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TRENDS IN INFANT MORTALITY IN NEW YORK CITY HEALTH AREAS SERVED BY CHILDREN AND YOUTH PROJECTS JOHN J. MCNAMARA, M.D., M.P.H. Assistant Professor of Public Health and Pediatrics Columbia University Associate Commissioner Department of Health of the City of New York
SOL BLUMENTHAL, Ph.D. Director, Office of Research Department of Health of the City of New York
CASSIE LANDERS, M.P.H. Research Assistant Columbia University School of Public Health New York, New York
CHILDREN AND YOUTH PROJECTS (CYP) are federally funded programs Vto provide comprehensive health services, particularly in areas with many low-income families. These programs were established under P. L. 89-97, the 1965 amendments to Title V of the Social Security Act. These projects are located within such existing health-care institutions as hospitals, health departments, and medical schools on the basis of documented community health needs and marginal resources. To improve the health status of defined populations of children, projects provide "comprehensive health and dental services; including screening, diagnosis, preventative services, treatment, correction of defects and aftercare both medical and dental."1 A parallel federal program, the Maternity and Infant Care Program (MIC), provides medical care to high-risk pregnant women and to infants throughout the first year of life. However, in New York City MIC provided only for pregnant women, and infants were referred to existing well-child clinics, CYP, and other established resources throughout the city. Address for reprint requests: Sol Blumenthal, Ph.D., City of New York Department of Health, 125 Worth Street, Room 604A, New York, N.Y. 10013.
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Fig. 1. Health Center Districts of the City of New York showing the locations of Children and Youth (C & Y) Projects (shaded areas).
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Eight CYP areas were established in four of the five boroughs of New York City during 1966 and 1967. The first program commenced in June 1966 and the last began in November 1967. Locations of the projects in areas of high need in Manhattan, Queens, Brooklyn, and the Bronx are identified in Figure 1. While approximately 50 health areas now receive these services, many high-risk areas such as Harlem, much of the South Bronx, and Brooklyn are not served by such projects. One index used to locate CYP and other comprehensive care projects and to serve as a norm for evaluation was a high infant-mortality rate.2 In those areas of New York City now served by CYP, infant mortality initially was much greater than the citywide average. Reduction in this discrepancy was a goal of the projects. To evaluate the impact of CYP on one aspect of child health in New York City, this study reviews infantmortality statistics in areas served by these projects. Trends in infant mortality are delineated, selected variables influencing infant mortality are analyzed, and comparisons are drawn between project areas and the whole city. MATERIALS AND METHODS New York City Vital Statistics by Health Areas and Health Center Districts for 1964 through 1975 provide the data utilized in this study. These reports are prepared annually by the Bureau of Health Statistics and Analysis of the Department of Health of the City of New York and summarize by health area the number of live births, deaths of those less than one year of age, and total deaths by cause. The Department of Health defines the infant-mortality rate as the number of infant deaths per 1,000 live births; the neonatal mortality rate is the number of deaths occurring in the first month of life per 1,000 live births; and the postneonatal mortality rate is the number of infant deaths occurring from 28 days to one year after birth per 1,000 live births. CYP catchment areas were divided into constituent health areas. Where part of a health area was involved, all data were utilized. For CYP health areas, the number of infant deaths and live births were determined for each year from 1964 to 1975, and then overall infant-mortality rates within catchment areas were computed from the aggregated number of deaths and births. In addition, rates were calculated by race and age at death. For interpretation, data were organized into two time periods of three years each: before and after the CYP. Bull. N.Y. Acad. Med.
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TABLE II. INFANT MORTALITY IN NEW YORK CITY AND CHILDREN AND YOUTH PROJECT AREAS Children and Youth Project Areas
New York City
Years
Preproject years Postproject years
Infant Infant deathsl mortality rate * live births
1964-1966 12,333/477,844 1967-1969 10,334/433,943 1970-1972 8,302/398,200
25.8 23.8 20.8
6,491/330,699
19.6
1973-1975
Change (total) t 7.8% 12.6% (19.4%) 5.8% (24.0%)
Infant Infant deathsl mortality rate * live births
1,817/61,383 1,545/56,887 1,206/53,971
29.6 27.2 22.3
895/43,715
20.5
Change (total) t 8.4 17.7% (24.7%) 8.1% (30.7%)
*Number of infant deaths per 1,000 live births.
tBase period.
The total percentage changes for long periods do not equal the sum of the changes for component years because the various percentages have different bases of comparison. The percent change column for 1967-1969 (7.8%) is compared with 1964-1966, the percent change for 1970-1972 (12.6%) is compared with 1967-1969, and the percent change shown for 1973-1975 (5.8%) is compared with (based on) 1970-1972. There are different bases used for these percent changes so that they do not add up to the percent changes shown in parentheses, which are all based on the 1964-1966 rates.
Rigorous evaluation of the effectiveness of these projects most appropriately should compare infant-mortality rates in CYP catchment areas to areas of similar socioeconomic status and ethnic configuration which are not receiving such services, but in the present study exact matching was not possible. Health areas adjacent to CYP do not provide matched controls. Nonadjacent health areas do not provide matched controls because of locational differences in the city health system such as differing degrees of accessibility to services and wide variation in ethnic and socioeconomic composition. Therefore, infant-mortality rates for New York City as a whole were compared to rates in areas receiving CYP services on the assumption that narrowing regional differences in key indicators of health status is a prime concern for compensatory health programs. Finally, the universe of New York City births and deaths is analyzed to show that all noted differences are real. RESULTS
The overall infant-mortality rate in New York City has declined from 26.8/1,000 live births in 1964 to 19.3/1,000 in 1975 (Table I). Between 1964 to 1966 and 1967 to 1969 the decline was 7.8%, between 1967 to 1969 and 1970 to 1972 it declined another 12.6% (19.4% total), and between 1970 to 1972 and 1973 to 1975 a further decline of 5.8% was Bull. N.Y. Acad. Med.
489 8
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recorded (Table II). The total decline from 1964-1966 to 1973-1975 was 24.1 %. Dramatic declines were experienced in Manhattan, the Bronx, and Brooklyn, where high rates had prevailed, but smaller reductions occurred in more middle- class areas such as Queens. Within health areas served by CYP the infant-mortality rate ranged from a high of 32.5/1,000 in 1964 to a low of 19.2 in 1974 (Table I). The rate rose to 21.4 in 1975. During 1964-1966, before initiation of these projects, the average rate for all CYP areas was 29.6, higher than the citywide Vol. 54, No. 5, May 1978
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TABLE III. INFANT-MORTALITY RATES* BY RACE FOR NEW YORK CITY (NYC) AND CHILDREN AND YOUTH PROJECT (CYP) AREAS
White Years
NYC
CYP
Nonwhite CYP NYC
Preproject years
1964-1966 1967-1969
20.7 19.4
24.6 22.7
39.1 35.5
38.6 34.0
Postproject years
1970-1972 1973-1975 Change 1964-1975
17.0 15.7
20.6 17.9
27.0 23.1
24.4 23.1
24.2%
27.2%
40.9%
40.2%
*Number of infant deaths per 1,000 live births.
average of 25.8 (Table II). By the interval 1973-1975 the average infantmortality rate in CYP areas had declined to a low of 20.5 while the citywide average was 19.6. In 1964 to 1969, prior to full activity of most CYP, the decline in infant mortality for CYP areas was 8.4%; between 1969 and 1972 the decline was 17.7% (24.7% total); and between 1972 and 1975 the rate declined an additional 8.1%. Over the decade from 1964-1966 to 1973-1975 the decline was 30.7%, compared to a citywide decline of 24.0% (Table II). These trends in infant mortality are shown graphically in Figure 2. Table III presents the infant-mortality rate in New York City and project areas by race. In project areas the rate for whites decreased 27.2% in the period under study, from 24.6/1,000 in 1964-1966 to 17.9 in 1973-1975. By comparison, the rate for all whites in New York City decreased 24.2% over the decade, from 20.7 in 1964-1966 to 15.7 in 1973-1975. The nonwhite infant-mortality rate for all of New York City decreased by 41% from 1964-1966 to 1973-1975, and for CYP areas it decreased by 40.2%. In 1964-1966 the rate for nonwhites in New York City was 39.1, but in CYP areas the rate was 38.6. The nonwhite infant-mortality rate in 1973-1975 reached a low of 23.1 for infants in both project areas and the city as a whole. The nonwhite infant-mortality rate for project areas and New York City as a whole are similar; however, whites in CYP areas have higher rates than citywide averages for all whites. The neonatal and postneonatal death rates by race are summarized in Table IV. In CYP areas the neonatal death rate for whites decreased by
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TABLE IV. INFANT MORTALITY* BY RACE AND AGE AT DEATH IN NEW YORK CITY AND CHILDREN AND YOUTH PROJECT AREAS New York Citv
Children and Youth
project areas Neonatal
Postneonatal
Neonatal
Postneonatal Nonwhite
White
Nonwhite
White
Nonwhite
White
Nonwhite
White
15.7
28.8
5.0
10.3
18.4
29.0
6.3
9.5
24.8 19.4 16.8
4.5 4.1 3.7
9.2 7.7 6.3
18.1 15.3 13.3
26.7 16.7 16.0
4.6 5.3 4.6
7.3 7.8 7.1
Preproject years
1964-1966
Postproject years
1967-1969 14.9 1970-1972 13.0 1973-1975 11.9 Change 1964-1975 24.2%
41.7% 26.0%
38.8% 27.7%
44.8% 27.0%
25.3%
*Number of infant deaths per 1,000 live births. Neonatal = 0 to 27 days after birth; postneonatal = 28 days to one year after birth.
27.7% in the period under study, compared to a 24.2% decrease in neonatal deaths for whites in New York City as a whole. The decrease for nonwhites was 44.8% in project areas and was 41.7% in all of New York City. The neonatal death rate for whites declined from 15.7 to 11.9 in New York City and declined from 18.4 to 13.3 in project areas. The neonatal rate for nonwhites in New York City declined from 28.8 to 16.8 and declined from 29.0 to 16.0 in project areas, a 41.7% and 44.8% decline, respectively. Between 1964-1966 and 1973-1975 postneonatal mortality rates for whites declined 26% in New York City and 27% in project areas. The rate for nonwhites declined 38.8% in the city as a whole and only 25.3% in project areas. For whites the decline was from 5.0 to 3.7 in the city as a whole and from 6.3 to 4.6 in areas receiving CYP services. For nonwhites the decline in the city was from 10.3 to 6.3 and the decline in project areas was from 9.5 to 7.1.
DIsCuSSION Reductions in infant mortality in New York City have been dramatic in recent years.3 The 1950s was a period of stagnation with respect to change in infant mortality in both New York City and the United States. Failure to reach the low infant mortality of other developed nations, in part, led to
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new experiments in health delivery and to enhanced concern for health and health services in the 1960s. This decade also was marked by vast urban demographic change, social upheaval, and economic prosperity. Planned social experiments in health delivery such as the CYP blossomed, yet the impact of these experiments remains ambiguous.4 In the 1970s cities continue to undergo demographic change, although at a decelerated speed. While surface social stability has been restored, economic prosperity has given way to decline; however, infant-mortality rates have continued to decline. The New York City rate of 19.3 for 1973 to 1975 represents an unprecedented decline in infant mortality. Project areas of high health need saw a decline in infant mortality from a rate substantially higher than the citywide average at the start of the program to one slightly below the citywide average in 1974. It may be ominous that in 1975, a poor economic year, this rate rose to the level experienced in 1972. These changes in infant-mortality rates are based on all births and deaths and represent real changes; however, from the social-policy viewpoint the significance of small marginal changes remains problematic. According to overall changes in the infant-mortality rate, changes occurred at a greater rate in project areas than in the city as a whole. The goal of narrowing differences in infant mortality between project areas and the rest of the city has been achieved. Whether the projects are responsible for this change requires further analysis. Historically, very high infantmortality rates have been affected markedly by relatively small per capita expenditures. For example, the approximately 20% infant mortality of the early 1900s was reduced to about 3% in the 1950s, primarily through improved sanitation, personal hygiene, and nutrition. To reduce this 3% mortality to 1% or less through intensive public intervention in personal health services might be possible, but certainly would be costly. Interpretation of the effectiveness of these programs will be difficult because other socioeconomic variables have not remained constant. It is apparent from the infant-mortality data under discussion that in project areas the white population in comparison to other white populations is more disadvantaged than the nonwhite population is in comparison to other nonwhite populations. The mortality rate for white infants in project areas exceeded citywide averages for nonwhites in 1964 and continues to do so in 1975. Averages for nonwhites in project areas were slightly less than citywide averages for nonwhites in 1964 and remained so in 1975. However, the major burden of infant deaths is still borne by nonwhites. Do Bull. N.Y. Acad. Med.
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TABLE V. CHANGE IN RACE OR ETHNIC COMPOSITION OF HEALTH AREAS SERVED BY CHILDREN AND YOUTH PROJECTS, 1960-1975 Children and Youth projects
Manhattan No. 1 Manhattan No. 2 Manhattan No. 3 Brooklyn No. 4 Brooklyn No. 5 Bronx No. 6 Bronx No. 7 Queens No. 8 Total
White + 1.3% -4.9% +8.7% -54.6% -46.7% -35.3% -77.3% -2.3% -26.4%
Nonwhite +8.5% +6.8% +7.7% +57.5% +42.6% +20.4% +50.8% +2.4% +24.6%
Puerto Rican -3.4% -2.0% -14.5% -2.4% +4.2% +15.0% +26.5% 0 +2.9%
these data imply that nonwhites in project areas utilize publicly provided services better, are more organized to secure such services in the first place, or have superior child-care practices? Given the major influence of nonwhite infant deaths on the overall rate, if such hypotheses prove true they might help to explain the greater overall rate of change in project areas than in the city as a whole. With regard to the age at death, project areas experienced a greater percentage change in the neonatal mortality rate than did the city as a whole. However, with respect to postneonatal rates, whites in project areas had a reduction greater than the citywide average for whites, while nonwhite postneonatal rates declined less than the citywide average. CYP, which provides comprehensive personal health services, would be expected to have their major health effect on postneonatal rates. Differential rate reductions are not noted. Other demographic changes5-10 might have produced the observed changes in infant mortality. Many social and health-service variables such as socioeconomic status, geographic area, urbanization, parity, age, education of mother, previous pregnancy experience, ethnicity, and availability of family-planning and abortion services, as well as utilization of prenatal and child-health services, have been correlated with infant mortality. Four major variables have been examined to ascertain their possible impact on changes in rates: ethnicity, age distribution of the population, abortion, and actual penetration of the project areas by CYP services. Based on data supplied by the New York City Department of City Planning, changes in the ethnic composition of project areas were outlined Vol. 54, No. 5, May 1978
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1 1970 Less than 1960
1970 More than 1960
WHITE
7075 +
- 74 ~~~~70
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Fig. 3. White and nonwhite populations of New York City by age and sex, 1960 and 1970. Reproduced by permission from Blumenthal, S.: Some New York City population characteristics. Stat. Health Rev. 1: 1, 1975.
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495 9
in Table V. Between 1960 and 1975 in all CYP project areas the white population declined 26.4%, the nonwhite population increased 24.6%, and the Puerto Rican population increased 2.9%. Concomitantly, the age distribution of the population of New York City changed (Figure 3). The white population has aged and the 0 to 4-year-old group has decreased. The nonwhite population retains a younger profile, and increases in the 0to-4-year-old group are noted. Between 1960 and 1970 "there was a reduction in white males (-22%) and females (-23%) under five years of age and an increase in the number of nonwhite males (+39%) and females (+36%) in the same age group."1 Given such changes, it is obvious that in project areas the major population at risk, nonwhite infants, has increased. The effect of ethnic change on infant mortality can be examined in isolation. Rounding to a 26% decline in white births, rounding to a 25% increase in nonwhite births and using 1964 infant-mortality rates as a base, the expected 1975 infant-mortality rates in project areas would be 32/1,000 live births compared to the observed 21.4. In the city as a whole, the expected rate would be 27.8 compared to the observed 19.3. Therefore, the observed declines in infant mortality cannot be attributed to the changing ethnic composition of the population because observed ethnic changes in the absence of other factors would lead to increased rates. A second major social change which could affect the infant-mortality rate is the passage of a liberalized abortion law in New York State. Published reports conflict as to how this affected the rate. In the Rochester and Monroe County area, Roughman notes "it was found that 50% of the explained decline in the birthrate and 25% of the explained reduction in the prematurity ratio were due to abortions. For infant mortality, change, however, was of minor influence."'2 A review of factors in the decline of infant mortality for New York City, however, concludes: "The recordbreaking low infant-mortality rate achieved in New York has come about as a result of a combination of significant and remarkable advances in medical technology and skills, coupled with an impressive number of social advances. Family planning and safe abortions, which have become available to all women regardless of financial status, have played a decisive role."'13 Analysis of abortion data from New York City for 1975 (Table VI) indicates that in the absence of abortion infant-mortality rates would remain essentially unchanged. This calculation assumes that teen-agers Vol. 54, No. 5, May 1978
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TABLE VI. ESTIMATED EFFECT OF ABORTIONS ON INFANT MORTALITY IN NEW YORK CITY, 1975 Womens' ages (years)
Less than 20 20 or more Age unknown Total
No. of women aborted (a)
Age-specific infant mortality rate * (b)
No. of expected infant deaths in absence of abortions (a xb)
17,126 63,942 358 81,426
24.7 15.9 24.7 (assumed)
423 1,017 9 1,449
No. of abortions and live births (d)
Infant deaths (c) No. expected in absence of abortion
1,449 Abortions
No. observed Total
2,110 Births 3,559
Estimated infant-mortality rate* without abortion (c d)
81,426 109,418 190,844
18.6/1000
*Number of infant deaths per 1,000 live births.
constitute the major high-risk group for infant mortality among women seeking abortions. Unwanted pregnancies in older women also might be subject to higher-than-average age-specific rates, and the incidence of abuse and neglect of unwanted children are not included in this estimate. However liberalized abortion alone does not account for the entire change in infant mortality observed from 1964 to 1975. Finally, the actual penetration of the target population and overlap with other services must be ascertained to estimate the effect of CYP on the declining infant-morality rate. In calendar year 1974, in five out of eight CYP for which data was available,"4 3,027 children less than one year of age were enrolled and 7,927 live births were noted in the catchment area served (Table VIIA). Therefore, CYP cared for some 38.2% of the infant population. (This number overestimates the penetration of the population slightly because some enrolled infants under one year of age undoubtedly were born in 1973.) In 60% of health areas (Table VIIB), projects were the only comprehensive child-health service. However, in 40% of health areas other neighborhood health centers and MIC projects provided similar services. Because MIC projects served only 14% of all CYP areas, their presence alone cannot account for the observed decline in the infantmortality rate.
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TABLE VIIA. UTILIZATION OF CHILDREN AND YOUTH PROJECTS (CYP) DURING CALENDAR YEAR 1974*
3,027 7,927 38.2%
CYP enrollees less than 1 year of age (a) Total live births in health areas served by CYP (b) Utilization of CYP by infants in catchment areas (a + b)
TABLE VIIB. OVERLAP OF CHILDREN AND YOUTH PROJECTS (CYP) AND OTHER CHILD-HEALTH SERVICES DURING CALENDAR YEAR 1974* Health areas (%) (No.)
Service CYP only CYP and Maternity and Infant Care projects (MIC) CYP and neighborhood health centers (NHC) CYP, MIC, and NHC Total
30 5 13 2 50
60% 10% 26% 4% 100%
*Data for five of the eight CYP was used.
CONCLUSIONS 1) In CYP catchment areas, infant-mortality rates decreased, essentially eliminating differences in infant mortality between these areas and the city as a whole. 2) There is no evidence that postneonatal rates in project areas improved in a differential fashion, yet this subset of the total infant-mortality rate should be most affected by a comprehensive child-health service. 3) Penetration of the at-risk child population was less than 40%. 4) Changes in ethnicity of the population and liberalized abortion laws do not explain the decline in infant mortality. Undoubtedly, CYP must be counted as only one small social element promoting change in health status. Changes in the socioeconomic status of the population, effects of migration, and provision of enhanced health services for pregnant women all probably contributed to greater change in this indicator of health status than postnatal care. However, in light of the recent increases in infant mortality, it is obvious that maintenance of a low infant-mortality rate-if not further reduction toward the national goal of 1%-will not automatically occur.
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REFERENCES Grants for Comprehensive Health Ser7. Chabot, M.. Garfinkel, J., and Pratt, M. vices for Children and Youth. Policies W.: Urbanization and differentials in and Procedures, HEW, Childrens white and nonwhite infant mortality. Bureau. Washington, D. C., Govt. Pediatrics 56: 777-81, 1975. Print. Off., 1965. 8. Morris, N. M., Udry, J., and Chase, C.: Chabot, A.: Improved infant mortality Shifting age- parity distribution of births rates in a population served by a comand the decrease in infant mortality. Am. prehensive neighborhood health proJ. Public Health 65: 359-62, 1975. gram. Pediatrics 47: 989-94, 1971. 9. Wright, N. H.: Family planning and inPakter, J. and Nelson, F.: Factors in the fant mortality: Rate decline in the U. S. unpredicted decline in infant mortality in Am. J. Epidemiol. 101: 182- 87, 1975. New York City. Bull. N. Y. Acad. Med. 10. Wallace, H. M.: Children and youth 50: 839-68, 1974. projects and related comprehensive Komaroff, A. and Duffell, P.: An evaluhealth care programs. Clin. Pediatr. 10: ation of selected federal categorical 487-94, 1971. health programs for the poor. Am. J. 11. Blumenthal, S.: Some New York City Public Health 66: 255-60, 1976. population characteristics. Stat. Health Donabedian, A., Rosenfeld, L., and Rev. 1: 1, 1975. Southern, E.: Infant mortality and 12. Roghmann, K.: Impact of New York socio-economic status in a metropolitan State Abortion Law. In: Child Health community. Public Health Rep. 80: and the Community. New York, Wiley, 1083-94, 1965. 1975, chap. 8, p. 213. Erhardt, C., Abramson, H., Pakter, J., 13. Pakter, loc. cit., p. 867. and Nelson, F.: An epidemiological 14. Minnesota Systems Research, Inc.: Sysapproach to infant mortality. Arch. tems development project. Personal Environ. Uealth 20: 743-57, 1970. communication.
Bull. N.Y. Acad. Med.
TRENDS IN INFANT MORTALITY IN NEW YORK CITY HEALTH AREAS SERVED BY CHILDREN AND YOUTH PROJECTS JOHN J. MCNAMARA, M.D., M.P.H. Assistant Professor of Public Health and Pediatrics Columbia University Associate Commissioner Department of Health of the City of New York
SOL BLUMENTHAL, Ph.D. Director, Office of Research Department of Health of the City of New York
CASSIE LANDERS, M.P.H. Research Assistant Columbia University School of Public Health New York, New York
CHILDREN AND YOUTH PROJECTS (CYP) are federally funded programs Vto provide comprehensive health services, particularly in areas with many low-income families. These programs were established under P. L. 89-97, the 1965 amendments to Title V of the Social Security Act. These projects are located within such existing health-care institutions as hospitals, health departments, and medical schools on the basis of documented community health needs and marginal resources. To improve the health status of defined populations of children, projects provide "comprehensive health and dental services; including screening, diagnosis, preventative services, treatment, correction of defects and aftercare both medical and dental."1 A parallel federal program, the Maternity and Infant Care Program (MIC), provides medical care to high-risk pregnant women and to infants throughout the first year of life. However, in New York City MIC provided only for pregnant women, and infants were referred to existing well-child clinics, CYP, and other established resources throughout the city. Address for reprint requests: Sol Blumenthal, Ph.D., City of New York Department of Health, 125 Worth Street, Room 604A, New York, N.Y. 10013.
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ITY48
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Fig. 1. Health Center Districts of the City of New York showing the locations of Children and Youth (C & Y) Projects (shaded areas).
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Eight CYP areas were established in four of the five boroughs of New York City during 1966 and 1967. The first program commenced in June 1966 and the last began in November 1967. Locations of the projects in areas of high need in Manhattan, Queens, Brooklyn, and the Bronx are identified in Figure 1. While approximately 50 health areas now receive these services, many high-risk areas such as Harlem, much of the South Bronx, and Brooklyn are not served by such projects. One index used to locate CYP and other comprehensive care projects and to serve as a norm for evaluation was a high infant-mortality rate.2 In those areas of New York City now served by CYP, infant mortality initially was much greater than the citywide average. Reduction in this discrepancy was a goal of the projects. To evaluate the impact of CYP on one aspect of child health in New York City, this study reviews infantmortality statistics in areas served by these projects. Trends in infant mortality are delineated, selected variables influencing infant mortality are analyzed, and comparisons are drawn between project areas and the whole city. MATERIALS AND METHODS New York City Vital Statistics by Health Areas and Health Center Districts for 1964 through 1975 provide the data utilized in this study. These reports are prepared annually by the Bureau of Health Statistics and Analysis of the Department of Health of the City of New York and summarize by health area the number of live births, deaths of those less than one year of age, and total deaths by cause. The Department of Health defines the infant-mortality rate as the number of infant deaths per 1,000 live births; the neonatal mortality rate is the number of deaths occurring in the first month of life per 1,000 live births; and the postneonatal mortality rate is the number of infant deaths occurring from 28 days to one year after birth per 1,000 live births. CYP catchment areas were divided into constituent health areas. Where part of a health area was involved, all data were utilized. For CYP health areas, the number of infant deaths and live births were determined for each year from 1964 to 1975, and then overall infant-mortality rates within catchment areas were computed from the aggregated number of deaths and births. In addition, rates were calculated by race and age at death. For interpretation, data were organized into two time periods of three years each: before and after the CYP. Bull. N.Y. Acad. Med.
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TABLE II. INFANT MORTALITY IN NEW YORK CITY AND CHILDREN AND YOUTH PROJECT AREAS Children and Youth Project Areas
New York City
Years
Preproject years Postproject years
Infant Infant deathsl mortality rate * live births
1964-1966 12,333/477,844 1967-1969 10,334/433,943 1970-1972 8,302/398,200
25.8 23.8 20.8
6,491/330,699
19.6
1973-1975
Change (total) t 7.8% 12.6% (19.4%) 5.8% (24.0%)
Infant Infant deathsl mortality rate * live births
1,817/61,383 1,545/56,887 1,206/53,971
29.6 27.2 22.3
895/43,715
20.5
Change (total) t 8.4 17.7% (24.7%) 8.1% (30.7%)
*Number of infant deaths per 1,000 live births.
tBase period.
The total percentage changes for long periods do not equal the sum of the changes for component years because the various percentages have different bases of comparison. The percent change column for 1967-1969 (7.8%) is compared with 1964-1966, the percent change for 1970-1972 (12.6%) is compared with 1967-1969, and the percent change shown for 1973-1975 (5.8%) is compared with (based on) 1970-1972. There are different bases used for these percent changes so that they do not add up to the percent changes shown in parentheses, which are all based on the 1964-1966 rates.
Rigorous evaluation of the effectiveness of these projects most appropriately should compare infant-mortality rates in CYP catchment areas to areas of similar socioeconomic status and ethnic configuration which are not receiving such services, but in the present study exact matching was not possible. Health areas adjacent to CYP do not provide matched controls. Nonadjacent health areas do not provide matched controls because of locational differences in the city health system such as differing degrees of accessibility to services and wide variation in ethnic and socioeconomic composition. Therefore, infant-mortality rates for New York City as a whole were compared to rates in areas receiving CYP services on the assumption that narrowing regional differences in key indicators of health status is a prime concern for compensatory health programs. Finally, the universe of New York City births and deaths is analyzed to show that all noted differences are real. RESULTS
The overall infant-mortality rate in New York City has declined from 26.8/1,000 live births in 1964 to 19.3/1,000 in 1975 (Table I). Between 1964 to 1966 and 1967 to 1969 the decline was 7.8%, between 1967 to 1969 and 1970 to 1972 it declined another 12.6% (19.4% total), and between 1970 to 1972 and 1973 to 1975 a further decline of 5.8% was Bull. N.Y. Acad. Med.
489 8
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recorded (Table II). The total decline from 1964-1966 to 1973-1975 was 24.1 %. Dramatic declines were experienced in Manhattan, the Bronx, and Brooklyn, where high rates had prevailed, but smaller reductions occurred in more middle- class areas such as Queens. Within health areas served by CYP the infant-mortality rate ranged from a high of 32.5/1,000 in 1964 to a low of 19.2 in 1974 (Table I). The rate rose to 21.4 in 1975. During 1964-1966, before initiation of these projects, the average rate for all CYP areas was 29.6, higher than the citywide Vol. 54, No. 5, May 1978
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TABLE III. INFANT-MORTALITY RATES* BY RACE FOR NEW YORK CITY (NYC) AND CHILDREN AND YOUTH PROJECT (CYP) AREAS
White Years
NYC
CYP
Nonwhite CYP NYC
Preproject years
1964-1966 1967-1969
20.7 19.4
24.6 22.7
39.1 35.5
38.6 34.0
Postproject years
1970-1972 1973-1975 Change 1964-1975
17.0 15.7
20.6 17.9
27.0 23.1
24.4 23.1
24.2%
27.2%
40.9%
40.2%
*Number of infant deaths per 1,000 live births.
average of 25.8 (Table II). By the interval 1973-1975 the average infantmortality rate in CYP areas had declined to a low of 20.5 while the citywide average was 19.6. In 1964 to 1969, prior to full activity of most CYP, the decline in infant mortality for CYP areas was 8.4%; between 1969 and 1972 the decline was 17.7% (24.7% total); and between 1972 and 1975 the rate declined an additional 8.1%. Over the decade from 1964-1966 to 1973-1975 the decline was 30.7%, compared to a citywide decline of 24.0% (Table II). These trends in infant mortality are shown graphically in Figure 2. Table III presents the infant-mortality rate in New York City and project areas by race. In project areas the rate for whites decreased 27.2% in the period under study, from 24.6/1,000 in 1964-1966 to 17.9 in 1973-1975. By comparison, the rate for all whites in New York City decreased 24.2% over the decade, from 20.7 in 1964-1966 to 15.7 in 1973-1975. The nonwhite infant-mortality rate for all of New York City decreased by 41% from 1964-1966 to 1973-1975, and for CYP areas it decreased by 40.2%. In 1964-1966 the rate for nonwhites in New York City was 39.1, but in CYP areas the rate was 38.6. The nonwhite infant-mortality rate in 1973-1975 reached a low of 23.1 for infants in both project areas and the city as a whole. The nonwhite infant-mortality rate for project areas and New York City as a whole are similar; however, whites in CYP areas have higher rates than citywide averages for all whites. The neonatal and postneonatal death rates by race are summarized in Table IV. In CYP areas the neonatal death rate for whites decreased by
Bull. N.Y. Acad. Med.
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TABLE IV. INFANT MORTALITY* BY RACE AND AGE AT DEATH IN NEW YORK CITY AND CHILDREN AND YOUTH PROJECT AREAS New York Citv
Children and Youth
project areas Neonatal
Postneonatal
Neonatal
Postneonatal Nonwhite
White
Nonwhite
White
Nonwhite
White
Nonwhite
White
15.7
28.8
5.0
10.3
18.4
29.0
6.3
9.5
24.8 19.4 16.8
4.5 4.1 3.7
9.2 7.7 6.3
18.1 15.3 13.3
26.7 16.7 16.0
4.6 5.3 4.6
7.3 7.8 7.1
Preproject years
1964-1966
Postproject years
1967-1969 14.9 1970-1972 13.0 1973-1975 11.9 Change 1964-1975 24.2%
41.7% 26.0%
38.8% 27.7%
44.8% 27.0%
25.3%
*Number of infant deaths per 1,000 live births. Neonatal = 0 to 27 days after birth; postneonatal = 28 days to one year after birth.
27.7% in the period under study, compared to a 24.2% decrease in neonatal deaths for whites in New York City as a whole. The decrease for nonwhites was 44.8% in project areas and was 41.7% in all of New York City. The neonatal death rate for whites declined from 15.7 to 11.9 in New York City and declined from 18.4 to 13.3 in project areas. The neonatal rate for nonwhites in New York City declined from 28.8 to 16.8 and declined from 29.0 to 16.0 in project areas, a 41.7% and 44.8% decline, respectively. Between 1964-1966 and 1973-1975 postneonatal mortality rates for whites declined 26% in New York City and 27% in project areas. The rate for nonwhites declined 38.8% in the city as a whole and only 25.3% in project areas. For whites the decline was from 5.0 to 3.7 in the city as a whole and from 6.3 to 4.6 in areas receiving CYP services. For nonwhites the decline in the city was from 10.3 to 6.3 and the decline in project areas was from 9.5 to 7.1.
DIsCuSSION Reductions in infant mortality in New York City have been dramatic in recent years.3 The 1950s was a period of stagnation with respect to change in infant mortality in both New York City and the United States. Failure to reach the low infant mortality of other developed nations, in part, led to
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new experiments in health delivery and to enhanced concern for health and health services in the 1960s. This decade also was marked by vast urban demographic change, social upheaval, and economic prosperity. Planned social experiments in health delivery such as the CYP blossomed, yet the impact of these experiments remains ambiguous.4 In the 1970s cities continue to undergo demographic change, although at a decelerated speed. While surface social stability has been restored, economic prosperity has given way to decline; however, infant-mortality rates have continued to decline. The New York City rate of 19.3 for 1973 to 1975 represents an unprecedented decline in infant mortality. Project areas of high health need saw a decline in infant mortality from a rate substantially higher than the citywide average at the start of the program to one slightly below the citywide average in 1974. It may be ominous that in 1975, a poor economic year, this rate rose to the level experienced in 1972. These changes in infant-mortality rates are based on all births and deaths and represent real changes; however, from the social-policy viewpoint the significance of small marginal changes remains problematic. According to overall changes in the infant-mortality rate, changes occurred at a greater rate in project areas than in the city as a whole. The goal of narrowing differences in infant mortality between project areas and the rest of the city has been achieved. Whether the projects are responsible for this change requires further analysis. Historically, very high infantmortality rates have been affected markedly by relatively small per capita expenditures. For example, the approximately 20% infant mortality of the early 1900s was reduced to about 3% in the 1950s, primarily through improved sanitation, personal hygiene, and nutrition. To reduce this 3% mortality to 1% or less through intensive public intervention in personal health services might be possible, but certainly would be costly. Interpretation of the effectiveness of these programs will be difficult because other socioeconomic variables have not remained constant. It is apparent from the infant-mortality data under discussion that in project areas the white population in comparison to other white populations is more disadvantaged than the nonwhite population is in comparison to other nonwhite populations. The mortality rate for white infants in project areas exceeded citywide averages for nonwhites in 1964 and continues to do so in 1975. Averages for nonwhites in project areas were slightly less than citywide averages for nonwhites in 1964 and remained so in 1975. However, the major burden of infant deaths is still borne by nonwhites. Do Bull. N.Y. Acad. Med.
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493
TABLE V. CHANGE IN RACE OR ETHNIC COMPOSITION OF HEALTH AREAS SERVED BY CHILDREN AND YOUTH PROJECTS, 1960-1975 Children and Youth projects
Manhattan No. 1 Manhattan No. 2 Manhattan No. 3 Brooklyn No. 4 Brooklyn No. 5 Bronx No. 6 Bronx No. 7 Queens No. 8 Total
White + 1.3% -4.9% +8.7% -54.6% -46.7% -35.3% -77.3% -2.3% -26.4%
Nonwhite +8.5% +6.8% +7.7% +57.5% +42.6% +20.4% +50.8% +2.4% +24.6%
Puerto Rican -3.4% -2.0% -14.5% -2.4% +4.2% +15.0% +26.5% 0 +2.9%
these data imply that nonwhites in project areas utilize publicly provided services better, are more organized to secure such services in the first place, or have superior child-care practices? Given the major influence of nonwhite infant deaths on the overall rate, if such hypotheses prove true they might help to explain the greater overall rate of change in project areas than in the city as a whole. With regard to the age at death, project areas experienced a greater percentage change in the neonatal mortality rate than did the city as a whole. However, with respect to postneonatal rates, whites in project areas had a reduction greater than the citywide average for whites, while nonwhite postneonatal rates declined less than the citywide average. CYP, which provides comprehensive personal health services, would be expected to have their major health effect on postneonatal rates. Differential rate reductions are not noted. Other demographic changes5-10 might have produced the observed changes in infant mortality. Many social and health-service variables such as socioeconomic status, geographic area, urbanization, parity, age, education of mother, previous pregnancy experience, ethnicity, and availability of family-planning and abortion services, as well as utilization of prenatal and child-health services, have been correlated with infant mortality. Four major variables have been examined to ascertain their possible impact on changes in rates: ethnicity, age distribution of the population, abortion, and actual penetration of the project areas by CYP services. Based on data supplied by the New York City Department of City Planning, changes in the ethnic composition of project areas were outlined Vol. 54, No. 5, May 1978
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1 1970 Less than 1960
1970 More than 1960
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Bull. N.Y. Acad. Med.
INFANT MORTALITY
-~~~~~~~NAN
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495 9
in Table V. Between 1960 and 1975 in all CYP project areas the white population declined 26.4%, the nonwhite population increased 24.6%, and the Puerto Rican population increased 2.9%. Concomitantly, the age distribution of the population of New York City changed (Figure 3). The white population has aged and the 0 to 4-year-old group has decreased. The nonwhite population retains a younger profile, and increases in the 0to-4-year-old group are noted. Between 1960 and 1970 "there was a reduction in white males (-22%) and females (-23%) under five years of age and an increase in the number of nonwhite males (+39%) and females (+36%) in the same age group."1 Given such changes, it is obvious that in project areas the major population at risk, nonwhite infants, has increased. The effect of ethnic change on infant mortality can be examined in isolation. Rounding to a 26% decline in white births, rounding to a 25% increase in nonwhite births and using 1964 infant-mortality rates as a base, the expected 1975 infant-mortality rates in project areas would be 32/1,000 live births compared to the observed 21.4. In the city as a whole, the expected rate would be 27.8 compared to the observed 19.3. Therefore, the observed declines in infant mortality cannot be attributed to the changing ethnic composition of the population because observed ethnic changes in the absence of other factors would lead to increased rates. A second major social change which could affect the infant-mortality rate is the passage of a liberalized abortion law in New York State. Published reports conflict as to how this affected the rate. In the Rochester and Monroe County area, Roughman notes "it was found that 50% of the explained decline in the birthrate and 25% of the explained reduction in the prematurity ratio were due to abortions. For infant mortality, change, however, was of minor influence."'2 A review of factors in the decline of infant mortality for New York City, however, concludes: "The recordbreaking low infant-mortality rate achieved in New York has come about as a result of a combination of significant and remarkable advances in medical technology and skills, coupled with an impressive number of social advances. Family planning and safe abortions, which have become available to all women regardless of financial status, have played a decisive role."'13 Analysis of abortion data from New York City for 1975 (Table VI) indicates that in the absence of abortion infant-mortality rates would remain essentially unchanged. This calculation assumes that teen-agers Vol. 54, No. 5, May 1978
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TABLE VI. ESTIMATED EFFECT OF ABORTIONS ON INFANT MORTALITY IN NEW YORK CITY, 1975 Womens' ages (years)
Less than 20 20 or more Age unknown Total
No. of women aborted (a)
Age-specific infant mortality rate * (b)
No. of expected infant deaths in absence of abortions (a xb)
17,126 63,942 358 81,426
24.7 15.9 24.7 (assumed)
423 1,017 9 1,449
No. of abortions and live births (d)
Infant deaths (c) No. expected in absence of abortion
1,449 Abortions
No. observed Total
2,110 Births 3,559
Estimated infant-mortality rate* without abortion (c d)
81,426 109,418 190,844
18.6/1000
*Number of infant deaths per 1,000 live births.
constitute the major high-risk group for infant mortality among women seeking abortions. Unwanted pregnancies in older women also might be subject to higher-than-average age-specific rates, and the incidence of abuse and neglect of unwanted children are not included in this estimate. However liberalized abortion alone does not account for the entire change in infant mortality observed from 1964 to 1975. Finally, the actual penetration of the target population and overlap with other services must be ascertained to estimate the effect of CYP on the declining infant-morality rate. In calendar year 1974, in five out of eight CYP for which data was available,"4 3,027 children less than one year of age were enrolled and 7,927 live births were noted in the catchment area served (Table VIIA). Therefore, CYP cared for some 38.2% of the infant population. (This number overestimates the penetration of the population slightly because some enrolled infants under one year of age undoubtedly were born in 1973.) In 60% of health areas (Table VIIB), projects were the only comprehensive child-health service. However, in 40% of health areas other neighborhood health centers and MIC projects provided similar services. Because MIC projects served only 14% of all CYP areas, their presence alone cannot account for the observed decline in the infantmortality rate.
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TABLE VIIA. UTILIZATION OF CHILDREN AND YOUTH PROJECTS (CYP) DURING CALENDAR YEAR 1974*
3,027 7,927 38.2%
CYP enrollees less than 1 year of age (a) Total live births in health areas served by CYP (b) Utilization of CYP by infants in catchment areas (a + b)
TABLE VIIB. OVERLAP OF CHILDREN AND YOUTH PROJECTS (CYP) AND OTHER CHILD-HEALTH SERVICES DURING CALENDAR YEAR 1974* Health areas (%) (No.)
Service CYP only CYP and Maternity and Infant Care projects (MIC) CYP and neighborhood health centers (NHC) CYP, MIC, and NHC Total
30 5 13 2 50
60% 10% 26% 4% 100%
*Data for five of the eight CYP was used.
CONCLUSIONS 1) In CYP catchment areas, infant-mortality rates decreased, essentially eliminating differences in infant mortality between these areas and the city as a whole. 2) There is no evidence that postneonatal rates in project areas improved in a differential fashion, yet this subset of the total infant-mortality rate should be most affected by a comprehensive child-health service. 3) Penetration of the at-risk child population was less than 40%. 4) Changes in ethnicity of the population and liberalized abortion laws do not explain the decline in infant mortality. Undoubtedly, CYP must be counted as only one small social element promoting change in health status. Changes in the socioeconomic status of the population, effects of migration, and provision of enhanced health services for pregnant women all probably contributed to greater change in this indicator of health status than postnatal care. However, in light of the recent increases in infant mortality, it is obvious that maintenance of a low infant-mortality rate-if not further reduction toward the national goal of 1%-will not automatically occur.
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REFERENCES Grants for Comprehensive Health Ser7. Chabot, M.. Garfinkel, J., and Pratt, M. vices for Children and Youth. Policies W.: Urbanization and differentials in and Procedures, HEW, Childrens white and nonwhite infant mortality. Bureau. Washington, D. C., Govt. Pediatrics 56: 777-81, 1975. Print. Off., 1965. 8. Morris, N. M., Udry, J., and Chase, C.: Chabot, A.: Improved infant mortality Shifting age- parity distribution of births rates in a population served by a comand the decrease in infant mortality. Am. prehensive neighborhood health proJ. Public Health 65: 359-62, 1975. gram. Pediatrics 47: 989-94, 1971. 9. Wright, N. H.: Family planning and inPakter, J. and Nelson, F.: Factors in the fant mortality: Rate decline in the U. S. unpredicted decline in infant mortality in Am. J. Epidemiol. 101: 182- 87, 1975. New York City. Bull. N. Y. Acad. Med. 10. Wallace, H. M.: Children and youth 50: 839-68, 1974. projects and related comprehensive Komaroff, A. and Duffell, P.: An evaluhealth care programs. Clin. Pediatr. 10: ation of selected federal categorical 487-94, 1971. health programs for the poor. Am. J. 11. Blumenthal, S.: Some New York City Public Health 66: 255-60, 1976. population characteristics. Stat. Health Donabedian, A., Rosenfeld, L., and Rev. 1: 1, 1975. Southern, E.: Infant mortality and 12. Roghmann, K.: Impact of New York socio-economic status in a metropolitan State Abortion Law. In: Child Health community. Public Health Rep. 80: and the Community. New York, Wiley, 1083-94, 1965. 1975, chap. 8, p. 213. Erhardt, C., Abramson, H., Pakter, J., 13. Pakter, loc. cit., p. 867. and Nelson, F.: An epidemiological 14. Minnesota Systems Research, Inc.: Sysapproach to infant mortality. Arch. tems development project. Personal Environ. Uealth 20: 743-57, 1970. communication.
Bull. N.Y. Acad. Med.
