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PubMed2000

Predictive value of plasma human chorionic gonadotrophin following assisted conception treatment.

A total of 429 pregnancies after assisted conception treatment was analysed, using receiver operator characteristic curves. The best balance between sensitivity and specificity for predicting viable (single and multiple births) and non-viable (fetal heart positive abortions, ectopic and biochemical pregnancies) outcomes was human chorionic gonadotrophin (HCG) 50 IU/l on day 14 and 200 IU/l on day 21 after treatment. Utilizing these indices all pregnancies could be classified into one of four groups. In group A (day 14 HCG <50 IU/l and day 21 <200 IU/l), the probability of a birth was 0%, pregnancy loss 72% and ectopic pregnancy 28%. Conversely for group D (day 14 HCG >50 IU/l and day 21 >1000 IU/l), the likelihood of a birth was 90%, pregnancy loss 8% and ectopic pregnancy only 1%. Between groups A and D there was, as expected, a gradually shifting balance in favour of a reduction in ectopic (28, 13, 3, 1%) and biochemical pregnancies (70, 36, 33, 2%) and an increase in fetal heart positive pregnancy losses (2, 6, 13, 7%) and births (0, 44, 50, 90%). The majority of multiple pregnancies (98%) occurred in group D. Two accurately linked HCG measurements allowed a greater predictive accuracy of pregnancy outcome than could be obtained using either alone.

Adult↗
PubMed2003

Defining the problem: the epidemiology of preterm birth.

Preterm birth is the major clinical problem associated with perinatal mortality, serious neonatal morbidity and moderate to severe childhood disability in prosperous countries. Its prevalence is affected by the way in which gestational age is assessed, by national differences in the registration of births, associated practices, such as burial costs, or maternity benefits, which encourage or discourage registration, and by the perceived viability of extremely preterm infants. Despite these uncertainties, there is reliable evidence that preterm births are increasing, especially births before 28 weeks gestation. Contributing factors include births following assisted reproductive therapy and ovulation induction, especially multiple births, and the increasing proportion of births among women >34 years. On the other hand, improvements in neonatal care have substantially increased the survival of preterm infants during the last 15 years. There is wider acceptance of the importance of infection as a factor in preterm birth, and increasing recognition that processes leading to preterm birth may be initiated in very early pregnancy (the initiation of pre-eclampsia, major birth defects, premature placental separation), or even prior to pregnancy (prior pregnancy losses). It is unclear whether the familiar clinical presentations of preterm labour and birth reflect different pathophysiological processes. The pathways which link those processes to the consistent pattern of social differences in the probability of preterm birth have prompted new research approaches but in 2002 'the stubborn challenge of preterm birth' remains just that.

Female↗
PubMed1996

Management and outcomes of 65 quadruplet pregnancies: sixteen years' experience in France.

OBJECTIVE: Data on the prognosis and management of multifetal pregnancies are of vital importance, particularly when the option of selective termination is considered. The present study details the obstetric management, neonatal outcome, and follow-up data of 65 quadruplet pregnancies in France. METHODS: To conduct the study, a questionnaire was sent to families registered with the National Association Helping Parents of Multiple Births (Association National d'Entraide des Parents de Naissance Multiples, A.N.E.P.N.M.). RESULTS: Of 116 questionnaires sent to families of quadruplets born between 1972 and 1988, 65 were received. Of these pregnancies, 58 were obtained with ovulation induction agents, 2 with IVF (in vitro fertilization) and GIFT (gamete intrafallopian transfer) and 5 were spontaneous. Diagnosis was made prior to 13 weeks gestation in 87.2% of cases. Most mothers were hospitalized prior to delivery--mean duration of 47 days. The mean gestational age at delivery was 31.2 +/- 3 weeks with a prematurity rate of 97%. Cesarean sections were performed in 51 cases and vaginal deliveries in 14. Neonatal and perinatal mortality rates were 68 and 104 per 1000, respectively. Birthweights of quadruplets ranged from 760 to 2455 g with a mean of 1615 g. CONCLUSION: Management of quadruplet pregnancies in France consists of early diagnosis, echographical and clinical monitoring, early reduction of maternal activity and cesarean deliveries. Our management of such pregnancies is of high quality as reflected by our obstetrical results. Lack of adequate management, as perceived by families of quadruplets, exists at two levels; a psychological (lack of psychological support) and a financial (lack of specific help).

Birth Weight↗
PubMed1988

Multiple pregnancy in the Maltese population.

This study analyses the multiple birth statistics for the Maltese Islands since 1959. Hospital twin births delivering during the period of 1983-1985 are analysed for a number of variables. The incidence of multiple pregnancy for the Maltese Islands appears to have decreased slightly since 1959 with an overall rate of 10.21 per 1000 maternities. The ratio of dizygotic to monozygotic twinning was computed to be 1.64. Patients with multiple pregnancies are shown to be generally elderly and multiparous. The pregnancy outcome is more likely to be complicated by an operative delivery, while the infant is more likely to be premature and of low birth weight. The perinatal mortality rate for multiple pregnancies is markedly in excess of that for singleton births.

Cause of Death↗
PubMed1988

Steroid contraceptive use and pregnancy outcome.

Contraceptive use in relation to pregnancy outcome was studied in 8,816 births in Chiang Mai, northern Thailand, by examination of newborn infants and interviews with their mothers. Four thousand twenty-three women used no contraception before the index pregnancy, 1,229 used the injectable contraceptive Depo Provera (DMPA), and 3,038 used oral contraceptives prior to or during pregnancy. No differences were observed between these groups with respect to still births, multiple pregnancies, and birthweight. Women who used oral contraceptives had unexpectedly low rates of major defects and may have been affected by self-selection bias, whereas the noncontraceptors had rates similar to other populations. There was a significantly increased association of polysyndactyly among infants of DMPA users relative to the other groups, which was most pronounced in offspring of women under age 30 years, and persisted after exclusion of subjects with a family history or infants with multiple abnormalities. However, in five out of the ten polysyndactyly cases, the last injection of DMPA occurred more than 9 months before conception, and only three cases had definite gestational exposure. The association of chromosomal anomalies was also significantly increased in infants of mothers who used DMPA. The unrelated nature of these defects, the lack of confirmation from other studies, the distant preconceptional exposure to DMPA in many cases, and chance effects due to multiple statistical comparisons make a causal association unlikely. Other birth defects that had been previously reported in some publications to be associated with progestational steroid exposure, such as neural tube defects, heart malformations, and limb reduction defects, were not found in this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Abnormalities, Drug-Induced↗
PubMed1988

The grandmultipara: is she still a risk?

Grandmultiparity is reported to increase both maternal and perinatal mortality and morbidity. Unique religious and demographic factors in Jerusalem allowed us to analyze a population wherein parity could be dissociated from socioeconomic status. A total of 7785 mothers was studied, 889 (11.5%) of whom were grandmultiparas. Comparison of grandmultiparous mothers with all others revealed no increase in the incidence of hypertension, diabetes, uterine atonia, antenatal or postnatal hemorrhage, cesarean sections, stillbirth rate, or congenital malformations. The grandmultipara had significantly lower neonatal mortality and low birth weight rates and a significantly higher incidence of multiple births and trisomy 21 (p less than 0.01). These results strongly suggest that grandmultiparity in and of itself in a healthy, economically stable population afforded modern medical care is not a major risk factor and that previous reports primarily reflected social class factors and not parity per se.

Female↗
PubMed1995

Describing the spread of biological populations using stochastic compartmental models with births.

This paper derives new models for describing the spread of biological populations in space and time from classical birth-death-migration processes. The spatial aspect is incorporated using compartmental analysis and is developed for two spatial areas (or compartments). The exact bivariate distributions for such processes are intractable; hence approximating distributions are constructed by matching cumulants. A basic Markovian model with exponential waiting times between births is investigated first. The individual effects of swarming, multiple births, and Erlang distributed waiting times, all of which enhance the biological realism, are investigated. A full model which includes all of these effects is then studied. The models are illustrated with observed data on the spread of the Africanized honey bee in French Guiana. A full model with swarming, with an average of 2.64 colonies per swarming episode, and with waiting times following an Erlang distribution with shape parameter 5 is found to provide the best description of the observed data. The methodology is very general and should have broad application for other biological population models involving dispersal and growth.

Africa↗
PubMed2003

The clustering of neonatal deaths in triplet pregnancies: application of response conditional multivariate logistic regression models.

BACKGROUND/OBJECTIVES: A population-based retrospective cohort study of triplet pregnancies was conducted to estimate individual probabilities of neonatal mortality (death within 28 days of birth) conditional on the number of neonatal deaths experienced by other infants in the triplet set. METHODS: Data on 4,697 triplet sets (14,091 births) were derived from the U.S. 1995-1997 matched multiple birth file assembled by the National Center for Health Statistics. Response conditional multivariate logistic regression was used to model the association of neonatal mortality among cotriplets. To account for the correlation of the outcomes among cotriplets, regression parameters were estimated by the methodology of generalized estimating equations with robust variance estimates. RESULTS: Compared with a triplet where both cotriplets survived the neonatal period, the adjusted odds ratio and 95% confidence interval (CI) for a neonatal death associated with one and two cotriplet neonatal deaths were 1.80 (95% CI 1.06, 3.04), and 13.41 (95% CI 2.31, 77.7), respectively, after adjusting for birthweight and gestational age. CONCLUSIONS: These results show strong evidence of clustering of neonatal deaths in triplet pregnancies.

Humans↗
PubMed2002

The impact of prenatal care on postneonatal deaths in the presence and absence of antenatal high-risk conditions.

OBJECTIVE: This study was undertaken to determine the association, if any, between prenatal care and postneonatal death in the presence and absence of high-risk pregnancy conditions. STUDY DESIGN: Data were derived from the national linked birth/infant death data set for the years 1995 to 1997 provided by the National Center for Health Statistics. Analyses were restricted to singleton live births that occurred after 23 completed weeks of gestation. Multiple births, congenital malformations, chromosomal abnormalities, missing data on gestational age, and birth weight less than 500 g were excluded. Multivariable logistic regression analyses were used to adjust for various antenatal high-risk conditions, maternal age, gravidity, gestational age at delivery, birth weight, maternal education, marital status, smoking, and alcohol use. Postneonatal death rate was defined as the number of deaths between 28 and 365 days of life per 1,000 neonatal survivors. RESULTS: For 10,512,269 singleton live births analyzed, 21,962 (2.1 per 1,000) resulted in postneonatal death. Postneonatal death rates were higher for African American women than white women in the presence (3.8 vs 1.7 per 1,000) and absence (11.2 vs 5.3 per 1,000) of prenatal care. Lack of prenatal care was associated with increased relative risk (RR) for postneonatal death, 1.8-fold in African American women and 1.6-fold in white women. Lack of prenatal care was associated with increased postneonatal death rates to a similar degree for the individual high-risk pregnancy conditions for both African American and white women. Lack of prenatal care was associated with increased postneonatal death rates, especially in the presence of postterm pregnancy (RR 2.3, 95% CI 1.6, 3.1), pregnancy-induced hypertension (RR 2.2, 95% CI 1.5, 3.4), intrapartum fever (RR 2.1, 95% CI 1.2, 3.5), and small-for-gestational-age infant (RR 1.6, 95% CI 1.3, 2.0). CONCLUSION: Lack of prenatal care should be considered as a high-risk factor for postneonatal death for both African American and white women, especially if the pregnancy has been complicated by postdates, pregnancy-induced hypertension, intrapartum fever or small-for-gestational-age infant.

Black or African American↗
PubMed2001

Risk factors for neonatal seizures: a population-based study, Harris County, Texas, 1992-1994.

Risk factors for neonatal seizures were evaluated in 116,048 infants born between 1992 and 1994 to residents of Harris County, Texas; 207 of these infants were diagnosed with clinical neonatal seizures. Information was obtained from the infant's birth certificate to assess the relation between seizures and birth weight, gender, ethnicity, place of birth, mother's age, method of delivery, parity, and multiple births. These factors were evaluated by univariate and multivariate analysis using logistic regression. For preterm infants, a birth weight of <1,500 g was the strongest risk factor (relative risk (RR) = 9.1, 95% confidence interval (CI): 4.7, 17.5), followed by birth in a private/university hospital (RR = 2.8, 95% CI: 1.5, 5.0) and male gender (RR = 1.8, 95% CI: 1.0, 3.4). For term infants, significant risk factors included birth by cesarean section (RR = 2.2, 95% CI: 1.5, 3.2), small birth weight for gestational age (RR = 1.9, 95% CI: 1.2, 2.9), birth in a private/university hospital (RR = 1.8, 95% CI: 1.1, 3.0), and maternal age of 18-24 compared with 25-29 years (RR = 1.6, 95% CI: 1.1, 2.3). Birth by assisted vaginal delivery and primiparity were marginally significant for term infants. Birth weight is a significant risk factor for neonatal seizures. The role of perinatal complications warrants further evaluation.

Birth Weight↗
PubMed1996

Risk factors associated with retinopathy of prematurity (ROP) in northern Jutland, Denmark 1990-1993.

This population-based, historical, follow-up study analysed possible risk factors for retinopathy of prematurity (ROP) and resulting visual impairment in newborns over a period of 3 1/2 years in the County of Northern Jutland, Denmark. The study subjects were 141 infants with birth weight < or = 1500 grams and gestational age < 35 completed weeks who survived to a first eye examination at 5 weeks. The incidence of ROP (all stages) was 18%, and the frequency of severe visual impairment from ROP was 14/100,000 live births. A logistic regression analysis identified low gestational age, multiple births, continuous oxygen treatment, and male sex as risk factors for ROP. The main factor in the prevention of ROP is to prevent preterm births.

Birth Weight↗
PubMed2006

The impact of breastfeeding on the health of HIV-positive mothers and their children in sub-Saharan Africa.

OBJECTIVE: We assessed the impact of breastfeeding by women infected with human immunodeficiency virus (HIV)-1 on their morbidity and risk of mortality and on the mortality of their children. METHODS: We analysed longitudinal data from two previous randomized clinical trials of mother-to-child transmission of HIV conducted between April 2000 and March 2003 in the Republic of Malawi, Africa. Mothers infected with HIV, and their newborns, were enrolled at the time of their child's birth; they then returned for follow-up visits when the child was aged 1 week, 6-8 weeks and then 3, 6, 9, 15, 18, 21 and 24 months. Patterns of breastfeeding (classified as exclusive, mixed or no breastfeeding), maternal morbidity and mortality, and mortality among their children were assessed at each visit. Descriptive and multivariate analyses were performed to determine the association between breastfeeding and maternal and infant outcomes. FINDINGS: A total of 2000 women infected with HIV were enrolled in the original studies. During the 2 years after birth, 44 (2.2%) mothers and 310 (15.5%) children died. (Multiple births were excluded.) The median duration of breastfeeding was 18 months (interquartile range (IQR)=9.0-22.5), exclusive breastfeeding 2 months (IQR=2-3) and mixed feeding 12 months (IQR=6-18). Breastfeeding patterns were not significantly associated with maternal mortality or morbidity after adjusting for maternal viral load and other covariates. Breastfeeding was associated with reduced mortality among infants and children: the adjusted hazard ratio for overall breastfeeding was 0.44 (95% confidence interval (CI)=0.28-0.70), for mixed feeding 0.45 (95% CI=0.28-0.71) and for exclusive breastfeeding 0.40 (95% CI=0.22-0.72). These protective effects were seen both in infants who were infected with HIV and those who were not. CONCLUSION: Breastfeeding by women infected with HIV was not associated with mortality or morbidity; it was associated with highly significant reductions in mortality among their children.

Adult↗
PubMed2002

Personal experiences of bereaved twins, parents of twins, and their carers.

We invited bereaved twins, parents of twins and carers to describe some of their personal experiences. We are grateful to all of them for their brave candour. We gave extra space to Kathy's story about the impacts of the loss of her own twin because it vividly illustrates the profound connections twinship can generate. Similarly we thought the cruelly long and complex saga of the life and death of Maxine's twins could help understanding of the distressing repercussions that often attend the low birth weight and prematurity that are so common amongst multiple births.

Attitude to Death↗
PubMed1988

[Classification of perinatal deaths as a function of birth weight and gestational age. New methodologic approach].

Perinatal mortality is closely related to infant birth weight. However, the examination of both gestational age and birth weight provides a more comprehensive approach. This study presents a method of evaluation which is readily applicable. Data were obtained from the computerized files of the maternity ward of the University Hospital of Caen. This report is based on case-reports of 17,952 single births, from May 1980 to July 1985 (cases of multiple birth have not been considered since their age/weight relationships are usually different). All stillborn infants and those who died within the first week of life were considered. Any infant whose gestational age was 28 weeks or more but who showed no sign of life at birth was considered stillborn. Gestational age was determined from the mother's last menstrual period, providing it concurred with the obstetrical evaluation (i.e. echographic measurements of foetus before 20 weeks of gestation). If not, the clinical evaluation was retained. Results are presented in the form of blocks, each one representing 1 week of gestational age and a birth weight of 500 g. The perinatal mortality rate was calculated for each block. Blocks of similar mortality rates (i.e. with no significant difference) were then pooled by means of a recently published method [3]. This difference between the mortality rates of 2 blocks (in percentages) may be measured by means of the chi-square test. The test enables the evaluation of the "distance" between two adjacent zones, which can be calculated for all the blocks of the graph, by pairs.(ABSTRACT TRUNCATED AT 250 WORDS)

Birth Weight↗
PubMed2005

A review of pregnancy outcomes after exposure to orally inhaled or intranasal budesonide.

BACKGROUND: Inadequately controlled rhinitis is associated with worsening asthma, one of the most common potentially serious causes of pregnancy complications. Recent evidence-based guidelines now stress the importance of inhaled corticosteroids as first-line therapy in controlling asthma during pregnancy, with preference given to budesonide. Both inhaled and intranasal budesonide formulations are rated Pregnancy Category B; all other inhaled and intranasal corticosteroids are rated Pregnancy Category C. OBJECTIVE: To review data from clinical and epidemiological studies investigating the effects of orally inhaled or intranasal budesonide on pregnancy outcomes. METHODS: Clinical and epidemiological studies on the effects of maternal exposure to orally inhaled or intranasal budesonide were identified through searches of the literature indexed on Medline or the Developmental and Reproductive Toxicology (DART) database through January 2005. The search terms used were: 'budesonide' and 'pregnancy'; 'pregnancy complications'; 'teratogens'; 'fetus'; 'embryo'; or 'toxicology'. The search was limited to English-language articles and those evaluating humans. Pertinent abstracts were identified from recent US asthma and allergy meetings. RESULTS: A total of five articles and three abstracts meeting the search criteria were identified. Retrospective epidemiological studies and a randomized, placebo-controlled, multicenter trial found no clinically or statistically significant effects on fetal outcomes among more than 6600 infants whose mothers were exposed to orally inhaled budesonide during pregnancy. Women who reported use of orally inhaled budesonide either during early pregnancy only or throughout pregnancy gave birth to infants of normal gestational age, birth weight, and length, with no increased rate of stillbirths, multiple births, or congenital malformations. In a retrospective case-control analysis, no association was found between inhaled budesonide or intranasal budesonide and the overall rate of infant cardiovascular defects. However, a marginally increased risk of less severe cardiovascular defects (odds ratio = 1.58, 95% confidence interval 1.02 to 2.46) was observed with intranasal budesonide in one analysis, possibly the result of a random association due to multiple testing or an unidentified confounder. CONCLUSION: Maternal exposure to orally inhaled budesonide during pregnancy is not associated with an increased risk of congenital malformations or other adverse fetal outcomes in studies of more than 6600 infants. Data on pregnancy outcomes after maternal exposure to intranasal budesonide are limited, but the totality of evidence, including pharmacological studies showing a much lower systemic exposure after intranasal administration, indicates its safety profile is at least comparable with that of orally inhaled budesonide.

Abnormalities, Drug-Induced↗
PubMed1991

Maternal reproductive history and birth characteristics in childhood acute lymphoblastic leukemia.

Using birth-registration data, a case-control study was done to investigate the possible associations of childhood acute lymphoblastic leukemia (ALL) with birth characteristics and maternal reproductive history. The data included cases born and diagnosed in Minnesota since 1969. Matched analyses were conducted using 337 cases and 1336 birth year-matched controls. There was a statistically significant increased odds of ALL for birth to older (greater than 35 years) mothers (odds ratio (OR) = 2.14, 95% confidence interval (CI) = 1.28, 3.58), older fathers (OR = 1.62, 95% CI = 1.14, 2.30), mothers with at least a high school education (OR = 1.61, 95% CI = 1.05, 2.48), and larger intervals (greater than 5 years) between the birth of the proband and the preceding sibling (OR = 1.86, 95% CI = 1.12, 3.09). The increased odds of ALL for birth by Caesarean section approached significance (OR = 1.42, P = 0.06). No overall association was found for: gender, race, paternal education, fetal-loss history, birth order, prenatal care history, pregnancy complications, inducement of labor, multiple birth, gestational age, or birth weight. Age at diagnosis was an important effect modifier of some analyses. For cases diagnosed before age 2 years, there was a 2.7-fold increased odds of ALL if the last pregnancy had resulted in a fetal loss (P = 0.03). For cases diagnosed before age 4 years, birth weight greater than 3800 g was associated with a significant 2.05-fold increased odds of ALL. These data strengthen the hypothesis that prenatal events may play a causative role in childhood ALL, particularly in those cases diagnosed at a younger age.

Abortion, Spontaneous↗
PubMed2006

In vitro fertilization with single blastocyst-stage versus single cleavage-stage embryos.

BACKGROUND: Single-embryo transfer has been recommended to reduce the incidence of multiple gestations when in vitro fertilization is performed in women under 36 years of age. We designed a prospective, randomized, controlled trial to determine whether there were any differences in the rates of pregnancy and delivery between women undergoing transfer of a single cleavage-stage (day 3) embryo and those undergoing transfer of a single blastocyst-stage (day 5) embryo. METHODS: We studied 351 infertile women under 36 years of age who were randomly assigned to undergo transfer of either a single cleavage-stage embryo (176 patients) or a single blastocyst-stage embryo (175 patients). Multifollicular ovarian stimulation was performed with a gonadotropin-releasing hormone antagonist and recombinant follicle-stimulating hormone. RESULTS: The study was terminated early after a prespecified interim analysis (which included 50 percent of the planned number of patients) found a higher rate of pregnancy among women undergoing transfer of a single blastocyst-stage embryo (P=0.02). The rate of delivery was also significantly higher in this group than in the group undergoing transfer of a single cleavage-stage embryo (32.0 percent vs. 21.6 percent; relative risk, 1.48; 95 percent confidence interval, 1.04 to 2.11). Two multiple births occurred, both of monozygotic twins, both of which were in the group undergoing transfer of a single cleavage-stage embryo. CONCLUSIONS: These findings support the transfer of a single blastocyst-stage (day 5) embryo in infertile women under 36 years of age.

Adult↗
PubMed2003

Annual summary of vital statistics--2002.

The crude birth rate in 2002 was 13.9 births per 1000 population, the lowest ever reported for the United States. The number of births, the crude birth rate, and the fertility rate (64.8) all declined slightly (by 1% or less) from 2001 to 2002. Fertility rates were highest for Hispanic women (94.0), followed by black (65.4), Asian or Pacific Islander (63.9), Native American (58.0), and non-Hispanic white women (57.5). Fertility rates declined slightly for all race/ethnic groups from 2001 to 2002. The birth rate for teen mothers continued to fall, dropping 5% from 2001 to 2002 to 42.9 births per 1000 women aged 15 to 19 years, another record low. The teen birth rate has fallen 31% since 1991; declines were more rapid for younger teens aged 15 to 17 (40%) than for older teens aged 18 to 19 (23%). The proportion of all births to unmarried women remained approximately the same at one third. Smoking during pregnancy continued to decline; smoking rates were highest among teen mothers. In 2002, 26.1% of births were delivered by cesarean section, up 7% since 2001 and 26% since 1996. The primary cesarean rate has risen 23% since 1996, whereas the rate of vaginal birth after a previous cesarean delivery has fallen 55%. The use of timely prenatal care increased slightly to 83.8% in 2002. From 1990 to 2002, the use of timely prenatal care increased by 6% (to 88.7%) for non-Hispanic white women, by 24% (to 75.2%) for black women, and by 28% (to 76.8%) for Hispanic women, thus narrowing racial disparities. The percentage of preterm births rose to 12.0% in 2002, from 10.6% in 1990 and 9.4% in 1981. Increases were largest for non-Hispanic white women. The percentage of low birth weight (LBW) births also increased to 7.8% in 2002, up from 6.7% in 1984. Twin and triplet/+ birth rates both increased by 3% from 2000 to 2001. Multiple births accounted for 3.2% of all births in 2001. The infant mortality rate (IMR) was 6.9 per 1000 live births (provisional data) in 2002 compared with 6.8 in 2001 (final data). The ratio of the IMR among black infants to that for white infants was 2.5 in 2001, the same as in 2000. Racial differences in infant mortality remain a major public health concern. The role of LBW in infant mortality remains a major issue. New Hampshire, Utah, and Massachusetts had the lowest IMRs. State-by-state differences in IMR reflect racial composition, the percentage of LBW, and birth weight-specific neonatal mortality rates for each state. The United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a record high of 77.2 years for all sex and race groups combined in 2001. Death rates in the United States continue to decline. Between 2000 and 2001, death rates declined for the 3 leading causes of death: diseases of the heart, malignant neoplasms, and cerebrovascular diseases. Death rates for children ages 1 to 19 years decreased for unintentional injuries by 3.3% in 2001; the death rate for chronic lower respiratory diseases decreased by 25% in 2001. Cancer and suicide levels did not change for children ages 1 to 19. A large proportion of childhood deaths continue to occur as a result of preventable injuries.

Adolescent↗