The 10 leading causes of infant death are shown in Table9. Since 1979, causes of death in the United States have been classified according to the International Classification of Diseases, 9th rev.27 In 1996, more than half of all infant deaths were attributable to the four leading causes of infant death: congenital anomalies, disorders relating to short gestation and unspecified LBW, sudden infant death syndrome (SIDS), and respiratory distress syndrome. IMRs from congenital anomalies have declined by 35% from 1979 to 1996. However this decline has been less than that for infant mortality as a whole. SIDS rates have fallen by 38% since 1992 when the American Academy of Pediatrics issued a recommendation to reduce the risk of SIDS by placing infants on their backs or sides to sleep.28-30 IMRs for respiratory distress syndrome have declined by >60% since 1989 when new medical treatments for this condition became widely available.31-33 Infant mortality for disorders related to short gestation and unspecified LBW, the second leading cause of infant death, exhibited the smallest decline since 1979 of any of the 10 leading causes of death. As discussed above, the prevention of LBW and preterm delivery is one of the most significant challenges facing the medical profession in the next decade.
Among all states in 1995, Massachusetts and Utah (Table 6) had the lowest IMR (5.2 and 5.4, respectively). Although the highest rate was noted for the District of Columbia, it is more appropriately comparable with rates for other large US cities because of the high concentrations of high-risk women in these areas. Eighteen states have already met the Year 2000 infant mortality health objective of an overall IMR ≤7.0.
Differences in IMRs by state reflect in part differences in the racial and socioeconomic composition of the population of states and regions of the country. Also, caution must be exercised in comparing IMRs among states as differences, although seemingly large, may not be statistically significant.
INTERNATIONAL COMPARISONS OF INFANT MORTALITY
Table 10 shows IMRs for countries with at least 2.5 million population, with rates equal to or less than the US rate in recent years based on relatively complete data. Although the IMR has decreased in recent years, the United States continues to be in a less than enviable position relative to the other industrialized countries; indeed, the US rate is higher than for all other countries listed in the Table except Greece. However, once again, we caution readers about overemphasizing the position of the United States in infant mortality because of the difficulty in obtaining accurate (and comparable) data for infant deaths even for developed countries.
As we noted last year, there are a number of possible reasons why the United States IMR remains higher than that for many other developed countries. One reason stems from reporting differences across countries related to the definition of a live birth, the timing of when births are reported, and the practices surrounding the reporting of stillbirths in a country.34-37 The magnitude of the effect of these reporting differences on the comparability of rates is unknown. Nevertheless, even if reporting conventions were similar, it is likely that the US rate would still remain higher than the rate for many other countries because of the high percentage of LBW, particularly VLBW, births that occur in this country relative to other developed countries.34,38
There were an estimated 2 322 265 deaths in the United States in 1996 (Table 1), 0.4% higher than the number for 1995 and the highest number ever reported. The preliminary death rate for 1996, however, was 875.4 deaths per 100 000 population, slightly lower than the final 1995 rate of 880.0. The preliminary age-adjusted death rate for 1996 was 493.6 deaths per 100 000 US standard population.2This rate was 2% lower than the final 1995 age-adjusted death rate of 503.9 and was a record low for the United States.18Age-adjusted death rates are better indicators than crude death rates for showing changes in mortality risk over time, because they control for variations in the age composition of the population.
Expectation of Life
The expectation of life at birth for a given year represents the average number of years that a group of infants would be expected to live if, throughout their lifetime, they were to experience the age-specific death rates prevailing during the year of their birth. Based on preliminary data for 1996, the expectation of life at birth reached a new record high of 76.1 years, an increase of 0.3 years from the previous year. In 1996, life expectancy at birth was 73.8 years for white males, 79.6 years for white females, 66.1 years for black males, and 74.2 years for black females. Life expectancy increased from the previous year by 0.9 year for black males, 0.4 year for white males, and 0.3 year for black females. Life expectancy for white females did not change from 1995.
Causes of Death
The 10 leading causes of death accounted for 81% of all deaths in the United States in 1996 (Table 11). Although their order has varied somewhat, these causes have generally been the same since 1984. Age-adjusted death rates were lower in 1996 than in 1995 for HIV infection, diseases of the heart, malignant neoplasms (cancer), cerebrovascular diseases, accidents and adverse effects (including deaths attributable to motor vehicles), chronic liver disease and cirrhosis, and suicide. Age-adjusted rates have increased since 1979 for a few leading causes of death. Including a 44% increase in deaths attributable to chronic obstructive pulmonary diseases, a 39% increase for diabetes mellitus, and a 12.5% increase for pneumonia and influenza.
HIV Infection and Other Infectious Diseases
In 1987, a special cause-of-death category was created to uniquely classify deaths attributable to HIV infection.39 From 1987 to 1994, the age-adjusted death rate for HIV infection nearly tripled from 5.5 to 15.4. Between 1994 and 1995, there was a leveling off of this steep upward trend,18 and between 1995 to 1996, the age-adjusted death rate for HIV infection showed a sharp 26% decline from 15.6 to 11.6. This marks the first year that there has been a decline in HIV mortality and indicates significant progress in the battle against this deadly disease.
Although they account for a relatively small percentage of all deaths (2.9% in 1996), the number of deaths attributable to infectious diseases has increased substantially since 1979. Although a large proportion of this increase since 1987 is attributable to increases in HIV infection, increases in other infectious diseases also contributed. In particular, the age-adjusted death rate for septicemia increased by 78.3% from 1979 to 1996, and the rate for viral hepatitis more than tripled during the same period.
The age-adjusted death rate for homicide and legal intervention declined by 11% from 9.4 in 1995 to 8.4 in 1996, marking a 23% decline since 1991. These declines are particularly noteworthy for the male population, for which mortality declined by 10% between 1995 and 1996 and by 21% since 1991.
Deaths Among Children
In 1996, an estimated 29 183 children and adolescents between 1 and 19 years died in the United States based on preliminary data (Table12). The death rate for children 1 to 4 years old in 1996 was 38.3 per 100 000 population, 6% lower than the rate of 40.6 in 1995. The respective death rates for children and teens also declined by 5%, from 25.5 in 1995 to 24.3 in 1996 and from 83.5 in 1995 to 79.2 in 1996. However, for children 5 to 9 years of age, the death rate rose slightly from 19.7 in 1995 to 19.8 in 1996, an increase that was not statistically significant. Since 1979, death rates have declined by 40% for children 1 to 4 years old, by 36% for children 5 to 9 years old, by 24% for children 10 to 14 years old, and by 20% for teens 15 to 19 years of age.
Although childhood mortality has declined substantially, a large proportion of these deaths continue to occur as a result of preventable injuries.40 Deaths attributable to accidents (unintentional injury), homicide, and suicide comprised the majority (63%) of all childhood deaths based on preliminary data from 1996. The leading cause of death in 1996 among children in all age groups is unintentional injury.
For children 1 to 4 years of age, unintentional injuries accounted for 36% of all deaths; injuries related to motor vehicles, drowning, and fire and burns were the most common and together accounted for 79% of all unintentional injury deaths in the age group. Since 1979, unintentional injury deaths have declined by 48% in this age group. An estimated 395 children 1 to 4 years old died from homicide, making homicide the fourth leading cause of death in this age group. Death rates for homicide increased for this age group between 1979 and 1994, but they have dropped 13% since 1994.
For children 5 to 9 years old, unintentional injuries accounted for nearly 43% of all deaths in 1996. The injury deaths occurring in this age group were primarily attributable to motor vehicles (including pedestrian and bicycle-related), drowning, and fire and burns, accounting for 82% of all unintentional injury and 35% of total deaths. The death rate attributable to unintentional injuries for children 5 to 9 years old has declined by nearly 50% from 16.4 in 1979 to 8.5 in 1996. Homicide was the fourth leading cause of death among 5- to 9-year-old children and account for nearly 5% of all deaths.
Unintentional injuries represented 41% of all deaths to children 10 to 14 years of age in 1996. Motor vehicles (including pedestrian and bicycle-related) accounted for 58% of all unintentional injuries and nearly 25% of all deaths in this age group. The death rate attributable to unintentional injuries for these children has declined by 40% since 1979. Homicide was the third leading cause of death for children 10 to 14 years of age. Although the death rate for homicide in this age group increased by 50% since 1979, it decreased by 14% from 1995 to 1996. The death rate for firearm-related homicide more than doubled between 1979 and 1996, but has also decreased by 19% since 1995. Suicide was the fourth leading cause of death among 10- to 14-year-old children, accounting for an estimated 300 deaths in 1996. The suicide rate in this age group doubled from 0.8 in 1979 to 1.6 in 1996.
For teens 15 to 19 years of age, unintentional injuries accounted for 46% of all deaths in 1996, and 79% of these deaths occurred as the result of motor vehicles (including pedestrian and bicycle-related). The unintentional injury death rate for teens has dropped by almost 40% since 1979. Homicide was the second leading cause of death among teens 15 to 19 years of age, accounting for 20% of all deaths. An estimated 2888 teens were victims of homicide in 1996. The teen homicide rate increased by 51% from 1979 to 1996, but decreased 15% between 1995 and 1996. A total of 85% of all teen deaths attributable to homicide were firearm-related. An estimated, 1801 teens 15 to 19 years of age committed suicide in 1996. Suicide was the third leading cause of death in this age group and accounted for 12% of all deaths.
In summary, unintentional injury mortality for children and teenagers has dropped substantially (nearly 50%) since 1979. These declines are at least in part attributable to injury prevention measures such as mandatory car seat requirements and smoke alarms and sprinkler systems in homes and schools.41 Nevertheless, despite current efforts, unintentional injuries continue to be the leading cause of death for children of all ages. Additional prevention efforts are still needed.
In contrast, although some decline occurred between 1995 and 1996, homicide and suicide mortality overall and that attributable to firearms, have generally increased since 1979, particularly for children 10 to 14 years old and teens 15 to 19 years old. Hopefully, the more recent declines in homicide and suicide signal the beginning of a long-term reversal in homicide and suicide mortality among children.
We thank Jean Sack, Librarian, Department of Population Dynamics, Johns Hopkins School of Public Health; and Gareth Jones of the Information Office at UNICEF, New York, for the international data on infant mortality. We also thank Tom Dunn for content review; and Stephanie Ventura and Mary Anne Freedman, the Director of the Division of Vital Statistics, NCHS, for supporting this effort and reviewing the manuscript. Finally, we thank Becky Newcomer for her administrative support and preparation of the manuscript.
- Received October 1, 1997.
- Accepted October 1, 1997.
Reprint requests to (B.G.) Johns Hopkins School of Hygiene and Public Health, 624 N Broadway, Baltimore, MD 21205.
- IMR =
- infant mortality rate •
- HIV =
- human immunodeficiency virus •
- NCHS =
- National Center for Health Statistics •
- LBW =
- low birth weight •
- VLBW =
- very low birth weight •
- NMR =
- neonatal mortality rate •
- PNMR =
- postneonatal mortality rate •
- SIDS =
- sudden infant death syndrome
- Guyer B,
- Strobino DM,
- Ventura SJ,
- MacDorman M,
- Martin JA
- ↵Ventura SJ, Peters KD, Martin JA, Maurer JD. Births and Deaths: United States, 1996. Monthly vital statistics report. Vol 46, No 1, Suppl 2. Hyattsville, MD: National Center for Health Statistics; 1997
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