Fetal, Perinatal, and Infant Mortality

Home , Infant mortality, Perinatal mortality

Danielle Ely, Ph.D. Division of Vital Statistics National Center for Health Statistics

Presented to the Secretary’s Advisory Committee on Infant Mortality December 4, 2018 Vital Statistics Data Files

• National data files currently available:

• Birth (natality) • 2017 final • Rapid Release provisional estimates through first quarter of 2018

• Mortality • 2017 final • Rapid Release provisional estimates through first quarter of 2018 Fetal death data file and cause of death

• Fetal availability: • 2016 final (demographic only) • 2015 and 2016 COD anticipated early 2019 • 2017 (both demographic and COD) anticipated early 2019

• Starting with 2017 fetal death data, cause of death will be released with the demographic file.

• NCHS has dramatically improved timing of COD coding for both general mortality and fetal death.

Vital Statistics Data Files continued • Linked birth/infant death

• 2016 period file; 2012 cohort file

• 2017 period file and 2013 cohort file anticipated early 2019

• Rapid Release provisional estimates through end of 2017 (quarter 4)

Infant mortality data

• Links birth and death certificate data for infant deaths (i.e., deaths within a year of birth). • Purpose: To use more detailed data from the birth certificate for infant mortality analysis (e.g., maternal demographic characteristics and pregnancy risk factors). • More accurate information on maternal race and ethnicity than mortality (i.e., birth certificate = maternal self-report.) • Historically: 2 files- period (2 birth years and 1 death year) and cohort (1 birth year and 2 death years). • Starting in 2017, users will be able to create their own cohort files by combining 2 period files.

• Improvements in timeliness of release of the infant mortality period file made possible by improvements in the timeliness of the mortality file.

Total fetal, early fetal, late fetal, and perinatal mortality rates:

8 United States, 2000-2016 6.97 7 Perinatal 6.61 6.02

6 Fetal 6.00

4 3.32 Early Fetal 3.15 3 3.31 Late Fetal 2.88 2 1,000 live births and fetal deaths 1

Infantper deaths 1,000 live births,deaths fetal per 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 SOURCE: NCHS, National Vital Statistics System. Total infant, neonatal, and postneonatal mortality rates: United States, 2000-2016 8

6.89 7 Total Infant

5.87 6

5 4.62 Neonatal 3.88 4

3 2.27 Postneonatal 1.99 2 1,000 live births and fetal deaths 1

Infantper deaths 1,000 live births,deaths fetal per 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Total infant, neonatal, postneonatal, and perinatal rates, United States 2011-2016

6.26 Perinatal 6.00 6 6.07 Total infant 5.87 5 4.06 3.88 4 Neonatal

2.01 1.99 2 Postneonatal

1 Infantper deaths 1,000 live births or infant deaths per 1,000births live and fetaldeaths

0 2011 2012 2013 2014 2015 2016 SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Changes in infant mortality rates from 2011 to 2016, United States

ME MT ND

OR MN VT NH ID MA SD WI NY

WY MI RI CT PA IA NJ NV NE OH IL IN DE UT DC WV CO MD VA KS CA MO KY

NC TN

AZ OK NM AR SC

MS AL GA

TX LA

HI Significantly lower IMR than 2011 Significantly higher IMR than 2011 No significant difference between 2011 and 2016 SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Perinatal mortality rates, by race and Hispanic origin of mother: 49 states and the District of Columbia, 2014-2016

12 2014 2015 2016 10.59 10.53 10.66 10

6 5.39 5.43 5.35 5.04

specified group 4.97 4.98

Rate per 1,000 live births and fetal deaths in 2

0 Non-Hispanic black Hispanic Non-Hispanic white NOTE: All years exclude data for Rhode Island, which did not report mother’s race or Hispanic origin for fetal deaths for 2015. SOURCE: NCHS, National Vital Statistics System.

Infant mortality rates by race and Hispanic origin of mother: United States, 2007-2016 14 13.63

12 Non-Hispanic Black 11.21 10

American Indian/Alaska Native 8.61 8 8.06

6 5.76 5.62 Hispanic 4.96 Non-Hispanic White 4.89 4.87 4 Asian or Pacific Islander 3.97 Infantper deaths 1,000 live births 2

0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Infant mortality rates by state: United States, 2016

WA NH ME VT MT ND OR MN MA ID SD WI NY MI WY RI CT PA IA . NJ NV NE OH IN DE UT IL DC WV CO VA MD KS MO CA KY NC TN OK AZ NM AR SC

MS AL GA

TX LA

FL AK U.S. rate is 5.87

HI Less than 4.00 8.00-8.99 4.00-4.99 9.00-9.99 5.00-5.99 6.00-6.99

NOTE: The range of rates is 3.47 in Vermont to 9.03 in Alabama per 1,000 live births. 7.00-7.99 Source: NCHS, National Vital Statistics System Infant mortality rates by state for infants of non-Hispanic white women: United States, 2013-2015

WA NH ME MT ND VT

OR MN

ID MA SD WI NY WY MI RI CT PA IA NJ NV NE OH DC IL IN DE UT CO WV VA MD KS CA MO KY

NC TN

AZ OK NM AR SC

MS AL GA

TX LA 2013-2015 U.S. Infant FL mortality rate for infants of non-Hispanic white women AK is 4.95.

HI Less than 4.00 4.00-4.99 5.00-5.99 NOTE: The range of rates is 2.52 in the District of Columbia to 7.04 in Arkansas per 1,000 live 6.00-6.99 births. 7.00-7.99 Source: NCHS, National Vital Statistics System Infant mortality rates by state for infants of Hispanic women: United States, 2013-2015

ME MT ND

OR MN VT NH ID MA SD WI NY WY MI RI CT PA IA NJ NV NE OH DE IL IN UT DC CO WV MD VA KS CA MO KY

NC TN AZ OK NM AR SC

MS AL GA

TX LA 2013-2015 U.S. Infant FL mortality rate for infants of Hispanic women is 4.99. AK

HI Less than 4.00 Unreliable, fewer 4.00-4.99 than 20 infant 5.00-5.99 deaths 6.00-6.99 NOTE: The range of rates is 3.94 in Iowa to 7.28 in Michigan per 1,000 live births. 7.00-7.99 Source: NCHS, National Vital Statistics System Infant mortality rates by state for infants of non-Hispanic black women: United States, 2013-2015

ME MT ND

OR MN VT NH ID MA SD WI NY

WY MI RI CT PA IA NJ NV NE OH IL IN DE UT WV DC CO MD VA KS CA MO KY

NC TN

AZ OK NM AR SC

MS AL GA

TX LA 2013-2015 U.S. Infant FL mortality rate for infants of non-Hispanic black women AK is 11.10.

Unreliable, fewer HI 8.00-8.99 9.00-9.99 than 20 infant 10.00-10.99 deaths 11.00-11.99 NOTE: The range of rates is 8.27 in Massachusetts to 14.28 in Wisconsin per 1,000 live births. 12.00 or more Source: NCHS, National Vital Statistics System Non-Hispanic white, Hispanic, and non-Hispanic black 2013-2015 infant mortality rates

Non-Hispanic White Hispanic Non-Hispanic Black

Le s s t ha n 4. 00 8.00-8.99 Unreliable, fewer 4.00-4.99 9.00-9.99 than 20 infant 5.00-5.99 10.00-10.99 deaths 6.00-6.99 11.00-11.99 7.00-7.99 12.00 or more

SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Mortality rates for five leading causes of infant death: United 160 States, 2007, 2015, and 2016 2007 2015 2016 140 134.9

121.8 122.2 120 112.7 102.7 99.5 100

60 57.0

41.1 38.4 39.4 40 35.7 38.0 29.7 32.4 30.8 Infantper deaths 100,000 live births

0 Congenital Malformations Low Birthweight Maternal Complications Sudden Infant death Unintentional injuries Syndrome SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Mortality rates for five leading causes of neonatal and postneonatal 100 97.7 death: United States, 2016 Neonatal Postneonatal 90 86.4

40 35.3 35.8 34.9 30 27.4 21.0 20 Infantper deaths 100,000 live births 14.0 9.1 10 6.4

0 Low Congenital Maternal Placenta, Bacterial Congenital SIDS Unintentional Diseases Homicide birthweight Malformations Complications cord, and Sepsis Malformations injury of the membrane circulatory complications system SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Five leading causes of neonatal death by race and Hispanic origin of mother: United States, 2016

Rank Non-Hispanic White Non-Hispanic Black Hispanic

1 Congenital Malformations Low Birthweight Congenital Malformations

2 Low Birthweight Congenital Malformations Low Birthweight

3 Maternal Complications Maternal Complications Maternal Complications

4 Placenta, Cord, and Membrane Placenta, Cord, and Membrane Placenta, Cord, and Membrane Complications Complications Complications 5 Bacterial Sepsis Bacterial Sepsis Bacterial Sepsis

SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Five leading causes of postneonatal death by race and Hispanic origin of mother: United States, 2016

Rank Non-Hispanic White Non-Hispanic Black Hispanic

1 SIDS SIDS Congenital Malformations

2 Congenital Malformations Unintentional Injuries SIDS

3 Unintentional Injuries Congenital Malformations Unintentional Injuries

4 Diseases of the Circulatory Diseases of the Circulatory Diseases of the Circulatory System System System

5 Homicide Homicide Septicemia/Homicide

SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. SIDS and SUID mortality rates: United States, 1999-2016

SIDS SUID 120

95.89 * 100 92.24 91.08 88.80

80 66.75 * 60 54.55 57.02

37.99 40

20 Infantper deaths 100,000 live births

0 1999 2001 2003 2005 2007 2009 2011 2013 2015

SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. NOTE: *New SUID reporting guide released in 2006, may have contributed to increase between 2006-2007 Percentage of preterm births by maternal race and Hispanic origin: United States, 2016

14 13.64

12 9.85 10 9.45

9.06

8 Percent 6

0 Total Non-Hispanic White Non-Hispanic Black Hispanic

NOTE: Gestational age is expressed in completed weeks based on the obstetric estimate of gestation. SOURCE: NCHS, National Vital Statistics System, Natality. Infant mortality rates by gestational age, United States, 2016

Preterm 200 190.15 180

160

140

120

100

40 20.12 Infantper deaths 1,000 live births 20 8.65 5.87 3.26 1.72 1.49 4.31 0 Total <32 32-33 34-36 37-38 39-40 41 42+ NOTE: Gestational age is expressed in completed weeks based on the obstetric estimate of gestation. SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Infant mortality rates for preterm births (less than 37 weeks) by maternal race and Hispanic origin: United States, 2016

<32 weeks 32-33 weeks 34-36 250 215.62

200 181.54 173.62

150

100

50 Infantper deaths 1,000 live births 19.63 19.42 22.06 8.77 11.13 7.42 0 Non-Hispanic White Non-Hispanic Black Hispanic

NOTE: Gestational age is expressed in completed weeks based on the obstetric estimate of gestation. SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Percent of preterm-related infant mortality by maternal race and Hispanic origin: United States, 2016

50 44.1

40 35.8 36.1

29.8 30

related causes related 20

10 Percentof deathsinfant due to preterm

0 Total Non-Hispanic White Non-Hispanic Black Hispanic

SOURCE: Ely DM. Infant Mortality Rate, by Urbanization Level*-National Vital Statistics System, United States, 2007 and 2015. Morbidity and Mortality Weekly ReportSOURCE (:MMWR): NCHS, National 66(41), Vital Statistics1122. 2017. System, Linked birth/ infant death data set. Infant mortality rates by urbanization level: United States, 2007

9 and 2015 Large urban counties Small or Medium urban counties Rural counties 8 7.45 7.09

7 6.78 6.38 6.36 6 5.44 5

2 Infantper deaths 1,000 live births

0 Large urban counties Small and medium urban counties Rural counties SOURCE: Ely DM. Infant Mortality Rate, by Urbanization Level*-National Vital Statistics System, United States, 2007 and 2015. Morbidity and Mortality Weekly

Infant mortality rates by urbanization level, 2007 and 2015 9 Small or Medium urban counties Rural counties

8 7.45 7.09 Rural 5% higher

7 6.78 6.36 6

3 Rural 7% higher 2 Infantper deaths 1,000 live births

0 Small and medium urban counties Rural counties

SOURCESOURCE:: NCHS, Ely National DM. Infant Vital Statistics Mortality System, Rate, Linked by birth/infantUrbanization death dataLevel* set. -National Vital Statistics System, United States, 2007 and 2015. Morbidity and Mortality Weekly R t (MMWR) 66(41) 1122 2017 Infant mortality rates by urbanization level: United States, 2007 and 2015 9 Large urban counties Rural counties 8 7.45

6.78 hs 7

rt 6.38 Rural 17% higher bivei 6 5.44

000 l 5 r 1,pe r 1,pe 4 hsta de hsta 3 ntInfa 2 Rural 25% higher

0 Large urban counties Rural counties SOURCE:SOURCE: NCHS, Ely National DM. Infant Vital Statistics Mortality System, Rate, Linked by birth/infantUrbanization death dataLevel* set. -National Vital Statistics System, United States, 2007 and 2015. Morbidity and Mortality Weekly

Total infant, neonatal, and postneonatal mortality rates by urbanization level: United States, 2016 8 Total infant Neonatal Postneonatal 7 6.70

6 5.74

5 4.09 4 3.85

3 2.61

2 1.89 Infantper deaths 1,000 live births 1

0 Rural Urban*

SOURCE: NCHS, National Vital Statistics System, Linked birth/ infant death data set. Conclusions - trends

• Fetal mortality was essentially unchanged from 2011-2016

• Infant mortality has also been essentially unchanged since 2011

• Accordingly, there have been no recent improvement in overall perinatal mortality

• Only four states significantly improved infant mortality rates in 2016 compared with 2011 • Lower rate in 2016: California, New Jersey, New York, Virginia

Conclusions – infant mortality by race and Hispanic origin • Non-Hispanic black infants continue to have infant mortality rates more than twice as high as those for non-Hispanic white, Asian or Pacific Islander, and Hispanic infants

• Native American or Alaska Native infants have the second highest infant mortality rates

• Compared with 2011, mortality rates for non-Hispanic white and Asian or Pacific Islander infants were lower in 2016; rates for the other 3 race and Hispanic origin groups were essentially unchanged

• The lowest mortality rates by state for infants of non-Hispanic black women were higher than the highest mortality rates by state for infants of non- Hispanic white and Hispanic women

Conclusions – total infant leading causes of death

• The five leading causes of infant mortality for 2016 were:

• congenital malformations • low birthweight • maternal complications • SIDS • unintentional injuries

• Consistently the leading 5 causes of infant mortality since 2006

Conclusions – neonatal leading causes of death • The five leading causes of neonatal mortality for 2016 were:

• low birthweight • congenital malformations • maternal complications • placenta, cord, and membrane complications • bacterial sepsis.

• Consistently the leading 5 causes of neonatal mortality since 2007 (except in 2011 when bacterial sepsis was ranked 6th) • Same 5 leading causes of neonatal mortality for non-Hispanic white, non- Hispanic black, and Hispanic infants

Conclusions – postneonatal leading causes of death • The five leading causes of neonatal mortality were:

• congenital malformations • SIDS • unintentional injuries • diseases of the circulatory system • homicide

• Consistently the leading 5 causes of postneonatal mortality since 2010 (before this, homicide/assault was ranked 6th or 7th for several years) • Same 5 leading causes of postneonatal mortality for non-Hispanic white, non- Hispanic black, and Hispanic infants (Hispanic infants also have septicemia tied for 5th) Conclusions – SIDS/SUID and preterm-related infant mortality

• Since 2007 (the year after new reporting guide released), SIDS rates declined 33% and SUID rates declined 7%

• Preterm-related causes of death accounted for more than 1/3 of infant deaths in 2016

• Large differences by race and Hispanic origin (e.g. 29.8% non-Hispanic white; 44.1% non-Hispanic black. Conclusions – urban / rural divide

• Total infant, neonatal, and postneonatal mortality rates are higher in rural counties than in urban counties

• Higher rural infant mortality has been consistent over time

• Differences between rural and urban counties have widened over time

Looking ahead

• 2017 linked file data will be based fully on the 2003 birth certificate revision

• Users will be able to make their own cohort files starting with the re- release of the 2017 data

• Will continue to make improvements to data timeliness Thank you!

Questions?