South Carolina Kids Count
The most serious birth problems are associated with very low birthweight (VLBW) of below 3.3 pounds and extreme prematurity of less than 32 weeks of gestation. These constitute 2 - 2.5% of all births. The extremely premature constitute 85% of very low birthweight babies; 78% of extremely premature births are VLBW. So, in most cases the VLBW and the extremely premature are the same babies. The consequences are enormous. The excess hospitalization cost of VLBW babies in South Carolina is approximately $100 million per year. Extremely premature babies with very low birthweight have much higher rates of mental retardation, neuromotor and neurological disabilities. Prevention of the 1,416 extremely premature and 1,073 VLBW births per year is a critical challenge for our state. Of these, 250 extremely premature and 235 VLBW cases are multiple birth deliveries (ie, twins, triplets, etc.).
The problem of prematurity and low birthweight is much greater among minorities, unmarried, less educated, teen and older mothers over age 35 and for multiple births. Their rates of very low birthweight are (in % for singleton births by race, marital status, age, and education of the mother and also for multiple births):
| All Births | Singleton Births | Multiple Births | |
|---|---|---|---|
| Race | |||
| White | 1.25 | 0.95 | 10.6 |
| African American and Other | 3.22 | 2.73 | 18.3 |
| Marital Status | |||
| Married | 1.45 | 1.10 | 11.3 |
| Unmarried | 3.33 | 2.82 | 20.1 |
| Paternity Acknowledged | 1.58 | 1.36 | 10.5 |
| Age | |||
| Teens | 2.43 | 2.08 | 15.6 |
| 20-24 | 2.12 | 1.28 | 16.1 |
| 25-34 | 1.69 | 1.33 | 11.4 |
| 35-39 | 2.01 | 1.52 | 11.5 |
| 40+ | 3.11 | 2.81 | 9.4 |
| Education | |||
| Under 12 | 2.27 | 1.90 | 17.3 |
| 12 | 2.24 | 1.87 | 14.5 |
| 1-3 College | 1.83 | 1.46 | 12.9 |
| TEC | 1.27 | 0.98 | 25.3 |
| 4+ College | 1.34 | 0.96 | 10.5 |
| Total | 1.97 | 1.60 | 13.43 |
By far the highest rates of VLBW are for 704 VLBW babies in multiple deliveries. While the multiple birth deliveries constitute only 3% of all births, they result in 21% of all VLBW babies, with a VLBW rate of 13.43%. Among the 97% of all births which are singletons, the highest rates of very low birthweight singleton births are for African-Americans and Others at 2.73%, Unmarried women at 2.82%, and mothers Age 40 and Older at 2.81%.
The enormous racial disparity for African-Americans and Others is 2.9 times the 0.95% rate of Whites. The lowest African-American and Other VLBW rates are for babies of mothers with TEC Education at 1.69% and Paternity Acknowledged (1.83%). The only White categories higher than these lowest minority rates are White mothers who are Unmarried (1.89%) and 40 or Older (1.64%). The lowest White categories, below 0.93%, are College Education (TEC & 4 or more years of college), Married, and Ages 25-34.
The lowest minority categories are TEC (1.69%), Paternity Acknowledgement (1.83%), followed by College 5+ years (2.29%), Married at 2.40%, and ages 25 -29 at 2.46%. The next group of minority rates falls in the range of 2.56% to 2.86%: Ages 15-24 and all Education groups except TEC and 5+ College. Then come the highest rates: Under Age 15 (3.09%), Ages 30-39 (3.15%), and Age 40 or Older (5.28%).
These minority rates provide intriguing hints regarding possible causes: TEC education indicating career-mindedness of less affluent women who cannot afford 4-year universities, Paternity Acknowledgement as a sign of a perceived harmonious and promising partner relationship, and Graduate School Education, suggesting career advancement. Next come Married women, though with a rate 0.57% higher than Paternity Acknowledged; perhaps some married women are discouraged by the reality of relationship problems with husbands and the burden of raising children. The highest minority rates are women Age 30 and Older who may have more health conditions or greater depression and anxiety as a result of life's problems which have eroded youthful optimism. Women with 12 Years Education, likely working hard for quite modest wages and troubled by life's challenges, have a higher rate of 2.86% as compared with those Under 9 Years Education (2.57%) and 9-11 Years Education (2.64%), a small but puzzling disparity that deserves investigation.
White categories below the overall White average of 0.95% are women with socially approved status: those with College Education, the Married but also Paternity Acknowledgement, and 25-34 Year Olds. These are the young adults who appear to be more mature, better educated, and enjoying permanent or promising relationships. The worst White rates are for those women who are Unmarried (1.89%) or give birth during their 40s (1.64%) or before Age 15 (5.23%). The next worst group is Under-Educated women with less than 12 years of school (1.42%) and Teens 15-19 (1.33%). The middle group just above the White average is Women with 12 Years Education (1.09%) and Ages 20-24 (1.08%), just before the primes ages of 25-34 when maturity and hopefulness are typically at their best stage.
When the data is viewed through several variables simultaneously, the interpretation changes somewhat. The tables below show VLBW rates for combinations of race, age, education, and marital status. Overall, the lowest rates (under 2%) are for births to White married women of all ages (0.96-1.17% under 30 and 1.01-1.51% age 30 and older) and to unmarried White women under 30 with paternity acknowledgement (0.52-1.13%) and 1-3 years of college. Also in the lowest group are African-Americans and other women under age 30 with paternity acknowledgement (1.29%), followed by Whites over 30 with paternity acknowledgement but less than a four-year education (1.37-1.40%), a small group of unmarried Whites over 30 with one to three years of college (1.59%), and African-American and Others over 30 with paternity acknowledgement and some college or at least a four-year college education (1.57-1.69%).
White
| Under 30 | 30 & Older | |||||
|---|---|---|---|---|---|---|
| Married | Paternity Acknowledged | Unmarried | Married | Paternity Acknowledged | Unmarried | |
| LT12 | 1.43 | 1.13 | 2.35 | 1.88 | 0.43 | 2.27 |
| 12 | 1.05 | 1.11 | 1.99 | 1.45 | 1.81 | 2.80 |
| College 1-3 | 1.00 | 0.52 | 1.79 | 1.19 | 1.37 | 1.59 |
| College 4 | 0.98 | 1.02 | 2.26 | 1.04 | 0.81 | 4.46 |
| College 5+ | 0.98 | 0.00 | 0.00 | 0.93 | 6.12 | 0.00 |
| TEC | 0.87 | 0.41 | 2.47 | 1.12 | 3.57 | 1.59 |
African American and Other
| Under 30 | 30 & Older | |||||
|---|---|---|---|---|---|---|
| Married | Paternity Acknowledged | Unmarried | Married | Paternity Acknowledged | Unmarried | |
| LT12 | 2.45 | 1.80 | 3.33 | 3.76 | 4.17 | 6.68 |
| 12 | 2.73 | 2.33 | 3.85 | 3.34 | 3.95 | 4.77 |
| College 1-3 | 2.78 | 1.29 | 3.74 | 3.42 | 1.69 | 5.19 |
| College 4 | 2.26 | 3.13 | 4.68 | 3.01 | 2.08 | 5.70 |
| College 5+ | 2.16 | 4.60 | 5.43 | 1.82 | 0.00 | 5.56 |
| TEC | 2.18 | 0.78 | 1.36 | 2.69 | 1.72 | 1.79 |
White
| Under 30 | 30 & Older | |||||
|---|---|---|---|---|---|---|
| Married | Paternity Acknowledged |
Unmarried | Married | Paternity Acknowledged |
Unmarried | |
| LT12 + 12 | 1.17 | 1.12 | 2.19 | 1.51 | 1.40 | 2.62 |
| 290/24,696 | 91/8,139 | 214/9,757 | 120/7,929 | 11/788 | 27/1,031 | |
| College 1-3 College 4 College 5+ TEC |
0.98 | 0.55 | 1.89 | 1.06 | 1.92 | 1.99 |
| 229/23,475 | 9/1,643 | 32/1,691 | 263/24,811 | 10/520 | 11/554 | |
African American and Other
| Under 30 | 30 & Older | |||||
|---|---|---|---|---|---|---|
| Married | Paternity Acknowledged |
Unmarried | Married | Paternity Acknowledged |
Unmarried | |
| LT12 + 12 | 2.67 | 2.18 | 3.62 | 3.40 | 3.99 | 5.20 |
| 154/5,767 | 135/6,286 | 804/22,242 | 100/2,943 | 29/727 | 122/2,347 | |
| College 1-3 College 4 College 5+ TEC |
2.52 | 1.63 | 3.61 | 2.93 | 1.64 | 4.98 |
| 137/5,767 | 41/2,511 | 182/5,037 | 143/4,886 | 10/610 | 57/1,145 | |
White
| Under 30 | 30 & Older | |||||
|---|---|---|---|---|---|---|
| Married | Paternity Acknowledged |
Unmarried | Married | Paternity Acknowledged |
Unmarried | |
| LT12 + 12 | 1.17 | 1.12 | 2.19 | 1.51 | 1.40 | 2.62 |
| 290/24,696 | 91/8,139 | 214/9,757 | 120/7,929 | 11/788 | 27/1,031 | |
| College 1-3 | 1.00 | 0.52 | 1.79 | 1.19 | 1.37 | 1.59 |
| 102/10,240 | 6/1,158 | 22/1,230 | 81/6,808 | 4/292 | 5/315 | |
| College 4 College 5+ TEC |
0.96 | 0.62 | 2.17 | 1.01 | 2.63 | 2.51 |
| 127/13,235 | 3/485 | 10/461 | 182/18,003 | 6/228 | 6/239 | |
African American and Other
| Under 30 | 30 & Older | |||||
|---|---|---|---|---|---|---|
| Married | Paternity Acknowledged |
Unmarried | Married | Paternity Acknowledged |
Unmarried | |
| LT12 + 12 | 2.67 | 2.18 | 3.62 | 3.40 | 3.99 | 5.20 |
| 154/5,767 | 135/6,286 | 804/22,242 | 100/2,943 | 29/727 | 122/2,347 | |
| College 1-3 | 2.78 | 1.29 | 3.74 | 3.42 | 1.69 | 5.19 |
| 82/2,952 | 23/1,782 | 140/3,744 | 68/1,991 | 6/355 | 39/751 | |
| College 4 College 5+ TEC |
2.22 | 2.47 | 3.25 | 2.59 | 1.57 | 4.98 |
| 55/2,476 | 18/729 | 42/1,293 | 75/2,895 | 4/255 | 57/1,145 | |
The highest VLBW rates (4.98-5.20%) are for unmarried African-American and other women over age 30. The next highest groups (over 3%) are for African-American and Other women: over 30 with paternity acknowledgement but no college education (3.99%); and under 30 and unmarried (3.25-3.74%); and over 30, married with less than four years of education (3.40-3.42%).
The middle group with VLBW rates of 2% to 3% includes unmarried Whites under 30 with no college or with at least four years of college (2.17-2.19%) and age 30 or older with no college or with four or more years of college (2.51-2.62%); a small group of Whites over 30 with four or more years of college and paternity acknowledgement (2.63%); and African-Americans and Others under age 30 who are married (2.22-2.78%) or with paternity acknowledgement (2.18% with no college and 2.47% with four or more years of college); and African-Americans and Others over 30 with four or more years of college (2.59%).
The data highlights the greater rates for African-Americans compared to Whites, unmarried compared to married women, and those 30 or older compared to under 30, especially African-Americans; while the lower rates are for married women, those with paternity acknowledgement (except African-Americans with no college), and women under age 30.
Although the data for these categories is factual and accurate, the implications regarding the causes of VLBW are at best speculative and not substantiated by research. The primary factors causing the physiological and hormonal precipitants of extreme prematurity and very low birthweight have not been proven. However, the differences across groups indicated by South Carolina data suggest some possible causes and potential areas for prevention. During 2004, South Carolina Kids Count worked with DHEC, March of Dimes, MUSC, and USC colleagues to investigate the data in more depth. DHEC staff analyzed 1993-2001 survey data from the South Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), to explore the possible impact of suspected causes of prematurity and VLBW, especially stress, domestic violence, lack of social support, substance use, unwanted pregnancy, and prenatal care deficiencies. It is our hope that this and further data analysis can help target pregnant women at greatest risk of prematurity and low birthweight so that prenatal care, social support, and other assistance can be provided in a more focused and intensive manner to the fewest women possible constituting the largest possible share of the risks of poor birth outcomes.
The PRAMS data for 1993-2001 shows that VLBW and MLBW were associated with identifiable causes of poor birth outcomes. The PRAMS data suggests more consistent influence of suspected risk factors for medium (intermediate) low birthweight (MLBW) of 1,500-2,499 grams than for very low birthweight (VLBW) under 1,500 grams. For all risk factors except drinking for Whites and stresses for African-Americans, the MLBW rates are associated with the risk factors. The strongest association is for smoking, unwanted pregnancy, abuse before and during pregnancy, lack of social support and low income. Other factors associated with MLBW are drinking for African-Americans but not Whites, and more stresses for Whites but not for African-Americans.
For VLBW, the PRAMS data shows more complicated associations. Factors associated with VLBW for Whites but not African-Americans are more stresses, lack of social support, abuse during pregnancy, and low income; whereas the only factor associated with VLBW for African-Americans but not Whites is drinking during pregnancy. For both African Americans and Whites, VLBW showed a modest association with abuse before pregnancy and with smoking.
These associations are a simple way of taking a first look at the possible causes. In the future more sophisticated data analysis should investigate which of these possible risk factors are more strongly indicated as likely targets for prevention. This data analysis will be pursued further during 2005.
| Indicators (Rate of Those With Risk Minus Rate of Those Without Risk) | VLBW (Under 1,500 Grams) | MLBW (1,500-2,499 Grams) | ||
|---|---|---|---|---|
| African American | White | African American | White | |
| Unwanted -vs- Intended | -22.7% | 1.0% | 15.5% | 26.5% |
| Did Not Want -vs- Wanted Then | -21.4% | 5.2% | 18.3% | 34.7% |
| Not Trying to Get Pregnant -vs- Trying | -17.7% | 15.6% | 15.7% | 29.9% |
| Smoked -vs- Not (Last Three Months Pregnant) | ||||
| (2000-2001) | 72.7% | 78.7% | 95.8% | 95.8% |
| (1993-1999) | -0.8% | 11.1% | 58.9% | 120.4% |
| Drank -vs- Not (Last Three Months Pregnant) | ||||
| (2000-2001) | 128.3% | -47.1% | 126.9% | -51.0% |
| (1993-1999) | 40.8% | -17.5% | 33.2% | -9.8% |
| Stresses -vs- None | ||||
| 3 to 5 | -1.2% | 6.8% | -7.1% | 0.7% |
| 6 to 18 | -1.2% | 31.1% | 3.4% | 48.3% |
| Abused -vs- Not (During Pregnancy) | ||||
| (2000-2001) | 53.1% | 73.3% | 66.7% | 136.7% |
| (1993-1999) | -3.0% | 28.7% | 19.2% | 24.3% |
| Abused -vs- Not (Before Pregnancy) | 7.5% | 15.0% | 18.6% | 41.3% |
| Lack of Social Support -vs- Support (During Pregnancy) | -2.2% | 31.4% | 28.5% | 64.7% |
| Income -vs-Over $40,000 | ||||
| Under $16,000 | -12.9% | 68.8% | 38.5% | 54.3% |
| $16,000-$25,000 | -13.2% | 42.9% | 6.7% | 30.7% |