Massachusetts Births 2009

Massachusetts Department of Public Health Bureau of Health Information, Statistics, Research and Evaluation July 2011

ii

Massachusetts Births 2009

Deval L. Patrick, Governor Timothy P. Murray, Lieutenant Governor JudyAnn Bigby, MD, Secretary of Health and Human Services John Auerbach, Commissioner of Public Health

Gerald F. OKeefe, Bureau Director Bureau of Health Information, Statistics, Research, and Evaluation Bruce Cohen, Director Division of Research and Epidemiology Stanley E. Nyberg, Registrar Registry of Vital Records and Statistics

Massachusetts Department of Public Health July 2011

Acknowledgments
This report was prepared by Isabel A. Cceres, Epidemiologist of the Division of Research and Epidemiology, Bureau of Health Information, Statistics, Research, and Evaluation; and Charlene Zion, and Kevin Foster of the Registry of Vital Records and Statistics. Special thanks go to: Gerald F. OKeefe, Bureau Director, and Bruce Cohen, Director, Division of Research and Epidemiology, Bureau of Health Information, Statistics, Research, and Evaluation; Stanley Nyberg, Registrar, Registry of Vital Records and Statistics; Karin Barrett, Sharon Pagnano, and Maria Vu, Registry of Vital Records and Statistics; Paul Oppedisano, Saul Franklin and Jamie Wilkins, MassCHIP; Emily Lu, and Hafsatou Diop, Bureau of Family Health and Nutrition. Also, thanks to: DPH peer reviewers for their comprehensive review of this publication. Support was also provided by DPH epidemiology intern Jennifer Evans. Data in this report have been collected through the efforts of the Registry of Vital Records and Statistics staff, including: Tara Andrews, Helen Ba, Pamela Corbin, June Deloney, Annie B. Hobbs, Ramona Irving, Judy Y. Lim, Maureen McKean, Robert McMahan, Venita Morabito, AnnMarie Neault, Denise O'Gara, Adele Pascar, Mary Risser, Phyllis Rotman, Mary Lou Rossetti, Monica Smith, Ian Skolnik, Crystal Steward, and Maisy Wong. Suggested Citation Massachusetts Births 2009. Boston, MA: Division of Research and Epidemiology, Bureau of Health Information, Statistics, Research, and Evaluation, Massachusetts Department of Public Health. July 2011. To obtain additional copies of this report, contact: Massachusetts Department of Public Health Bureau of Health Information, Statistics, Research, and Evaluation 250 Washington Street, 6th floor Boston, MA 02108 or Massachusetts Department of Public Health Registry of Vital Records and Statistics 150 Mt. Vernon St. 1st Floor Dorchester, MA 02125 617-740-2670 This and other Department of Public Health publications can be downloaded from the following website: http://www.mass.gov/dph/pubstats.htm To obtain more information on births in Massachusetts and other Department of Public Health data call 888-MAS-CHIP (toll free in MA) or 617-624-5629, or to download the Departments free, Internet-based public health information application, MassCHIP, onto your computer, visit the MassCHIP website at: http://masschip.state.ma.us

iv

TABLE OF CONTENTS
Note to Readers ..........................................................................................................................9 Highlights ..................................................................................................................................10 Introduction ...............................................................................................................................12 Methods .....................................................................................................................................12 Results .......................................................................................................................................13 Table 1. Trends in Birth Characteristics, Massachusetts: 1990, 1995-2009..............................24 Table 2. Birth Characteristics by Maternal Race/Hispanic Ethnicity and Birthplace, Massachusetts: 2009 ..................................................................................................................25 Table 3. Birth Characteristics by Maternal Ancestry, Massachusetts: 2009 ..............................26 Figure 1. Trends in the Number of Births by Mothers Age Group, Massachusetts: 1980-2009 27 Table 4. Age-Specific and Crude Birth Rates, Massachusetts: 1990 and 2009 ........................28 Table 5. Trends in Number and Percent Distribution of Births by Plurality and Age Massachusetts: 1995-2009.........................................................................................................29 Table 6. Summary of Selected Teen Birth Characteristics, Massachusetts: 2009 ....................30 Table 7. Trends in Teen Birth Rates for Selected Communities, Ranked by 2009 Teen Birth Rate, Massachusetts: 1999, 2008, and 2009 .............................................................................31 Figure 2. Birth Rates among Females Ages 15-19 Years by Mothers Race/Hispanic Ethnicity, Massachusetts: 1999 and 2009 ..................................................................................................32 Table 8. Births by Birthweight, Race/Hispanic Ethnicity, Massachusetts: 2009.........................33 Table 9. Low Birthweight by Plurality and Maternal Age, Massachusetts: 1999-2009................34 Table 10. Births by Gestational Age, Race/Hispanic Ethnicity, Massachusetts: 2009...............35 Figure 3. Percent of Mothers who Reported Smoking during Pregnancy, Massachusetts: 19902009 ............................................................................................................................................36 Figure 4. Percent of Mothers who Reported Smoking during Pregnancy by Mothers Race/Hispanic Ethnicity, Massachusetts: 2009 ..........................................................................36 Figure 5. Trends in Adequacy of Prenatal Care by Race and Hispanic Ethnicity, Massachusetts: 1996-2009...................................................................................................................................37 Figure 6. Adequacy of Prenatal Care by Selected Maternal Characteristics, Massachusetts: 2009 ............................................................................................................................................38

Figure 7. Distribution of Prenatal Care Payment Source, Massachusetts: 2009 .......................39 Table 11. Trends in Infant, Neonatal, and Post Neonatal Mortality by Race/Hispanic Ethnicity, Massachusetts: 1991-2009.........................................................................................................40 Figure 8. Infant Mortality Rates by Race/Hispanic Ethnicity, Massachusetts: 2009 ..................42 Table 12. Resident Birth Characteristics, 30 Largest Municipalities, Massachusetts: 2009 ......43 Table 13. Birth Characteristics by Licensed Maternity Facility, Massachusetts: 2009...............45 Table 14. Comparison of Massachusetts Perinatal Health Indicators with Healthy People 2020 Objectives, Massachusetts: 2006-2009 ......................................................................................47 Appendix: ..................................................................................................................................49 Table 15. Resident Birth Characteristics, Community Health Network Areas (CHNAs), Massachusetts: 2009 ..................................................................................................................51 Figure 9. Percent of Mothers Breastfeeding or Intending to Breastfeed by Age Group, Massachusetts: 2009 ..................................................................................................................53 Figure 10. Percent of Mothers who Reported Smoking during Pregnancy by Mothers Race/Hispanic Ethnicity and Educational Attainment, Massachusetts: 2009 .............................54 Figure 11. Distribution of Reported Smoking Status during Pregnancy by Smoking Status Prior to Pregnancy, Massachusetts: 2009...........................................................................................55 Table 16. Parity by Age of Mother, Massachusetts: 2009 .........................................................56 Table 17. Selected Birth Characteristics by Maternal Education, Massachusetts: 2009 ...........57 Table 18. Inter-pregnancy Interval (IPI) and Birth Outcomes -- Pregnancies to Multiparous Mothers, Massachusetts: 2009 ...................................................................................................58 Figure 12. Inter-pregnancy Interval (IPI) by Selected Birth Outcomes: LBW and Preterm -Pregnancies to Multiparous Mothers, Massachusetts: 2009 ......................................................59 Table 19. Inter-pregnancy Interval (IPI) by Maternal Characteristics -- Pregnancies to Multiparous Mothers, Massachusetts: 2009 ...............................................................................60 Figure 13. Inter-pregnancy Interval (IPI) Distribution by Maternal Age -- Pregnancies to Multiparous Mothers, Massachusetts: 2009 ...............................................................................61 Figure 14. Comparison of Teen vs. Adult Births, Selected Characteristics, Massachusetts: 2009 ....................................................................................................................................................62 Figure 15. Trend in Birth Rates among Females ages 15-19, Massachusetts and the United States: 1985-2009.......................................................................................................................63 Table 20. Resident Teen Birth Characteristics, 30 Largest Municipalities, Massachusetts: 2009 ....................................................................................................................................................64 6

Table 21. Trends in Infant, Neonatal, and Post Neonatal Mortality by Race, Massachusetts: 1981-2009...................................................................................................................................66 Figure 16. Infant Mortality Rates and 95% Confidence Intervals by Race.................................69 Figure 17. Infant Mortality Rates, Massachusetts: 1842-2009...................................................70 Figure 18. Trends in the Timing of Infant Deaths, Massachusetts: 1990-2009 .........................71 Table 22. Feto-Infant Mortality Rate1 by Birthweight, Massachusetts: 2000-2009 ....................72 Figure 19. Feto-Infant Mortality Rate, Massachusetts: 2000-2009 ............................................73 Table 23. Fetal and Infant Deaths by Birthweight and Gestational Age, Massachusetts: 19982009 ............................................................................................................................................74 Figure 20. Trends in Pregnancy-Associated and Maternal Mortality, Massachusetts: 1993-2009 ....................................................................................................................................................75 Table 24. Number of Pregnancy-Associated and Maternal Deaths, Massachusetts: 1998-2009 ....................................................................................................................................................75 Figure 21. Low Birthweight among Smoking and Non-Smoking Mothers by Race and Hispanic Ethnicity, Massachusetts: 2009 ..................................................................................................76 Table 25. Low Birthweight (LBW) by Maternal Age, Race/Hispanic Ethnicity, Massachusetts: 2009 ............................................................................................................................................77 Table 26. Adequacy of Prenatal Care Utilization: Summary and Component Indices, Massachusetts: 2009 ..................................................................................................................78 Table 27. Adequacy of Prenatal Care Summary by Selected Characteristics, Massachusetts: 2009 ............................................................................................................................................79 Table 28. Adequacy of Prenatal Care Initiation by Selected Characteristics, Massachusetts: 2009 ............................................................................................................................................80 Table 29 Adequacy of Prenatal Care Visits by Selected Characteristics, Massachusetts: 2009 ....................................................................................................................................................81 Table 30. Birth Characteristics by Race/Hispanic Ethnicity and Source of Prenatal Care Payment, Massachusetts: 2009..................................................................................................82 Table 31. Cesarean Deliveries and Vaginal Births after Cesarean (VBACs) by Licensed Maternity Facility, All Births, Massachusetts: 2009.....................................................................84 Table 32. Cesarean Deliveries for Singleton Births by Licensed Maternity Facility and Number of Previous Births, Massachusetts: 2009...................................................................................86 Table 33. Birth Characteristics: Occurrence and Resident Births and Infant Deaths, Massachusetts Municipalities: 2009 ...........................................................................................88 Table 34. Birth Characteristics: Occurrence and Resident Births and Infant Deaths by County, Massachusetts: 2009 ..................................................................................................................96 7

Table 35. Birth Characteristics: Occurrence and Resident Births and Infant Deaths, Massachusetts Community Health Network Areas (CHNAs), Massachusetts: 2009..................97 Technical Notes ........................................................................................................................98 Data Cautions............................................................................................................................98 Changes in the Collection of Race/Ethnicity Information .....................................................98 Population Denominators ........................................................................................................99 Table 36. 2009 Massachusetts Population Estimates by Age Group, Gender, Race and Hispanic Ethnicity (mutually exclusive) .....................................................................................101 Change in Measurement of Adequacy of Prenatal Care .....................................................102 Tests of Statistical Significance ............................................................................................106 Confidence Intervals and Infant Mortality Rates..................................................................107 Table 37. 95% Confidence Intervals for Infant Mortality Rates by Race and Hispanic Ethnicity, Massachusetts: 1990-2009.......................................................................................................108 Definition of Rates and Ratios...............................................................................................109 Table A1. Population Estimates for Massachusetts Communities: 2005.................................112 Table A2. Population Estimates for Massachusetts Community Health Network Areas (CHNAs) and Counties: 2005...................................................................................................................115 Glossary...................................................................................................................................116 Massachusetts Birth Certificate: 2009 ..................................................................................121 Massachusetts Births 2009 Evaluation Form.......................................................................123

Note to Readers
Please review the information below before reading the report. 1. Starting with this years publication, the following new statistics will be presented: Early Term Births: Presented for the state and by maternal race (Table 10) and by maternal facilities (Table 13). Please see the Glossary for definitions of gestational age. Smoking during Pregnancy by Source of Prenatal Care Payment: Presented for the state, by maternal race and source of prenatal care payment (Table 30). 2. Population: Population estimates from the National Center for Health Statistics for 2005, which are the most up-to-date information available on the number of persons by age, race, and sex at the sub-state level, were used to calculate community rates. Data for 2009 were used to calculate statewide rates, e.g., fertility rate, teen birth rate, etc. Please note: If the population in your community increased from 2005 to 2009, the rates listed in this publication may overestimate the actual rate. If the population in your community declined from 2005 to 2009, the rates given in the publication may underestimate the actual rate. When new population data are available for cities and towns, revised rates will be available from MassCHIP (http://masschip.state.ma.us). Please see the Appendix for detailed information about population. 3. Rate, Proportion, and Number comparisons: The comparison of rates, proportions, and numbers is based on tests of statistical significance. Comparative words, for example, higher, lower, increase, and decrease are used only when the statistics being compared are statistically different (i.e., statistically significant at the P .05 level). Please see the Technical Notes for a discussion of how statistical significance is determined. All statistics presented, unless stated otherwise, are based upon the number of births and not on the number of mothers. Proportions are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 4. Comparisons with National Birth Statistics and Healthy People 2020: Preliminary US birth statistics for 20091 and Preliminary US death statistics for 20092 were used for comparison with the 2009 Massachusetts birth figures. Starting with this years publication, the Maternal, Infant, and Child Health objectives for Healthy People 20203 were used to measure the states progress toward meeting the targets set for 2020 (Table 14). 5. Infant Mortality: The infant mortality statistics in this report are based upon a preliminary death file. Infant mortality statistics based upon the final death file may differ from those in this report. 6. Resident births: All data in this publication are resident data unless otherwise stated. Resident data include all events that occur to residents of the Commonwealth, wherever they occur (see Methods in Page 12).
7. Race and Ethnicity: In the text, the race categories, White, Black, American Indian, Asian,

and Hispanic are mutually exclusive, for example, when we refer to White mothers, this means White non-Hispanic mothers, with the exception of Table 21 (see notes for Table 21).
1

Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary Data for 2009. National vital statistics reports web release; vol 59 no 3. Hyattsville, MD: National Center for Health Statistics. 2010.

Kochanek KD, Xu JQ, Murphy SL, Minio AM, Kung HC. Deaths: Preliminary Data for 2009. National Vital Statistics Reports; vol 59 no 4. Hyattsville, MD: National Center for Health Statistics. 2011.
3

U.S. Department of Health and Human Services. Healthy People 2020. December 2010. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=26

Highlights

In 2009 the total number of births to Massachusetts resident women was 74,966, reflecting 2,003 less births than in 2008. This decline in births was essentially driven by 2,001 less births to White women in 2009, compared with 2008. There were significant declines in birth rates among women ages 25-29 years (from 89.7 to 85.3 births per 1,000 women population ages 25-29), and among women ages 30-34 years (from 115.1 to 111.2 births per 1,000 women population ages 30-34). The 2009 teen birth rate4 in Massachusetts (19.5 births per 1,000 women ages 15-19) did not change from 2008 (20.1 births per 1,000) however it continued its downward trend since 1990. Compared with 2007, the teen birth rate declined overall by 11%. During this period this decline was driven by a 32% decline in the rate of Asian teens, a 14% decline in the rate of White teens and an 11% decline in the rate of Hispanic teens. The overall preliminary 2009 Massachusetts Infant Mortality Rate (IMR) did not change from 2008 (4.7 infant deaths per 1,000 live births in 2009 vs. 5.0 in 2008). However, for the first time in 2009, the neonatal IMR for Black mothers (5.0 neonatal deaths per 1,000 live births) was not statistically different from the neonatal IMR for White mothers (3.6 neonatal deaths per 1,000). Because of small numbers, neonatal IMRs are less precise and have wide confidence intervals. Neonatal deaths occur within 28 days of birth and accounted for 75% of all infant deaths in 2009 (266 out of 354). o In 2009, for the first time in 20 years, the Black to White IMR gap narrowed, from 3.6 in 1990 to 1.9 in 2009, and the Black to White neonatal IMR gap narrowed from 3.6 in 1990 to 1.6 in 2009, to less than a half the gap in 1990. For the first time in thirteen consecutive years the primary cesarean delivery rate5 decreased from the previous year. The rate in 2009 was 23.6%, compared with 24.2% in 2008. The overall cesarean delivery rate in 2009 continued to vary across Massachusetts maternity hospitals, ranging from 15.3% to 45.1%, and by maternal ethnicity, ranging from 22.4% among Cambodian to 44.2% among Brazilian mothers. In 2009, the proportion of mothers with their prenatal care (PNC) paid through public sources (including Medicaid/MassHealth, Medicare, free care, other public programs) increased by 2%, from 35.2% in 2008 to 36.4% in 2009. This proportion increased only among Black mothers (by 5%). Three out of four births to mothers with their PNC paid through public sources are paid by Medicaid/MassHealth. For the first time since 2001, the percentage of mothers who received adequate prenatal care increased by 3%, from 82.1% in 2008 to 84.3% in 2009. Adequacy of prenatal care utilization (APNCU) began declining in 2001 after it reached a record of 85.2%, the highest since it was introduced as an indicator in 1996. This years increase was driven by an increase of 2% in the initiation of prenatal care visits, that is, more mothers began their prenatal care in the first trimester, from 81.0% in 2008 to 82.6% in 2009.

State teen birth rates were calculated using 2009 population data; however, please note that 2009 community teen birth rates use 2005 population estimates.
5

Primary cesarean rate is calculated as the number of primary cesarean delivery births divided by the total number of births to mothers with no prior cesareans and multiplied by 100.

10

Breastfeeding initiation remains high at 82%. It increased among all mothers, from 80.8% in 2008 to 82.0% in 2009, and across all racial groups. While initiation figures are high, exclusive breastfeeding for at least four weeks after initiation was only 47%6. Disparities in birth outcomes by race and ethnicity, education, source of prenatal care payments, and by community persist. The Black IMR was 1.9 times higher than the White IMR (7.6 vs. 4.0 infant deaths per 1,000 live births). The birth rate for Hispanic teens was 5.5 times that of Whites (63.1 vs. 11.5 births per 1,000 women ages 15-19 years). Compared with mothers who had a college degree or more, mothers with a high school education or less were less likely to receive adequate prenatal care, more likely to report smoking during their pregnancies, and more likely to deliver low birth weight (LBW) infants (less than 2,500 grams or 5.5 pounds). Mothers with their prenatal care paid through Medicaid/MassHealth were almost 6 times more likely to report smoking during pregnancy than those with their prenatal care paid through private sources (15.3% vs. 2.7%). Among the 30 largest Massachusetts municipalities, Fall River, Lowell, and Weymouth recorded the highest percentages of gestational diabetes mellitus (GDM) (8.6%, 8.1%, and 6.7% respectively).

Massachusetts Preliminary 2009 Pregnancy Risk Assessment Monitoring System (PRAMS) data.

11

Introduction
This report presents detailed data on the number and characteristics of Massachusetts births in 2009 including maternal behaviors and health characteristics, medical services utilization by pregnant mothers, and infant health characteristics. These data are obtained from the Massachusetts Standard Certificate of Live Birth and the accompanying confidential health and demographic data for each birth record. Birth certificate data are essential for surveillance, research, programs such as the Universal Newborn Hearing Screening and the Birth Defects Monitoring program, and high-risk infant identification. In addition, birth certificate data are used for the Maternal and Child Health (MCH) five-year needs assessment process to prioritize interventions and services, and for data system development including the Pregnancy to Early Life Longitudinal (PELL) database and the Pregnancy Risk Assessment Monitoring System (PRAMS). The Registry of Vital Records and Statistics and the Massachusetts birthing facilities play a critical role in the collection of birth information for administrative purposes and provide data to programs for decision-making, which guides many public health initiatives. Examples of these are the Gestational Diabetes Summit, in October 2007, and the Massachusetts Perinatal Quality Summit, in May 2011, both as collaborative efforts, with results of their works informing programs, hospitals and health care providers across the state.

Methods
Data on births are based on information from the Massachusetts Standard Certificate of Live Birth (1989 revision) filed with the Registry of Vital Records and Statistics. Medical information, such as birth weight and gestational age, is based on information supplied by hospitals and birthing facilities. Demographic and behavioral data, such as race and ethnicity and smoking during pregnancy, are supplied by the women who gave birth. For example, women chose their race from five categories: White, Black, Asian/Pacific Islander, American Indian, and Other. Mothers identified their ancestry by selecting one of the 38 ancestry/ethnicity groups7. Vital statistics birth data may be presented in terms of either maternal residence or place of birth. Resident data include all events that occur to residents of the Commonwealth, regardless of where they happen. In Massachusetts, a resident is a person with a permanent address in one of the 351 cities or towns. Occurrence data include all events that occur within the state, whether to residents or nonresidents. All data in this publication are for Massachusetts residents unless otherwise stated. There is an agreement among the 50 states, District of Columbia, Puerto Rico, Virgin Islands, Guam, and Canadian provinces that allows for the exchange of statistical copies of birth and death records for events occurring in a state other than the state of residence.

See the Technical Notes for a list of ancestries listed in check boxes.

12

Results
Number and Birth Rate In 2009, there were 74,966 births to Massachusetts resident mothers compared with 76,969 in 2008. The number of births to Massachusetts residents has declined by 19% since 1990 and by 3% from 2008. The birth rate among women of reproductive age (defined as the number of births per 1,000 females ages 15-44 years) declined by 11% between 1990 and 2009 and by 2% from 2008 (Table 1). The mean or average maternal age at first birth in 2009 was 27.7 years, which was the same as that of 2008. Asian mothers had the highest mean age at first birth (29.6 years) and Hispanic mothers had the lowest mean age (23.2 years). There were no significant changes in the mean age at first birth for any of the other race and Hispanic categories. Births to women ages 25-34 years accounted for 55% of all births in 2009 (Table 4). Compared with 2008, the 2009 birth rates decreased among mothers ages 25-29 years (by 5%), and 30-34 years (by 3%). The decline among the 25-29 age group was driven by a 6% decline in the birth rate of Whites and by a 12% decline in the birth rate of Asians. The decline among the 30-34 age group was driven by a 5% decline in the birth rate of Whites (race- and age-specific birth rates not shown). Births by Race, Hispanic Ethnicity, and Mothers Birthplace The percentage of births to White mothers decreased from 67.2% in 2008 to 66.4% in 2009. There has been an overall decrease of 15% in the percentage of births to White mothers since 1990, when it was 78.4%. In 2009, the percentage of births to Asian, Hispanic, and Black mothers remained stable compared to the 2008 figures. However, these percentages have increased since 1990 by 120%, 61%, and 20%, respectively (Table 1). The percentage of births to non-US-born mothers remained stable between 2008 and 2009 (27.7% in 2008 vs. 27.4% in 2009). However, this proportion decreased among White (by 3%), Hispanic (by 3%) and Asian (by 1.5%) mothers in this period (Table 2, 2008 data not shown). The percentage of births to US-born mothers has changed since 2005 by maternal race. Between 2005 and 2009, the proportion of births to US-born mothers decreased among White (by 1%) and Black (by 7%) mothers, while it increased significantly among Hispanic (by 15%) and Asian (by 34%) mothers. In 2009, 37% of Hispanic and 15% of Asian mothers were born in the US, compared with 32% and 11% in 2005, respectively (Table 2, 2005 data not shown). Emerging Populations While each of the following populations accounted for less than 3% of all births in 2009, the number of births to mothers with Dominican, Asian Indian, and African ancestry continued to increase from the previous year, by 6%, 6%, and 5% respectively (Table 3, 2008 data not shown). Births by Age Group There has been a marked change in the age distribution of Massachusetts women giving birth since 1980. Approximately 25% of women giving birth in 1980 were 30 years and older compared with 53% in 2009 (Figure 1). The 2009 proportion was similar to that of 2008.

13

Compared with 2008, the largest decreases were among women ages 35-39 years with 649 less births, followed by births to women ages 25-29, with 550 less births in 2009 (Table 4, 2008 data not shown). Marital Status The percentage of mothers who were not married at the time of delivery increased by 2% between 2008 and 2009, from 34.0% in 2008 to 34.7% in 2009 (Table 1). In 2009, Hispanics continued to have the highest percentage of unmarried mothers at 67.6% followed by Black mothers at 58.9%. Among the largest ethnic maternal groups, this statistic increased the most among mothers of Portuguese (by 9.7%), European (by 7.6%) and Puerto Rican ancestry (by 2.7%). In 2009, among the 30 largest cities in the state, Springfield (72.4%), Lawrence (70.7%), and New Bedford (63.5%) had the largest proportion of births to mothers who were not married at time of delivery, while Brookline (5.2%), Newton (7.5%), and Cambridge (15.3%) had the lowest. Between 2008 and 2009, the largest increases in this proportion were seen in Leominster (from 35.0% to 41.3%), Pittsfield (from 52.0% to 58.4%), and Chicopee (from 49.4% to 54.8%) (Table 12, 2008 data not shown). This proportion was highest among mothers with less than a high school education (76.6%), followed by those with a high school education (59.0%) (Table 17). Breastfeeding In 2009, the percentage of mothers who breastfed or intended to breastfeed (not exclusively to breast milk) at time of discharge reached a record high of 82% (Table 2), a 2% increase from the 2008 figure. This proportion was highest among Asian mothers (89.3%) and lowest among White mothers (79.9%) and increased by 2% among US-born (50 states and DC) mothers (Table 2, 2008 data not shown). Among the largest maternal ethnic groups, the breastfeeding proportion increased for American (by 2%), Puerto Rican (by 4%), Portuguese (by 5%), and Cambodian (by 10%) mothers (Table 3, 2008 data not shown). Mothers with a postgraduate education had the highest proportion of breastfeeding infants at 93.1% while those with less than a high school education had the lowest at 70.5%. Between 2008 and 2009, the proportion of breastfed infants increased for all levels of education, except among mothers with a college education. The largest increases were among mothers with a high school education (by 3%) followed by those with less than a high school education (by 2%) (Table 17, 2008 data not shown). This statistic also increased for mothers with prenatal care paid through Medicaid/MassHealth (by 3%) and for those with prenatal care paid through private insurance (by 1%) (Table 30, 2008 data not shown). Multiple Births The total percentage of multiple births (twins, triplets or more) has been stable since 2002, after having a 5% increase per year between 1989 and 2002. In 2009, the total proportion of multiple births was 4.7%, compared with 4.5% in 2008. This marginal increase was driven by a 6% increase in the percentage of multiple births among mothers less than 35 years of age, from 3.7% to 3.9%. The proportion of multiple births among mothers ages 35 years and older remained stable from 2008, at 7.5%. This proportion was almost twice that of mothers less than 35 years of age in 2009 (Table 5). In 2009, 95.3% of births were singletons (71,423 births), 4.5% were twins (3,386 births), and 0.2% were triplets or higher order multiples (157 births) (Table 5). White mothers continue to

14

have the highest proportion of multiple births at 5.3%, while Hispanic mothers continue to have the lowest at 3.0%. In 2009, the proportion of multiple births was highest among mothers with post-graduate and college educational attainment (6.6% and 6.4% respectively). Both of these proportions increased from the 2008 figures (Table 17). Teen Births In 2009, there were 4,477 births among women ages 15-19 years, which was a decrease of 106 births from 2008 (Table 1). The Massachusetts teen birth rate in 2009 was 19.5 births per 1,000 females ages 15-19 years, compared with 20.1 births per 1,000 females ages 15-19 years in 2008. The Massachusetts teen birth rate in 2009 was 50% below the 2009 US teen birth rate of 39.1 births per 1,000 female ages 15-19 years8. Six percent of all births in 2009 were to women under 20 years of age. This proportion was highest among Puerto Rican (22%), Cambodian (15%), and Dominican (13%) women (Table 3), and among women with prenatal care paid through Medicaid (14%) (Table 30). Twenty-nine percent of teen births were to teenagers 15-17 years (1,318 births), while 71% were to teenagers 18 and 19 years old (3,159) (Table 6). The number of births to the youngest mothers (ages 10-14 years) was 51 in 2009, 40 in 2008, and 49 in 2007. These are small numbers and fluctuate from year to year. Between 2008 and 2009, there was not a significant increase in the birth rate for this age group. In 2009, the youngest mother in Massachusetts was 12 years old, a year younger than that of 2008. In 2009, teen birth rates decreased for Hispanics (by 5%) and Asians (by 16%). The rate for Hispanic teens was 5.5 times that of Whites (63.1 vs. 11.5 births per 1,000 women ages 15-19 years). When 2009 teen birth rates were compared with those of 1999, all race and ethnicity rates had declined significantly (Figure 2). Among Massachusetts municipalities with the highest number of teen births, teen birth rates were highest in Holyoke (96.8), Lawrence (79.0), and Chelsea (76.0)9. For the calculation of the 2009 city-specific teen birth rates, the latest population estimates available for cities by age, race, and gender are for the year 2005. Note that teen birth rates for 2009 using 2005 population estimates will be overestimated if the female teen population in these cities increased between 2005 and 2009, and teen birth rates will be underestimated if the female teen population in these cities decreased between 2005 and 2009. Between 2008 and 2009, teen birth rates declined in Chelsea, Fall River, Holyoke, and Worcester, while these rates increased in North Adams (from 28.3 to 51.3 births per 1,000 females ages 15-19 years), Taunton (from 24.5 to 42.9), and Springfield (from 61.4 to 72.1 births per 1,000 females ages 15-19 years) (Table 7, 2008 data not shown).

Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2009. National vital statistics reports web release; vol 59 no 3. Hyattsville, MD: National Center for Health Statistics. 2010.

Birth rates for cities and towns were calculated using MDPH population estimates for 2005, which are the most upto-date information available on the number of persons by age, race, and sex at the sub-state level. Please note: If the population in your community increased from 2005 to 2009, the rates listed may overestimate the actual rate. If the population in your community declined from 2005 to 2009, the rates given in the publication may underestimate the actual rate.

15

Low Birth weight The percentage of low birth weight (LBW) infants (less than 2,500 grams or 5.5 pounds) was 7.8% in 2009, the same as in 2008. This proportion increased by 35% since 1990 when it was 5.8% (Table 1). Since 2004, the proportion of LBW infants in Massachusetts has remained stable. Black infants continue to have the highest percentage of LBW at 10.8% followed by Hispanic infants at 8.6%. Among Asians, this proportion decreased between 2008 and 2009, from 8.4% to 7.6% (Table 2). Infants of African American (12.4%), Haitian (12.4%), Cambodian (11.7%), and Puerto Rican (10.0%) mothers had significantly higher LBW rates than the state overall LBW rate of 7.8% (Table 3). The percentage of low birth weight among twin births is about 10 times larger than that among singletons. In 2009, 5.5% of singleton births were LBW; whereas, 52.7% of twins and 93.6% of higher order births were LBW (Table 9). The percentage of very low birth weight (VLBW) infants (less than 1,500 grams or 3.3 pounds), was 1.4% in 2009, similar to that in 2008 at 1.3%. The proportion of VLBW infants born to women ages 35 and older was 1.7%, compared with 1.3% among women less than 35 years of age (Table 9). Black infants continue to have the highest percentage of VLBW at 2.2% followed by Hispanic infants at 1.7% (Table 8). Preterm and Term Deliveries The percentage of preterm infants (infants delivered before the 37th week of gestation) was 8.7% in 2009, similar to that of 2008 (Table 1). Black and Hispanic mothers continued to have the highest percentage of preterm infants at 10.5% and 9.3%, respectively, while Asians continued to have the lowest at 7.3% (Table 10). There were no significant changes from the 2008 proportion of preterm infants by race and ethnicity. Among maternal ancestry groups, African American (11.5%), Haitian (11.0%), and Puerto Rican (10.7%) mothers had higher preterm rates than the state overall rate (8.7%). The percentage of infants delivered very early (before the 28th week of gestation) was 0.7% in 2009. This proportion has remained stable since 1997 when it was 0.6% (close to 500 births each year). Black women had the highest percentage (1.1%) of infants delivered very early, followed by Hispanics (0.9%). Asian and White mothers had the lowest proportion of infants delivered very early (0.5% and 0.6%, respectively) (Table 10). In 2009, late preterm infants (infants delivered between 34-36 weeks of gestation) comprised 71% of all preterm births in the state. Infants born 34-36 weeks are at heightened risk for adverse health outcomes when compared with infants delivered at higher gestational ages10. In 2009, the percentage of late preterm births was 6.2% (Table 1), the same as that of 2008. This report for the first time differentiates between early and full term births (Table 10). There is growing evidence of increased neonatal morbidity and mortality among early term infants (infants born between 37-38 weeks of gestation), compared with those born between 39-41 weeks of gestation)11,12,13 the latter also known as full term infants.
Shapiro-Mendoza CK. Pediatrics 2008; 121:e223-232; Escobar GJ Arch Dis Child 2005; 90:125; Escobar G. Semin Perinatol 2006; 30:28-33; Morse SB Pediatr Res 2006A in Adams-Chapman I Clin Perinatol 2006;33:947; Tomashak KM. J Pediatr 2007; 151:450; Linnet KM. Arch Dis Child 2006; 91:655. 11 Reddy U et al. Term Pregnancy: A Period of Heterogeneous Risk for Infant Mortality. Obstetrics & Gynecology Volume 117- Issue 6 - pp 1279-1287. doi:10.1097/AOG.0b013e3182179e28. June 2011. 12 Zhang Xu, Kramer MS. Variation in mortality and morbidity by gestational age among infants born at term. J Pediatr. Mar;154(3):358-62. 2009.
10

16

The state proportion of infants born at early term has been increasing between 1997 and 2004. Since 2004, this proportion has remained stable and, in 2009, the state proportion of infants born at early term was 20.8%, a decrease of 8% from the 2008 proportion. The decline in the proportion of early term infants was driven by declines in this proportion among Asian (by 12%) and White (by 9%) infants. The proportion of infants born at early term was higher than the states figure for Asian (23.8%) and Black (22.3%) infants and was lower than the states figure for White infants (20.1%) (Table 10, 2008 data not shown). In 2009, there was a wide variation of this proportion by maternity facilities, from 9.8% in Holyoke Hospital to 29.4% in Milford Regional Medical Center (Table 13). Smoking In 2009, 5,116 mothers reported smoking during pregnancy, accounting for 6.8% of all births this year. This proportion remained similar to that of 2008 (6.9%) and has declined by 65% since 1990 (19.3%) (Figure 3). White mothers continued to have the highest reported percentage of smoking during pregnancy at 8.1% followed by Black (5.3%) and Hispanic mothers (5.0%) (Figure 4). White mothers accounted for 78% of all mothers who reported smoking during pregnancy in 2009. The proportion of mothers who reported smoking during pregnancy did not change from those of 2008 for any of the race and Hispanic ethnicity groups. Native American, Portuguese, African American, American, and Puerto Rican mothers had the highest proportion of mothers who reported smoking during pregnancy in 2009. Each of these proportions was significantly higher than the state overall rate. While mothers who had prenatal care paid for by Medicaid/MassHealth accounted for only 27% of all births, they encompass 59% of mothers who reported smoking during pregnancy in 2009. This group had 5 times the smoking rate of mothers with prenatal care paid through private insurance (15.3% vs. 2.7% respectively) (Table 30). In 2009, among the 30 largest cities in the state, the highest reported smoking during pregnancy rates were in Pittsfield (23.2%), Fall River (19.9%), and New Bedford (14.4%) while the lowest were in Newton (1.2%), Cambridge (1.0%) and Brookline (0.2%) (data not shown). The latter three cities are the only among the 30 largest cities that reached the HP2020 target of 1.4% (or less) of women reporting smoking during pregnancy (Table 14). Mothers with less than a high school education had the highest proportion of smoking during pregnancy (17.7%) and this proportion was much higher than that of mothers with a postgraduate education (0.3%) (Table 17). In 2009, mothers who reported smoking during pregnancy were 1.7 times more likely to have a low birth weight infant than those who reported non-smoking during pregnancy (12.4% vs. 7.4%) (Figure 21). Prenatal Care In 2009, for the first time since 2001 the percentage of women receiving adequate prenatal care (PNC) increased to 84.3%, which was a 3% increase from the 2008 figure of 82.1% (Table 1). Adequacy of prenatal care utilization (APNCU) is a measure of the timing and number of prenatal care visits, not an assessment of the quality of PNC. APNCU began declining in 2001 after it reached a record of 85.2%, the highest since it was introduced as an indicator in 1996. This years increase was driven by a 2% increase in the initiation of prenatal care visits, that is,
Engle WA, Kominiarek MA. Late preterm infants, early term infants and the timing of elective deliveries. Clin Perinatol 35(2):32541. 2008.
13

17

more mothers began their prenatal care in the first trimester, 82.6% in 2009, compared with 81.0% in 2008 (Table 2). The increase from 2008 in the proportion of women receiving adequate PNC was significant across all racial groups except for Black women. In 2009, Hispanic (79.2%) and Black (76.0%) mothers continued to have proportions lower than the state overall proportion of mothers receiving adequate prenatal care. This proportion was highest among White (86.8%) and Asian (84.2%) mothers (Figure 5). Among the largest maternal ancestry groups, Chinese (88.3%), European (87.8%), Brazilian (87.0%), and American (86.6%) mothers had significantly higher rates of APNCU than the state overall rate of 84.3%. These groups experienced an increase in this proportion from their respective figures in 2008. Lowest proportions of APNCU were among African (75.0%), Cambodian (74.0%), Cape Verdean (72.0%), and Haitian (70.3%) mothers (Table 3). Mothers with the following maternal characteristics had lower proportion of adequate prenatal care: less than 18 years old, less than a high school education, smoking during pregnancy, unmarried, and non-US-born (Figure 6). Publicly Financed and Privately Insured Prenatal Care Maternal characteristics and birth outcomes varied according to whether PNC was paid through public14 programs or through private15 insurance. In 2009, Medicaid/MassHealth accounted for 74% of all PNC payments through public programs. The percentage of mothers who had their prenatal care paid through public programs was 36.1% in 2009, a 2% increase from the 2008 figure of 35.2% (Figure 7). Among teen mothers this proportion was 76.5% in 2009 (Table 20), similar to that in 2008 (77.0%). In 2009, the rate of mothers with their PNC paid through public sources increased among Black (by 5%) and White (by 2%) mothers, compared with the 2008 rates. Hispanic mothers continued to have the highest rate of PNC paid through public funds at 72.6%, followed by Black mothers at 61.3% (Table 30). Between 2008 and 2009, among the 30 largest cities in the state, the proportion of mothers with public sources for prenatal care payments increased the most in Chicopee (from 48.0% to 56.9%), Haverhill (from 35.0% to 40.4%), and Pittsfield (from 55.5% to 60.0%) (Table 12). Overall, in Massachusetts, 26.8% of mothers had prenatal care paid through Medicaid/ MassHealth. However, Medicaid/MassHealth payment for PNC varied widely by race/Hispanic ethnicity. About half of Hispanic and Black mothers had their PNC paid through Medicaid/MassHealth; whereas, 19.7% of Asian and 19.0% of White mothers PNC was paid through Medicaid/MassHealth (Table 30).

14 Public programs include: Medicaid/MassHealth, CommonHealth, Healthy Start, and Medicare (may also be HMO or managed care), or free care. 15

Private insurance include: Commercial indemnity plan, commercial managed care (HMO, PPO, IPP, IPA, and other), or other private insurance.

18

Cesarean Delivery The overall cesarean delivery rate in 2009 was 33.6%. Though this was not a statistically significant decline from the 2008 rate of 34.3% (Table 1), this is the first year since 1996 this rate is below (by 2%) the previous years rate. Since 1997, the overall cesarean delivery rate and the primary cesarean delivery rate16 had been increasing steadily. However, this steady increase has slowed down in the last five years. In 2009, the primary cesarean delivery rate for the state declined for the first time in 13 years to 23.6%, compared with 24.2% in 2008 (Table 31, 2008 data not shown). Primary cesarean deliveries accounted for 59% of all cesarean births in 2009 (Table 31). The decline in this rate from the previous year is mainly driven by a 4% decline in the primary cesarean delivery rate among White mothers with PNC paid through private insurance (from 26.6% in 2008 to 25.6% in 2009) (data not shown). In 2009, Hispanic and Asian mothers continued to have the lowest cesarean delivery rates (29.4% and 31.6%, respectively), while White and Black mothers continued to have the highest rates (34.8% and 33.8%, respectively). Between 2008 and 2009, the largest declines were seen among women born in the US (by 2%) (Table 2) and among women ages 30-34 years (by 4%) (data not shown). Among the largest ethnic groups, Brazilian mothers had the highest percentage of cesarean deliveries (44.2%), followed by Asian Indian (39.4%), Haitian (38.3%) and Portuguese (38.2%) mothers. Cambodian (22.4%), Honduran (24.0%), and Guatemalan (24.1%) mothers had the lowest percentage of cesarean deliveries in 2009 (Table 3). Women with prenatal care paid through private sources had higher cesarean delivery rates (35.9%) than those paid through public sources (30.0%) (Table 30). In 2009, Brockton Hospital (45.1%), Metrowest Medical Center-Framingham Campus (42.8%) and South Shore Hospital (42.1%) had the highest overall cesarean delivery rates. Among those with the lowest rates were Heywood Memorial Hospital (15.3%), Holyoke Hospital (18.2%), and Tobey Hospital (22.1%). Between 2008 and 2009, 11 of the 48 maternity hospitals experienced a decline in this rate, while 5 of the 48 experienced increases (Table 13). Nulliparous women (giving birth for the first time) with term gestation (>= 37 weeks) of a singleton in vertex position (NTSV) was introduced as a quality obstetric measure with a focus on primary cesareans by both the American College of Obstetricians and Gynecologists (ACOG)17 and the Department of Health and Human Services for Healthy People 2010, Objective 16-9, Reduce Cesarean Births in Low Risk Women.18 In 2009, 28.3% of NTSV births were delivered by cesarean in the state, compared with 29.6% in 2008. This rate is within 25% of the HP2020 target of 23.9% (Table 14). In 2009, among NTSV births, the cesarean rates by maternity facilities in Massachusetts ranged from 11.1% to 46.4% (data not shown). The facility with the highest rate was more than four times the rate of the facility with the lowest rate for this low risk population.
16

The primary cesarean rate is the number of primary cesarean delivery births divided by the total number of births to mothers with no prior cesareans multiplied by 100. American College of Obstetricians and Gynecologists Task Force on Cesarean Delivery. Evaluation of cesarean delivery. Washington (DC): American College of Obstetricians and Gynecologists; 2000. p. 1-59.

17

US Department of Health and Human Services. Objectives for Improving Health (Part B: Focus Areas 15-28). Vol 2. In: Healthy People 2010. 2nd ed. Washington (DC): US Government Printing Office; 2000. p. 16-29, 16-31.

18

19

Gestational Diabetes Mellitus (GDM) In 2009, the prevalence of GDM increased by 15% from the 2008 figure, from 4.0% to 4.7% (Table 1). This increase was seen among White (by 16%), Hispanic (by 15%), and Asian (by 11%) mothers. Black mothers also experienced an increase of 11% but this was not statistically significant. Asians continued to have the highest prevalence of GDM (8.6%), while White and Hispanic mothers had the lowest (4.0% and 4.7%, respectively). The prevalence of gestational diabetes mellitus (GDM) increases with increasing maternal age. In 2009, the prevalence of GDM among women ages 45 years and older was 12.0%, which was almost 5 times that of women ages 20-24 years (2.5%). This rate increased across all age groups from 2008, and the largest increase was among women ages 20-24 years (by 31%). Among the largest maternal ethnic groups, Asian Indian (10.2%), Chinese (9.4%), Vietnamese (8.8%), Haitian (7.3%), and African (7.2%) mothers had a higher prevalence of GDM than the overall state prevalence. African American (3.5%), European (3.6%) and American (4.3%) mothers had a significantly lower prevalence of GDM than the states figure (Table 3). Between 2008 and 2009, this rate increased among Native American (by 162%, from 1.9% to 5.0%), African (by 34%, from 5.4% to 7.2%), Dominican (by 33%, from 3.4% to 4.6%), Chinese (by 21%, from 7.8% to 9.4%), Puerto Rican (by 21%, from 4.2% to 5.1%), European (by 20%, from 3.0% to 3.6%) and American (by 18%, from 3.6% to 4.3%) (Table 3, 2008 data not shown). Between 2008 and 2009, the prevalence of GDM increased in seven of the 30 largest cities of the state: Peabody (by 88%, from 2.6% to 4.9%), Weymouth (by 83%, from 3.6% to 6.6%), Brookline (by 73%, from 2.6% to 4.5%), Framingham (by 59%, from 2.8% to 4.5%), Newton (by 54%, from 3.1% to 4.7%), Worcester (by 51%, from 4.3% to 6.5%), and Waltham (by 49%, from 4.1% to 6.1%). Plymouth was the only city in this group that experienced a significant decline between 2008 and 2009 (by 63%, from 2.7% to 1.0%) and became the city with the lowest prevalence of GDM in its group (Table 12, 2008 data not shown). Infant Mortality Rate (IMR) In 2009, there were 354 infant deaths (deaths of infants less than one year of age) compared with 382 in 2008 (Table 11). The IMR was 4.7 deaths per 1,000 live births in 2009, compared with 5.0 deaths per 1,000 live births in 2008. This change was not statistically significant. While the IMR has decreased by 33% since 1990, from 7.0 to 4.7 deaths per 1,000 live births, it has remained stable in the last decade. The majority of infant deaths occur in the neonatal period (before 28 days of life). The remaining infant deaths occur in the post neonatal period (between 28 and 364 days of life). In 2009, three out of four (75%) infant deaths occurred in the neonatal period and 25% in the post neonatal period (Figure 18). The proportion of neonatal deaths, out of all infant deaths, was highest among Asian (89%) and White (78%) mothers and lowest among Hispanic (69%) and Black (66%) mothers. The IMR among Black mothers reached a record low in 2009. It declined by 35% from 2008, from 11.7 to 7.6 deaths per 1,000 live births. The decline in IMR among Black mothers between 2008 and 2009 was driven by a 42% decline in the IMR during the neonatal period for this group, from 8.6 in 2008 to 5.0 in 2009, neonatal deaths per 1,000 live births. Though the magnitude of the decline among Black mothers in both, their IMR and neonatal IMR was large, these did not reach significance (Table 11).

20

However, in 2009, for the first time in 20 years, the ratio of Black to White IMR narrowed, from 3.6 in 1990 to 1.9 in 2009. Also, in 2009, for the first time in 20 years, the neonatal IMR for Black mothers was not statistically different from the neonatal IMR for White mothers (5.0 among Black mothers versus 3.1 among White mothers), and the Black to White neonatal IMR ratio also decreased significantly, from 3.6 in 1990 to 1.6 in 2009 (Table 11, 1990 data not shown). The post neonatal IMR remained stable between 2008 and 2009 and, in 2009, the post neonatal IMR among Black mothers (2.6 deaths per 1,000 live births) continued to be higher than the state post neonatal IMR (1.2 deaths per 1,000 love births) (Table 11). Birth Characteristics in the 30 Largest Massachusetts Cities and Towns In 2009, in the 30 largest municipalities in the Commonwealth, maternal characteristics and outcomes varied (Table 12): The proportion of mothers receiving adequate prenatal care ranged from 67.8% in Pittsfield to 91.3% in Framingham. The proportion of mothers with prenatal care paid through public sources (government programs including Medicaid/MassHealth, Healthy Start, Medicare, CommonHealth, free care and other) ranged from 5.3% in Brookline to 75.5% in Lawrence. The proportion of mothers that were unmarried at time of delivery ranged from 5.2% in Brookline to 72.4% in Springfield. Plymouth had the largest proportion of births to White mothers (93%), Brockton had the largest proportion of births to Black mothers (53%), Lawrence had the largest proportion of births to Hispanic mothers (81%), and Quincy had the largest proportion of births to Asian or other race mothers (32%). The gestational diabetes mellitus (GDM) prevalence was significantly higher than the statewide prevalence of 4.7% in the following four communities: Fall River (8.6%), Lowell (8.1%), Worcester (6.5%), and Quincy (6.3%). Five communities recorded low birth weight percentages that were higher than the statewide average of 7.8%: New Bedford (10.5%), Lowell (10.3%), Waltham (10.1%), Springfield (9.0%), and Boston (8.9%). Twelve of the 30 largest communities had higher rates of reported smoking during pregnancy than the state rate of 6.8%. In Pittsfield (23.3%) the rate was over three times higher than the state rate. In Fall River (19.9%), New Bedford (14.4%), and Chicopee (13.9%) these rates were between two and three times the state rate. The IMR in Boston (6.5 infant deaths per 1,000 live births) was higher than the state IMR of 4.7 infant deaths per 1,000 live births. Based on a three-year IMR from 2007-2009, which is a more stable rate than a one-year rate, Fall River (8.2), Springfield (8.1), and Brockton (8.0) had the highest IMRs. In seventeen of the thirty largest communities the teen birth rates per 1,000 women ages 15-19 were significantly higher than the statewide rate of 19.6. The highest rates were in Lawrence (79.0), Springfield (72.1), and New Bedford (58.5). Birth Characteristics by Hospital Listed below are hospitals that in 2009 had the three highest and three lowest rates of early term, overall cesarean deliveries, low birth weight infants, publicly funded deliveries, and deliveries with adequate prenatal care (Table 13). Non-hospital facilities are not included in this section.

21

Early Term Births (37-38 weeks) (state: 20.8%) Highest percentages in: MILFORD REGIONAL MEDICAL CENTER EMERSON HOSPITAL CARITAS NORWOOD HOSPITAL Lowest percentages in: HOLYOKE HOSPITAL BRIGHAM AND WOMEN'S HOSPITAL TOBEY HOSPITAL Overall Cesarean Deliveries (state: 33.7%) Highest percentages in: BROCKTON HOSPITAL METROWEST MEDICAL CENTER-FRAMINGHAM UNION SOUTH SHORE HOSPITAL Lowest percentages in: HEYWOOD MEMORIAL HOSPITAL HOLYOKE HOSPITAL BAYSTATE FRANKLIN MEDICAL CENTER Low Birth weight (LBW) (state: 7.7%) Highest percentages in: TUFTS MEDICAL CENTER CARITAS ST. ELIZABETH'S MEDICAL CENTER OF BOSTON BAYSTATE MEDICAL CENTER Lowest percentages in: NANTUCKET COTTAGE HOSPITAL FAIRVIEW HOSPITAL MARTHA'S VINEYARD HOSPITAL Publicly Funded Prenatal Care (state: 35.6%) Highest percentages in: BOSTON MEDICAL CENTER HOLYOKE HOSPITAL LAWRENCE GENERAL HOSPITAL Lowest percentages in: NEWTON WELLESLEY HOSPITAL WINCHESTER HOSPITAL EMERSON HOSPITAL Adequacy of Prenatal Care by Facility (state: 84.4%) Highest percentages in: NORTH SHORE BIRTH CENTER MARTHA'S VINEYARD HOSPITAL BRIGHAM AND WOMEN'S HOSPITAL Lowest percentages in: CARITAS NORWOOD HOSPITAL CARITAS ST. ELIZABETH'S MEDICAL CENTER OF BOSTON CARITAS GOOD SAMARITAN MEDICAL CENTER 22

(%) 29.4 25.9 25.7 9.8 14.2 14.6

45.1 42.8 42.1 15.3 18.2 21.1

27.7 14.9 12.4 0.8 1.2 1.3

77.9 72.9 69.0 4.0 5.8 8.0

96.2 95.3 95.1 58.3 62.5 63.7

A Comparison of Massachusetts and US Indicators According to the US birth statistics for 200919, the following Massachusetts perinatal health indicators in 2009 were significantly different than those for the US: The fertility rate (births to women ages 15-44 years per 1,000 women ages 15-44 years) in Massachusetts was 55.1, 17% below the US fertility rate at 66.7. The teen birth rate in Massachusetts (19.6 births per 1,000 females ages 15-19 years) was 50% lower than the US teen birth rate (39.1 births per 1,000 females ages 15-19 years). The percentage of unmarried mothers in Massachusetts (34.7%) was 15% lower than the US percentage of unmarried mothers (41.0%). The percentage of low birthweight in Massachusetts (7.8%) was 4% lower than the US low birthweight rate of 8.2%. The state rate reached the new HP2020 target (7.8%) in 2008. The Cesarean delivery rate in Massachusetts (33.7%) was 2% higher than the US Cesarean delivery rate (32.9%). The IMR in Massachusetts (4.7 deaths per 1,000 live births) was 27% lower than the US IMR in 2009 (6.4 deaths per 1,000 live births) 20. Healthy People 2020 Objectives In December of 2010, the US Department of Health and Human Services set new targets for the year 2020 for each measurable Healthy People objective 2020 (HP2020)21. Table 14 presents the most recent Massachusetts data and measures the Commonwealths progress toward meeting the targets set for sixteen of the HP2020 Maternal, Infant, and Child Health (MICH) objectives. The revised targets for the year 2020 have been set to reduce more current national baseline measures using data sources from the National Vital Statistics System (NVSS), CDC, and NCHS. These new targets are more attainable than those set for the year 2010. For twelve of sixteen HP2020 objectives presented, Massachusetts has met the 2020 targets (Table 14). For four objectives, the 2009 Massachusetts indicators are within 25% of the 2020 target goals: very low birthweight infants born at Level III hospitals, cesareans among low-risk women giving birth for the first time (this group is also known as NTSV births: nulliparous, term, singleton, vertex births), cesareans among low-risk women who had a prior cesarean, and smoking during pregnancy.

Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2009. National vital statistics reports web release; vol 59 no 3. Hyattsville, MD: National Center for Health Statistics. 2010.
20

19

Kochanek KD, Xu JQ, Murphy SL, Minio AM, Kung HC. Deaths: Preliminary Data for 2009. National Vital Statistics Reports; vol 59 no 4. Hyattsville, MD: National Center for Health Statistics. 2011.. U.S. Department of Health and Human Services. Healthy People 2020. December 2010. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=26

21

23

Table 1. Trends in Birth Characteristics, Massachusetts: 1990, 1995-2009

Characteristic
Births
1

1990
n
2 3

1995
81,562 55.5 63,043 77.3 5,858 7.2 3,355 4.1 8,077 9.9 5,990 30.3 20,857 25.6 16,758 20.6

1996
80,164 54.6 61,829 77.1 5,491 6.9 3,398 4.2 7,756 9.7 5,758 28.5 20,253 25.3 15,675 19.6

1997
80,321 54.7 61,204 76.2 5,482 6.8 3,719 4.6 8,211 10.2 5,801 28.5 20,640 25.7 15,742 19.6

1998
81,406 55.6 61,764 75.9 5,549 6.8 3,748 4.6 8,665 10.6 5,823 28.1 21,191 26.0 16,975 20.9

1999
80,866 55.9 60,402 74.7 5,844 7.2 4,138 5.2 8,815 10.9 5,515 26.7 21,448 26.5 18,080 22.4

2000
81,582 57.1 60,051 73.6 5,755 7.1 4,667 5.7 9,247 11.3 5,305 25.9 21,621 26.5 19,086 23.4 2,245 2.8

2001
81,014 56.6 59,115 73.0 5,862 7.2 4,784 5.9 9,410 11.6 4,979 24.9 21,620 26.7 20,639 25.5 2,402 3.0 5,795 7.2 6,412 8.0 4,428 5.5 80.4 85.2

2002
80,624 56.8 58,136 72.1 5,948 7.4 5,300 6.6 9,543 11.8 4,642 23.3 21,604 26.8 22,553 28.0 2,633 3.3 6,060 7.5 6,795 8.5 4,726 5.9 79.9 84.7

2003
80,167 56.8 57,604 71.9 5,902 7.4 5,224 6.5 9,764 12.2 4,639 23.0 22,262 27.8 23,392 29.2 2,693 3.4 6,115 7.6 6,963 8.7 4,800 6.0 79.9 84.5

2004
78,460 56.2 55,322 70.5 6,053 7.7 5,454 7.0 9,798 12.5 4,559 22.2 22,376 28.5 24,295 31.0 2,741 3.5 6,125 7.8 7,222 9.2 5,016 6.4 79.5 84.2

2005
76,824 55.6 53,469 69.6 6,077 7.9 5,251 6.8 10,061 13.1 4,539 21.7 23,170 30.2 24,732 32.3 2,666 3.5 6,073 7.9 6,925 9.0 4,808 6.3 78.9 84.0

2006
77,670 56.9 52,975 68.2 6,452 8.3 5,469 7.0 10,696 13.8 4,722 21.3 24,977 32.2 25,901 33.4 2,925 3.8 6,150 7.9 6,954 9.0 4,918 6.3 77.6 83.1

2007
77,934 57.2 52,620 67.5 6,462 8.3 5,758 7.4 10,861 13.9 4,944 22.0 26,010 33.4 26,240 33.7 3,279 4.2 6,147 7.9 6,980 9.0 4,945 6.4 77.8 82.8

2008
76,969 56.5 51,760 67.2 6,652 8.6 5,958 7.7 10,895 14.2 4,583 20.1 26,146 34.0 26,240 34.3 3,086 4.0 5,955 7.8 6,750 8.8 4,753 6.2 76.9 82.1

2009
74,966 55.1 49,759 66.4 6,945 9.3 5,939 7.9 10,986 14.7 4,477 19.5 26,029 34.7 25,067 33.6 3,445 4.7 5,804 7.8 6,516 8.7 4,602 6.2 79.1 84.3

92,461 62.1 72,483

Rate Race of Mother White non-Hispanic Black non-Hispanic Asian Hispanic n % n % n % n % Teen Births (Ages 15-19) Births to Unmarried n Rate n % Cesarean Deliveries n % Gestational Diabetes
5 4 4 4 4

78.4 7,158 7.7 3,349 3.6 8,406 9.1 7,258

3

35.4 22,837 24.7 20,615 22.3

24

n %

Low Birthweight

n %

5,388 5.8 5,899 6.5 3,977 4.4 80.1

5,174 6.4 6,438 7.9 4,546 5.6 84.2

5,105 6.4 5,705 7.2 3,966 5.0 79.9 83.3

5,617 7.0 5,831 7.3 3,949 4.9 80 82.9

5,655 7.0 6,117 7.6 4,186 5.2 79.8 82.9

5,708 7.1 6,136 7.6 4,153 5.2 79.4 82.9

5,711 7.1 6,582 8.3 4,509 5.7 79.1 83.3

Preterm

n %

Late Preterm

n %

Adequate Prenatal Care Kessner Index

9 10

% %

APNCU Index

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. Births presented in all tables are resident live births unless otherwise specified. 2. Differences in numbers of births from previous publications are the result of updated files. 3. Birth rates represent the total number of births to women ages 15-44 years per 1,000 females ages 15-44; teen birth rates refer to number of births per 1,000 females ages 15-19. Population data for computing 2009 birth rates at the state level were provided by the US Census Bureau. See the Population Denominators section of the Technical Notes for further information. 4. Percentages are calculated based on births, including those to mothers of unknown race. 5. Gestational diabetes is defined as glucose intolerance found during pregnancy for the first time. It excludes cases with pre-existing diabetes. 6. Low birthweight: less than 2,500 grams or 5.5 pounds. 7. Preterm: <37 weeks gestation. 8. Late preterm: 34-36 weeks of gestation. 9. Adequacy of prenatal care in Massachusetts has historically been measured with the Kessner Index, based on the timing of care and number of visits. This measure is calculated based on only those births with known adequacy of prenatal care. Changes in the calculation of the Kessner Index in 1996, as well as computational adjustments made for 1996-2000 data, make data prior to 1996 noncomparable to data from 1996 onward. 10. Beginning with Births 2001, the APNCU Index has replaced the Kessner Index as the standard measurement of adequacy of prenatal care (see Technical Notes for more information).

24

Table 2. Birth Characteristics by Maternal Race/Hispanic Ethnicity and Birthplace, Massachusetts: 2009

Race and Hispanic Ethnicity (by mothers birthplace)

State Total US inc. DC 7 US Territories 8 Non-US-born White Non-Hispanic US inc. DC 7 US Territories 8 Non-US-born Black non-Hispanic US inc. DC 7 US Territories 8 Non-US-born Hispanic US inc. DC 7 US Territories 8 Non-US-born Asian US inc. DC 7 US Territories 8 Non-US-born 9 American Indian US inc. DC 7 US Territories 8 Non-US-born 10 Other US inc. DC 7 US Territories 8 Non-US-born 11 Unknown

Births n 74,966 52,406 1,983 20,567 49,759 43,497 54 6,205 6,945 3,293 21 3,630 10,986 4,011 1,903 5,070 5,939 895 1 5,042 122 114 1 7 1,036 452 3 581 179
%
1

Teen Births <18 Years <20 Years n 4,528 3,607 360 558 1,977 1,883 9 84 602 511 5 86 1,697 1,001 345 349 140 123 0 17 13 13 0 0 92 69 1 22 7 % 6.0 6.9 18.2 2.7 4.0 4.3 16.7 1.4 8.7 15.5 23.8 2.4 15.4 25.0 18.1 6.9 2.4 13.7 0.0 0.3 10.7 11.4 0.0 8.9 15.3 --6 3.8 3.9 n 1,369 1,096 127 144 484 461 3 19 185 163 2 20 604 385 122 96 57 54 0 3 5 5 0 0 32 26 0 6 2 % 1.8 2.1 6.4 0.7 1.0 1.1 --6 0.3 2.7 4.9 --6 0.6 5.5 9.6 6.4 1.9 1.0 6.0 0.0 --6 4.1 4.4 0.0 3.1 5.8 0.0 1.0 6 -n 1,014 699 41 268 582 522 1 56 156 73 0 83 182 79 40 61 62 8 0 53 0 0 0 0 26 11 0 15 6

Birthweight Very Low

2

Prenatal Care Low

3

Adequate n 61,669 43,811 1,507 16,343 42,167 36,944 36 5,184 5,116 2,529 21 2,565 8,476 3,120 1,446 3,908 4,945 722 1 4,222 86 78 1 7 788 346 2 440 91

1 Trimester n 60,758 43,388 1,500 15,861 41,975 36,793 39 5,140 4,927 2,446 19 2,461 8,133 2,985 1,439 3,707 4,771 681 0 4,090 82 74 1 7 775 332 2 441 95 % 82.6 84.4 76.6 78.5 85.9 86.2 73.6 84.1 72.3 75.7 90.5 69.2 75.3 75.3 76.5 74.9 81.0 76.4 0.0 81.8 69.5 67.3 --6
100.0

st

Cesarean Deliveries n 25,067 17,660 559 6,846 17,209 15,050 10 2,149 2,342 1,041 7 1,294 3,212 1,143 540 1,527 1,872 227 1 1,644 35 34 0 1 365 136 1 228 32 % 33.6 33.9 28.3 33.4 34.8 34.8 18.5 34.7 33.8 31.7 33.3 35.7 29.4 28.6 28.5 30.3 31.6 25.4 --6 32.7 28.9 30.1 --6 35.5 30.3 --6 39.5 25.4

Breastfeeding5 n 60,261 39,854 1,522 18,880 38,857 33,088 42 5,727 5,962 2,546 18 3,397 9,166 3,027 1,459 4,678 5,273 734 1 4,538 92 84 1 7 828 307 1 520 83 % 82.0 77.9 77.5 92.7 79.9 78.0 79.2 93.2 86.2 77.7 85.7 93.9 84.3 76.2 77.4 93.2 89.3 82.6 --6 90.6 76.0 74.3 --6
100.0

100.0 69.9 2.6 27.4 66.4 87.4 0.1 12.5 9.3 47.4 0.3 52.3 14.7 36.5 17.3 46.1 7.9 15.1 --6 84.9 0.2 93.4 --6 5.7 1.4 43.6 --6 56.1 0.2

% 1.4 1.3 2.1 1.3 1.2 1.2 --6 0.9 2.2 2.2 0.0 2.3 1.7 2.0 2.1 1.2 1.0 0.9 0.0 1.1 0.0 0.0 0.0 2.5 2.4 0.0 2.6 4.8

n 5,804 4,078 209 1,508 3,547 3,132 8 404 750 411 2 336 940 383 199 356 451 86 0 364 6 6 0 0 91 45 0 46 19

% 7.8 7.8 10.6 7.4 7.2 7.2 14.8 6.5 10.8 12.5 --6 9.3 8.6 9.6 10.5 7.1 7.6 9.6 0.0 7.2 5.0 5.4 0.0 8.8 10.0 0.0 7.9 15.1

% 84.3 85.7 77.3 81.5 86.8 87.0 67.9 85.1 76.0 78.9 100.0 73.2 79.2 79.1 77.3 80.0 84.2 81.2 --6 84.7 72.9 70.9 --6 100.0 79.3 80.1 --6 78.7 82.0

25

77.0 75.8 --6 77.9 79.8

86.6 75.6 --6 95.1 82.2

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. In the column Births %, the percentages of the race/Hispanic groups (bolded) are based on the state total (including births of unknown race/ethnicity), and the birthplace percents for the race/ethnicities are based on the total number in race/Hispanic ethnicity category. For all other categories, percentages are based on row totals. 2. Very low birthweight: less than 1,500 grams or 3.3 pounds. 3. Low birthweight: less than 2,500 grams or 5.5 pounds. 4 Based on Adequacy of Prenatal Care Utilization (APNCU) Index. 5. Mother was breastfeeding or was intending to breastfeed at the time the birth certificate was completed. 6. Calculations based on 1-4 events are excluded. 7. The category US Territories includes women born in Puerto Rico, the US Virgin Islands, and Guam. Approximately 95% of the births in this category were to women born in Puerto Rico. 8. The category Non-US-born includes women born outside of the 50 US states, District of Columbia, and the US territories. 9. Mothers who selected American Indian as their race. 10. Mothers who indicated Other as their race. 11. Mothers who did not indicate a race/ethnicity.

25

Table 3. Birth Characteristics by Maternal Ancestry, Massachusetts: 2009

Maternal Ancestry State Total American European Puerto Rican African-American Brazilian Dominican Asian Indian African Chinese Haitian Salvadoran Cape Verdean Portuguese South American Middle Eastern Guatemalan Vietnamese Cambodian Mexican Korean Honduran
Native American
8

Births1 N % 74,966 100.0 29,380 39.2 14,701 19.6 4,894 6.5 2,761 3.7 2,248 3.0 2,142 2.9 1,643 2.2 1,633 2.2 1,557 2.1 1,209 1.6 1,138 1.5 1,053 1.4 959 1.3 888 1.2 861 1.1 848 1.1 721 1.0 622 0.8 490 0.7 417 0.6 313 0.4 245 0.3

Teen Births <18 years <20 Years N % N % 1,369 1.8 4,528 6.0 401 1.4 1,584 5.4 45 0.3 242 1.6 394 8.1 1,089 22.3 125 4.5 410 14.8 17 0.8 54 2.4 97 4.5 282 13.2 --7 0 0.0 1 6 0.4 22 1.3 --7 --7 2 4 12 1.0 36 3.0 29 2.5 101 8.9 39 3.7 123 11.7 15 1.6 61 6.4 15 1.7 51 5.7 --7 2 8 0.9 28 3.3 80 9.4 --7 2 14 1.9 44 7.1 93 15.0 25 5.1 46 9.4 --7 0 0.0 1 9 2.9 28 8.9 8 3.3 23 9.4

Prenatal Care Low Birthwt2 Adequate3 1st Trimester N % N % N % 5,804 7.8 61,669 84.3 60,758 82.6 2,223 7.6 25,060 86.6 25,120 86.6 885 6.1 12,531 87.8 12,326 85.9 489 10.0 3,725 77.3 3,646 75.3 343 12.4 2,135 79.5 2,096 77.4 135 6.0 1,917 87.0 1,842 83.3 185 8.7 1,689 80.6 1,630 77.4 142 8.7 1,388 85.2 1,390 85.2 127 7.8 1,198 75.0 1,139 70.7 90 5.8 1,367 88.3 1,338 86.3 150 12.4 803 70.3 773 65.6 80 7.0 899 83.7 841 76.1 92 8.8 741 72.0 695 67.0 78 8.1 810 86.0 821 86.2 61 6.9 722 83.7 699 80.3 55 6.4 660 78.2 665 78.5 64 7.6 615 75.6 507 61.8 55 7.6 590 83.8 575 80.8 72 11.7 455 74.0 385 62.4 20 4.1 372 78.6 375 78.5 17 4.1 354 86.3 355 86.4 22 7.1 236 79.5 218 71.2 11 4.5 190 80.2 177 74.4

Late Cesarean Preterm4 Section N % N % 4,602 6.2 25,067 33.6 1,833 6.3 10,071 34.4 827 5.7 5,059 34.7 362 7.4 1,365 28.0 211 7.7 855 31.1 115 5.2 986 44.2 126 5.9 752 35.4 82 5.0 646 39.4 85 5.2 573 35.2 78 5.0 458 29.5 73 6.0 463 38.3 60 5.3 277 24.4 74 7.0 305 29.0 63 6.6 366 38.2 66 7.5 274 31.0 48 5.6 281 32.7 51 6.1 203 24.1 46 6.4 214 29.7 50 8.1 139 22.4 25 5.2 165 34.0 13 3.1 124 29.7 9 2.9 75 24.0 14 5.7 74 30.3

BreastGestational feeding5 Diabetes6 N % N % 60,261 82.0 3,445 4.7 22,205 76.0 1,245 4.3 12,509 86.3 518 3.6 3,617 74.5 248 5.1 2,104 76.5 95 3.5 2,123 95.4 111 5.0 1,896 89.6 97 4.6 1,586 96.9 167 10.2 1,546 94.8 116 7.2 1,418 91.5 146 9.4 1,124 93.0 87 7.3 1,082 95.5 56 5.0 911 87.2 41 3.9 546 60.0 52 5.4 830 94.6 43 4.9 792 92.2 47 5.5 760 90.8 35 4.2 577 80.7 63 8.8 408 66.3 37 6.0 443 92.3 20 4.1 392 94.9 23 5.5 301 96.2 10 3.2 184 76.0 12 5.0

26

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. In 2009, certain ancestry groups were combined: Lebanese, Iranian, Israeli, and Other Middle Eastern ancestries were combined into Middle Eastern; Colombian and Other South American were combined into South American; and Nigerian and Other African were combined into African. 1. In the column Births, percentages are based on column total (state total of births, including births for which maternal ethnicity is unknown and other). For all other categories, percentages are based on row totals. 2. Low birthweight: less than 2,500 grams or 5.5 pounds. 3. Based on Adequacy of Prenatal Care Utilization (APNCU) Index. 4. Late preterm: 34-36 weeks gestation. 5. Mother was breastfeeding or was intending to breastfeed at the time the birth certificate was completed. 6. Gestational diabetes is defined as glucose intolerance found during pregnancy for the first time. It excludes cases with pre-existing diabetes. 7. Calculations based on 1-4 events are excluded. 8. Mothers who selected Native American as their ancestry.

26

Figure 1. Trends in the Number of Births by Mothers Age Group, Massachusetts: 1980-2009

60,000

50,000

Ages 30+
39,921 40,000

Number of Births

Ages < 30
30,000

35,045

20,000

10,000

0
1 980 1 981 1 982 1 983 1 984 1 985 1 986 1 987 1 988 1 989 1 990 1 991 1 992 1 993 1 994 1 995 1 996 1 997 1 998 1 999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

27

Table 4. Age-Specific and Crude Birth Rates, Massachusetts: 1990 and 2009 1990 Mothers Age 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+3 Birth Rate4 (ages 15-44) Crude Birth Rate5 Births1 124 7,259 18,115 29,913 25,687 9,795 1,522 46 92,290 92,461 Rate 1.3 35.1 69.5 107.2 93.9 40.1 6.9 0.3 62.2 15.4 2009 Births 51 4,477 12,048 18,469 23,143 13,521 3,040 193 74,698 74,966 Rate2 0.3 19.5 52.3 85.3 111.2 60.4 12.3 0.7 55.1 11.4 Percent Change in Rate -76.9% -44.4% -24.7% -20.4% 18.4% 50.6% 78.3% 133.3% -11.4% -26.0%

NOTE: All percentages are calculated based on only births with known values for the characteristic(s) of interest, unless otherwise stated. 1. 2. 3. 4. 5. Differences in the number of births from previous publications are the result of updated files. The number of births for all age groups does not always add to the total number of births because mothers age is sometimes not recorded on the birth certificate. Population estimates from the National Center for Health Statistics for 2009 were used to calculate birth rates at the state level. Denominator is the female population ages 45-49. Rate represents the total number of births to women ages 15-44 per 1,000 females in the population ages 15 to 44. Births per 1,000 residents (male and female). Includes births to mothers of all age groups and mothers for whom age is unknown.

28

Table 5. Trends in Number and Percent Distribution of Births by Plurality and Age Massachusetts: 1995-2009
Singletons Age Group Twins n 78,935 77,355 77,203 78,004 77,473 78,075 77,409 76,673 76,367 74,677 73,258 74,146 74,498 73,475 71,423 65,669 63,560 62,598 62,719 61,816 61,659 60,704 59,736 59,347 57,618 56,380 57,237 57,977 57,080 55,906 13,264 13,793 14,602 15,282 15,657 16,412 16,703 16,936 17,015 17,055 16,874 16,901 16,519 16,392 15,513 % 96.8 96.5 96.1 95.8 95.8 95.7 95.6 95.1 95.3 95.2 95.4 95.5 95.6 95.5 95.3 97.2 96.9 96.7 96.4 96.4 96.4 96.3 96.0 95.9 96.0 96.3 96.3 96.3 96.3 96.1 95.0 94.8 93.6 93.6 93.5 93.3 93.0 92.1 92.9 92.4 92.5 92.8 93.2 92.6 92.5 n 2,429 2,621 2,856 3,114 3,147 3,263 3,371 3,708 3,551 3,538 3,375 3,375 3,310 3,365 3,386 1,787 1,935 1,949 2,193 2,147 2,205 2,211 2,379 2,389 2,229 2,086 2,116 2,144 2,111 2,202 642 686 907 921 1,000 1,058 1,160 1,329 1,162 1,309 1,289 1,257 1,166 1,254 1,184 % 3.0 3.3 3.6 3.8 3.9 4.0 4.2 4.6 4.4 4.5 4.4 4.3 4.2 4.4 4.5 2.6 2.9 3.0 3.4 3.3 3.4 3.5 3.8 3.9 3.7 3.6 3.6 3.6 3.6 3.8 4.6 4.7 5.8 5.6 6.0 6.0 6.5 7.2 6.3 7.1 7.1 6.9 6.6 7.1 7.1 Multiples1 Triplets or more Total Multiples n 198 194 262 288 246 244 234 243 249 245 190 149 126 129 157 141 126 170 170 150 130 134 127 118 142 102 89 87 78 80 57 68 92 118 96 114 100 116 131 103 88 60 39 51 77 % 0.2 0.2 0.3 0.4 0.3 0.3 0.3 0.3 0.3 0.3 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.3 0.3 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.1 0.1 0.1 0.1 0.4 0.5 0.6 0.7 0.6 0.6 0.6 0.6 0.7 0.6 0.5 0.3 0.2 0.3 0.5 n 2,627 2,815 3,118 3,402 3,393 3,507 3,605 3,951 3,800 3,783 3,565 3,524 3,436 3,494 3,543 1,928 2,061 2,119 2,363 2,297 2,335 2,345 2,506 2,507 2,371 2,188 2,205 2,231 2,189 2,282 699 754 999 1,039 1,096 1,172 1,260 1,445 1,293 1,412 1,377 1,317 1,205 1,305 1,261 % 3.2 3.5 3.9 4.2 4.2 4.3 4.4 4.9 4.7 4.8 4.6 4.5 4.4 4.5 4.7 2.9 3.1 3.3 3.6 3.6 3.6 3.7 4.0 4.1 4.0 3.7 3.7 3.7 3.7 3.9 5.0 5.2 6.4 6.4 6.5 6.7 7.0 7.9 7.1 7.6 7.5 7.2 6.8 7.4 7.5 Total births2 n 81,562 80,164 80,321 81,406 80,866 81,582 81,014 80,624 80,167 78,460 76,824 77,670 77,934 76,969 74,966 67,597 65,621 64,717 65,082 64,113 63,994 63,049 62,242 61,854 59,989 58,569 59,442 60,208 59,269 58,188 13,963 14,547 15,601 16,321 16,753 17,584 17,963 18,381 18,308 18,467 18,251 18,218 17,724 17,697 16,774 % 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Year All Ages 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Ages <35 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Ages 35+ 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

1. Numbers of multiples (n) represent individual infants rather than sets of infants. 2. Differences in the number of births from previous publications are the result of updated files.

29

Table 6. Summary of Selected Teen Birth Characteristics, Massachusetts: 2009

Ages 15-17 State total Race/Hispanic Ethnicity White non-Hispanic Black non-Hispanic Asian Hispanic Other Birthplace US States / D.C. Puerto Rico / US Terr. Non-US-born Prenatal care funding Public Private, other Adequacy of Prenatal Care3 4 Adequate Total Adequate Intensive Adequate Basic Intermediate Inadequate/None Unknown Parity5 1 2 3+ Smoking during Pregnancy Yes No Birthweight < 500 g 500-1,499 g 1,500-2,499 g LBW (<2,499 g) 2,500-3,999 g 4000+ g Gestational age < 28 weeks < 37 weeks 37-42 weeks 43+ weeks Plurality Singleton Multiple birth N 1,318 N 473 179 56 572 36 1,056 123 137 985 305 Ages 18-19 %1 70.6% %2 47.3% 13.2% 2.6% 34.7% 2.2% 91.4% 8.5% 15.1% 76.6% 23.4% Combined Ages 15-19 N 4,477 N 1,966 596 139 1,665 104 3,567 356 551 3,360 1,030 %1 100.0% %2 44.0% 13.3% 3.1% 37.2% 2.3% 87.8% 8.8% 13.6% 76.5% 23.5% %1 N 29.4% 3,159 Maternal Demographics N %2 35.9% 13.6% 4.3% 43.5% 2.7% 80.2% 9.3% 10.4% 1,493 417 83 1,093 68 2,511 233 414

76.4% 2,375 23.6% 725 Pregnancy-Related Factors 68.4% 32.1% 36.3% 8.5% 21.6% 1.5% 93.3% 6.4% --6 2,322 1,036 1,286 266 496 75 2,631 453 54

901 423 478 112 285 20 1,224 84 4 126 1,191

73.5% 32.8% 40.7% 8.4% 15.7% 2.4% 83.8% 14.4% 1.7% 13.7% 86.3%

3,223 1,459 1,764 378 781 95 3,855 537 58 559 3,914

72.0% 32.6% 39.4% 8.4% 17.4% 2.1% 86.6% 12.1% 1.3% 12.5% 87.5%

9.6% 433 90.4% 2,723 Birth Outcomes 0.4% 2.1% 7.3% 9.8% 85.5% 4.6% 1.6% 9.9% 90.1% 0.0% 98.3% 1.7% 6 47 227 280 2,674 187 25 287 2,852 0 3,090 69

5 28 96 129 1,122 61 21 130 1,183 0 1,296 22

0.2% 1.5% 7.2% 8.9% 85.1% 6.0% 0.8% 9.1% 90.9% 0.0% 97.8% 2.2%

11 75 323 409 3,796 248 46 417 4,035 0 4,386 91

0.2% 1.7% 7.3% 9.2% 85.2% 5.6% 1.0% 9.4% 90.6% 0.0% 98.0% 2.0%

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. For state total row, percentages are based on total births to females ages 15-19. For the rest of the table, percentages are based on births for a given age group and characteristic. 2. Percents are based on state total of the age group. 3. Based on Adequacy of Prenatal Care Utilization (APNCU) Index. 4. Adequate Total = Adequate Basic + Adequate Intensive. 5. Number of live births including the current birth. 6. Calculations based on 1-4 events are excluded.

30

Table 7. Trends in Teen Birth Rates for Selected Communities, Ranked by 2009 Teen Birth Rate Massachusetts: 1999, 2008, and 2009
19992 2009 Rank Municipality1 State Total 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Holyoke Lawrence Chelsea Springfield New Bedford Lynn Southbridge Pittsfield Revere Lowell North Adams Fall River Taunton Chicopee Fitchburg Brockton Haverhill Everett Attleboro Leominster Worcester Methuen Boston Framingham Somerville Number of Teen Births 5,515 147 277 90 485 221 174 41 48 29 235 30 150 83 63 94 169 82 32 33 60 304 42 761 54 64 Teen Birth Rate3 26.7 98.7 100.5 92.7 83.4 73.3 62.6 73.7 34.1 25.0 61.4 41.2 52.1 51.5 35.6 59.8 55.6 47.5 32.1 28.3 50.5 45.0 33.0 37.3 27.9 34.1 2008 Number of Teen Births
4,583

2009 Teen Birth Rate3

20.1

Number of Teen Births

4,477

Teen Birth Rate23,4

19.5

174 245 97 373 186 164 34 60 53 193 16 159 40 59 60 155 61 43 30 29 256 30 565 53 33

115.3 80.9 97.0 61.4 62.9 53.2 60.9 47.2 50.3 48.7 28.3 56.2 24.5 33.9 38.4 42.6 32.0 40.6 26.4 23.1 36.4 22.6 28.6 27.1 15.2

146 239 76 438 173 172 31 70 56 210 29 129 70 72 64 137 70 37 39 41 219 40 521 50 40

96.8 79.0 76.0 72.1 58.5 55.8 55.6 55.1 53.2 53.0 51.3 45.6 42.9 41.4 40.9 37.7 36.7 34.9 34.4 32.7 31.1 30.1 26.4 25.6 18.4

31

1. Selected communities include the 25 Massachusetts cities and towns with the greatest number of teen births. Ranking is by 2009 teen birth rate. 2. Source for 1999 births and rates: Massachusetts Community Health Information Profile (MassCHIP), MDPH, v3.0 r321, October 2009; natality dataset. 3. Rates are per 1,000 females ages 15-19 per city/town. 4. Population estimates from the National Center for Health Statistics for 2009 were used to calculate birth rates at the state level. Birth rates for cities and towns were calculated using MDPH population estimates for 2005, which are the most up-todate information available on the number of persons by age, race, and sex at the sub-state level. Please note: If the population in your community increased from 2005 to 2009, the rates listed may overestimate the actual rate. If the population in your community declined from 2005 to 2009, the rates given in the publication may underestimate the actual rate. As soon as new population data are available for cities and towns, revised rates will be available from MassCHIP http://masschip.state.ma.us.

31

Figure 2. Birth Rates among Females Ages 15-19 Years by Mothers Race/Hispanic Ethnicity, Massachusetts: 1999 and 2009

120

100 Births per 1,000 Women Ages 15-19

98.8 1999 2009

80 63.1 60 57.4

32

40

32.3 23.4 27.4 19.5 10.9

20

15.9 11.5

0 White non-Hispanic Black non-Hispanic Hispanic Asian Total

Note: Teen birth rate is number of births to females ages 15-19 per 1,000 females ages 15-19. Denominators for 1999 state rates are based on the 1999 MISER Population Estimates. 2009 birth rates are based on the 2008 population estimates from the National Center for Health Statistics.

32

Table 8. Births by Birthweight, Race/Hispanic Ethnicity, Massachusetts: 2009

Total n
74,966 117 396 501 1,147 3,643 12,240 27,804 21,679 6,007 912 82 438 1,014

Birthweight
(in grams)
State Total <500 500-999 1,000-1,499 1,500-1,999 2,000-2,499 2,500-2,999 3,000-3,499

White nonHispanic n %1
100.0 0.1 0.4 0.6 1.5 4.5 14.5 36.1 31.5 9.3 1.4 0.1 0.6 1.2

Black nonHispanic n
6,945 20 75 61 136 458 1,494 2,666 1,584 372 64 6 9 156

Hispanic n %1
100.0 0.2 0.6 0.8 1.6 5.3 18.6 39.4 26.2 6.4 0.8 0.1 0.4 1.7

Asian n
5,939 15 25 22 77 312 1,326 2,508 1,356 238 44 3 13 62

Other n
1,158 2 13 11 22 49 205 443 307 84 16 0 6 26

Unknown race/ethnicity n
179 3 3 0 2 11 19 40 37 9 2 0 53 6

%1

%1

%1
100.0 0.3 0.4 0.4 1.3 5.3 22.4 42.3 22.9 4.0 0.7 -2

%1
100.0 -2

100.0 49,759 0.2 0.5 0.7 1.5 4.9 16.4 50 215 317 737 2,228 7,166

100.0 10,986 0.3 1.1 0.9 2.0 6.6 21.5 38.4 22.8 5.4 0.9 0.1 0.1 2.2 27 65 90 173 585 2,030 4,305 2,862 702 89 10 48 182

1.1 1.0 1.9 4.3 17.8 38.5 26.6 7.3 1.4 0.0 0.5 2.3

37.3 17,842 29.1 15,533 8.1 1.2 0.1 0.6 1.4 4,602 697 63 309 582

33

3,500-3,999 4,000-4,499 4,500-4,999 >=5,000 Unknown birthweight VLBW (0-1,499 g) LBW4 (0-2,499 g)
3

0.2 1.0

5,804

7.8

3,547

7.2

750

10.8

940

8.6

451

7.6

97

8.4

19

NOTE: Percentages for detailed birthweight rows (<500 through Unknown birthweight) are calculated based on births including those with unknown birthweight. Percentages for VLBW and LBW rows are calculated based on births with known birthweight only. 1. Percentages are based on column totals. 2. Calculations based on values of 1-4 are excluded. 3. Very Low Birthweight (VLBW): less than 1,500 grams (3.3 lbs.). 4. Low Birthweight (LBW): less than 2,500 grams (5.5 lbs.).

33

Table 9. Low Birthweight by Plurality and Maternal Age, Massachusetts: 1999-2009

Age Group (years) Year Singleton Twin VLBW1 n % All Ages a 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 731 722 730 699 713 740 701 687 693 627 677 569 555 576 537 539 565 552 534 533 492 525 162 167 154 161 174 174 149 151 160 135 152 0.9 0.9 0.9 0.9 0.9 1.0 1.0 0.9 0.9 0.9 1.0 0.9 0.9 1.0 0.9 0.9 1.0 1.0 0.9 0.9 0.9 0.9 1.0 1.0 0.9 1.0 1.0 1.0 0.9 0.9 1.0 0.8 1.0 LBW2 n % 3,869 3,886 3,931 3,972 4,006 4,015 4,126 4,264 4,258 4,039 3,886 3,082 3,096 3,147 3,129 3,161 3,128 3,198 3,342 3,317 3,134 3,093 787 790 784 842 844 886 927 919 941 905 792 5.0 5.1 5.1 5.2 5.3 5.4 5.6 5.8 5.7 5.5 5.5 5.0 5.1 5.2 5.2 5.3 5.4 5.7 5.8 5.7 5.5 5.6 5.0 4.9 4.7 5.0 5.0 5.2 5.5 5.4 5.7 5.6 5.1 VLBW1 n % 324 284 310 342 331 324 322 308 306 324 276 231 204 235 237 256 207 215 217 223 218 174 93 80 75 105 75 117 107 89 83 106 102 10.3 8.9 9.2 9.2 9.3 9.2 9.5 9.1 9.2 9.7 8.2 10.8 9.4 10.7 10.0 10.7 9.3 10.3 10.3 10.4 10.4 7.9 9.3 7.7 6.5 7.9 6.5 9.0 8.3 7.1 7.1 8.5 8.7 LBW2 n % 1,617 1,603 1,654 1,855 1,877 1,879 1,765 1,746 1,772 1,803 1,771 1,124 1,097 1,156 1,229 1,325 1,224 1,149 1,157 1,191 1,181 1,187 493 506 498 626 552 655 616 587 581 622 584 51.6 50.0 49.2 50.2 52.9 53.2 52.3 51.8 53.6 53.8 52.7 52.6 50.7 52.4 51.9 55.5 55.0 55.1 54.8 55.6 56.2 54.2 49.5 48.6 43.2 47.1 47.5 50.2 47.8 46.8 49.8 49.8 49.9 Multiples Triplets or more VLBW1 LBW2 n % n % 65 84 74 68 71 84 75 46 54 55 61 49 49 41 42 38 56 47 28 45 34 36 16 35 33 26 33 28 28 18 9 21 25 26.5 35.0 32.9 28.0 28.5 34.4 39.5 31.1 42.9 42.6 38.9 32.9 38.0 31.3 33.1 32.2 39.7 46.1 31.5 51.7 43.6 45.0 16.7 31.5 35.1 22.4 25.2 27.2 31.8 30.5 23.1 41.2 32.5 222 222 210 233 232 231 181 140 117 113 147 138 125 120 125 114 133 100 83 85 70 76 84 97 90 108 118 98 81 57 32 43 71 90.6 92.5 93.3 95.9 93.2 94.7 95.3 94.6 92.9 87.6 93.6 92.6 96.9 91.6 98.4 96.6 94.3 98.0 93.3 97.7 89.7 95.0 87.5 87.4 95.7 93.1 90.1 95.1 92.0 96.6 82.1 84.3 92.2 Total Births Total Multiples VLBW1 LBW2 n % n % 389 368 384 410 402 408 397 354 360 379 337 280 253 276 279 294 263 262 245 268 252 210 109 115 108 131 108 145 135 107 92 127 127 11.5 10.7 10.7 10.4 10.6 10.8 11.1 10.1 10.5 10.9 9.6 12.3 11.0 11.8 11.2 11.7 11.1 12.0 11.1 12.0 11.6 9.2 10.0 10.0 8.7 9.1 8.4 10.3 9.8 8.1 7.6 9.8 10.2 1,839 1,825 1,864 2,088 2,109 2,110 1,946 1,886 1,889 1,916 1,918 1,262 1,222 1,276 1,354 1,439 1,357 1,249 1,240 1,276 1,251 1,263 577 603 588 734 670 753 697 644 613 665 655 54.5 53.0 52.0 53.0 55.6 55.9 54.6 53.6 55.0 55.1 54.5 55.2 53.3 54.6 54.2 57.5 57.3 57.1 56.3 57.2 57.4 55.6 52.8 52.3 47.2 50.8 51.9 53.5 50.6 49.0 50.9 51.2 52.5 VLBW1 n % 1,120 1,090 1,114 1,109 1,115 1,148 1,098 1,041 1,053 1,006 1,014 849 808 852 816 833 828 814 779 801 744 735 271 282 262 292 282 319 284 258 252 262 279 1.4 1.4 1.4 1.4 1.4 1.5 1.4 1.3 1.4 1.3 1.4 1.3 1.3 1.4 1.3 1.3 1.4 1.4 1.3 1.3 1.3 1.3 1.6 1.6 1.5 1.6 1.5 1.7 1.6 1.4 1.4 1.5 1.7 LBW2 n % 5,708 5,711 5,795 6,060 6,115 6,125 6,072 6,150 6,147 5,955 5,804 4,344 4,318 4,423 4,483 4,600 4,485 4,447 4,582 4,593 4,385 4,356 1,364 1,393 1,372 1,576 1,514 1,639 1,624 1,563 1,554 1,570 1,447 7.1 7.1 7.2 7.5 7.6 7.8 7.9 7.9 7.9 7.8 7.8 6.8 6.9 7.0 7.2 7.5 7.5 7.6 7.7 7.6 7.4 7.5 8.2 8.1 7.7 8.6 8.3 8.9 8.9 8.6 8.8 8.9 8.7

Ages < 35

34
Ages 35+

NOTE: Very Low Birthweight (VLBW) births are a subset of Low Birthweight (LBW) births. All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. Very Low Birthweight (VLBW): less than 1,500 grams (3.3 lbs.). 2. Low Birthweight (LBW): less than 2,500 grams (5.5 lbs.).

34

Table 10. Births by Gestational Age, Race/Hispanic Ethnicity, Massachusetts: 2009

Gestational Age (weeks completed) State Total <20 20-23 24-27 28-31 32-33 34-36 37-38 39 40 41 42 43 44+ Preterm5 (<37) Very Early6 (<28) (28-33) Late (34-36) Term ( >=37 ) Early Term (37-38) (39-41) (>=42) Unknown7
1

Total n
74,544 13 144 330 620 807 4,602 15,515 22,380 22,099 7,561 459 13 1 6,516 487 1,427 4,602 68,028 15,515 52,040 473 422

White nonHispanic n
49,464 8 61 189 396 546 3,009 9,960 15,030 14,666 5,272 317 9 1 4,209 258 942 3,009 45,255 9,960 34,968 327 295

Black nonHispanic n
6,937 2 23 54 91 84 471 1,545 1,880 2,112 624 48 3 0 725 79 175 471 6,212 1,545 4,616 51 8

Hispanic n
2 37 56 94 107 719 2,322 3,218 3,237 1,089 59 0 0 1,015 95 201 719 9,925 2,322 7,544 59 46

Asian n
0 14 24 23 53 321 1,408 1,892 1,729 437 26 1 0 435 38 76 321 5,493 1,408 4,058 27 11

Other3 n
1 3 7 16 14 70 255 327 321 130 7 0 0 111 11 30 70 1,040 255 778 7 7

Unknown

%2
100.0 0.0 0.2 0.4 0.8 1.1 6.2 20.8 30.0 29.6 10.1 0.6 0.0 --4 8.7 0.7 1.9 6.2 91.3 20.8 69.8 0.6

%2
100.0 0.0 0.1 0.4 0.8 1.1 6.1 20.1 30.4 29.6 10.7 0.6 0.0 --4 8.5 0.5 1.9 6.1 91.5 20.1 70.7 0.7

%2
100.0 --4 0.3 0.8 1.3 1.2 6.8 22.3 27.1 30.4 9.0 0.7 --4 0.0 10.5 1.1 2.5 6.8 89.5 22.3 66.5 0.7

%2
--4 0.3 0.5 0.9 1.0 6.6 21.2 29.4 29.6 10.0 0.5 0.0 0.0 9.3 0.9 1.8 6.6 90.7 21.2 69.0 0.5

%2
0.0 0.2 0.4 0.4 0.9 5.4 23.8 31.9 29.2 7.4 0.4 --4 0.0 7.3 0.6 1.3 5.4 92.7 23.8 68.5 0.5

%2
--4 --4 0.6 1.4 1.2 6.1 22.2 28.4 27.9 11.3 0.6 0.0 0.0 9.6 1.0 2.6 6.1 90.4 22.2 67.6 0.6

n
124 0 6 0 0 3 12 25 33 34 9 2 0 0 21 6 3 12 103 25 76 2 55

10,940 100.0

5,928 100.0

1,151 100.0

35

NOTE: Percentages are calculated based on births with known gestational age only. 1. A clinical estimate of the number of weeks of pregnancy completed; as estimated by the attendant at birth or the postnatal physician. 2. Percentages are based on column total. 3. Other races include American Indian and others not specified. 4. Calculations based on values of 1-4 are excluded. 5. Also known as early gestational age, premature delivery, or preterm delivery. 6. Also known as extremely premature delivery, or extremely preterm delivery. 7. Estimate of gestational age not provided and excluded from percentage calculations.

35

Figure 3. Percent of Mothers who Reported Smoking during Pregnancy Massachusetts: 1990-2009
25% 19.3% 20% Percent of Mothers

15%

10%

6.8%

5%

0%
19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09

Year
Note: Smoking information provided on the birth certificate as reported by the mother. Due to self-reported nature, data on smoking prevalence should be interpreted cautiously.

Figure 4. Percent of Mothers who Reported Smoking during Pregnancy by Mothers Race/Hispanic Ethnicity, Massachusetts: 2009
25%

20%

Percent of Mothers

15%

10%

8.1% 5.3% 5.0% 1.6%

6.8%

5%

0% White nonHispanic Black non-Hispanic Hispanic Asian Total

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. Asian data should be interpreted with caution because of small numbers. Smoking information is provided on the birth certificate as reported by the mother. Due to selfreported nature, data on smoking prevalence should be interpreted cautiously.

36

Figure 5. Trends in Adequacy of Prenatal Care by Race and Hispanic Ethnicity, Massachusetts: 1996-2009

90 88.2

White non-Hispanic
86.8

Percent of Live Births with Adequate Prenatal Care

85.9 85

85.2 84.3 84.6

83.3

Massachusetts
83.0

84.2

Asian

82.1

80 79.3

79.0 79.3

79.2

Hispanic
76.6 76.0 76.5 76.1 75 74.2 76.0

Black nonHispanic

72.2

70 1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Year

PLEASE NOTE THAT FOR PURPOSES OF VISUAL REPRESENTATION THE VERTICAL SCALE OF GRAPH REPRESENTS A SMALL INTERVAL (from 70% to 90%). 1. All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. Please note that the Adequacy of Prenatal Care Utilization (APNCU) Index is an assessment of the timing and number of prenatal care visits and not an evaluation of the quality of care delivered.

37

Figure 6. Adequacy of Prenatal Care by Selected Maternal Characteristics, Massachusetts: 2009

Younger Teens (<18 yrs) Education (< 12 yrs) Smokers Unmarried Non-U.S.-born First-time Mothers Breastfeeding Mothers Age 35+ More than College Multiple Births
4 2 1

69.1% 73.6% 74.2% 78.0% 81.5% 84.7% 85.2% 88.1% 89.6% 91.8%

State Total 0% 10% 20% 30% 40% 50% 60% 70% 80%

84.3% 90% 100%

Percent of Mothers with Adequate Prenatal Care

NOTE: All percentages are calculated based on the Adequacy of Prenatal Care Utilization (APNCU) Index. Characteristics of interest are not mutually exclusive, except as noted. 1. Women 20 years of age and older. 2. Marital status at time of birth. 3. Non-US-born includes women born outside of the 50 U.S. states, District of Columbia, and U.S. territories (Puerto Rico, U.S. Virgin Islands, Guam). 4. Mother was breastfeeding or was intending to breastfeed at the time the birth certificate was completed.

38

Figure 7. Distribution of Prenatal Care Payment Source, Massachusetts: 2009

Other 0.7%

Self-Paid 0.5%

Public 36.1%

Private 62.7%

NOTE: Sources of Prenatal Care Payment are private: Commercial indemnity plan, commercial managed care

(HMO, PPO, IPP, IPA, and other), or other private insurance; public: Government programs including Commonhealth, Healthy Start, Medicaid/MassHealth, and Medicare (may also be HMO or managed care), or free care; other: Worker's Compensation and other sources.

39

Table 11. Trends in Infant, Neonatal, and Post Neonatal Mortality by Race/Hispanic Ethnicity, Massachusetts: 1991-2009 INFANT MORTALITY (less than one year of age) White nonBlack nonHispanic Hispanic Hispanic 3 3 n Rate n Rate n Rate3 381 5.5 101 15.0 80 9.4 371 5.5 110 16.4 67 7.9 346 5.3 84 13.1 77 9.3 343 5.3 79 12.6 64 7.6 275 4.4 65 11.1 58 7.2 289 4.7 63 11.4 40 5.1 294 4.8 64 11.7 55 6.7 287 4.6 59 10.6 58 6.7 285 4.7 72 12.3 49 5.5 232 3.8 74 12.8 48 5.2 245 4.1 71 12.1 69 7.3 239 4.1 69 11.6 67 7.0 235 4.1 75 12.7 55 5.6 210 3.8 70 11.5 75 7.6 230 4.3 57 9.4 78 7.7 221 4.2 72 11.1 62 5.8 206 3.9 66 10.2 81 7.4 194 3.7 78 11.7 86 7.9 198 4.0 53 7.6 77 7.0 NEONATAL MORTALITY (birth to 27 days) White nonBlack nonHispanic Hispanic Hispanic n Rate3 n Rate3 n Rate3 266 3.9 72 10.7 53 6.2 274 4.0 76 11.4 51 6.0 245 3.7 64 10.0 55 6.7 240 3.7 58 9.3 40 4.7 198 3.1 50 8.5 39 4.8 222 3.6 34 6.2 27 3.5 228 3.7 44 8.0 43 5.2 218 3.5 47 8.5 43 5.0 226 3.7 58 9.9 39 4.4 177 2.9 57 9.9 37 4.0 190 3.2 56 9.5 49 5.2 185 3.2 49 8.2 50 5.2 179 3.1 56 9.5 38 3.9 167 3.0 51 8.4 57 5.8 168 3.1 40 6.6 57 5.8 173 3.3 53 8.2 42 3.9 141 2.7 48 7.4 53 4.9 153 3.0 57 8.6 65 6.0 155 3.1 35 5.0 53 4.8

State Total1 Year 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 n 577 569 523 499 419 403 425 414 418 377 407 397 383 376 391 369 380 382 354 Rate3 6.5 6.5 6.2 6.0 5.1 5.0 5.3 5.1 5.2 4.6 5.0 4.9 4.8 4.8 5.1 4.8 4.9 5.0 4.7

Asian n 14 16 13 8 19 8 10 10 8 19 15 16 14 15 18 10 18 16 19 Rate3 4.2 4.9 3.9 2.4 5.5 2.2 2.6 2.7 1.9 4.1 3.1 3.0 2.7 2.7 3.4 1.8 3.1 2.7 3.2 n 1 5 3 5 2 2 2 0 4 4 7 6 4 6 8 3 4 8 6

Other2 Rate3 --4 5.1 --4 5.3 --4 --4 --4 0.0 --4 --4 4.1 3.8 --4 3.5 4.3 --4 --4 5.1 5.2

State Total1 Year 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 n 401 415 375 349 298 290 323 315 332 288 308 299 285 291 282 279 263 291 266 Rate3 4.5 4.8 4.4 4.2 3.6 3.6 4.0 3.9 4.1 3.5 3.8 3.7 3.6 3.7 3.7 3.6 3.4 3.8 3.5

Asian n 10 10 9 7 10 5 7 7 5 14 10 13 10 12 11 7 15 10 17 Rate3 3.0 3.0 2.7 2.1 2.9 1.4 1.8 1.9 1.2 3.0 2.1 2.4 1.9 2.2 2.1 1.3 2.6 1.7 2.9 n 0 4 2 4 1 1 1 0 4 3 3 2 2 4 5 3 4 6 5

Other2 Rate3 0.0 --4 --4 --4 --4 --4 --4 0.0 --4 --4 --4 --4 --4 --4 2.7 --4 --4 3.8 4.3

40

Table 11 (contd). Trends in Infant, Neonatal, and Post Neonatal Mortality by Race/ Hispanic Ethnicity, Massachusetts: 1991-2009
POST NEONATAL MORTALITY (28-364 days) White nonBlack nonHispanic Hispanic Hispanic 3 3 n Rate n Rate n Rate3 115 97 101 103 77 67 66 69 59 55 55 54 56 43 62 48 65 41 43 1.7 1.4 1.5 1.6 1.2 1.1 1.1 1.1 1.0 0.9 0.9 0.9 1.0 0.8 1.2 0.9 1.2 0.8 0.9 29 34 20 21 15 29 20 12 14 17 15 20 19 19 17 19 18 21 18 4.3 5.1 3.1 3.3 2.6 5.3 3.7 2.2 2.4 2.9 2.6 3.4 3.2 3.1 2.8 2.9 2.8 3.2 2.6 27 16 22 24 19 13 12 15 10 11 20 17 17 18 20 20 28 21 24 3.2 1.9 2.7 2.8 2.3 1.7 1.5 1.7 1.1 1.2 2.1 1.8 1.7 1.8 2.0 1.9 2.6 1.9 2.2

State Total Year 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 n 176 154 148 150 121 113 102 99 86 89 99 98 98 85 109 90 117 91 88

Asian n 4 6 4 1 9 3 3 3 3 5 5 3 4 3 7 3 3 6 2 Rate3 --4 1.8 --4 --4 2.6 --4 --4 --4 --4 1.1 1.0 --4 --4 --4 1.3 --4 --4 1.0 --4 n 1 1 1 1 1 1 1 0 0 1 4 4 2 2 3 0 3 2 1

Other2 Rate3 --4 --4 --4 --4 --4 --4 --4 0.0 0.0 --4 --4 --4 --4 --4 --4 0.0 --4 --4 --4

Rate3 2.0 1.8 1.7 1.8 1.5 1.4 1.3 1.2 1.1 1.1 1.2 1.2 1.2 1.1 1.4 1.2 1.5 1.2 1.2

Note that infant deaths are based on a preliminary death file as of the release of this report. 1. Deaths of infants of unknown race are included in the total calculation. For rate computations, births of infants of unknown race are allocated into the race categories according to the distribution of births of known race. 2. Other: American Indian and Other races. 3. Rates are expressed per 1,000 live births. 4. Calculations based on values of 1-4 are excluded.

41

Figure 8. Infant Mortality Rates by Race/Hispanic Ethnicity, Massachusetts: 2009

15

Infant Deaths per 1,000 Live Births

10 7.6

7.0

4.7 4.0 3.2

State

White Non- Black NonHispanic Hispanic

Hispanic

Asian

42

Table 12. Resident Birth Characteristics, 30 Largest Municipalities, Massachusetts: 2009

Mother's Race and Ethnicity White Municipality Rank Population Crude (by pop. Birth nonsize) Rate2 Hispanic %3
STATE TOTAL Attleboro Barnstable Boston Brockton Brookline Cambridge Chicopee Fall River Framingham Haverhill Lawrence Leominster Lowell Lynn Malden Medford Methuen New Bedford Newton Peabody Pittsfield Plymouth Quincy Revere Somerville Springfield Taunton Waltham Weymouth Worcester 29 25 1 6 18 5 21 9 14 15 12 30 4 8 17 22 27 7 11 24 28 20 10 26 13 3 19 16 23 2 6,593,587 43364 47902 558435 100366 56422 101529 54599 92117 65651 60032 81591 42120 105749 92186 56730 53801 44532 94502 83346 50954 43949 54781 90458 45551 75372 156358 56348 59564 53708 179839 11.4 13.1 8.7 14.3 14.7 12.0 12.5 11.8 13.0 14.9 14.9 17.5 12.5 16.4 16.3 17.2 12.8 12.9 14.4 9.7 9.6 11.8 11.5 14.0 15.6 13.3 15.6 13.2 13.7 11.6 14.4 66.4 78.1 82.0 40.5 32.8 70.0 54.7 68.9 77.6 64.7 71.7 13.2 68.0 43.0 32.2 45.8 69.6 63.1 59.2 73.4 81.1 79.7 92.8 55.0 50.0 58.8 23.2 79.6 51.9 82.5 59.0
1

Birth weight Gestational

(<2500 g) (<1500 g)

Black Hispanic Asian nonor Hispanic Other4 %3 %3 %3

9.3 3.2 4.3 27.6 53.0 2.1 14.6 4.2 6.0 8.0 3.2 2.7 5.3 7.6 14.8 18.3 12.7 2.3 12.0 2.9 2.9 6.8 2.1 7.2 5.1 8.8 20.2 9.0 8.3 5.9 14.4 14.7 7.1 7.0 22.0 9.7 4.6 7.0 23.8 11.1 17.2 20.3 81.3 20.1 19.8 42.7 8.2 5.1 27.0 25.0 4.7 9.7 7.1 2.2 5.5 34.0 16.9 51.7 6.9 20.4 2.9 18.9 9.5 11.1 6.7 9.9 4.3 23.1 23.4 3.0 5.3 10.0 4.2 2.7 6.6 29.4 9.9 27.6 12.4 7.3 3.7 18.9 6.4 6.0 2.9 32.1 11.0 15.0 4.8 4.2 19.1 8.7 7.7

Very Low %
1.4 1.8 2.4 1.7 1.8 0.7 1.3 0.9 1.7 1.5 1.1 1.8 0.9 1.8 1.3 1.2 1.0 1.4 1.8 1.1 2.0 1.2 0.8 0.9
--5

Low %
7.8 9.2 7.2 8.9 8.5 8.7 8.1 7.6 8.6 7.8 5.6 8.4 7.4 10.3 7.2 8.6 7.4 9.8 10.5 7.6 7.1 8.5 5.9 6.6 7.2 8.3 9.0 8.1 10.1 6.9 8.7

Diabetes %
4.7 3.0
--5

1.2 2.3 1.3 2.7 1.1 1.7

4.0 4.6 4.5 4.6 4.8 8.6 4.5 3.0 4.4 4.9 8.1 3.8 4.8 3.2 4.5 4.2 4.7 4.9 3.9 1.0 6.3 5.6 4.3 5.4 4.0 6.1 6.6 6.5

43

Table 12 (contd). Resident Birth Characteristics, 30 Largest Municipalities, Massachusetts: 2009

Birth Municipality1 Adequate Teen Mothers Public Payment Prenatal Care6 for Prenatal Care Unmarried 15 to 19 years %
STATE TOTAL Attleboro Barnstable Boston Brockton Brookline Cambridge Chicopee Fall River Framingham Haverhill Lawrence Leominster Lowell Lynn Malden Medford Methuen New Bedford Newton Peabody Pittsfield Plymouth Quincy Revere Somerville Springfield Taunton Waltham Weymouth Worcester 84.3 85.9 84.4 85.9 73.0 89.9 86.7 79.4 85.8 91.3 84.6 73.8 84.2 79.5 82.7 84.2 86.5 81.2 76.9 90.2 91.0 67.8 89.3 89.8 83.2 85.5 72.1 77.0 85.0 90.2 73.3
7

b) Infant Mortality Rate9

Deaths Neonatal Mortality Rate9

%
36.1 19.3 52.4 42.3 65.4 5.3 18.2 56.9 69.8 44.5 40.4 75.5 40.8 58.0 67.2 41.6 26.2 36.7 58.0 8.5 34.2 60.0 26.1 33.1 55.8 36.1 74.5 40.6 29.0 26.2 48.1

%
34.7 29.6 36.7 44.2 57.4 5.2 15.3 54.8 61.4 30.4 42.3 70.7 41.3 55.0 56.9 26.9 21.3 37.1 63.5 7.5 28.3 58.4 27.2 25.1 40.0 29.2 72.4 47.4 23.6 27.6 48.6

n Rate8
4,477 39 21 521 137 2 16 72 129 50 70 239 41 210 172 24 11 40 173 4 16 70 20 23 56 40 438 70 22 10 219 19.5 34.4 15.4 26.4 37.7 --5 4.1 41.4 45.6 25.6 36.7 79.0 32.7 53.0 55.8 16.8 6.2 30.1 58.5 --5 11.2 55.1 12.0 11.1 53.2 18.4 72.1 42.9 9.4 6.9 31.1

2009 2007-2009 2009 2007-2009

4.7
--5 --5

4.9
--5

3.6
--5 --5

3.6
--5 --5

6.5 6.8 0.0 6.3

--5

6.7 6.7 8.0

--5

4.2 5.1
--5 --5

7.0 5.8 4.7

--5 --5 --5

3.7

--5 --5 --5 --5

3.5 4.8 8.2 3.3 4.4 5.9 3.2 6.6 5.7 3.9 2.4 2.9 7.0 2.0 5.3 5.0
--5

4.9 4.1 0.0 5.5

--5 --5 --5 --5

4.9 5.4
--5

4.2
--5 --5 --5 --5 --5 --5 --5 --5 --5

2.7 3.2 6.3 2.6 3.7 4.3

--5

3.5

4.7 4.0 3.5

--5 --5

0.0
--5 --5

4.8
--5

6.0 5.3
--5 --5 --5

3.9

4.8 5.3 6.2 8.1 7.2 2.1 2.5 7.7

6.0 3.7
--5 --5 --5

5.3 2.0 3.3 3.8 0.0 2.9 3.5 5.1 5.9 2.7
--5 --5

2.7

5.5

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. The 30 largest municipalities are the cities/ towns in Massachusetts with the largest populations (See Technical Notes). 2. Crude birth rates represent the number of births per 1,000 residents (male and female). 3. For the category of Mothers Race and Ethnicity, percentages are calculated based on the state total of resident births, including births for which mothers race/Hispanic ethnicity is unknown. 4. Mothers who designated themselves as Asian, American Indian, or Other. 5. Calculations based on 1-4 events are excluded. 6. Based on the Adequacy of Prenatal Care Utilization (APNCU) Index. Please see Glossary for definition. 7. Public payment sources include CommonHealth, Healthy Start, Medicaid/MassHealth, and Medicare (may be HMO or managed care), or free care. 8. Births per 1,000 female residents ages 15-19; rates for cities and towns were calculated using MDPH population estimates for 2005, which are the most up-to-date information available on the number of persons by age, race, and sex at the sub-state level. 9. Deaths per 1,000 live births. See Definitions of Rates section in the Glossary for definitions of infant and neonatal mortality rates.

44

Table 13. Birth Characteristics by Licensed Maternity Facility, Massachusetts: 2009

(2) (3) (4) (5) (6)

Facility

(1)

Occurrence Births Location

Low Birth weight

Public Pay for PNC

Adequate Prenatal Care

State Total Anna Jaques Hospital Baystate Franklin Medical Center Baystate Mary Lane Hospital Baystate Medical Center Berkshire Medical Center Beth Israel Deaconess Medical Center Beverly Hospital Boston Medical Center Brigham And Womens Hospital Brockton Hospital Cambridge Birth Center Cambridge Hospital Cape Cod Hospital Caritas Good Samaritan Medical Center Caritas Holy Family Hospital And Medical Center Caritas Norwood Hospital Caritas St. Elizabeths Medical Center Of Boston Charlton Memorial Hospital Cooley Dickinson Hospital Emerson Hospital Fairview Hospital Falmouth Hospital Harrington Memorial Hospital Heywood Memorial Hospital Holyoke Hospital Jordan Hospital Lawrence General Hospital Newburyport Greenfield Ware Springfield Pittsfield Boston Beverly Boston Boston Brockton Cambridge Cambridge Barnstable Brockton Methuen Norwood Boston Fall River Northampton Concord Great Barrington Falmouth Southbridge Gardner Holyoke Plymouth Lawrence

(n) 75,443 735 487 154 4,314 648 4,792 2,173 2,411 8,144 1,192 117 1,317 899 891 1,015 509 957 1,591 773 1,133 166 546 339 503 529 676 1,602

(%) 7.7 3.5 2.7 6.5 12.4 4.8 11.5 5.3 10.0 11.0 6.8 0.0 2.6 5.3 5.7 5.6 4.1 14.9 5.9 3.2 4.7 1.2 4.2 3.2 3.4 4.5 4.9 5.9

(%) 35.6 32.8 50.3 55.6 52.9 54.7 19.1 34.3 77.9 20.7 68.8 12.8 68.5 51.2 62.1 39.4 25.6 23.1 56.3 28.2 8.0 49.4 41.8 55.9 46.5 72.9 34.2 69.0

(%) 84.4 85.3 80.7 85.6 78.1 66.0 86.1 92.4 69.6 95.1 79.4 76.1 78.9 85.0 63.7 78.4 58.3 62.5 88.1 93.3 84.1 87.9 89.5 90.0 80.6 74.2 86.1 76.8

Early Term (%)

Cesarean Deliveries

20.8 15.2 17.5 20.8 24.1 19.3 23.4 24.6 25.5 14.2 22.8 17.1 22.0 16.1 22.4 22.0 25.7 23.8 17.8 15.9 25.9 19.9 22.7 17.4 16.9 9.8 19.0 21.7

(%) 33.7 34.4 21.1 29.9 32.5 29.6 38.7 34.8 29.8 34.8 45.1 0.0 25.9 33.9 39.1 40.9 38.9 39.9 37.4 30.4 35.6 28.3 40.0 30.1 15.3 18.2 33.7 32.6

45

Table 13 (contd). Birth Characteristics by Maternity Facility, Massachusetts: 2009

(2) (3) (4) (5) (6)

Facility

(1)

Occurrence Births Location

Low Birth weight

Public Pay for PNC

Adequate Prenatal Care

Leominster Hospital Lowell General Hospital Marthas Vineyard Hospital Massachusetts General Hospital Melrose-Wakefield Hospital Mercy Medical Center Metrowest Medical Center-Framingham Union Campus Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Cottage Hospital Newton Wellesley Hospital North Adams Regional Hospital North Shore Birth Center North Shore Medical Center - Salem Hospital Saint Vincent Hospital South Shore Hospital St. Lukes Hospital Sturdy Memorial Hospital Tobey Hospital Tufts Medical Center UMass Memorial Medical Center West Campus Winchester Hospital Other Hospitals Home, Enroute & Dr. Off.

Leominster Lowell Oak Bluffs Boston Melrose Springfield Framingham Milford Taunton Cambridge Nantucket Newton North Adams Beverly Salem Worcester Weymouth New Bedford Attleboro Wareham Boston Worcester Winchester

(n) 1,099 2,391 149 3,601 1,212 1,258 1,522 982 576 2,084 123 3,512 273 106 1,594 1,967 3,558 1,501 880 493 1,228 4,242 2,116 4 359

(%) 3.7 6.5 1.3 10.2 5.1 3.6 5.0 3.4 4.2 4.1 0.8 4.2 4.4 0.0 4.4 4.2 5.5 7.6 3.5 3.0 27.7 11.8 6.3
--7

(%) 50.3 48.7 51.7 28.6 29.0 60.9 43.3 30.5 40.6 18.5 50.8 4.0 54.2 22.6 51.9 24.6 19.5 50.9 14.1 40.7 43.5 35.5 5.8
--7

(%) 85.0 82.2 95.3 89.2 90.1 79.8 94.2 91.9 71.1 88.7 71.9 89.3 90.8 96.2 84.6 86.9 93.8 74.9 84.2 85.9 89.0 71.7 86.7
--7

Early Term (%)

Cesarean Deliveries

16.3 25.2 20.8 20.4 18.5 24.1 19.5 29.4 25.0 16.6 18.7 21.1 21.2 16.0 23.0 22.3 21.1 25.7 19.1 14.6 23.3 19.2 23.9
--7

(%) 25.7 34.1 32.2 31.2 40.5 25.1 42.8 38.0 29.9 23.5 29.3 37.8 26.7 0.0 34.4 26.2 42.1 37.6 34.2 22.1 39.4 29.3 35.5
--7

9.4

21.3

65.1

14.2

0.3

NOTES: All percentages are calculated based on only those occurrence births with known values for the characteristic(s) of interest. 1. A licensed maternity facility is a medical unit licensed by the Commonwealth for the care of women during pregnancy and childbirth. 2. See Glossary for definition of occurrence births. 3. Less than 2,500 grams (5.5 lbs.) 4. Public payment for prenatal care (PNC) includes Medicaid/MassHealth, CommonHealth, Medicare, Healthy Start, other government programs, and free care. 5. Based on the APNCU Index. 6. Birth at 37 or 38 week of gestation. 7. Calculations based on 1-4 events are excluded.

46

Table 14. Comparison of Massachusetts Perinatal Health Indicators with Healthy People 2020 Objectives, Massachusetts: 2006-2009
Healthy People 2020 Objectives1 (Focus Area: Maternal, Infant and Child Health MICH2) Massachusetts HP2020 Target Has Massachusetts achieved HP2020 target? = YES = NO, but within 25% of target = NO, > 25% from target

2006

2007

2008

2009

Fetal, Infant, and Maternal Deaths

MICH-1.1. Fetal Mortality Rate3 MICH-1.2. Perinatal Mortality Rate4 MICH-1.3. Infant Mortality Rate5 MICH-1.4. Neonatal Mortality Rate6 MICH-1.5. Postneonatal Mortality Rate7 MICH-5. Maternal Mortality Ratio8 5.6 5.9 6.0 4.1 2.0 11.4 5.0 5.7 4.8 3.6 1.2 8.9 5.1 5.2 4.9 3.4 1.5 8.9 5.0 5.6 5.0 3.8 1.2 10.3 5.0 5.5 4.7 3.5 1.2

4.0

Risk Factors
MICH-8.1. Low Birthweight9 (%) MICH-8.2. Very Low Birthweight MICH-9.1. Preterm (%)
11 10

7.8 (%) 1.4 11.4

7.9 1.3 9.0

7.9 1.4 9.0

7.8 1.3 8.8

7.8 1.4 8.7

Prenatal Care
MICH-10.1. Care beginning in first trimester (%) MICH-10.2. Early and adequate care12 (%) 77.9 77.6 82.1 83.1 82.0 82.8 81.0 82.1 82.6 84.3

Obstetrical Care
MICH-33. Very Low Birthweight10 Infants 13 born at Level III Hospitals (%) MICH-7.1. Cesarean Sections: Low-Risk14 Women Giving Birth for the First Time (%) MICH-7.2. Cesarean Sections: Low-Risk14 Women with Prior Cesarean Section (%) 82.5 23.9 81.7 76.8 28.5 91.3 81.1 29.3 91.1 76.2 29.6 91.1 81.1 28.3 90.4

O O O

Breastfeeding
MICH-21.1. Breastfeeding15 (%) 81.9 79.9 79.2 80.8 82.0

Prenatal Substance Exposure

MICH-11.3. Abstinence from Smoking15 (%) 98.6 92.6 92.5 93.1 93.2

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. National health promotion and disease prevention agenda established by the US Dept. of Health and Human Services. 2. Goal: to improve the health and well-being of women, infants, children, and families. 3. Number of fetal deaths per 1,000 fetal deaths plus live births. 4. Number of fetal and infant deaths in perinatal period (from 28 weeks gestation (inclusive) to 6 days (inclusive) after birth per 1,000 fetal deaths plus live births. 5. Number of infant deaths (under one year of age) per 1,000 live births. 6. Number of deaths to infants less than 28 days of age per 1,000 live births. 7. Number of deaths to infants 28-364 days of age per 1,000 live births. 8. See Definition of Rates section in Technical Notes. 9. Less than 2,500 grams, or 5.5 pounds. 10. Less than 1,500 grams, or 3.3 pounds. 11. Born before completion of 37th week of gestation. 12. Based on Adequacy of Prenatal Care Utilization Index (see Glossary). 13. Facilities for high-risk deliveries and neonates that can provide care to very small infants, including mechanical ventilation and neonatal surgery and special care for transferred patients and for which a full-time neonatologist serves as the director. 14. Low-risk= full term birth, singleton, vertex presentation. 15. HP2020 specifies objective as mother ever breastfeeding. Massachusetts data is based on mothers self-report of current breastfeeding or intention to breastfeed, and of smoking during pregnancy.

47

48

Appendix:
Additional Tables & Figures Technical Notes Glossary

49

50

Table 15. Resident Birth Characteristics, Community Health Network Areas (CHNAs), Massachusetts: 2009
Crude Birth Rate2 Mother's Race and Ethnicity White Black Asian nonnonand Hispanic Hispanic Hispanic Other3 %4
STATE TOTAL Community Health Network of Berkshire County Upper Valley Health Web (Franklin County) Partnership for Health in Hampshire County (Northampton) The Community Health Connection (Springfield) Community Health Network of Southern Worcester County Community Partners for Health (Milford) Community Health Network of Greater Metro West (Framingham) Community Wellness Coalition (Worcester) Fitchburg/Gardner Community Health Network Greater Lowell Community Health Network Greater Lawrence Community Health Network Greater Haverhill Community Health Network Community Health Network North (Beverly/Gloucester) North Shore Community Health Network Greater Woburn/Concord/Littleton Community Health Network North Suburban Health Alliance (Medford/Malden/Melrose) Greater Cambridge/Somerville Community Health Network West Suburban Health Network (Newton/Waltham) Alliance for Community Health (Boston/Chelsea/Revere/Winthrop) Blue Hills Community Health Alliance (Greater Quincy) Four (For) Communities (Holyoke, Chicopee, Ludlow, Westfield) Greater Brockton Community Health Network South Shore Community Partners in Prevention (Plymouth) Greater Attleboro-Taunton Health & Education Response Partners for a Healthier Community (Fall River) Greater New Bedford Health & Human Services Coalition Cape and Islands Community Health Network 6,593,587 131,965 88,506 151,801 299,490 119,141 160,521 379,658 303,669 261,369 272,893 195,176 148,557 119,378 287,352 209,597 257,235 273,883 253,138 711,603 372,309 161,454 242,404 188,787 252,919 141,977 199,955 252,204 11.4 8.6 9.2 7.1 12.3 11.2 11.4 11.4 12.7 10.7 12.5 13.5 11.6 9.3 11.8 10.2 13.7 13.2 10.4 14.4 11.5 12.0 11.7 10.2 11.1 11.1 11.0 8.4 66.4 84.9 90.3 81.2 44.0 87.4 91.0 77.4 66.1 79.4 61.8 41.0 81.6 87.7 59.1 73.3 65.7 64.3 71.0 42.2 69.0 61.1 58.0 93.7 84.9 82.0 71.6 84.8

CHNA1

Population

%4
9.3 4.0 1.3 2.4 14.3 1.5 1.1 3.1 10.2 3.0 4.9 2.2 1.9 1.6 8.3 3.5 11.7 8.7 4.4 22.7 9.9 3.6 31.1 1.7 4.4 4.7 8.9 4.1

%4
14.7 5.6 3.7 6.6 36.6 8.8 3.8 8.0 13.3 12.8 12.0 50.8 11.5 3.9 25.0 4.4 8.3 8.6 9.3 24.7 4.2 32.5 6.3 1.9 4.3 8.7 16.1 5.8

%4
9.5 5.0 2.4 9.6 5.1 2.2 3.9 11.4 10.2 4.3 20.9 5.9 4.2 5.4 7.3 18.6 14.3 18.0 15.2 10.3 16.8 2.7 4.3 2.4 6.1 4.5 3.2 5.1

(<1500 g) (<2500)

Very Low BWT %

Low BWT %

GDM

%
4.7 3.5 3.6 3.8 5.6 6.8 4.2 4.4 6.0 5.0 6.9 4.3 3.7 6.1 3.7 5.2 4.2 4.2 4.8 4.2 5.3 4.8 4.9 2.7 3.3 7.7 4.9 1.5

1.4 1.0 2.1 0.9 2.0 1.3 1.3 1.3 1.5 1.2 1.4 1.5 1.3
--5

7.8 7.2 7.7 7.3 8.5 7.9 6.8 7.0 8.3 6.7 8.3 8.4 5.8 5.3 7.3 7.3 7.7 7.7 7.8 8.9 7.5 8.8 8.1 5.6 7.8 8.2 9.0 7.2

51

1.5 1.0 1.1 1.1 1.5 1.5 1.1 1.4 1.1 1.0 1.6 1.5 1.6 1.6

51

Table 15 (contd) Resident Birth Characteristics, Community Health Network Areas (CHNAs), Massachusetts: 2009
Births CHNA1 Adequate Prenatal Care6 %
84.3 75.4 83.6 88.1 76.3 80.7 88.4 88.7 75.8 84.2 83.9 78.3 87.0 90.9 87.1 86.6 86.1 87.2 87.8 85.9 88.4 79.4 79.9 90.8 83.3 86.6 79.0 86.4

Deaths Infant Mortality Rate9 2009 2007-2009

4.7
--5

Public Teen Mothers Payment7 for Unmarried 15 to 19 years Prenatal Care % % n Rate8
36.1 54.4 44.3 30.3 61.0 32.9 22.0 21.7 36.4 34.7 37.0 51.2 30.3 22.6 45.2 10.9 31.2 20.3 14.1 42.6 24.1 58.3 46.0 22.7 25.9 62.9 47.3 44.6 34.7 49.8 39.4 28.3 58.1 39.9 21.3 18.1 37.9 36.2 38.2 49.7 32.5 22.5 39.7 13.9 23.5 17.0 12.7 42.2 21.9 54.1 42.2 24.0 31.7 54.6 54.8 36.0 4,477 122 62 54 505 93 67 120 243 190 263 290 103 32 225 38 90 67 37 662 80 242 183 56 172 143 228 110 19.5 27.2 21.9 6.4 48.3 23.9 13.2 11.4 22.6 21.7 29.4 43.7 22.6 8.2 25.7 6.8 12.6 8.2 3.6 28.0 7.7 42.4 20.8 9.5 22.2 33.0 35.0 16.8

Neonatal Mortality Rate9 2009 2007-2009

3.5
--5

i)

STATE TOTAL

4.9 3.9 7.7 4.5 6.1 4.9 2.1 4.6 5.9 5.0 4.4 5.3 4.0 2.1 5.1 3.1 3.7 3.8 1.7 6.0 5.0 5.3 5.7 3.5 5.6 7.2 6.2 4.3

3.6 2.5 6.1 3.4 4.4 3.4 1.4 4.0 4.4 3.8 3.0 3.9 3.1
--5

Community Health Network of Berkshire County Upper Valley Health Web (Franklin County) Partnership for Health in Hampshire County (Northampton) The Community Health Connection (Springfield) Community Health Network of Southern Worcester County Community Partners for Health (Milford) Community Health Network of Greater Metro West (Framingham) Community Wellness Coalition (Worcester) Fitchburg/Gardner Community Health Network Greater Lowell Community Health Network Greater Lawrence Community Health Network Greater Haverhill Community Health Network Community Health Network North (Beverly/Gloucester) North Shore Community Health Network Greater Woburn/Concord/Littleton Community Health Network North Suburban Health Alliance (Medford/Malden/Melrose) Greater Cambridge/Somerville Community Health Network West Suburban Health Network (Newton/Waltham) Alliance for Community Health (Boston/Chelsea/Revere/Winthrop) Blue Hills Community Health Alliance (Greater Quincy) Four (For) Communities (Holyoke, Chicopee, Ludlow, Westfield) Greater Brockton Community Health Network South Shore Community Partners in Prevention (Plymouth) Greater Attleboro-Taunton Health & Education Response Partners for a Healthier Community (Fall River) Greater New Bedford Health & Human Services Coalition Cape and Islands Community Health Network

13.4
--5

12.2
--5

4.1
--5

2.7
--5

3.8 6.5 3.6 4.3 4.4 6.1

--5 --5

3.3 5.1 2.9 3.6 2.9 3.8

--5

52

5.0 4.2 4.5 4.4

--5

0.0 3.5 4.2 4.0 3.9

--5

5.4 4.9 5.7 5.0 5.2 10.0 3.8 3.2 4.2

4.0 4.2 3.6 2.8 3.1 6.4

--5

2.7 2.3

3.6 2.8 3.1 3.1 1.5 4.4 3.6 3.6 4.0 1.8 3.5 5.4 4.7 2.7

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. Please see TableA1 for cities/ towns by CHNA. 2. Crude birth rates represent the number of births per 1,000 residents (male and female). 3. For the category of Mothers Race and Ethnicity, percentages are calculated based on the state total of resident births, including births for which mothers race/Hispanic ethnicity is unknown. 4. Mothers who designated themselves as Asian, American Indian, or Other. 5. Calculations based on 1-4 events are excluded. 6. Based on the Adequacy of Prenatal Care Utilization (APNCU) Index. Please see Glossary for definition. 7. Public payment sources include CommonHealth, Healthy Start, Medicaid/MassHealth, and Medicare (may be HMO or managed care), or free care. 8. Births per 1,000 female residents ages 15-19; rates for cities and towns were calculated using MDPH population estimates for 2005, which are the most up-to-date information available on the number of persons by age, race, and sex at the sub-state level. 9. Deaths per 1,000 live births. See Definitions of Rates section in the Glossary for definitions of infant and neonatal mortality rates.

52

Figure 9. Percent of Mothers Breastfeeding or Intending to Breastfeed by Age Group, Massachusetts: 2009

100%

90% 82.1% 80% 70.1% 70% 60.8% Percent of Mothers 60% 74.4%

85.8%

85.1%

86.3%

84.4%

82.0%

50%

40%

30%

20%

10%

0% 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+ Total Age Group of Mother (in years)

NOTE: Information about breastfeeding is reported by the mother at the time of the birth. For race-specific breastfeeding rates see Table 2.

53

Figure 10. Percent of Mothers who Reported Smoking during Pregnancy by Mothers Race/Hispanic Ethnicity and Educational Attainment, Massachusetts: 2009
Massachusetts Total
40% 30% 20% 10% 0%
TOTAL Less than High School High School Graduate Some College College or More

17.7% 12.2% 6.8% 7.9% 0.6%

White non-Hispanics
40% 30% 20% 10% 0%
TOTAL Less than High School High School Graduate Some College College or More

Black non-Hispanics
40% 30%

35.8%

17.4% 8.1% 10.0% 0.6%

20% 10% 0%
TOTAL

13.0% 5.3%
Less than High School

5.8%

3.8%
Some College

0.9%
College or More

High School Graduate

Hispanics
40% 30% 20% 10% 0%
TOTAL Less than High School High School Graduate Some College College or More

Asian non-Hispanics
40% 30% 20%

5.0%

7.4%

4.7%

3.5%

0.6%

10% 0%

9.0% 1.6%
TOTAL Less than High School

3.3%
High School Graduate

2.5%
Some College

0.1%
College or More

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. Smoking information provided on the birth certificate as reported by the mother. Because smoking is self-reported, data on smoking prevalence should be interpreted cautiously. Asian data should be interpreted with caution because of small numbers.

54

Figure 11. Distribution of Reported Smoking Status during Pregnancy by Smoking Status Prior to Pregnancy, Massachusetts: 2009 Reported Smoking Status1 Prior to Pregnancy: Reported Smoking Status1 During Pregnancy: 55
Still No Smo ke 99.9%

Non-Smokers 86.4% (64,717)

Light Smokers 8.4% (6,380)

Moderate Smokers 4.7% (3,287)

Heavy Smokers 0.5% (410)

Moderate Mod 13.2% Light 38.6%

Heavy 7.3% Q uit 16 .1%

Quit 31.4%

M od 2 3 .7 % Light 5 2 .9 %

Quit 61.1%

Light 55.3%

99.9% of Non-Smokers continued not smoking (0.1% started smoking)

61% of Light Smokers quit Smoking

87% of Moderate Smokers decreased the number of cigarettes smoked daily or quit

93% of Heavy Smokers decreased the number of cigarettes smoked daily or quit

1. Light Smokers=1-10 cigarettes daily; Moderate Smokers=11-20 cigarettes daily; Heavy Smokers=21 cigarettes or more daily.

55

Table 16. Parity by Age of Mother, Massachusetts: 2009

Age of Mother (years) Total Births Parity1 1st
34,004 45.8 50 98.0 3,855 86.6 7,101 59.4 9,039 49.4 9,236 40.3 3,792 28.4 860 28.7 67 31.8

2nd
25,481 34.3 1

3rd
9,943 13.4 0 0.0 55 1.2 1,030 8.6 2,259 12.3 3,261 14.2 2,724 20.4 587 19.6 27 12.8

4th
3,167 4.3 0 0.0 3

5th+
1,628 2.2 0 0.0 0 0.0 60 0.5 322 1.8 500 2.2 516 3.9 204 6.8 26 12.3

State Total

N2 %3 N2 %3 N2 %3 N2 %3 N2 %3 N2 %3 N2 %3 N2 %3 N2 %3

74,966 100.0 51 100.0 4,477 100.0 12,048 100.0 18,469 100.0 23,143 100.0 13,521 100.0 3,040 100.0 213 100.0

10-14

--

15-19

537 12.1 3,513 29.4 5,970 32.6 8,898 38.8 5,378 40.3 1,115 37.2 69 32.7

--

20-24

247 2.1 713 3.9 1,013 4.4 937 7.0 232 7.7 22 10.4

25-29

30-34

35-39

40-44

45+

1. The number of live births including this birth. 2. State totals include births of unknown parity and unknown mothers age. 3. Percents may not sum to 100.0 due to rounding. 4. Calculations based on values of 1-4 are excluded.

56

Table 17. Selected Birth Characteristics by Maternal Education, Massachusetts: 2009

Less than High School n
State Total Race White non-Hispanic Black non-Hispanic Hispanic Asian Age (years) 20-29 30-39 40+ Non-US-born2 Unmarried Publicly-financed prenatal care Very low birthweight Low birthweight
4 5 3

High School Graduate n

18,809

Some College n
15,823

College Graduate n
19,545

More than College n

12,772

%1
10.4

%1
25.2

%1
21.2

%1
26.1

%1
17.1

7,811

2,577 976 3,628 457

5.2 14.1 33.1 7.7

10,813 2,498 4,091 1,000

21.8 36.0 37.3 16.9

10,517 2,115 2,147 758

21.2 30.5 19.6 12.8

15,552 1,043 797 1,947

31.3 15.0 7.3 32.8

10,232 304 308 1,772

20.6 4.4 2.8 29.9

3,856 1,535 137 3,132 5,980 6,579 109 685 5,462 2,069 5,444 151 1,384

12.7 4.2 4.2 40.1 76.6 85.6 1.4 8.8 72.4 26.6 70.5 1.9 17.7

10,929 5,560 497 5,926 11,089 11,832 323 1,658 14,819 5,965 13,694 673 2,295

35.9 15.2 15.4 31.5 59.0 64.0 1.7 8.9 80.4 31.9 73.8 3.6 12.2

8,226 6,662 538 3,652 6,565 5,850 211 1,185 13,065 5,483 12,080 630 1,245

27.0 18.2 16.6 23.1 41.5 38.6 1.3 7.5 85.0 34.9 79.4 4.0 7.9

5,355 13,028 1,146 4,628 1,812 1,771 242 1,391 17,033 7,003 17,238 1,219 152

17.6 35.6 35.4 23.7 9.3 9.2 1.2 7.1 88.9 36.0 89.2 6.2 0.8

2,068 9,782 918 3,182 506 375 108 842 11,202 4,496 11,756 849 37

6.8 26.8 28.4 24.9 4.0 3.0 0.9 6.6 89.6 35.4 93.1 6.6 0.3

Adequate prenatal care Cesarean delivery Breastfeeding

6

Multiple births Smoking during pregnancy

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. For state total, race and age categories, percentages are based on row totals. For all other categories, percentages are based on state column totals. 2. Includes women born outside of the 50 US States, Washington D.C., and Puerto Rico/US territories (the US Virgin Islands, and Guam). 3. Very low birthweight: less than 1,500 grams or 3.3 pounds. 4. Low birthweight: less than 2,500 grams or 5.5 pounds. 5. Based on the Adequacy of Prenatal Care Utilization (APNCU) Index. Please see Glossary for definition. 6. Mother was breastfeeding or was intending to breastfeed at the time the birth certificate was completed.

57

Table 18. Inter-pregnancy Interval (IPI) and Birth Outcomes -- Pregnancies to Multiparous Mothers, Massachusetts: 2009

IPI1 (months)

Pregnancies to Multiparous2 Mothers

Birth Weight (BW) Low (<2,500 g) n %LBW Very Low (<1,500 g) n %VLBW

Gestational Age (GA) Preterm3 (<37 wk) n %Preterm Very Early4 (<28 wk) n %VEGA

State Total <6 6-11 12-17 18-23 24-29 30-35 36-41 42-47 48+

38,262 1,745 4,273 5,538 5,024 3,944 3,026 2,272 1,823 10,617

2,096 108 190 221 210 176 159 136 109 787

5.5% 6.2% 4.4% 4.0% 4.2% 4.5% 5.3% 6.0% 6.0% 7.4%

334 19 36 36 29 21 21 20 14 138

0.9% 1.1% 0.8% 0.7% 0.6% 0.5% 0.7% 0.9% 0.8% 1.3%

2,620 158 282 313 279 214 185 168 128 893

6.8% 9.1% 6.6% 5.7% 5.6% 5.4% 6.1% 7.4% 7.0% 8.4%

169 9 23 20 13 8 11 9 7 69

0.4% 0.5% 0.5% 0.4% 0.3% 0.2% 0.4% 0.4% 0.4% 0.6%

Short

0-11 12-35 36+

6,018 17,532 14,712

298 766 1,032

5.0% 4.4% 7.0%

55 107 172

0.7% 0.6% 1.2%

440 991 1,189

25.2% 56.8% 68.1%

32 52 85

1.8% 3.0% 4.9%

1. Interpregnancy Interval (IPI) is the time in months between the date of last menstrual period of current pregnancy and the date of previous live birth. 2. Multiparous is defined as having given birth two or more times. 3. Also known as premature delivery. 4. Very early gestational age (VEGA) refers to birth before 28 weeks of gestational age and is also known as extremely preterm delivery.

58

Figure 12. Inter-pregnancy Interval (IPI) by Selected Birth Outcomes: LBW and Preterm -Pregnancies to Multiparous Mothers, Massachusetts: 2009

%LBW
10% 9%
9.1%

%Preterm

8.4% 7.4% 6.6% 5.7% 6.2% 5.3% 4.4% 4.0% 4.2% 4.5% 5.6% 5.4% 6.0% 6.0% 6.1% 7.0% 7.4%

Percent of Pregnancies

8% 7% 6% 5% 4% 3% 2% 1% 0% <6 6-11 12-17 18-23 24-29 30-35

36-41

42-47

48+

IPI (months)
Short IPI

NOTE: Inter-pregnancy Interval (IPI) is the time in months between the date of last menstrual period of current pregnancy and the date of previous live birth. Short IPIs (less than 12 months) and IPIs over 35 months were associated with higher proportions of low birthweight (less than 2,500 grams or 5.5 pounds) and premature deliveries (gestational age less than 37 weeks).

59

Table 19. Inter-pregnancy Interval (IPI) by Maternal Characteristics -- Pregnancies to Multiparous Mothers, Massachusetts: 2009
Total Pregnancies Parity >1 n State Total2 Age < 20 20-34 35+ Race Ethnicity White non-Hispanic Black non-Hispanic Hispanic Asian non-Hispanic Education High School or less BA or Assoc More than college Delivery Payment Source Public Private Region3 of Residence Western MA Central MA Northeast MA Metrowest MA Southeast MA Boston Region Town of Residence4 38,262 % 100% n 6,018 IPI1 Short < 12 months % 15.7% 12-35 months n 17,532 % 45.8% 36+ months n 14,712 % 38.5%

543 26,534 11,185

1.4% 69.3% 29.2%

262 4,553 1,203

48.3% 17.2% 10.8%

250 12,408 4,874

46.0% 46.8% 43.6%

31 9,573 5,108

5.7% 36.1% 45.7%

24,830 3,828 6,182 2,815

64.9% 10.0% 16.2% 7.4%

4,089 592 916 338

16.5% 15.5% 14.8% 12.0%

12,537 1,273 2,199 1,248

50.5% 33.3% 35.6% 44.3%

8,204 1,963 3,067 1,229

33.0% 51.3% 49.6% 43.7%

14,350 17,917 5,934

37.5% 46.8% 15.5%

2,316 2,784 908

16.1% 15.5% 15.3%

5,262 8,656 3,592

36.7% 48.3% 60.5%

6,772 6,477 1,434

47.2% 36.2% 24.2%

14,687 22,612

38.4% 59.1%

2,432 3,429

16.6% 15.2%

5,328 11,714

36.3% 51.8%

6,927 7,469

47.2% 33.0%

4,641 5,364 7,835 8,490 7,209 4,723

12.1% 14.0% 20.5% 22.2% 18.8% 12.3%

798 919 1221 1264 1128 688

17.2% 17.1% 15.6% 14.9% 15.6% 14.6%

2035 2429 3621 4439 3162 1846

43.8% 45.3% 46.2% 52.3% 43.9% 39.1%

1808 2016 2993 2787 2919 2189

39.0% 37.6% 38.2% 32.8% 40.5% 46.3%

Top 10 Fitchburg (22.9%) Haverhill (20.8%) Springfield (20.4%) Westfield (19.7%) Fall River (18.8%) Natick (18.5%) Chicopee (18.0%) Holyoke (17.7%) Woburn (17.3%) Lowell (17.0%)

Top 10 Arlington (62.4%) Brookline (60.5%) Newton (57.3%) Attleboro (54.8%) Natick (54.0%) Medford (54.0%) Billerica (51.9%) Braintree (50.9%) Salem (50.6%) Cambridge (50.3%)

Top 10 Chelsea (58.3%) Revere (53.0%) Brockton (50.8%) Malden (50.0%) Randolph (49.5%) Everett (49.0%) Lawrence (47.5%) Lynn (46.4%) Fall River (46.0%) Boston (45.6%)

1. Inter-pregnancy Interval (IPI) is the time in months between the date of last menstrual period of current pregnancy and the date of previous nd live birth among multiparous mothers, i.e. among those giving birth to their 2 or later child. 2. State total includes pregnancies with known IPI. 3. Regions of the state defined by the Executive Office of Health and Human Services 4. Among towns with at least 200 mothers giving birth to nd their 2 or later child.

60

Figure 13. Inter-pregnancy Interval (IPI) Distribution by Maternal Age -- Pregnancies to Multiparous Mothers, Massachusetts: 2009

Short IPI

IPI 12-35 months

IPI 36+ months

35+ Maternal Age (years)

12%

44%

46%

20-34

17%

47%

36%

< 20

42%

46%

6%

0%

20%

40%

60%

80%

100%

NOTE: Inter-pregnancy Interval (IPI) is the time in months between the date of last menstrual period of current pregnancy and the date of nd previous live birth among multiparous mothers, i.e. among those giving birth to their 2 or later child.

61

Figure 14. Comparison of Teen vs. Adult Births, Selected Characteristics, Massachusetts: 2009

under 20 years old

100% 93.9% 90%

20 years or older

83.5% 80% 76.6%

85.0%

73.4% 70% 68.3%

60% Percent

62

50%

40% 33.4% 30.9% 30%

20% 12.4% 10% 6.5% 9.3% 8.7% 9.2% 7.7%

0% Unmarried Smoking During Pregnancy Public Source of Prenatal Care Payment First Trimester Prenatal Care Adequate Prenatal Care Preterm Birth Low Birthw eight

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. Three age groups are used for teen births: 10-14, 15-19, and <20. The 10-14 group refers to young teens, and the 15-19 group is the age group referred to as teens by the Centers for Disease Control and Prevention. For this publication, <20 is used when comparing young women with adult women. Definitions: Adequate Prenatal Care = based on Adequacy of Prenatal Care Utilization (APNCU) Index. See Appendix (Glossary and Technical Notes) for more details on the APNCU Index. Preterm Birth = gestational age less than 37 weeks, based on clinical estimate of gestational age. Low Birthweight = less than 2,500 grams (5.5 lbs.).

62

Figure 15. Trend in Birth Rates among Females ages 15-19, Massachusetts and the United States: 1985-2009

70 59.9 60 51.0 50.2 50.6 50 53.0 57.3 62.1 60.7 59.6 58.9

56.8

54.4

52.3

Births per 1,000 women ages 15-19

51.1

49.6

48.5 45.8

United States1
42.9 41.9 42.5 41.5 41.7 41.2 40.4

40 30.7 32.5

39.1

35.9 35.4 35.4 34.5 34.0 33.2 30.3 28.5 28.5 28.1 26.7 25.9 24.9

30

28.7 29.1

63

23.3 23.0 22.2 21.7 21.3 22.0

20.1 19.5

20

10

Massachusetts2

0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year

Teen birth rate is the number of births to females ages 15-19 per 1,000 females ages 15-19 Data sources: 1) U.S. annual natality data (NCHS) and 1990 U.S. Census data (population data used in denominators); 2) Massachusetts: annual birth data files, decennial Census counts (1990) and intercensal population estimates based on MISER (Massachusetts Institute for Social and Economic Research) population estimates for 1991 through 1998. 1999 rates are calculated using the 1999 DPH Massachusetts population estimates and Massachusetts (Department of Public Health) Modified Age, Race/Ethnicity, & Sex Estimates 2000-2005, released October 2006 (see Technical Notes in Appendix). 2009 birth rates are based on the 2009 population estimates from the National Center for Health Statistics. PLEASE NOTE: DIFFERENCES BETWEEN THESE RATES AND PREVIOUSLY PUBLISHED DATA REFLECT UPDATES IN POPULATION ESTIMATES.

63

Table 20. Resident Teen Birth Characteristics, 30 Largest Municipalities, Massachusetts: 2009
Total Population Rank Female Population, ages 15-19 228,275 29 25 1 6 18 5 21 9 14 15 12 30 4 8 17 22 27 7 11 24 28 20 10 26 13 3 19 16 23 2 1,134 1,360 19,770 3,638 1,451 3,923 1,738 2,829 1,955 1,908 3,027 1,254 3,966 3,084 1,430 1,776 1,327 2,955 3,500 1,432 1,270 1,672 2,078 1,053 2,170 6,074 1,631 2,340 1,452 7,036 Mother's Race and Hispanic Ethnicity (% of teen births) White nonHispanic 44.0 74.4 61.9 8.7 24.8 --4 33.3 50.0 70.5 36.0 57.1 7.5 56.1 32.4 24.0 25.0 54.5 57.5 46.8 --4 56.3 77.1 95.0 56.5 26.8 22.5 9.2 71.4 18.2 100.0 63.9 Black nonHispanic 13.3 0.0 19.0 43.5 50.4 --4 40.0 4.2 5.4 14.0 5.7 2.1 0.0 2.4 10.5 33.3 18.2 0.0 15.0 --4 6.3 11.4 5.0 26.1 1.8 20.0 20.4 10.0 9.1 0.0 5.0 Hispanic 37.2 23.1 14.3 41.7 21.2 --4 26.7 43.1 18.6 50.0 34.3 87.9 43.9 32.4 50.3 25.0 27.3 42.5 34.1 --4 31.3 8.6 0.0 17.4 55.4 47.5 67.7 12.9 63.6 0.0 28.8 Asian or other3 5.4 2.6 4.8 6.2 3.6 --4 0.0 2.8 5.4 0.0 2.9 2.5 0.0 32.9 15.2 16.7 0.0 0.0 4.0 --4 6.3 2.9 0.0 0.0 16.1 10.0 2.7 5.7 9.1 0.0 2.3

Municipality1 State Total Attleboro Barnstable Boston Brockton Brookline Cambridge Chicopee Fall River Framingham Haverhill Lawrence Leominster Lowell Lynn Malden Medford Methuen
New Bedford

Number of Teen Births 4,477 39 21 520 137 2 15 72 129 50 70 239 41 210 171 24 11 40 173 4 16 70 20 23 56 40 437 70 22 10 219

Teen Birth Rate2 19.5 34.4 15.4 26.3 37.7 --4 3.8 41.4 45.6 25.6 36.7 79.0 32.7 53.0 55.4 16.8 6.2 30.1 58.5 --4 11.2 55.1 12.0 11.1 53.2 18.4 71.9 42.9 9.4 6.9 31.1

64

Newton Peabody Pittsfield Plymouth Quincy Revere Somerville Springfield Taunton Waltham Weymouth Worcester

64

Table 20 (contd). Resident Teen Birth Characteristics, 30 Largest Municipalities, Massachusetts: 2009
Municipality State Total Attleboro Barnstable Boston Brockton Brookline Cambridge Chicopee Fall River Framingham Haverhill Lawrence Leominster Lowell Lynn Malden Medford Methuen New Bedford Newton Peabody Pittsfield Plymouth Quincy Revere Somerville Springfield Taunton Waltham Weymouth Worcester Public Payment for Prenatal Care5 (%) 76.5 36.4 71.4 73.6 87.5 --4 50.0 84.7 92.6 88.0 71.4 86.9 80.5 83.7 85.0 82.6 81.8 64.1 64.1 --4 75.0 82.9 73.7 91.3 76.4 76.9 89.1 62.5 86.4 80.0 74.9 Unmarried (%) 93.8 89.7 90.5 96.2 92.7 --4 100.0 90.3 93.0 88.0 92.9 96.7 95.1 96.2 89.0 87.5 100.0 97.5 97.1 --4 100.0 98.6 100.0 91.3 91.1 92.5 94.3 90.0 90.9 90.0 93.6 Low Birthweight6 (%) 9.2 --4 28.6 10.6 8.0 0.0 --4 9.7 9.3 20.0 . 9.6 . 10.0 9.2 --4 --4 --4 11.6 0.0 0.0 --4 --4 0.0 --4 --4 8.7 15.7 27.3 --4 10.0 Preterm (%)
7

Adequate Intensive 33.3 42.1 33.3 25.9 27.2 --4 53.3 32.9 63.8 62.0 31.4 28.5 46.3 31.4 33.1 33.3 54.5 22.5 30.8 --4 35.7 15.7 25.0 --4 55.6 25.6 27.5 23.2 59.1 --4 25.1

Adequacy of Prenatal Care8 Adequate Intermediate Basic 40.3 34.2 28.6 54.2 41.2 0.0 --4 41.4 16.5 26.0 44.3 39.7 41.5 37.1 36.3 45.8 --4 45.0 38.4 --4 57.1 41.4 50.0 65.2 24.1 35.9 36.5 52.2 31.8 70.0 42.5 8.6 --4 --4 7.6 10.3 0.0 --4 8.6 0.0 . 8.6 15.1 . 7.1 8.1 0.0 --4 --4 12.2 0.0 --4 27.1 0.0 --4 --4 --4 9.6 14.5 --4 0.0 14.6

Inadequate9 17.8 21.1 33.3 12.3 21.3 --4 --4 17.1 19.7 . 15.7 16.7 . 24.3 22.5 20.8 --4 22.5 18.6 --4 0.0 15.7 25.0 --4 16.7 33.3 26.4 10.1 --4 --4 17.8

9.4 --4 --4 11.3 10.9 0.0 --4 8.3 7.8 20.0 . 8.8 . 10.5 9.2 --4 0.0 15.0 11.0 0.0 0.0 --4 --4 0.0 --4 12.5 10.0 14.3 31.8 --4 7.3

65

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. The 30 largest municipalities are the cities and towns in Massachusetts with the largest populations according to the Massachusetts (Department of Public Health) Modified Age, Race/Ethnicity, & Sex Estimates 2005 (MMARS05), released October 2006 (see Technical Notes in Appendix). 2. Birth rates represent the number of births per 1,000 females ages 15-19. Birth rates for cities and towns were calculated using MDPH population estimates for 2005, which are the most up-to-date information available on the number of persons by age, race, and sex at the sub-state level. 3. Mothers who designated themselves as Asian, American Indian, or Other. 4. Calculations based on values of 1-4 are excluded. 5. See Glossary under "Prenatal Care Payment Source." 6. Less than 2,500 grams or 5.5 pounds. 7. Less than 37 weeks of gestational age. 8. Based on Adequacy of Prenatal Care Utilization (APNCU) Index. Please see Glossary and Technical Notes in the Appendix for definitions of index and adequacy categories. 9. Inadequate includes those mothers with no prenatal care.

65

Table 21. Trends in Infant, Neonatal, and Post Neonatal Mortality by Race, Massachusetts: 1981-2009 INFANT MORTALITY (less than one year of age) BY RACE1 Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 State Total2 n Rate4 710 9.6 764 10.1 682 9.0 699 8.9 745 9.1 695 8.4 608 7.2 693 7.9 697 7.6 649 7.0 577 6.5 569 6.5 523 6.2 499 6.0 419 5.1 403 5.0 425 5.3 414 5.1 418 5.2 377 4.6 407 5.0 397 4.9 383 4.8 376 4.8 391 5.1 369 4.8 380 4.9 382 5.0 354 4.7 White n Rate4 616 9.1 656 9.4 579 8.3 601 8.4 608 8.1 560 7.5 486 6.4 546 7.0 549 6.8 519 6.4 461 6.0 438 5.7 423 5.7 407 5.6 333 4.7 329 4.7 349 5.0 345 4.9 334 4.8 280 4.0 314 4.5 306 4.5 290 4.3 285 4.3 308 4.8 283 4.4 286 4.4 280 4.4 246 4.0 Black n Rate4 85 18.2 102 21.3 89 19.0 82 16.4 126 23.8 123 22.0 110 17.5 133 19.5 131 17.7 106 13.7 102 13.8 114 15.8 87 12.5 81 12.0 65 10.3 65 10.8 66 10.6 59 9.3 75 11.4 76 11.7 77 11.7 74 11.1 78 11.8 75 11.1 63 9.3 75 10.5 73 10.0 83 11.5 53 7.3 Asian/Other3 n Rate4 8 6.1 5 3.3 12 7.4 13 7.5 11 6.1 11 4.6 12 4.5 13 3.8 17 4.8 24 6.5 14 3.9 17 4.7 13 3.5 11 2.9 21 5.5 8 2.0 10 2.4 10 2.3 9 1.9 19 3.6 16 3.0 17 2.9 15 2.6 15 2.5 20 3.5 10 1.7 18 2.8 19 2.9 54 8.4

66

Table 21 (contd). Trends in Infant, Neonatal, and Post Neonatal Mortality by Race1, Massachusetts: 1981-2009 NEONATAL MORTALITY (birth to 27 days old) Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 State Total2 n Rate4
510 573 482 472 538 478 432 477 479 446 401 415 375 349 298 290 323 315 332 288 308 299 285 291 282 279 263 291 266 6.9 7.6 6.3 6.0 6.6 5.8 5.1 5.4 5.2 4.8 4.5 4.8 4.4 4.2 3.6 3.6 4.0 3.9 4.1 3.5 3.8 3.7 3.6 3.7 3.7 3.6 3.4 3.8 3.5

White n Rate4
442 494 411 411 447 383 343 383 376 347 319 325 300 280 237 249 271 261 265 214 239 235 217 224 226 215 194 218 186 6.5 7.1 5.9 5.8 6.0 5.2 4.6 4.9 4.7 4.3 4.1 4.3 4.1 3.8 3.3 3.5 3.9 3.7 3.8 3.1 3.5 3.4 3.2 3.4 3.5 3.3 3.0 3.4 3.0

Black n Rate4
59 75 63 49 85 89 80 87 95 80 72 79 66 60 50 35 45 47 61 58 59 51 58 54 45 56 52 62 36 12.4 15.7 13.4 9.8 16.0 15.9 12.7 12.8 12.8 10.3 9.8 10.9 9.5 8.9 7.9 5.8 7.2 7.4 9.3 8.9 9.0 7.6 8.8 8.0 6.6 7.8 7.2 8.6 4.9

Asian/Other3 n Rate4
5 3 7 8 5 5 9 6 8 9 10 11 9 9 11 5 7 7 6 14 10 13 10 13 11 7 15 11 43 3.8 --5 4.3 4.6 2.8 2.1 3.4 1.8 2.3 5.1 2.8 3.1 2.4 2.4 2.9 1.2 1.7 1.6 1.3 2.7 1.9 2.2 1.8 2.2 1.9 1.2 2.4 1.7 6.7

67

Table 21 (contd). Trends in Infant, Neonatal, and Post Neonatal Mortality by Race1, Massachusetts: 1981-2009 POST NEONATAL MORTALITY (28-364 days old) Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 State Total2 n Rate4
200 191 200 227 207 217 176 216 218 203 176 154 148 150 121 113 102 99 86 89 99 98 98 85 109 90 117 91 88 2.7 2.5 2.7 2.9 2.5 2.6 2.1 2.5 2.4 2.2 2.0 1.8 1.7 1.8 1.5 1.4 1.3 1.2 1.1 1.1 1.2 1.2 1.2 1.1 1.4 1.2 1.5 1.2 1.2

White n Rate4
174 162 168 190 161 177 143 163 173 172 142 113 123 127 96 80 78 84 69 66 75 71 73 61 82 68 92 62 60 2.6 2.3 2.4 2.6 2.1 2.3 1.8 2.1 2.1 2.1 1.8 1.5 1.7 1.7 1.3 1.1 1.1 1.2 1.0 0.9 1.1 1.0 1.1 0.9 1.3 1.1 1.4 1.0 1.0

Black n Rate4
26 27 26 33 41 34 30 46 36 26 30 35 21 21 15 30 21 12 14 18 18 23 20 21 18 19 21 21 17 5.8 5.6 5.6 6.6 7.8 6.1 4.8 6.7 4.9 3.4 4.1 4.8 3.0 3.1 2.4 5.0 3.4 1.9 2.1 2.8 2.7 3.4 3.0 3.1 2.7 2.6 2.9 2.9 2.3

Asian/Other3 n Rate4
3 2 5 5 6 6 3 7 9 5 4 6 4 2 10 3 3 3 3 5 6 4 5 3 7 3 3 8 11 --5 --5 3.1 2.9 3.3 2.5 --5 2.0 2.5 1.4 --5 1.7 --5 --5 2.6 --5 --5 --5 --5 1.0 1.1 --5 0.9 --5 1.6 --5 --5 1.2 1.7

Note: Infant deaths are based on a preliminary death file as of the release of this report. 1. Hispanic origin could not be identified from the Massachusetts death certificate before 1989; thus, Hispanic trend data are not available. Most Hispanics are included in the race category of White. Hispanic infant mortality data for the years 1990 through 2005 are presented in Table 11. 2. Deaths of infants of unknown race are included in the total calculation. For rate computations, infants of unknown race are allocated into the race categories according to the distribution of births of known race. 3. Other: American Indian and Other races. 4. Rates are expressed per 1,000 live births. 5. Calculations based on values of 1-4 are excluded.

68

Figure 16. Infant Mortality Rates and 95% Confidence Intervals by Race Massachusetts: 1980-20091,2,3

30 28 26 24

Deaths per 1,000 Live Births

22 20 18 16 14 12 10 8 6 4 2 0
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Black

White
Year

1. See Technical Notes for explanation. 2. For rate computations, infant births of unknow n race are allocated into race categories according to the distribution of the births of know n race. 3. On tables and graphs w hich include data prior to June 1986, the race classifications do not include ethnicity; most Hispanics are included in the race category of w hites.

69

Deaths per 1,000 live births

100 150 200 250 50 0

NOTE: Data not available for 1850.

Figure 17. Infant Mortality Rates, Massachusetts: 1842-2009

70
Year
2009

18 4 18 5 49 18 5 18 3 5 18 7 61 18 6 18 5 6 18 9 73 18 7 18 7 81 18 8 18 5 8 18 9 9 18 3 97 19 0 19 1 0 19 5 0 19 9 1 19 3 17 19 2 19 1 2 19 5 29 19 3 19 3 3 19 7 41 19 4 19 5 4 19 9 5 19 3 5 19 7 6 19 1 65 19 6 19 9 7 19 3 77 19 8 19 1 8 19 5 89 19 9 19 3 9 20 7 01 20 0 20 5 09

Figure 18. Trends in the Timing of Infant Deaths, Massachusetts: 1990-2009

100%

28-364 Days
31%
80%

25%

Percent of Infant Deaths

60%

1-27 Days
25%

25%

40%

< 1 Day
20%

44%

50%

0%
19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09

Year

71

Table 22. Feto-Infant Mortality Rate1 by Birthweight, Massachusetts: 2000-2009

Birthweight
<500 500-749 750-999 1,000-1,249 1,250-1,499 1,500-1,999 72 2,000-2,499 2,500-4,000 4001+ Unknown Birthweight Feto-Infant Mortality Rate2

2000
940.2 500.0 182.2 125.4 84.6 41.8 15.3 2.2 1.5 (37) 9.9

2001
938.3 487.0 146.9 83.0 84.6 40.3 12.2 2.6 1.5 (23) 9.7

2002
943.5 525.5 188.6 131.4 95.8 38.3 11.9 2.5 1.7 (17) 9.1

2003
923.1 523.4 220.7 142.9 67.7 31.3 16.4 2.3 2.5 (30) 10.3

2004
912.0 561.8 157.7 124.1 74.4 38.0 14.8 2.5 1.3 (19) 9.5

2005
910.9 564.7 187.8 100.7 73.6 37.2 12.8 2.4 2.5 (11) 10.1

2006
943.2 544.1 247.2 112.4 65.8 35.2 15.2 2.4 2.3 (34) 9.3

2007
934.1 487.3 282.2 87.3 63.3 39.1 14.6 2.7 2.3 (10) 9.8

2008
944.9 588.0 238.1 80.4 72.1 32.5 16.0 2.4 1.4 (16) 9.7

2009
909.1 474.7 238.7 124.5 87.5 41.7 16.9 2.5 1.9 (14) 9.6

1. Fetal and infant deaths per 1,000 live births plus fetal deaths. 2. The feto-infant mortality rate is calculated here excluding fetal deaths, infant deaths, and births of unknown birthweight. Source: Starting with Massachusetts Births 2003, linked death-cohort files of MA resident infant deaths for the years 2000-2009 have been used for the calculation of infant mortality.

72

Figure 19. Feto-Infant Mortality Rate, Massachusetts: 2000-2009

Infant MR
12

Fetal MR

Feto-Infant MR

10 Fetal and Infant Deaths per 1,000 Fetal Deaths + Infant Births

9.7 8.9 8.9

10.1 9.5

10.1 9.3

9.8

9.7

9.6

5.2 4.6 4.5 4.4

5.6

5.1

5.3 4.9

4.9 4.4

5.0 4.8

4.9 4.8

4.9 4.7

73

4.5

4.3

4.5

4.5

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

NOTES: In this graph, Infant, Fetal, and Feto-Infant Mortality Rates include all deaths (including those with unknown birthweight). The Infant Mortality Rate in this graph includes fetal deaths in the denominator unlike the conventional IMR. The Infant Mortality Rate and Fetal Mortality Rate may not add up to the Feto-Infant Mortality Rate due to rounding.

Source: Starting with Massachusetts Births 2003, linked death-cohort files of MA resident infant deaths for the years 2000-2009 have been used for the calculation of infant mortality.

73

Table 23. Fetal and Infant Deaths by Birthweight and Gestational Age, Massachusetts: 1998-2009

Year

Fetals <24 wks or <500 grams 216 (25.5%) 214 (25.4%) 203 (25.1%) 174 (22.0%) 165 (22.3%) 218 (26.3%) 177 (22.7%) 210 (26.3%) 178 (24.1%) 184 (23.7%) 178 (23.5%) 158 (21.6%)

Fetals 24 wks and 500 grams 219 215 234 214 210 246 240 213 210 215 209 221 (25.8%) (25.6%) (28.9%) (27.1%) (28.3%) (29.6%) (30.8%) (26.7%) (28.5%) (27.7%) (27.5%) (30.2%)

Infants <24 wks or <500 grams 183 196 168 197 185 189 182 174 173 149 194 156 (21.6%) (23.3%) (20.7%) (24.9%) (25.0%) (22.8%) (23.3%) (21.8%) (23.4%) (19.2%) (25.6%) (21.3%)

Infants 24 wks and 500 grams 230 216 205 206 181 177 181 201 177 227 178 198 (27.1%) (25.7%) (25.3%) (26.0%) (24.4%) (21.3%) (23.2%) (25.2%) (24.0%) (29.3%) (23.5%) (27.0%) 848 841 810 791 741 830 780 798 738 775 759 733

Total

1998 1999 2000 2001

74

(100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%)

2002 2003 2004 2005 2006 2007 2008 2009

Source: Starting with Massachusetts Births 2003, linked death-cohort files of MA resident infant deaths for the years 1998-2009 have been used for the calculation of infant mortality.

74

Figure 20. Trends in Pregnancy-Associated and Maternal Mortality, Massachusetts: 1993-2009

Pregnancy-Associated Mortality Ratio
40 Deaths per 100,000 Live Births 35 30 25 20 15 10 5 0 2.3 8.6 16.4 10.3 10.3 18.6 30.3 35.1 29.7

Maternal Mortality Ratio

0.0

4.0

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

NOTE: Ratios shown in graph are per 100,000 live births. Ratios are based on occurrence births, not resident births. Pregnancy-associated death is defined as the death of a woman while pregnant or within one year of termination of pregnancy, irrespective of cause. The pregnancy-associated mortality ratio is the number of pregnancy-associated deaths per 100,000 live occurrence births (see Definition of Rates and Technical Notes in Appendix for further information). Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes. Maternal mortality ratio is the number of maternal deaths per 100,000 live occurrence births (see Definition of Rates and Technical Notes in Appendix for more information.)

Table 24. Number of Pregnancy-Associated and Maternal Deaths, Massachusetts: 1998-2009

Year

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Pregnancy Associated Deaths1 Maternal Deaths2

23 3

27 0

29 1

27 4

19 2

15 4

13 5

23 8

22 7

22 7

23 8

14 3

1. Pregnancy-associated death is defined as the death of a woman while pregnant or within one year of termination of pregnancy, irrespective of cause. 2. Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes.

75

Figure 21. Low Birthweight among Smoking and Non-Smoking Mothers by Race and Hispanic Ethnicity, Massachusetts: 2009

20% 18% 16% 14%

Smokers
16.9% 14.7% 11.6% 10.5% 8.3% 6.8%

Non-Smokers

12.6%

12.4%

Percent

12% 10% 8% 6% 4% 2% 0%

7.5%

7.4%

White nonHispanic

Black nonHispanic

Hispanic

Asian

Massachusetts Total

Race and Hispanic Ethnicity

NOTE: Maternal smoking is self-reported on the Parent Worksheet of the Birth Certificate; these data should be interpreted cautiously. Low birthweight: less than 2,500 grams or 5.5 pounds.

76

Table 25. Low Birthweight (LBW) by Maternal Age, Race/Hispanic Ethnicity, Massachusetts: 2009
Mother's Age (in years) State Total <18 18-19 20-24 25-29 30-34 35-39 40+
2

Total LBW1 Infants n 5,804 133 280 917 1,364 1,662 1,097 350 %3 7.8 9.8 8.9 7.7 7.4 7.2 8.2 10.8

White nonHispanic n 3,547 37 116 435 810 1,107 785 257 %3 7.1 7.6 7.8 6.7 6.8 6.6 7.7 10.6

Black nonHispanic n 750 19 52 170 179 185 115 30 %3 10.8 10.3 12.5 11.0 9.9 10.9 11.4 10.3

Hispanic n 940 59 94 257 239 180 81 30 %3 8.6 9.8 8.6 7.8 8.4 9.0 8.7 13.0

Asian n 451 15 13 39 108 150 103 23 %3 7.6 26.3 15.7 7.4 7.1 6.7 8.2 9.3

Other4 n 97 3 5 15 25 28 13 8 %3 8.4
--6

Unknown5 n 19 0 0 1 3 12 0 2

7.4 7.4 7.0 9.1 8.7 20.5

NOTE: 1. Low Birthweight (LBW): less than 2,500 grams or 5.5 pounds. 2. State totals include women of unknown age. 3. Percentages are based upon the number of low birthweight infants divided by the total births in each age and race/ethnicity category. 4. Other races include American Indian and others not specified. 5. Race and/or mothers age unknown. 6. Calculations based on values of 1-4 are excluded.

77

Table 26. Adequacy of Prenatal Care Utilization: Summary and Component Indices, Massachusetts: 2009

Adequate Total1

Adequate Intensive2

Adequate Basic2

Intermediate2

Inadequate2

Unknown2

n
Summary Index Adequacy of Prenatal Care Utilization Component Indices3 Adequacy of Initiation Adequacy of Received Services (Visits)
3

61,669

84.3

28,171

38.5

33,498

45.8

4,758

6.5

6,698

9.2

1,841

66,881

91.5

30,228

41.3

36,653

50.1

3,711

5.1

2,533

3.5

1,841

78

67,173

91.9

32,584

44.6

34,589

47.3

5,192

7.1

760

1.0

1,841

NOTE: All percentages are calculated based on the Adequacy of Prenatal Care Utilization (APNCU) Index. 1. Adequate Total is the sum of Adequate Intensive and Adequate Basic categories. 2. For definitions of these categories, please see the Technical Notes in the Appendix. 3. For an explanation of the APNCU Index (summary index) and its component indices, please see Technical Notes in the Appendix (page 102).

78

Table 27. Adequacy of Prenatal Care Summary by Selected Characteristics, Massachusetts: 2009
Summary Index State Total Adequate Total1 n 61,669 % 84.3% Adequate Intensive n 28,171 % 38.5% Adequate Basic n 33,498 % 45.8% Intermediate n 4,758 % 6.5% Inadequate n 6,698 % 9.2%
Unknown

n 1,841

Maternal Demographics Age <18 931 18-19 2,322 20-24 9,159 25-29 15,037 30-34 19,834 35-39 11,600 40+ 2,786 Educational Attainment < High school 5,462 High school 14,819 Some college 13,065 College 17,033 > College 11,202 Race/Ethnicity Hispanic 8,476 White non-Hispanic 42,167 Black non-Hispanic 5,116 Asian 4,945 Other 874 Birthplace US/D.C. 43,811 1,507 Puerto Rico/US Terr. Non-US-born 16,343 Pregnancy-Related Factors Parity2 1 28,327 2-3 29,598 4+ 3,584 3 Smoking Yes 3,712 No 57,876 Birth Outcomes Plurality Singleton 58,540 Multiple birth 3,129 Birthweight <500 g 97 500-1,499 g 758 1,500-2,499 g 3,988 2,500-3,999 g 50,883 4,000+ g 5,888 Gestational Age <28 weeks 420 <37 weeks 5,506 37-42 weeks 56,142

69.1% 75.3% 77.8% 83.7% 87.6% 88.1% 88.2% 72.4% 80.4% 85.0% 88.9% 89.6% 79.2% 86.8% 76.0% 84.2% 78.6% 85.7% 77.3% 81.5%

439 1,036 4,125 6,783 8,810 5,517 1,461 2,575 6,824 6,263 7,477 4,979 3,771 19,445 2,236 2,219 446 20,176 651 7,337

32.6% 33.6% 35.0% 37.7% 38.9% 41.9% 46.2% 34.1% 37.0% 40.7% 39.0% 39.8% 35.2% 40.0% 33.2% 37.8% 40.1% 39.5% 33.4% 36.6%

492 1,286 5,034 8,254 11,024 6,083 1,325 2,887 7,995 6,802 9,556 6,223 4,705 22,722 2,880 2,726 428 23,635 856 9,006

36.5% 41.7% 42.8% 45.9% 48.7% 46.2% 41.9% 38.3% 43.4% 44.3% 49.9% 49.7% 44.0% 46.8% 42.8% 46.4% 38.5% 46.2% 43.9% 44.9%

118 266 994 1,287 1,278 688 127 686 1,502 934 1,019 613 941 2,943 450 336 82 3,209 208 1,341

8.8% 8.6% 8.4% 7.2% 5.6% 5.2% 4.0% 9.1% 8.1% 6.1% 5.3% 4.9% 8.8% 6.1% 6.7% 5.7% 7.4% 6.3% 10.7% 6.7%

299 496 1,618 1,646 1,519 873 247 1,397 2,115 1,371 1,103 694 1,283 3,486 1,165 594 156 4,101 235 2,361

22.2% 16.1% 13.7% 9.2% 6.7% 6.6% 7.8% 18.5% 11.5% 8.9% 5.8% 5.5% 12.0% 7.2% 17.3% 10.1% 14.0% 8.0% 12.1% 11.8%

21 75 277 499 512 360 93 266 373 453 390 263 286 1,163 214 64 46 1,285 33 522

84.7% 85.0% 76.6% 74.2% 85.1%

12,658 13,689 1,732 1,875 26,257

37.9% 39.3% 37.0% 37.5% 38.6%

15,669 15,909 1,852 1,837 31,619

46.9% 45.7% 39.6% 36.7% 46.5%

2,106 2,284 356 436 4,319

6.3% 6.6% 7.6% 8.7% 6.3%

2,995 2,942 741 858 5,823

9.0% 8.4% 15.8% 17.1% 8.6%

576 600 114 110 1,667

84.0% 91.8% 91.5% 89.8% 85.7% 84.0% 85.6% 91.7% 87.7% 84.0%

25,460 2,711 91 679 3,147 22,100 2,119 389 4,818 23,339

36.5% 79.5% 85.8% 80.5% 67.6% 36.5% 30.8% 84.9% 76.7% 34.9%

33,080 418 6 79 841 28,783 3,769 31 688 32,803

47.5% 12.3% 5.7% 9.4% 18.1% 47.5% 54.8% 6.8% 11.0% 49.1%

4,706 52 0 13 174 4,072 496 6 183 4,571

6.8% 1.5% 0.0% 1.5% 3.7% 6.7% 7.2% 1.3% 2.9% 6.8%

6,469 229 9 73 491 5,621 496 32 592 6,086

9.3% 6.7% 8.5% 8.6% 10.6% 9.3% 7.2% 7.0% 9.4% 9.1%

1,708 133 11 53 137 1,147 121 29 235 1,215

NOTE: All percentages are calculated based on the Adequacy of Prenatal Care Utilization (APNCU) Index. See Glossary and Technical Notes in Appendix for definitions of Index and its categories. 1. Adequate Total is the sum of Adequate Intensive and Adequate Basic. 2. Parity is the number of live births including this birth. 3. Smoking during pregnancy is self-reported by the mother and should be interpreted with caution.

79

Table 28. Adequacy of Prenatal Care Initiation by Selected Characteristics, Massachusetts: 2009
Based on month of PNC Initiation State Total Maternal Demographics Age <18 18-19 20-24 25-29 30-34 35-39 40+ Educational Attainment < High school High school Some college College > College Race/Ethnicity Hispanic White non-Hispanic Black non-Hispanic Asian Other Birthplace US/D.C. Puerto Rico/US Terr. Non-US-born Pregnancy-Related Factors Parity2 1 2-3 4+ Smoking3 Yes No Birth Outcomes Plurality Singleton Multiple birth Birthweight <500 g 500-1,499 g 1,500-2,499 g 2,500-3,999 g 4,000+ g Gestational Age <28 weeks <37 weeks 37-42 weeks Adequate Total1 n 66,881 % 91.5% Adequate Intensive n 30,228 % 41.3% Adequate Basic n 36,653 % 50.1% Intermediate n 3,711 % 5.1% Inadequate n 2,533 % 3.5%
Unknown

n 1,841

1,059 2,617 10,262 16,445 21,222 12,344 2,932 6,210 16,500 14,071 18,149 11,857 9,482 45,403 5,632 5,303 962 47,330 1,732 17,811

78.6% 84.9% 87.2% 91.5% 93.8% 93.8% 92.8% 82.3% 89.5% 91.5% 94.7% 94.8% 88.6% 93.4% 83.7% 90.3% 86.5% 92.6% 88.8% 88.9%

365 1,055 4,115 7,248 10,192 5,879 1,374 2,189 6,795 6,111 9,287 5,815 3,926 20,844 2,716 2,274 426 21,643 669 7,909

27.1% 34.2% 35.0% 40.3% 45.0% 44.7% 43.5% 29.0% 36.9% 39.8% 48.5% 46.5% 36.7% 42.9% 40.4% 38.7% 38.3% 42.3% 34.3% 39.5%

694 1,562 6,147 9,197 11,030 6,465 1,558 4,021 9,705 7,960 8,862 6,042 5,556 24,559 2,916 3,029 536 25,687 1,063 9,902

51.5% 50.6% 52.2% 51.2% 48.7% 49.1% 49.3% 53.3% 52.6% 51.8% 46.3% 48.3% 51.9% 50.5% 43.3% 51.6% 48.2% 50.2% 54.5% 49.4%

193 288 957 900 787 458 128 852 1,200 786 521 345 791 1,926 567 343 79 2,365 139 1,207

14.3% 9.3% 8.1% 5.0% 3.5% 3.5% 4.1% 11.3% 6.5% 5.1% 2.7% 2.8% 7.4% 4.0% 8.4% 5.8% 7.1% 4.6% 7.1% 6.0%

96 179 552 625 622 359 100 483 736 513 485 307 427 1,267 532 229 71 1,426 79 1,027

7.1% 5.8% 4.7% 3.5% 2.7% 2.7% 3.2% 6.4% 4.0% 3.3% 2.5% 2.5% 4.0% 2.6% 7.9% 3.9% 6.4% 2.8% 4.1% 5.1%

21 75 277 499 512 360 93 266 373 453 390 263 286 1,163 214 64 46 1,285 33 522

30,619 32,097 3,993 4,202 62,592

91.6% 92.2% 85.3% 83.9% 92.0%

14,331 14,273 1,509 1,503 28,684

42.9% 41.0% 32.2% 30.0% 42.2%

16,288 17,824 2,484 2,699 33,908

48.7% 51.2% 53.1% 53.9% 49.9%

1,633 1,639 429 482 3,221

4.9% 4.7% 9.2% 9.6% 4.7%

1,176 1,088 259 322 2,205

3.5% 3.1% 5.5% 6.4% 3.2%

576 600 114 110 1,667

63,694 3,187 97 772 4,186 55,340 6,427 427 5,717 61,138

91.4% 93.5% 91.5% 91.5% 90.0% 91.4% 93.4% 93.2% 91.0% 91.5%

28,602 1,626 32 404 2,027 24,761 2,970 200 2,816 27,403

41.0% 47.7% 30.2% 47.9% 43.6% 40.9% 43.2% 43.7% 44.8% 41.0%

35,092 1,561 65 368 2,159 30,579 3,457 227 2,901 33,735

50.3% 45.8% 61.3% 43.6% 46.4% 50.5% 50.2% 49.6% 46.2% 50.5%

3,572 139 4 47 261 3,126 269 21 313 3,395

5.1% 4.1% --4 5.6% 5.6% 5.2% 3.9% 4.6% 5.0% 5.1%

2,449 84 5 25 206 2,110 184 10 251 2,266

3.5% 2.5% 4.7% 3.0% 4.4% 3.5% 2.7% 2.2% 4.0% 3.4%

1,708 133 11 53 137 1,147 121 29 235 1,215

NOTE: All percentages are calculated based on the Adequacy of Prenatal Care Utilization (APNCU) Index. See Glossary and Technical Notes in Appendix for definitions of Index and its categories. 1. Adequate Total is the sum of Adequate Intensive and Adequate Basic. 2. Parity is the number of live births including this birth. 3. Smoking during pregnancy is self-reported by the mother and should be interpreted with caution. 4. Calculations based on values of 1-4 are excluded.

80

Table 29 Adequacy of Prenatal Care Visits by Selected Characteristics, Massachusetts: 2009

Based on number of PNC Visits State Total Maternal Demographics Age <18 18-19 20-24 25-29 30-34 35-39 40+ Educational Attainment < High school High school Some college College > College Race/Ethnicity Hispanic White non-Hispanic Black non-Hispanic Asian Other Birthplace US/D.C. Puerto Rico/US Terr. Non-US-born Pregnancy-Related Factors Parity2 1 2-3 4+ Smoking3 Yes No Birth Outcomes Plurality Singleton Multiple birth Birthweight <500 g 500-1,499 g 1,500-2,499 g 2,500-3,999 g 4,000+ g Gestational Age <28 weeks <37 weeks 37-42 weeks Adequate Total1 n 67,173 % 91.9% Adequate Intensive n 32,584 % 44.6% Adequate Basic n 34,589 % 47.3% Intermediate n 5,192 % 7.1% Inadequate n 760 % 1.0%
Unknown

n 1,841

1,176 2,733 10,441 16,385 21,124 12,334 2,980 6,601 16,477 14,214 17,969 11,815 9,555 44,973 6,070 5,477 1,000 47,089 1,697 18,379

87.2% 88.6% 88.7% 91.2% 93.3% 93.7% 94.3% 87.5% 89.4% 92.5% 93.8% 94.5% 89.3% 92.5% 90.2% 93.2% 89.9% 92.1% 87.0% 91.7%

636 1,342 5,111 7,869 9,857 6,138 1,631 3,445 8,121 7,179 8,269 5,510 4,605 21,730 2,977 2,670 545 22,794 794 8,989

47.2% 43.5% 43.4% 43.8% 43.6% 46.6% 51.6% 45.7% 44.0% 46.7% 43.2% 44.0% 43.0% 44.7% 44.2% 45.4% 49.0% 44.6% 40.7% 44.8%

540 1,391 5,330 8,516 11,267 6,196 1,349 3,156 8,356 7,035 9,700 6,305 4,950 23,243 3,093 2,807 455 24,295 903 9,390

40.1% 45.1% 45.3% 47.4% 49.8% 47.1% 42.7% 41.8% 45.3% 45.8% 50.6% 50.4% 46.3% 47.8% 46.0% 47.8% 40.9% 47.5% 46.3% 46.8%

142 304 1,133 1,387 1,343 734 149 805 1,665 1,012 1,064 641 1,036 3,155 541 360 93 3,499 227 1,466

10.5% 9.9% 9.6% 7.7% 5.9% 5.6% 4.7% 10.7% 9.0% 6.6% 5.6% 5.1% 9.7% 6.5% 8.0% 6.1% 8.4% 6.8% 11.6% 7.3%

30 47 197 198 164 93 31 139 294 144 122 53 109 468 120 38 19 533 26 200

2.2% 1.5% 1.7% 1.1% 0.7% 0.7% 1.0% 1.8% 1.6% 0.9% 0.6% 0.4% 1.0% 1.0% 1.8% 0.6% 1.7% 1.0% 1.3% 1.0%

21 75 277 499 512 360 93 266 373 453 390 263 286 1,163 214 64 46 1,285 33 522

30,862 31,996 4,140 4,326 62,757

92.3% 91.9% 88.4% 86.4% 92.3%

14,716 15,613 2,152 2,343 30,196

44.0% 44.8% 46.0% 46.8% 44.4%

16,146 16,383 1,988 1,983 32,561

48.3% 47.0% 42.5% 39.6% 47.9%

2,257 2,486 437 524 4,663

6.8% 7.1% 9.3% 10.5% 6.9%

309 342 104 156 598

0.9% 1.0% 2.2% 3.1% 0.9%

576 600 114 110 1,667

63,839 3,334 101 822 4,378 55,514 6,297 441 5,975 61,174

91.6% 97.8% 95.3% 97.4% 94.1% 91.6% 91.5% 96.3% 95.1% 91.6%

29,687 2,897 95 737 3,483 25,793 2,435 408 5,232 27,337

42.6% 85.0% 89.6% 87.3% 74.9% 42.6% 35.4% 89.1% 83.3% 40.9%

34,152 437 6 85 895 29,721 3,862 33 743 33,837

49.0% 12.8% 5.7% 10.1% 19.2% 49.1% 56.1% 7.2% 11.8% 50.7%

5,132 60 0 13 200 4,448 528 6 200 4,986

7.4% 1.8% 0.0% 1.5% 4.3% 7.3% 7.7% 1.3% 3.2% 7.5%

744 16 5 9 75 614 55 11 106 639

1.1% 0.5% 4.7% 1.1% 1.6% 1.0% 0.8% 2.4% 1.7% 1.0%

1,708 133 11 53 137 1,147 121 29 235 1,215

NOTE: All percentages are calculated based on the Adequacy of Prenatal Care Utilization (APNCU) Index. See Glossary and Technical Notes in Appendix for definitions of Index and its categories. 1. Adequate Total is the sum of Adequate Intensive and Adequate Basic. 2. Parity is the number of live births including this birth. 3. Smoking during pregnancy is selfreported by the mother and should be interpreted with caution.

81

Table 30. Birth Characteristics by Race/Hispanic Ethnicity and Source of Prenatal Care Payment, Massachusetts: 2009
Births1 Race/Ethnicity and Payment Source STATE TOTAL4 Public Medicaid5 Other Public6 Private7 White non-Hispanic Public Medicaid5 Other Public6 Private7 Black non-Hispanic Public Medicaid5 Other Public6 Private7 Hispanic Public Medicaid5 Other Public6 Private7 Asian Public Medicaid5 Other Public6 Private7 Other9 Public Medicaid5 Other Public6 Private7 n
74,966 26,443 19,666 6,777 46,002 49,759 12,279 9,643 2,636 35,615 6,945 4,219 3,155 1,064 2,591 10,986 7,887 5,242 2,645 2,895 5,939 1,490 1,187 303 4,382 1,158 543 415 128 498

%
100.0 36.1 26.8 9.2 62.7 100.0 25.3 19.9 5.4 73.4 100.0 61.3 45.9 15.5 37.7 100.0 72.6 48.2 24.3 26.6 100.0 25.3 20.1 5.1 74.3 100.0 51.0 39.0 12.0 46.8

Teen Births <18 Years <20 Years n % n

1,369 1,027 794 233 297 484 311 255 56 154 185 145 118 27 31 604 502 359 143 88 57 45 43 2 12 37 24 19 5 11 1.8 3.9 4.0 3.4 0.6 1.0 2.5 2.6 2.1 0.4 2.7 3.4 3.7 2.5 1.2 5.5 6.4 6.8 5.4 3.0 1.0 3.0 3.6 --8 0.3 3.2 4.4 4.6 3.9 2.2 4,528 3,402 2,663 739 990 1,977 1,314 1,099 215 592 602 468 385 83 118 1,697 1,427 1,007 420 233 140 113 106 7 25 105 77 63 14 21

%
6.0 12.9 13.5 10.9 2.2 4.0 10.7 11.4 8.2 1.7 8.7 11.1 12.2 7.8 4.6 15.4 18.1 19.2 15.9 8.0 2.4 7.6 8.9 2.3 0.6 9.1 14.2 15.2 10.9 4.2

Birthweight Very Low 2 Low3 n % n

1,014 377 257 120 536 582 149 106 43 372 156 79 54 25 73 182 126 79 47 43 62 16 12 4 43 26 7 6 1 5 1.4 1.4 1.3 1.8 1.2 1.2 1.2 1.1 1.6 1.0 2.2 1.9 1.7 2.3 2.8 1.7 1.6 1.5 1.8 1.5 1.0 1.1 1.0 --8 1.0 2.2 1.3 1.4 --8 1.0 5,804 2,198 1,624 574 3,297 3,547 928 721 207 2,413 750 435 322 113 293 940 667 446 221 235 451 131 107 24 314 97 34 25 9 39

%
7.8 8.3 8.3 8.5 7.2 7.1 7.6 7.5 7.9 6.8 10.8 10.3 10.2 10.6 11.3 8.6 8.5 8.5 8.4 8.1 7.6 8.8 9.0 7.9 7.2 8.4 6.3 6.0 7.0 7.8

82

Table 30 (contd). Birth Characteristics by Race/Hispanic Ethnicity and Source of Prenatal Care Payment, Massachusetts: 2009
Prenatal Care Race/Ethnicity by PNC Payment Source STATE TOTAL4 Public Medicaid5 Other Public6 Private7 White non-Hispanic Public Medicaid5 Other Public6 Private7 Black non-Hispanic Public Medicaid5 Other Public6 Private7 Hispanic Public Medicaid5 Other Public6 Private7 Asian Public Medicaid5 Other Public6 Private7 Other9 Public Medicaid5 Other Public6 Private7 Adequate10 n %
61,669 19,967 15,106 4,861 40,433 42,167 9,615 7,592 2,023 31,556 5,116 2,900 2,282 618 2,173 8,476 5,920 4,003 1,917 2,469 4,945 1,112 899 213 3,805 874 402 313 89 412 84.3 77.1 78.0 74.2 89.0 86.8 79.4 79.8 78.1 89.8 76.0 71.2 74.4 61.7 85.3 79.2 76.9 77.5 75.6 86.4 84.2 75.6 76.4 72.4 87.3 78.6 74.9 76.2 70.6 83.7

Began 1st Trimester n %

60,758 19,103 14,483 4,620 40,345 41,975 9,276 7,316 1,960 31,656 4,927 2,781 2,187 594 2,105 8,133 5,635 3,850 1,785 2,411 4,771 1,002 808 194 3,743 857 389 303 86 413 82.6 73.2 74.5 69.4 88.6 85.9 76.3 76.6 75.2 89.9 72.3 67.4 70.6 57.6 82.0 75.3 72.4 74.2 68.9 84.1 81.0 67.8 68.5 65.3 85.8 76.2 72.3 73.7 67.7 83.8

Cesarean Delivery Breastfeeding11 n % n %

25,067 7,941 5,928 2,013 16,481 17,209 3,870 3,000 870 12,856 2,342 1,381 1,011 370 928 3,212 2,158 1,503 655 1,005 1,872 351 278 73 1,502 400 175 130 45 184 33.6 30.0 30.2 29.7 35.9 34.8 31.5 31.1 33.0 36.1 33.8 32.8 32.1 34.8 35.9 29.4 27.4 28.7 24.8 34.7 31.6 23.6 23.4 24.1 34.3 34.8 32.2 31.3 35.2 37.0 60,261 19,834 14,394 5,440 39,521 38,857 8,229 6,211 2,018 30,001 5,962 3,532 2,635 897 2,344 9,166 6,481 4,315 2,166 2,600 5,273 1,134 890 244 4,111 920 442 328 114 447 82.0 75.2 73.3 80.5 86.0 79.9 67.2 64.6 76.8 84.4 86.2 83.8 83.6 84.4 90.5 84.3 82.3 82.4 82.1 89.9 89.3 76.3 75.1 80.8 93.9 85.4 81.4 79.0 89.1 89.8

Smoking12 n %
5,116 3,683 3,013 670 1,248 4,015 2,753 2,349 404 1,115 365 311 234 77 43 547 478 301 177 55 96 73 69 4 19 89 66 58 8 16 6.8 13.9 15.3 9.9 2.7 8.1 22.4 24.4 15.3 3.1 5.3 7.4 7.4 7.2 1.7 5.0 6.1 5.7 6.7 1.9 1.6 4.9 5.8 --8 0.4 7.7 12.2 14.0 6.3 3.2

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. In the Births column, percentages are based on race/ethnicity category totals (in column). For all other characteristics, percentages are based on the total number of births for the race/ethnicity by payment source for the row. 2. Very low birthweight: less than 1,500 grams or 3.3 pounds. 3. Low Birthweight: less than 2,500 grams or 5.5 pounds. 4. Total births do not equal Public + Private because Workers Compensation, self-paid, and other are in the state total but not shown in the table. 5. Medicaid/MassHealth. 6. Other Public: CommonHealth, Healthy Start, Medicare, other government programs, and free care. 7. Private: commercial indemnity plans or commercial managed care organizations (HMO, PPO, IPP, or IPA). It does not include Self-Paid/Other. 8. Calculations based on values of 1-4 are excluded. 9. Other: Mothers who designated their race as American Indian or Other. 10. Based on the Adequacy of Prenatal Care Utilization (APNCU) Index. 11. Mother was breastfeeding or was intending to breastfeed at the time the birth certificate was completed. 12. Mother reported smoking during pregnancy.

83

Table 31. Cesarean Deliveries and Vaginal Births after Cesarean (VBACs) by Licensed Maternity Facility, All Births, Massachusetts: 2009
Facility
1

Occurrence Births2

Total Cesareans N %3,4 33.7 34.4 21.1 29.9 32.5 29.6 38.7 34.8 29.8 34.8 45.1 25.9 33.9 39.1 40.9 38.9 39.9 37.4 30.4 35.6 28.3 40.0 30.1 15.3 18.2 33.7 32.6 25.7 34.1 32.2 31.2 40.5 25.1

Primary Cesareans2 N 15,033 136 66 23 860 99 1,149 388 414 1,841 313 195 186 192 233 114 249 387 147 201 35 130 66 36 56 135 244 167 497 29 661 304 184 %3,5

Repeat Cesareans N %3,6

VBACs2 N %7 8.7

State Total Anna Jaques Hospital Baystate Franklin Medical Center Baystate Mary Lane Hospital Baystate Medical Center Berkshire Medical Center Beth Israel Deaconess Medical Center Beverly Hospital Boston Medical Center Brigham And Women's Hospital Brockton Hospital Cambridge Hospital Cape Cod Hospital Caritas Good Samaritan Medical Center Caritas Holy Family Hospital And Medical Center Caritas Norwood Hospital Caritas St. Elizabeth's Medical Center Of Boston Charlton Memorial Hospital Cooley Dickinson Hospital Emerson Hospital Fairview Hospital Falmouth Hospital Harrington Memorial Hospital Heywood Memorial Hospital Holyoke Hospital Jordan Hospital Lawrence General Hospital Leominster Hospital Lowell General Hospital Martha's Vineyard Hospital Massachusetts General Hospital Melrose-Wakefield Hospital Mercy Medical Center

75,443 735 487 154 4,314 648 4,792 2,173 2,411 8,144 1,192 1,317 899 891 1,015 509 957 1,591 773 1,133 166 546 339 503 529 676 1,602 1,099 2,391 149 3,601 1,212 1,258

25,292 253 103 46 1,401 192 1,853 639 719 2,827 538 341 305 348 415 198 380 595 235 403 47 217 102 77 96 228 522 282 815 48 1,125 491 316

23.6 10,259 22.7 14.9 17.6 23.3 18.3 28.7 24.8 19.7 26.5 32.8 17.1 23.9 26.2 28.1 27.6 31.2 28.0 22.0 22.0 22.7 28.5 21.9 7.9 11.8 23.4 18.5 17.0 24.1 22.3 21.4 29.7 16.4 117 37

91.3 975 86.7 86.0

18 13.3 6 14.0 0 0.0

23 100.0 541 93 704 251 305 986 225 146 119 156 182 84 131 87.8 86.1 89.8 92.3 99.0

75 12.2 15 13.9 80 10.2 21 3 7.7 --8

84.9 175 15.1 94.9 83.4 99.2 98.7 98.4 87.5 85.1 12 5.1 --8 --8 -8

29 16.6 1 2 3

12 12.5 23 14.9 0 0.0

208 100.0 88 202 83.0 91.8

18 17.0 18 0 0 1 8.2 0.0 0.0 --8

12 100.0 87 100.0 36 41 40 93 278 115 318 97.3 89.1 75.5 93.9 97.9 97.5 95.5

5 10.9 13 24.5 6 6 3 15 0 51 0 5 6.1 2.1 --8 4.5 0.0 9.9 0.0 3.6

19 100.0 464 90.1

187 100.0 132 96.4

84

Table 31 (contd). Cesarean Deliveries and Vaginal Births after Cesarean Section (VBACs) by Licensed Maternity Facility, All Births, Massachusetts: 2009
Facility
1

Occurrence 2 Births

Total Cesareans N %3,4 42.8 38.0 29.9 23.5 29.3 37.8 26.7 34.4 26.2 42.1 37.6 34.2 22.1 39.4 29.3 35.5

Primary Cesareans2 N 363 229 98 332 18 764 40 325 311 911 357 167 68 294 613 406 %3,5 29.4 27.5 19.6 17.8 17.1 26.3 16.7 23.9 18.3 31.3 27.6 22.8 15.3 28.5 17.2 23.1

Repeat Cesareans N 289 144 74 158 18 562 33 223 204 588 206 134 41 190 629 345 %3,6 100.0 96.0 97.4 70.5 100.0 92.0 100.0 95.7 77.3 91.3 100.0 91.8 85.4 96.0 91.4 97.2

VBACs2 N 0 6 2 66 0 49 0 10 60 56 0 12 7 8 59 10 %7 0.0 4.0 --8 29.5 0.0 8.0 0.0 4.3 22.7 8.7 0.0 8.2 14.6 4.0 8.6 2.8

Metrowest Medical Center-Framingham Union Campus Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Cottage Hospital Newton Wellesley Hospital North Adams Regional Hospital North Shore Medical Center - Salem Hospital Saint Vincent Hospital South Shore Hospital St. Luke's Hospital Sturdy Memorial Hospital Tobey Hospital Tufts Medical Center UMASS Memorial Medical Center - West Campus Winchester Hospital

1,522 982 576 2,084 123 3,512 273 1,594 1,967 3,558 1,501 880 493 1,228 4,242 2,116

652 373 172 490 36 1,326 73 548 515 1,499 563 301 109 484 1,242 751

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated. 1. A licensed maternity facility is a medical unit licensed by the Commonwealth for the care of women during pregnancy and childbirth. 2. See Glossary for definitions of occurrence births, primary and repeat Cesarean sections, and VBACs. The percentages provided in this table are based on occurrence births, and may differ from data that are based on resident births presented elsewhere in this book. 3. The percentage of Cesarean births reported is not adjusted for risk factors such as mothers age, birthweight, or complications of labor and delivery, which would influence the number of procedures in a particular facility. Caution should be used when comparing unadjusted percentages. 4. Percentage of total Cesarean = (total Cesarean births/all births) x 100. 5. Percentage primary Cesarean = (primary Cesarean /all births-repeat Cesarean -VBACs) x 100. 6. Percentage repeat Cesarean = (repeat Cesarean / (repeat Cesarean + VBACs)) x100. 7. Percentage VBACs= (VBAC deliveries/ (repeat Cesarean + VBAC)) x 100. 8. Calculations based on values of 1-4 are excluded.

85

Table 32. Cesarean Deliveries for Singleton Births by Licensed Maternity Facility and Number of Previous Births, Massachusetts: 2009
First Birth Facility1 State Total Anna Jaques Hospital Baystate Franklin Medical Center Baystate Mary Lane Hospital Baystate Medical Center Berkshire Medical Center Beth Israel Deaconess Medical Center Beverly Hospital Boston Medical Center Brigham And Womens Hospital Brockton Hospital Cambridge Hospital Births2 33,071 323 217 58 1,810 279 2,174 703 992 3,755 486 655 383 343 435 230 420 724 351 498 85 235 150 202 249 301 656 445 1,058 72 1,633 623 C-section n %3 10,374 109 48 15 557 78 755 209 268 1,134 230 155 121 133 176 90 156 277 112 152 28 95 47 24 36 94 167 110 340 25 431 237 31.4 33.7 22.1 25.9 30.8 28.0 34.7 29.7 27.0 30.2 47.3 23.7 31.6 38.8 40.5 39.1 37.1 38.3 31.9 30.5 32.9 40.4 31.3 11.9 14.5 31.2 25.5 24.7 32.1 34.7 26.4 38.0 Second or Later Birth without prior C-section Births2 27,472 255 215 73 1,683 252 1,527 588 1,057 2,584 445 473 360 375 379 177 310 624 295 385 67 213 144 246 220 250 621 518 941 58 1,201 361 C-section n %3 2,543 20 14 8 163 17 154 65 109 263 61 30 39 47 47 18 41 84 25 31 5 29 11 12 20 23 49 45 112 4 84 40 9.3 7.8 6.5 11.0 9.7 6.7 10.1 11.1 10.3 10.2 13.7 6.3 10.8 12.5 12.4 10.2 13.2 13.5 8.5 8.1 7.5 13.6 7.6 4.9 9.1 9.2 7.9 8.7 11.9
--4

Second or Later Birth with prior C-section Births2 10,459 123 41 19 551 98 740 225 297 951 223 173 116 151 175 94 143 199 104 205 11 87 35 46 53 98 271 117 314 19 483 181 C-section n %3 9,509 105 35 19 479 83 661 205 294 793 211 144 115 149 172 82 122 199 86 187 11 87 34 41 40 92 265 114 299 19 432 181 90.9 85.4 85.4 100.0 86.9 84.7 89.3 91.1 99.0 83.4 94.6 83.2 99.1 98.7 98.3 87.2 85.3 100.0 82.7 91.2 100.0 100.0 97.1 89.1 75.5 93.9 97.8 97.4 95.2 100.0 89.4 100.0

86

Cape Cod Hospital Caritas Good Samaritan Medical Center Caritas Holy Family Hospital And Medical Center Caritas Norwood Hospital Caritas St. Elizabeths Medical Center Of Boston Charlton Memorial Hospital Cooley Dickinson Hospital Emerson Hospital Fairview Hospital Falmouth Hospital Harrington Memorial Hospital Heywood Memorial Hospital Holyoke Hospital Jordan Hospital Lawrence General Hospital Leominster Hospital Lowell General Hospital Marthas Vineyard Hospital Massachusetts General Hospital Melrose-Wakefield Hospital

7.0 11.1

86

Table 32 (contd). Cesarean Deliveries for Singleton Births by Licensed Maternity Facility and Number of Previous Births, Massachusetts: 2009
First Birth Facility1 Mercy Medical Center Metrowest Medical Center-Framingham Union Campus Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Cottage Hospital Newton Wellesley Hospital North Adams Regional Hospital North Shore Medical Center - Salem Hospital Saint Vincent Hospital South Shore Hospital Births2 511 697 424 267 1,105 58 1,669 135 675 839 1,545 636 389 214 517 1,782 888 C-section n %3 136 298 157 73 267 15 569 30 225 218 655 253 124 39 160 460 286 26.6 42.8 37.0 27.3 24.2 25.9 34.1 22.2 33.3 26.0 42.4 39.8 31.9 18.2 30.9 25.8 32.2 Second or Later Birth without prior C-section Births2 588 498 380 229 700 47 1,080 101 647 813 1,211 618 333 216 371 1,611 789 C-section n %3 41 40 51 23 39 3 75 6 76 60 139 82 31 20 51 68 68 7.0 8.0 13.4 10.0 5.6
--4

Second or Later Birth with prior C-section Births2 133 287 146 72 212 18 590 30 221 255 614 204 142 45 174 611 347 C-section n %3 128 287 140 70 146 18 541 30 211 195 558 204 130 38 166 553 337 96.2 100.0 95.9 97.2 68.9 100.0 91.7 100.0 95.5 76.5 90.9 100.0 91.5 84.4 95.4 90.5 97.1

St. Lukes Hospital Sturdy Memorial Hospital Tobey Hospital Tufts Medical Center UMass Memorial Medical Center - West Campus Winchester Hospital

6.9 5.9 11.7 7.4 11.5 13.3 9.3 9.3 13.7 4.2 8.6

87

NOTE: All percentages are calculated based on only those births with known values for the characteristic(s) of interest, unless otherwise stated.

1. A licensed maternity facility is a medical unit licensed by the Commonwealth for the care of women during pregnancy and childbirth. 2. See Glossary for definitions of occurrence births. 3. The percentage of Cesarean births reported is not adjusted for risk factors such as mothers age, birthweight, or complications of labor and delivery, which would influence the number of procedures in a particular facility. Caution should be used when comparing unadjusted percentages. 4. Calculations based on 1-4 events are excluded.

87

Table 33. Birth Characteristics: Occurrence and Resident Births and Infant Deaths, Massachusetts Municipalities: 2009 Table 33 (contd).
Community Occurrence 1 Births Resident 2 Births Low 3 Birthweight Teen Births 15-19 yr Infant 4 Deaths Neonatal 5 Deaths Fetal 6 Deaths

STATE TOTAL ABINGTON ACTON ACUSHNET ADAMS AGAWAM ALFORD AMESBURY AMHERST ANDOVER ARLINGTON ASHBURNHAM ASHBY ASHFIELD ASHLAND ATHOL ATTLEBORO AUBURN AVON AYER BARNSTABLE BARRE BECKET BEDFORD BELCHERTOWN BELLINGHAM BELMONT BERKLEY BERLIN BERNARDSTON BEVERLY BILLERICA BLACKSTONE BLANDFORD BOLTON BOSTON BOURNE BOXBOROUGH BOXFORD BOYLSTON BRAINTREE BREWSTER BRIDGEWATER

75,443 1 1 0 1 1 0 0 7 3 6 0 0 1 0 1 882 1 1 0 901 1 0 2 1 2 2 0 0 0 2,282 1 0 0 0 21,177 0 0 0 0 2 0 0

74,966 201 179 90 63 197 0 210 156 273 621 46 27 10 225 134 567 150 49 110 417 58 14 149 123 202 282 60 19 11 476 457 96 7 42 7,976 192 39 42 38 424 66 171

5,804 16 15 5 6 17 0 16 7 11 50
--7 --7

4,477
--7 --7

7 5 11 0 7 5
--7 --7 --7

0 9 7 52 5
--7 --7

0 0
--7

10 39
--7 --7

30 5
--7

8 21
--7 --7 --7 --7

12 13 17 11
--7

10
--7 --7

0 0 16 34 8 0
--7

0 0 13 13
--7 --7

711 12
--7 --7

0 521 12
--7

6 28
--7

0 0 14 6
--7

354 1 3 0 0 1 0 1 1 4 2 1 0 5 2 1 2 4 0 0 3 1 0 2 0 0 0 21 0 0 1 2 1 0 0 52 0 0 1 0 0 0 0

266 1 3 0 0 1 0 1 1 2 1 1 0 5 2 1 1 4 0 0 1 0 0 2 0 0 0 15 0 0 0 2 0 0 0 39 0 0 1 0 0 0 0

378
--7

0 0
--7

0 0
--7 --7 --7 --7

0 0 0 0
--7 --7 --7

0 0
--7

0 0
--7

0
--7 --7

0 0 0
--7 --7

0 0 0 43 0 0 0 0 0
--7 --7

88

Table 33 (contd).
Community Occurrence 1 Births Resident 2 Births Low 3 Birthweight
--7

Teen Births 15-19 yr

--7

Infant 4 Deaths

Neonatal 5 Deaths

Fetal 6 Deaths

BRIMFIELD BROCKTON BROOKFIELD BROOKLINE BUCKLAND BURLINGTON CAMBRIDGE CANTON CARLISLE CARVER CHARLEMONT CHARLTON CHATHAM CHELMSFORD CHELSEA CHESHIRE CHESTER CHESTERFIELD CHICOPEE CHILMARK CLARKSBURG CLINTON COHASSET COLRAIN CONCORD CONWAY CUMMINGTON DALTON DANVERS DARTMOUTH DEDHAM DEERFIELD DENNIS DIGHTON DOUGLAS DOVER DRACUT DUDLEY DUNSTABLE DUXBURY EAST BRIDGEWATER EAST BROOKFIELD EAST LONGMEADOW EASTHAM EASTHAMPTON EASTON EDGARTOWN

0 2,085 0 3 0 2 3,535 0 0 0 1 0 0 0 1 0 2 0 2 0 0 0 0 0 1,135 0 2 0 1 0 0 0 1 1 2 0 0 0 0 0 0 0 0 0 2 0 0

26 1,474 33 676 12 319 1,266 234 22 120 12 135 29 328 702 23 14 8 643 6 9 167 57 11 126 8 10 40 251 212 266 47 136 58 101 31 325 94 26 91 136 23 135 33 156 212 37

125
--7

137
--7 --7

59 0 18 102 15 0 6 0 7 7 20 72 0
--7

0 7 16
--7

0 6 0 5 0 6 76
--7

0
--7

0 49 0 0 13
--7 --7

72 0
--7

13
--7

7
--7

0 0
--7 --7 --7 --7

0
--7

14 11 15
--7

18 6
--7

17 7
--7 --7

10
--7

--

--7

18 9 0 6 8
--7 --7 --7

0 13 5
--7 --7 --7 --7 --7 --7

16 17
--7

6 7
--7

0 10 0 0 0 0 8 1 0 1 0 0 0 1 1 0 0 0 4 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 2 1 0 0 0 0 0 0

0 6 0 0 0 0 7 1 0 1 0 0 0 1 1 0 0 0 3 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0

0 16 0
--7

0 0 8 0 0 0 0
--7

0
--7 --7

0 0 0 0 0 0
--7

0 0 0 0 0 0 0
--7

0 0
--7 --7

0 0
--7

0
--7

0 0 0
--7

0
--7 --7 --7

89

Table 33 (contd).
Community Occurrence 1 Births Resident 2 Births Low 3 Birthweight
--7 --7 --7

Teen Births 15-19 yr

Infant 4 Deaths

Neonatal 5 Deaths

Fetal 6 Deaths

EGREMONT ERVING ESSEX EVERETT FAIRHAVEN FALL RIVER FALMOUTH FITCHBURG FLORIDA FOXBOROUGH FRAMINGHAM FRANKLIN FREETOWN GARDNER GAY HEAD GEORGETOWN GILL GLOUCESTER GOSHEN GOSNOLD GRAFTON GRANBY GRANVILLE GREAT BARRINGTON GREENFIELD GROTON GROVELAND HADLEY HALIFAX HAMILTON HAMPDEN HANCOCK HANOVER HANSON HARDWICK HARVARD HARWICH HATFIELD HAVERHILL HAWLEY HEATH HINGHAM HINSDALE HOLBROOK HOLDEN HOLLAND HOLLISTON

1 0 0 2 0 1,592 547 2 0 2 1,527 1 1 505 0 0 1 1 0 0 0 0 0 167 490 5 1 2 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0

9 17 32 626 137 1,202 257 586 4 139 976 302 75 240 3 87 9 266 9 0 217 29 11 46 200 87 55 29 64 91 35 5 133 102 22 28 90 15 895 3 7 238 9 110 167 20 116

0 ---7

51 8 103 19 53 0 6 76 26 6 20 0
--7 --7

37 7 129 17 64
--7

5 50
--7

5 24 0 0
--7

15 0 0 18
--7 --7 --7

9 0 0 5
--7

0
--7

15
--7

6
--7 --7 --7 --7

15 0 0 0 0
--7 --7

0 5 8
--7 --7 --7

0
--7

9
--7

0 50 0
--7

0 6 0 70 0 0
--7

19 0 9 17
--7

0 6 0
--7 --7

0 0 0 7 0 5 2 0 0 0 5 1 0 5 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 2 0 0 0 0 1 0 0 3 0 1 0 0 3

0 0 0 6 0 3 2 0 0 0 3 1 0 5 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 2 0 0 0 0 1 0 0 3 0 0 0 0 1

0 0
--7 --7

0 7
--7 --7

0
--7 --7

0 0 0 0 0 0 0 0 0
--7

0 0 0
--7 --7 --7 --7

0 0
--7

0
--7 --7

0 0 0 0
--7

0 0
--7

0 0 0 0
--7

90

Table 33 (contd).
Community Occurrence 1 Births Resident 2 Births Low 3 Birthweight Teen Births 15-19 yr Infant 4 Deaths Neonatal 5 Deaths Fetal 6 Deaths

HOLYOKE HOPEDALE HOPKINTON HUBBARDSTON HUDSON HULL HUNTINGTON IPSWICH KINGSTON LAKEVILLE LANCASTER LANESBOROUGH LAWRENCE LEE LEICESTER LENOX LEOMINSTER LEVERETT LEXINGTON LEYDEN LINCOLN LITTLETON LONGMEADOW LOWELL LUDLOW LUNENBURG LYNN LYNNFIELD MALDEN MANCHESTER MANSFIELD MARBLEHEAD MARION MARLBOROUGH MARSHFIELD MASHPEE MATTAPOISETT MAYNARD MEDFIELD MEDFORD MEDWAY MELROSE MENDON MERRIMAC METHUEN MIDDLEBOROUGH MIDDLEFIELD

533 0 0 0 1 1 0 1 0 0 1 0 1,605 0 0 0 1,102 0 1 0 1 0 0 2,398 1 0 6 0 2 0 0 0 0 3 1 0 0 2 0 3 1 1,213 1 0 1,017 0 0

653 52 133 40 223 80 28 97 119 86 67 21 1,426 55 90 25 528 8 206 8 59 81 102 1,736 157 90 1,502 88 973 27 243 156 29 528 239 124 39 138 72 691 113 295 49 36 574 234 4

68
--7

146
--7

8 0 20 10
--7

0 0 14 5
--7

8 12
--7

5
--7 --7 --7 --7

5
--7

120 5 7 0 39 0 24
--7 --7

239
--7

6 0 41 0
--7 --7 --7 --7 --7

8 6 178 14
--7

210 5
--7

104 6 84 0 23 16
--7

172
--7

34 11 6 0
--7

24 0 9 5 0 22 5 10 0
--7

5 51 9 19
--7 --7

0 11
--7 --7

56 9
--7

0 5 40 22 0

5 0 0 0 1 0 0 0 1 0 0 0 10 0 0 0 1 0 0 0 0 0 0 10 1 0 7 0 2 0 0 4 0 7 0 0 0 0 0 1 2 2 0 0 1 1 0

3 0 0 0 1 0 0 0 0 0 0 0 6 0 0 0 1 0 0 0 0 0 0 6 0 0 4 0 2 0 0 4 0 5 0 0 0 0 0 1 2 2 0 0 1 1 0

8 0
--7

0
--7

0 0
--7

0 0 0 0 11 0 0 0
--7

0
--7

0 0 0
--7

8 0
--7

8 0 6 0 0
--7

0
--7 --7 --7

0
--7

0
--7

0
--7

0 0 5 0 0

91

Table 33 (contd).
Community Occurrence 1 Births Resident 2 Births Low 3 Birthweight
--7

Teen Births 15-19 yr

Infant 4 Deaths

Neonatal 5 Deaths

Fetal 6 Deaths

MIDDLETON MILFORD MILLBURY MILLIS MILLVILLE MILTON MONROE MONSON MONTAGUE MONTEREY MONTGOMERY MOUNT WASHINGTON NAHANT NANTUCKET NATICK NEEDHAM NEW ASHFORD NEW BEDFORD NEW BRAINTREE NEW MARLBOROUGH NEW SALEM NEWBURY NEWBURYPORT NEWTON NORFOLK NORTH ADAMS NORTH ANDOVER NORTH ATTLEBORO NORTH BROOKFIELD NORTH READING NORTHAMPTON NORTHBOROUGH NORTHBRIDGE NORTHFIELD NORTON NORWELL NORWOOD OAK BLUFFS OAKHAM ORANGE ORLEANS OTIS OXFORD PALMER PAXTON PEABODY PELHAM

0 983 1 0 0 0 0 0 2 0 0 0 0 125 3 2 0 1,504 0 1 0 0 736 3,515 0 274 0 1 0 0 786 1 1 0 0 0 512 149 0 0 0 0 1 0 2 0 0

61 365 145 85 40 264 0 70 97 6 9 1 22 152 432 298 0 1,363 4 15 6 41 180 806 82 157 308 302 46 149 205 122 207 21 175 90 365 64 8 83 16 10 155 121 29 487 10

21 11 8
--7

0 11 5
--7 --7 --7

21 0
--7

5 0
--7

0 5 14
--7

0
--7

0 0 0
--7

7 38 15 0 143 0
--7

0
--7

7 61 9 11 32 16
--7

6 0 0 173 0 0 0 0 10
--7 --7

29 10 7
--7 --7

15 16 8 13 5 20 8 34 6
--7

13
--7

17
--7

10 0 6
--7

8 0 0 6 6
--7

0 6
--7

0 7 9
--7

32
--7

16
--7

0 3 0 1 0 2 0 0 0 0 0 0 0 0 2 0 0 5 0 1 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 4 0

0 3 0 1 0 2 0 0 0 0 0 0 0 0 2 0 0 4 0 1 0 0 0 1 0 0 1 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 3 0

0
--7 --7 --7 --7 --7

0
--7

0 0 0 0 0
--7

0 0 0 9 0 0 0 0 0
--7 --7 --7

0
--7

0 0 0 0 0 0 0 0
--7

0 0
--7 --7 --7

0
--7

0
--7

92

Table 33 (contd).
Community Occurrence 1 Births Resident 2 Births Low 3 Birthweight Teen Births 15-19 yr Infant 4 Deaths Neonatal 5 Deaths Fetal 6 Deaths

PEMBROKE PEPPERELL PERU PETERSHAM PHILLIPSTON PITTSFIELD PLAINFIELD PLAINVILLE PLYMOUTH PLYMPTON PRINCETON PROVINCETOWN QUINCY RANDOLPH RAYNHAM READING REHOBOTH REVERE RICHMOND ROCHESTER ROCKLAND ROCKPORT ROWE ROWLEY ROYALSTON RUSSELL RUTLAND SALEM SALISBURY SANDISFIELD SANDWICH SAUGUS SAVOY SCITUATE SEEKONK SHARON SHEFFIELD SHELBURNE SHERBORN SHIRLEY SHREWSBURY SHUTESBURY SOMERSET SOMERVILLE SOUTH HADLEY SOUTHAMPTON SOUTHBOROUGH

0 0 0 0 0 649 0 0 679 0 1 0 3 2 0 1 0 0 0 0 0 0 0 0 0 1 1 1,595 2 0 0 0 0 0 0 1 0 1 0 1 1 3 0 8 1 0 0

182 100 2 12 13 518 4 88 629 19 25 16 1,263 384 150 268 94 712 5 41 221 49 4 60 7 21 76 527 72 5 163 233 1 154 88 102 26 18 17 58 371 12 127 1,001 134 41 77

10 7 0
--7 --7

5 5 0 0
--7

44 0 7 37 0
--7

70 0
--7

20
--7

0 83 39 15 22 7 51 0
--7

0 0 23 9 8
--7

0 56 0
--7

8
--7

5
--7 --7 --7 --7 --7 --7

0
--7

0
--7 --7

42 5 0 11 17 0 12
--7 --7 --7 --7 --7

20 8 0
--7

5 0
--7

0
--7 --7 --7

0
--7 --7 --7

5 23 0 9 83 13
--7

5 40 8 0 0

2 0 0 0 1 3 0 0 1 0 0 1 6 6 0 1 0 2 0 0 1 0 0 0 0 0 1 1 0 0 2 0 0 0 0 0 0 1 0 1 0 0 0 6 1 0 1

2 0 0 0 1 3 0 0 0 0 0 0 4 5 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 6 1 0 1

0
--7

0 0 0
--7

0 0
--7

0 0 0 7
--7

0 0 0
--7

0 0
--7

0 0 0 0 0 0
--7 --7

0 0
--7

0 0 0 0
--7 --7

0 0
--7

0 0
--7

0 0 0

93

Table 33 (contd).
Community Occurrence 1 Births Resident 2 Births Low 3 Birthweight Teen Births 15-19 yr Infant 4 Deaths Neonatal 5 Deaths Fetal 6 Deaths
--7

SOUTHBRIDGE SOUTHWICK SPENCER SPRINGFIELD STERLING STOCKBRIDGE STONEHAM STOUGHTON STOW STURBRIDGE SUDBURY SUNDERLAND SUTTON SWAMPSCOTT SWANSEA TAUNTON TEMPLETON TEWKSBURY TISBURY TOLLAND TOPSFIELD TOWNSEND TRURO TYNGSBOROUGH TYRINGHAM UPTON UXBRIDGE WAKEFIELD WALES WALPOLE WALTHAM WARE WAREHAM WARREN WARWICK WASHINGTON WATERTOWN WAYLAND WEBSTER WELLESLEY WELLFLEET WENDELL WENHAM WEST BOYLSTON WEST BRIDGEWATER WEST BROOKFIELD WEST NEWBURY

340 0 0 5,590 0 1 0 0 0 1 2 0 0 0 0 577 3 1 1 0 0 1 0 0 0 3 0 1 0 0 2 155 493 1 0 0 1 2 0 2 0 0 0 0 1 0 1

235 78 126 2,445 56 10 250 265 81 97 138 24 80 126 134 741 95 281 54 6 44 75 11 97 2 64 153 275 20 199 815 110 216 59 6 3 445 105 234 215 20 9 28 58 49 35 38

20 10 15 221
--7

31 5 9 438
--7

0 15 23 6
--7

0 5 9
--7 --7

8
--7

5
--7

0 0 5
--7

12 60 7 21 9 0
--7

5 70 6 12
--7

0 0
--7 --7

6
--7

6 0 7 8 14
--7

5
--7 --7

8 7 0
--7

6 82 5 20 8
--7

22 12 17
--7 --7

0 30 12 20 15
--7

0 5
--7

26
--7 --7 --7

0
--7 --7

0
--7 --7

9 5
--7

0 0

0 0 0 13 0 0 2 0 0 0 0 0 0 0 1 3 0 1 0 0 0 0 0 0 0 0 0 1 0 0 3 0 2 0 0 0 0 2 1 0 0 0 0 0 0 1 0

0 0 0 9 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 3 0 2 0 0 0 0 2 1 0 0 0 0 0 0 1 0

0
--7

27 0 0
--7 --7

0 0
--7

0 0
--7

0
--7

0 0 0 0 0 0 0
--7

0 0
--7

0 0 5
--7 --7

0 0 0 0
--7 --7

0 0 0
--7 --7

0 0 0 0

94

Table 33 (contd).
Community Occurrence 1 Births Resident 2 Births Low 3 Birthweight Teen Births 15-19 yr Infant 4 Deaths Neonatal 5 Deaths Fetal 6 Deaths
--7

WEST SPRINGFIELD WEST STOCKBRIDGE WEST TISBURY WESTBOROUGH WESTFIELD WESTFORD WESTHAMPTON WESTMINSTER WESTON WESTPORT WESTWOOD WEYMOUTH WHATELY WHITMAN WILBRAHAM WILLIAMSBURG WILLIAMSTOWN WILMINGTON WINCHENDON WINCHESTER WINDSOR WINTHROP WOBURN WORCESTER WORTHINGTON WRENTHAM YARMOUTH

3 0 1 0 6 1 0 0 0 0 0 3,561 0 0 0 1 0 4 1 2,119 0 0 2 6,220 0 0 0

372 4 24 243 440 171 13 48 80 119 114 623 9 160 80 17 46 238 107 222 2 165 504 2,592 4 105 220

31 0 0 16 37 8
--7 --7

27 0
--7 --7

17
--7

0
--7

7 6 8 43
--7

0
--7 --7

8 5 0 8 16 6 10 0 20 40 226 0 7 18

10 0 7
--7

0 0
--7

12 0 0 7 17 219 0 0 11

1 0 0 0 1 0 0 0 0 0 0 2 0 1 0 0 0 0 1 0 0 0 4 10 0 4 1

0 0 0 0 1 0 0 0 0 0 0 2 0 0 0 0 0 0 1 0 0 0 4 7 0 4 1

0 0 0
--7 --7

0 0 0
--7

0
--7

0 0 0
--7

0
--7 --7 --7

0 0
--7

14 0 0 0

Note that infant deaths are based on a preliminary death file as of the release of this report. 1. Births occurring in a geographical place (state, city/town) regardless of the residency of the mother. See Glossary for more details. 2. Births to mothers who report their usual place of residence as a particular geographical place (state, or city/town). See Glossary for more details. 3. Less than 2,500 grams (5.5 lbs.). 4. Death of a child whose age is less than one year. 5. Death of a child whose age is less than 28 days. 6. A stillbirth delivered, extracted or expulsed at 20 weeks gestation or more or weighs 350 grams or more. 7. Due to small numbers (n=1-4), exact count not provided.

95

Table 34. Birth Characteristics: Occurrence and Resident Births and Infant Deaths by County, Massachusetts: 2009

Resident Births2 County Occurrence Births1

75,443 1,449 1,094 4,558 151 7,252 499 6,139 958 15,506 125 4,095 3,261 21,178 9,178

Deaths Infant Deaths4

354 9 4 38 0 37 9 26 3 83 0 27 29 55 34

Number
74,966 1,790 1,136 6,149 188 8,860 652 5,662 1,105 17,977 152 7,127 5,317 9,555 9,296

Low Birthweight3
5,804 130 82 525 16 604 53 487 79 1,387 7 519 368 854 693

Teen Births (15-19 years)

4,477 102 122 507 6 650 50 747 56 606
--7

Neonatal Deaths5
266 5 4 24 0 25 8 17 3 68 0 23 20 41 28

Fetal Deaths6
378 9 10 29
--7

STATE TOTAL Barnstable Berkshire Bristol Dukes Essex Franklin Hampden Hampshire Middlesex Nantucket Norfolk Plymouth Suffolk Worcester

46 5 45 6 74
--7

130 267 660 572

28 29 48 44

Note that infant deaths are based on a preliminary death file as of the release of this report. 1. Births occurring in a geographical place (state, city/town) regardless of the residency of the mother. See Glossary for more details. 2. Births to mothers who report their usual place of residence as a particular geographical place (state, or city/town). See Glossary for more details. 3. Less than 2,500 grams (5.5 lbs.). 4. Death of a child whose age is less than one year. 5. Death of a child whose age is less than 28 days. 6. A stillbirth delivered, extracted or expulsed at 20 weeks gestation or more or weighs 350 grams or more. 7. Due to small numbers (n=1-4), exact count not provided.

96

Table 35. Birth Characteristics: Occurrence and Resident Births and Infant Deaths, Massachusetts Community Health Network Areas (CHNAs), Massachusetts: 2009
Resident Births2 Community Health Network Area
STATE TOTAL Community Health Network of Berkshire County Upper Valley Health Web (Franklin County) Partnership for Health in Hampshire County (Northampton) The Community Health Connection (Springfield) Community Health Network of Southern Worcester County Community Partners for Health (Milford) Community Health Network of Greater Metro West (Framingham) Community Wellness Coalition (Worcester) Fitchburg/Gardner Community Health Network Greater Lowell Community Health Network Greater Lawrence Community Health Network Greater Haverhill Community Health Network Community Health Network North (Beverly/Gloucester) North Shore Community Health Network Greater Woburn/Concord/Littleton Community Health Network North Suburban Health Alliance (Medford/Malden/Melrose) Greater Cambridge/Somerville Community Health Network West Suburban Health Network (Newton/Waltham) Alliance for Community Health (Boston/Chelsea/Revere/Winthrop) Blue Hills Community Health Alliance (Greater Quincy) Four (For) Communities (Holyoke, Chicopee, Ludlow, Westfield) Greater Brockton Community Health Network South Shore Community Partners in Prevention (Plymouth) Greater Attleboro-Taunton Health & Education Response Partners for a Healthier Community (Fall River) Greater New Bedford Health & Human Services Coalition Cape and Islands Community Health Network

Deaths Infant
4

Occurrence Births1
75,443 1,094 500 958 5,595 343 994 1,543 6,226 1,624 2,401 2,625 741 2,284 1,602 3,267 1,222 3,552 3,521 21,181 4,082 544 2,088 680 1,461 1,592 1,998 1,725

Number
74,966 1,136 818 1,077 3,689 1,338 1,824 4,324 3,857 2,809 3,421 2,642 1,716 1,110 3,392 2,144 3,527 3,615 2,625 10,231 4,278 1,935 2,827 1,919 2,798 1,582 2,202 2,130

LBW

Teen Births (15-19 years)

4,477 122 62 54 505 93 67 120 243 190 263 290 103 32 225 38 90 67 37 662 80 242 183 56 172 143 228 110

Neonatal5
266 4 10 3 10 2 6 22 11 10 10 10 3 0 12 9 14 14 4 41 18 7 8 6 18 3 6 5

Fetal6
378 10 6 6 34 6 6 26 21 13 18 17 7
--7

5,804 82 63 78 312 105 124 303 318 187 285 222 97 50 235 157 271 276 204 913 319 170 228 107 218 130 197 153

354 4 11 3 15 2 7 28 14 12 15 16 3 1 17 9 16 16 4 55 21 11 14 10 28 6 7 9

97

18 6 15 12
--7

49 17 11 23 7 10 8 10 12

Note that infant deaths are based on a preliminary death file as of the release of this report. 1. Births occurring in a geographical place (state, city/town) regardless of the residency of the mother. See Glossary for more details. 2. Births to mothers who report their usual place of residence as a particular geographical place (state, city/town). See Glossary for more details. 3. Less than 2,500 grams (5.5 lbs.). 4. Death of a child whose age is less than one year. 5. Death of a child whose age is less than 28 days. 6. A stillbirth delivered, extracted or expulsed at 20 weeks gestation or more or weighs 350 grams or more. 7. Due to small numbers (n=14), exact count not provided. 97

Technical Notes

Data Cautions
Limitations of small numbers: Cells in some tables in this publication, and particularly those tables specific to individual cities and towns, contain small numbers. Rates and proportions based on fewer than five observations are suppressed, and trends based upon small numbers should be interpreted cautiously. Differences with previously published data Numbers and rates in this publication may differ from those in previous reports because of updated birth and death files, or release of the most up-to-date population estimates for a given year (see Population Denominators for details on population files).

Self-reported data Many statistics reported in this publication, such as maternal smoking, education, and race/ethnicity are self-reported, and are subject to the usual limitations of this type of information.

Changes in the Collection of Race/Ethnicity Information

Assignment of an Infant's Race/Ethnicity Prior to 1989, the race/ethnicity of an infant was assigned by combining information on the race/ethnicity of the mother and the race/ethnicity of the father. Since 1989, Massachusetts has followed the recommendation of the National Center for Health Statistics of classifying births according to the self-reported race/ethnicity of the mother. Therefore, beginning in 1989, the race/ethnicity of an infant is identical to the self-reported race/ethnicity of the infant's mother.

Addition of Information on Hispanic Ethnicity Beginning in 1986, an identifier for Hispanic ethnicity was added to the birth certificate; in 1989, an identifier for Hispanic ethnicity was added to the death certificate. Prior to these changes, most infants and mothers of Hispanic ethnicity were included with Whites and it was not possible to accurately calculate Hispanic-specific rates of natality and mortality.

98

Changes in Mothers Ancestry Reporting The following table is from the Parent Worksheet for the birth certificate, which is the selfreported information we use to report on mothers ancestry.
MOTHERs ANCESTRY HISPANIC/LATINA 1 2 3 4 5 6 Puerto Rican Dominican Mexican Cuban Colombian Salvadoran
Please mark the one category that best describes the mothers ancestry of ethnic heritage:

AFRICAN/AFRICAN AMERICAN 29 30 31 African-American/ Afro-American Nigerian Other African specify):_______________

7 Other Central American (specify) ______________________________ 8 Other South American (specify) ______________________________ 9 Other Hispanic/Latina (specify):

MIDDLE EASTERN 32 Lebanese 33 Iranian 34 Israeli 35 Other Middle Eastern (specify):________ AMERICAN ANCESTRY 36 Native American/ American Indian (specify tribe/affiliation):__________________ 37 American EUROPEAN and OTHER ancestries 38 European (specify): _____________________________________ 39 Other (specify): _____________________________________

ASIAN/PACIFIC ISLANDER 10 Chinese 17 Laotian 18 Pakistani 11 Vietnamese 12 Cambodian 19 Thai 20 Hawaiian 13 Asian Indian 14 Korean 21 Other Asian/Pacific Islander(specify) __________________________________ 15 Filipino 16 Japanese PORTUGUESE SPEAKING 22 23 Cape Verdean 24 Other Portuguese (specify): Brazilian ______________________________

WEST INDIAN/CARIBBEAN ISLANDER 25 26 27 Haitian Jamaican Barbadian 28 OtherWest Indian/Caribbean Islander (specify):_________________________

Beginning in 2006, we eliminated the Other categories from the mothers ancestries and used the literal ancestry text to create new categories such as Honduran and Guatemalan, which a large number of mothers wrote in for Other Hispanic/Latina. In 2006, we reported on groups that had greater than 400 births. Since 2007, certain ancestry groups were combined to form meta-groups: Lebanese, Iranian, Israeli, and Other Middle Eastern ancestries were combined into Middle Eastern; Colombian and Other South American were combined into South American; and Nigerian and Other African were combined into African.

Population Denominators
In the Massachusetts Births 2009, there are two sources for the population denominators used to calculate population-based rates. For state level birth rates e.g., birth rate, teen birth rate, teen birth rates by race and Hispanic ethnicity, age-specific birth rates, and the crude birth rate, we used the latest available population for 2009, the MARS (Modified Age, Race/Ethnicity, and Sex) file, which is produced by the National Center for Health Statistics (NCHS) and the Census Bureau Population Estimates Program. This file has data by single year or age, sex, race and Hispanic ethnicity in the five mutually exclusive categories used by the Department: White NonHispanic, Black Non-Hispanic, Asian Non-Hispanic, American Indian/Alaska Native Non-

99

Hispanic, and Hispanic. These estimates are not available for geographic levels below the county. See the Note to Readers at the beginning of this report. For city and town rates, we have used population estimates for 2005, which are the most up-todate population estimates available by age, race, and sex at the sub-county level. If the population in your community increased from 2005 to 2009, the rates listed may overestimate the actual rate. If the population in your community declined from 2005 to 2009, the rates given in the publication may underestimate the actual rate. As soon as new population data are available, revised rates will be posted on MassCHIP, the Departments online database (http://masschip.state.ma.us). Note on Population Estimate Changes Due to Readjustment for Boston and Medford: In 2006, the cities of Boston and Medford challenged the Census Bureaus population estimates for their cities. Boston disagreed with the estimates that showed Boston had lost 30,000 in population since 2000. The Census Bureau accepted much of that challenge and increased the city's estimated population for 2005 from 559,034 to 596,638, an increase of 37,604 or 6.7%. The Census Bureau accepted Medfords challenge and increased its estimate for 2005 from 53,523 to 55,798, an increase of 2,275 or 4.3%. The combined population increase for the two cities was 39,879. One impact of these adjustments was an increase in the states female teen population of 12,111. Since the Census Bureaus 2006 population estimates are based upon their (final) 2005 estimates, this means that the 2006 teen population is 13,540 larger than the original 2005 estimate. Refer to Table 36 for the statewide age, race, and sex population distribution. Source for 2009 Population Estimates National Center for Health Statistics. Postcensal estimates of the resident population of the United States for July 1, 2000-July 1, 2009, by year, county, age, bridged race, Hispanic origin, and sex (Vintage 2009). Prepared under a collaborative arrangement with the US Census Bureau; released July 23, 2010. Available from: http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm as of March 28, 2011. Source for 2005 Population Estimates (used for city/town rates) Massachusetts Department of Public Health, Bureau of Health Information, Statistics, Research, and Evaluation, Division of Research and Epidemiology. Massachusetts Department of Public Health Modified Age, Race/Ethnicity, and Sex (MMARS00-05) which is based upon 2005 estimates produced by the National Center for Health Statistics in collaboration with the Census Bureaus Population Estimation Program. October 2006. Available on the Internet from: http://masschip.state.ma.us. For additional information about population and MDPH estimation methods, refer to the Technical Notes in the report, Massachusetts Births 2005, which can be downloaded from the following website: http://www.mass.gov/dph/pubstats.htm

100

Table 36. 2009 Massachusetts Population Estimates by Age Group, Gender, Race and Hispanic Ethnicity (mutually exclusive)
Age Group Total1 White NonHispanic Black NonHispanic Female 0 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50+ All Females 0 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50+ All Males 0 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50+ State Total
189,011 191,868 195,001 229,058 230,539 216,562 208,118 223,718 247,981 268,646 1,188,102 3,388,604 196,840 199,699 204,087 234,200 230,811 222,663 208,249 218,204 241,855 262,104 986,271 3,204,983 385,851 391,567 399,088 463,258 461,350 439,225 416,367 441,922 489,836 530,750 2,174,373 6,593,587 128,120 136,030 144,689 170,817 172,995 159,809 150,384 168,118 197,243 222,225 1,050,764 2,701,194 134,452 142,040 151,953 175,253 171,920 160,654 148,342 163,343 192,251 217,408 872,329 2,529,945 262,572 278,070 296,642 346,070 344,915 320,463 298,726 331,461 389,494 439,633 1,923,093 5,231,139 16,986 15,993 15,294 18,451 17,830 15,786 15,279 15,374 15,489 15,559 51,337 213,378 526 544 475 694 640 655 540 523 545 658 2,337 8,137 533 540 502 639 652 632 548 526 586 644 2,116 7,918 1,059 1,084 977 1,333 1,292 1,287 1,088 1,049 1,131 1,302 4,453 16,055 13,643 12,679 10,830 12,715 14,473 16,280 17,692 17,230 14,139 12,052 35,924 177,657 13,774 12,552 10,372 11,590 12,936 14,981 16,709 17,113 13,676 11,866 32,263 167,832 27,417 25,231 21,202 24,305 27,409 31,261 34,401 34,343 27,815 23,918 68,187 345,489 29,736 26,622 23,713 26,381 24,601 24,032 24,223 22,473 20,565 18,152 47,740 288,238 30,748 27,639 25,280 27,998 27,332 28,941 27,105 22,979 20,716 17,106 38,799 294,643 60,484 54,261 48,993 54,379 51,933 52,973 51,328 45,452 41,281 35,258 86,539 582,881

Native American NonHispanic

Asian NonHispanic

Hispanic2

Male
17,333 16,928 15,980 18,720 17,971 17,455 15,545 14,243 14,626 15,080 40,764 204,645

Total
34,319 32,921 31,274 37,171 35,801 33,241 30,824 29,617 30,115 30,639 92,101 418,023

1. National Center for Health Statistics. Postcensal estimates of the resident population of the US for July 1, 2000July 1, 2009, by year, county, age, bridged race, Hispanic origin, and sex (Vintage 2009). Prepared under a collaborative arrangement with the US Census Bureau; released July 23, 2010. Available from: http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm as of March 28, 2011 2. Persons of Hispanic ethnicity are NOT included in the race categories. These estimates are used to calculate statewide population based rates published in this report.

101

Change in Measurement of Adequacy of Prenatal Care

Change in Adequacy of Prenatal Care Indicator since Massachusetts Births 2001: (This discussion is based on excerpts from An Overview of the APNCU Index by Milton Kotelchuck, Sept. 1994, available online at http://www.mchlibrary.info/databases/HSNRCPDFs/Overview_APCUIndex.pdf. Accessed December 2003). Beginning with Massachusetts Births 2001, adequacy of prenatal care is being measured using a new method. The Adequacy of Prenatal Care Utilization (APNCU) Index, developed by Dr. Milton Kotelchuck, has replaced the Kessner Index, which had been used in the Advanced Data Births and Massachusetts Births series. The APNCU Index is the standard used in Healthy People 2010 and by the majority of states. It improves upon the Kessner Index in various ways, the most important being the ability to distinguish between inadequate prenatal care due to the timing of initiation and inadequate care due to insufficient prenatal care visits. The APNCU Index also improves upon the Kessner Index by correcting some of its principal faults. First, the APNCU Index more accurately assesses adequacy of visits for term pregnancies; the Kessner Index characterizes 9 or more visits as adequate, due to an early computer database limitation, which only allowed for a single-digit number to record prenatal care visits. Other faults of the Kessner Index include its bias towards measurement of adequacy of initiation of care, and its various computational algorithms due to inadequate initial documentation. Table 1 of this report provides a comparison of data on adequacy of prenatal care from 19962009 as measured by these two separate indices. Below are the definitions for the APNCU Index categories and its two component indices (initiation and received services), and the definition of the Kessner Index categories. Also below is a short summary of the major differences in classification of adequacy of prenatal care using the Kessner Index and the APNCU Index. The APNCU Index characterizes prenatal care (PNC) utilization by measuring two distinct components of prenatal care -- adequacy of initiation and adequacy of received services (visits). Each of these components is measured as an independent index, and the APNCU Index is a summary of these 2 component indices. As with the Kessner Index, the APNCU Index does not assess quality of the prenatal care that is delivered, only its utilization. Adequacy of Prenatal Care Utilization (APNCU) Index: Definition of Categories Category Adequate Intensive Adequate Basic Intermediate Inadequate Unknown
1

Month Prenatal Care Began 1, 2, 3, or 4 1, 2, 3, or 4 1, 2, 3, or 4 Month 5 or later

% of Expected1 Prenatal Care Visits 110% or more 80 109% 50 79% Less than 50%

Prenatal care information not recorded

The number of expected visits is determined based on standards set by the American College of Obstetricians and Gynecologists (ACOG).

102

Component Indices of the APNCU Index: Definitions of Categories

Component Indices and Summary Index: The first component index is "Adequacy of Initiation," which describes the adequacy of when prenatal care began during pregnancy. The assumption underlying this scale is that the earlier PNC begins the better. The month or trimester prenatal care begins is widely used as a measure to assess the adequacy of timing of initiation of PNC, since it accurately and succinctly describes when PNC begins. The APNCU Index uses this measure to determine the adequacy of initiation. The second component index, "Adequacy of Received Services (visits), characterizes the adequacy of received PNC visits during the time period after prenatal care is begun until the delivery. This component attempts to characterize if the woman received the appropriate number of prenatal care visits for the time period in which she received PNC services. [The appropriate number of visits is based on recommendations of the American College of Obstetricians and Gynecologists for an uncomplicated pregnancy. For example, a woman beginning prenatal care during the first month of pregnancy who delivers during the 40th week of gestation (and has no complications with her pregnancy) should receive 14 visits]. The two component indices are measured independently from one another, and can be used as separate indices, since the policy and practice issues underlying whether women are beginning care early and whether they are receiving the recommended amount of visits may be quite distinct. However, because of the popularity and utility of using one overall adequacy of PNC index, the two component indices are combined into a single summary index the Adequacy of Prenatal Care Utilization (APNCU) Index. Index Categories Both component indices and the summary index (APNCU Index) characterize PNC as one of five categories: adequate intensive, adequate basic, intermediate, inadequate, or unknown. The category "adequate basic" refers to the minimum recommended level of care (for a pregnancy with no complications), while "adequate intensive" refers to a level of care exceeding recommended standards. The sum of the "adequate basic" and "adequate intensive" categories is the total adequacy score. In addition, the inadequate category can be subdivided to isolate those women who received no PNC. [For definitions of categories, please see the Technical Notes in the Appendix.] [For more detail on the methodology of the APNCU Index, please call the Bureau of Health Information, Statistics, Research & Evaluation at 617-624-5600].

103

Adequacy of Initiation Index

Category Adequate Intensive Adequate Basic Intermediate Inadequate Unknown Month Prenatal Care Began 1 or 2 3 or 4 5 or 6 Month 7 or later, or no PNC Prenatal care initiation information not recorded

Adequacy of Received Services (Visits) Index

Category Adequate Intensive Adequate Basic Intermediate Inadequate Unknown % of Expected Prenatal Care Visits 110% or more 80 109% 50 79% Less than 50% Information on prenatal care visits not recorded

Kessner Index of Adequacy of Prenatal Care: Definition of Categories

Category Adequate Intermediate Inadequate Trimester Care Began 1 1 2 1 2 3 No prenatal care Unknown -Unknown Number of Visits 9 or more 5-8 5 or more 1-4 1-4 1 or more 0 Unknown

104

Summary of Major Differences in Categorization of Adequacy of Prenatal Care between the Kessner Index and the APNCU Index The two different methods used in the Kessner Index and APNCU Index to calculate adequacy of prenatal care can result in differences in how each one classifies adequacy of prenatal care. These differences only occur under certain conditions, not in all cases (see "Explanation" column). The Kessner Index but the APNCU Index classifies prenatal care as classifies prenatal care as Intermediate Adequate Basic Explanation

This is primarily due to the fact that the APNCU Index allows for prenatal care in the 4th month of pregnancy to be considered adequate if the mother received 80-109% of expected visits, whereas the Kessner Index only allows for care begun in the first trimester (months 1-3) to be considered adequate. This is primarily due to the fact that the APNCU requires that the mother must make at least 50% of the expected visits for a normal pregnancy, i.e., 7 visits, which is 50% of the recommended 14 visits for a normal pregnancy, to be intermediate, while the Kessner Index allows 5 or 6 visits to meet intermediate status if the initiation of PNC is in the second trimester. This is primarily due to the consideration of expected visits (based on when the mother initiated care and the length of gestation) using the APNCU Index, which bases expected visits on the ACOG recommendations, which can be as high as 14 visits if a gestational period is 40 weeks, whereas the Kessner Index considers 9 visits sufficient in all cases. The APNCU Index added an "Adequate Intensive" category, which is not used in the Kessner Index. This allows analysis of situations in which more than normal care is received (e.g. women with high-risk conditions, pregnancy complications).

Intermediate

Inadequate

Adequate

Intermediate

Adequate

Adequate Intensive

105

Tests of Statistical Significance

Since the 2005 report, statistics presented in the text section have been tested to determine whether they differ significantly from a target statistic. For example, the number of births in 2009 was compared with the number of births in 2008, to determine whether their difference could have occurred by chance. When a difference is unlikely to have occurred by chance, it is referred to as significant. Note that with respect to statistical difference, the language in the reports beginning with 2005 differs from that of past reports, and caution must be used when comparing the text of previous reports with this years report. In testing for statistical significance, we have used the testing methods from the National Center for Health Statistics (NCHS). These methods are presented in the following document: National Vital Statistics Reports, Volume 52, Number 10 Births: Final Data for 2002 by Joyce A. Martin, M.P.H.; Brady E. Hamilton, Ph.D.; Paul D. Sutton, Ph.D.; Stephanie J. Ventura, M.A.; Fay Menacker, Dr. P.H.; and Martha L. Munson, M.S.; From the Division of Vital Statistics, NCHS. Technical Notes, Significance testing section beginning on page 110. This document is available from the following website: http://www.cdc.gov/nchs/products/pubs/pubd/nvsr/52/52-23.htm For comparisons of more than 100 events, whether they are rates, proportions, or numbers, the binomial distribution is assumed, and confidence intervals are examined to see whether they overlap (Refer to the Confidence Intervals and Infant Mortality Rates section in this Appendix for an explanation of using confidence intervals to determine statistical significance.) When the number of events is less than 100, a Poisson distribution is assumed, and confidence intervals are constructed based upon the Poisson distribution. For more details and exact formulas for calculating confidence intervals or other tests of statistical significance, refer to the publication listed above. When two statistics are determined to differ significantly, they then are referred to in the text with language expressing differences, such as higher and lower, or increased and decreased. Otherwise, differences that are not significant are reported as having no change or no statistical difference.

106

Confidence Intervals and Infant Mortality Rates Beginning with the 1992 Advance Data: Births publication, 95% confidence intervals were added to the calculation of infant mortality rates (IMRs). The confidence interval (CI) provides a measure of stability of the IMR and a basis for comparing rates to determine if they are statistically different. Rates can be compared for the same group in different years or for different groups in the same year. The width of the CI reflects the stability of the IMR. For example, a narrow CI reflects high stability, and a wide interval reflects low stability. If the CIs around two IMRs being compared do not overlap, the difference between the two rates is statistically significant. The following table and chart illustrate the concept of statistically significant differences using actual data from 1989, 1993, 1996, and 2000.

Comparison of Infant Mortality Rates and Confidence Intervals for Selected Years Year 1989 1993 1996 2000 IMR (per 1,000 births) 7.6 6.2 5.0 4.6 95% Confidence Interval (7.0-8.2) (5.7-6.7) (4.5-5.5) (4.2-5.1)

(1989) 7.0

7.6

8.2

(1993)

5.7

6.2

6.7

(1996) 4.5

5.0

5.5

(2000) 4.2

4.6

5.1

4.5

5.0

6.0

7.0

8.0

8.5

Infant Deaths per 1,000 Live Births

The difference between the 1993 IMR and 1996 IMR is statistically significant the confidence intervals do not overlap. The same is true for the differences between the 1989 IMR and each annual IMR for 1993, 1996, and 2000. However, the difference between the 1996 and 2000 IMRs is not statistically significant, since their confidence intervals overlap.

107

Table 37. 95% Confidence Intervals for Infant Mortality Rates by Race and Hispanic Ethnicity, Massachusetts: 1990-2009
Total1 Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 n 649 577 569 523 499 419 403 425 414 418 377 407 397 383 376 391 369 380 382 354 Rate (95% CI) 7.0 6.5 6.5 6.2 6.0 5.1 5.0 5.3 5.1 5.2 4.6 5.0 4.9 4.8 4.7 5.1 4.8 4.9 5.0 4.7 (6.5, 7.5) (6.0, 7.0) (6.0, 7.0) (5.7, 6.7) (5.4, 6.5) (4.6, 5.6) (4.5, 5.5) (4.8, 5.8) (4.6, 5.6) (4.7, 5.7) (4.2, 5.1) (4.5, 5.5) (4.4, 5.4) (4.3, 5.3) (4.3, 5.3) (4.6, 5.6) (4.3, 5.2) (4.4, 5.4) (4.5, 5.5) (4.2, 5.2)
2

White non-Hispanic n 442 381 371 346 343 275 289 294 294 285 232 245 239 235 210 230 221 206 194 198 Rate (95% CI) 6.1 5.5 5.5 5.3 5.3 4.4 4.7 4.8 4.6 4.7 3.8 4.1 4.1 4.1 (5.5, 6.7) (4.9, 6.1) (4.9, 6.1) (4.7, 5.9) (4.7, 5.9) (3.8, 4.9) (4.1, 5.2) (4.2, 5.3) (4.1, 5.2) (4.2, 5.3) (3.4, 4.3) (3.6, 4.7) (3.6, 4.6) (3.6, 4.6)
2

Black non-Hispanic n 98 101 110 84 79 65 63 64 64 72 74 71 69 75 70 57 72 66 78 53 Rate (95% CI) 13.7 (11.0, 16.4) 15.0 (12.1, 17.9) 16.4 (13.4, 19.4) 13.1 (10.3, 15.9) 12.6 (9.8, 15.4) 11.1 (8.4, 13.8) 11.4 (8.6, 14.2) 11.7 (8.8, 14.5) 10.6 (7.9, 13.3) 12.3 (9.5, 15.1) 12.8 (9.9, 15.7) 12.1 (9.3, 14.9) 11.6 (8.9, 14.3) 12.7 (9.8, 15.5) 11.5 (8.9, 14.2) 9.4 (7.0, 11.8) 11.1 (8.6, 13.7) 10.2 (7.8, 12.6) 11.7 (9.1, 14.3) 7.6 (5.6, 9.7)
2

Hispanic n 77 80 67 77 64 58 40 55 55 49 48 69 67 55 75 78 62 81 86 77 Rate (95% CI) 9.1 9.4 7.9 9.3 7.6 7.2 5.1 6.7 6.7 5.5 5.2 7.3 7.0 5.6 (7.1, 11.1) (7.3, 11.5) (6.0, 9.8) (7.2, 11.4) (5.7, 9.4) (5.3, 9.0) (3.5, 6.7) (4.9, 8.4) (5.0, 8.4) (4.0, 7.1) (3.7, 6.6) (5.6, 9.1) (5.3, 8.7) (4.1, 7.1)
2

Asian n 24 14 16 13 8 19 8 10 10 8 19 15 16 14 15 18 10 18 16 19 Rate2 (95% CI) 7.0 4.2 4.9 3.9 2.4 5.5 2.2 2.6 2.7 1.9 4.1 3.1 3.0 2.7 (4.2, 10.0) (2.0, 6.4) (2.5, 7.3) (1.8, 6.0) (0.7, 4.0) (3.0, 8.0) (0.7, 3.7) (1.0, 4.2) (1.0, 4.3) (0.6, 3.3) (2.2, 5.9) (1.6, 4.7) (1.5, 4.5) (1.3, 4.1)

108

3.8 (3.3, 4.3) 4.3 (3.7, 4.9) 4.2 (3.6, 4.7) 3.9 (3.4, 4.4) 3.7 (3.2, 4.3) 4.0 (3.4, 4.5)

7.6 (5.9, 9.4) 7.8 (6.0, 9.5) 5.8 (4.4, 7.2) 7.4 (5.8, 9.1) 7.9 (6.2, 9.5) 7.0 (5.4, 8.6)

2.7 (1.4, 4.1) 3.4 (1.8, 5.0) 1.8 (0.7, 3.0) 3.1 (1.7, 4.6) 2.7 (1.4, 4.0) 3.2 (1.8, 4.6)

1. Deaths of infants of unknown race are excluded except for the total calculation. For rate computations, births of infants of unknown race are allocated into the race categories according to the distribution of births of known race. 2. Rates are expressed per 1,000 live births.

In 2009, the Black infant mortality rate was 7.6 deaths per 1,000 live births (95% CI: 5.6, 9.7), which was about two times greater than the White infant mortality rate of 4.0 (95% CI: 3.4, 4.5). The difference in these two rates was statistically significant. The rate of infant mortality for Blacks was also significantly elevated compared with Asians (3.2, 95% CI: 1.8, 4.6) in 2009.

Definition of Rates and Ratios

Age-Specific Birth Rate The number of children born to women in a specific age group divided by the population of women in that specific age group, multiplied by 1,000. Age-Specific Birth Rate = Number of births to females ages X to Y years Number of females ages X to Y years in the population X 1,000

Birth Rate (See Age-Specific Birth Rate, Crude Birth Rate, Fertility Rate, and Teen Birth Rate) Cesarean Section Rates Total Cesarean Delivery Rate = Primary Cesarean Delivery Rate = Repeat Cesarean Delivery Rate = VBAC Rate = Number of Cesarean births Number of occurrence births X 100

Number of primary Cesarean births [Number of occurrence births-(number of repeat Cesarean births +VBACs)] Number of repeat Cesarean births (Number of repeat Cesarean births+number of VBACs) Number of VBACs (Number of repeat Cesarean births+number of VBACs)

X 100

X 100 X 100

Crude Birth Rate Crude Birth Rate = Number of resident live births Total resident population X 1,000

Fertility Rate (sometimes referred to as "Birth Rate") Fertility Rate = Number of births to females ages 15-44 years Number of females ages 15-44 years in the population X 1,000

Fetal Mortality Rate Fetal Mortality Rate = Number of fetal deaths Number of fetal deaths plus live births in the same year X 1,000

109

Feto-Infant Mortality Rate ii) Feto-Infant Mortality Rate = Number of fetal deaths + Number of infant deaths Number of fetal deaths + live births in the same year X 1,000

(Refer to the definitions of Fetal Mortality Rate and Infant Mortality Rate for more details.)

Infant Mortality Rate (IMR) The death rate among infants less than one year old per 1,000 live births. Number of resident deaths of infants less than one year old in a year Number of resident live births in the same year

Infant Mortality Rate =

X 1,000

Inter-pregnancy Interval (IPI) Inter-pregnancy interval is the time, in months, between the date of last menstrual period of current pregnancy and the date of previous live birth. IPI is calculated for each mother currently giving birth to their second or later child. Number of mothers giving birth to their 2nd or later child with IPI <12 months Number of mothers giving birth to their 2nd or later child in the same year Number of mothers giving birth to their 2nd or later child with IPI between 12 and 35 months Number of mothers giving birth to their 2nd or later child in the same year Number of mothers giving birth to their 2nd or later child with IPI >=36 months Number of mothers giving birth to their 2nd or later child in the same year

%Short IPI =

X 100

% IPI 12 to 35 = months

X 100

% IPI = 36+ months

X 100

Maternal Mortality Ratio (MMR) The number of maternal deaths per 100,000 live occurrence births. The term "ratio" is used instead of "rate" in this report because the numerator (number of deaths) is not a subset of the denominator (live births). The ideal measure would incorporate the total number of pregnancies not just live births in the denominator. However, pregnancies that result in late fetal death or end in induced terminations are difficult to record, and data are often incomplete. As a result, the population at risk of maternal death is generally taken as the number of live births, which is assumed to be a good proxy for the number of pregnancies.

110

Maternal Mortality Ratio (MMR) =

Number of maternal deaths Number of occurrence live births in the same year

X 100,000

Neonatal Mortality Rate (NMR) The death rate among infants less than 28 days of age per 1,000 live births. Number of resident deaths of infants less than 28 days of age in a year Number of resident live births in the same year

Neonatal Mortality Rate =

X 1,000

Perinatal Mortality Rate Number of fetal deaths from 28 weeks gestation plus infant deaths (less than 7 days old) Number of fetal deaths plus live births in the same year

Perinatal Mortality Rate =

X 1,000

Post Neonatal Mortality Rate The death rate among infants 28 days of age to less than one year old per 1,000 live births. Number of resident deaths of infants 28 days of age to less than one year of age in a year Number of resident live births in the same year

Post Neonatal Mortality Rate =

X 1,000

Pregnancy-Associated Mortality Ratio (PAMR) The number of pregnancy-associated deaths per 100,000 live occurrence births. The term "ratio" is used instead of rate in this report because the numerator includes some maternal deaths that were not related to live-born infants and thus were not included in the denominator. Pregnancy-Associated Mortality Ratio (PAMR) = Teen Birth Rate Teen birth rate = Number of births to females ages 15-19 years old Number of females ages 15-19 years old in the population X 1,000 Number of pregnancy-associated deaths Number of occurrence live births in the same year X 100,000

Total Rate of Change Total rate of change between two numbers or rates is expressed as a percentage in this report (e.g. The Massachusetts birth rate decreased by 12% from 1990 to 1996.): Pn-Po Po X 100

where, Pn = rate during later time period Po = rate during earlier time period 111

Table A1. Population Estimates for Massachusetts Communities: 2005

TOWN NAME Abington Acton Acushnet Adams Agawam Alford Amesbury Amherst Andover Aquinnah (Gay Head) Arlington Ashburnham Ashby Ashfield Ashland Athol Attleboro Auburn Avon Ayer Barnstable Barre Becket Bedford Belchertown Bellingham Belmont Berkley Berlin Bernardston Beverly Billerica Blackstone Blandford Bolton Boston Bourne Boxborough Boxford Boylston Braintree Brewster Bridgewater Brimfield Brockton Brookfield Brookline Buckland Burlington Cambridge Canton Carlisle Carver Charlemont Charlton Chatham Chelmsford Chelsea Cheshire Chester Chesterfield Chicopee Chilmark Clarksburg Clinton Cohasset Colrain COUNTY Plymouth Middlesex Bristol Berkshire Hampden Berkshire Essex Hampshire Essex Dukes Middlesex Worcester Middlesex Franklin Middlesex Worcester Bristol Worcester Norfolk Middlesex Barnstable Worcester Berkshire Middlesex Hampshire Norfolk Middlesex Bristol Worcester Franklin Essex Middlesex Worcester Hampden Worcester Suffolk Barnstable Middlesex Essex Worcester Norfolk Barnstable Plymouth Hampden Plymouth Worcester Norfolk Franklin Middlesex Middlesex Norfolk Middlesex Plymouth Franklin Worcester Barnstable Middlesex Suffolk Berkshire Hampden Hampshire Hampden Dukes Berkshire Worcester Norfolk Franklin CHNA 22 15 26 1 4 1 12 3 11 27 17 9 9 2 7 2 24 8 22 9 27 9 1 15 3 6 17 24 9 2 13 10 6 4 9 19 27 15 12 8 20 27 22 5 22 5 19 2 15 17 20 15 23 2 5 27 10 19 1 21 3 21 27 1 9 20 2
POPULATION1

TOWN NAME Concord Conway Cummington Dalton Danvers Dartmouth Dedham Deerfield Dennis Dighton Douglas Dover Dracut Dudley Dunstable Duxbury East Bridgewater East Brookfield East Longmeadow Eastham Easthampton Easton Edgartown Egremont Erving Essex Everett Fairhaven Fall River Falmouth Fitchburg Florida Foxborough Framingham Franklin Freetown Gardner Georgetown Gill Gloucester Goshen Gosnold Grafton Granby Granville Great Barrington Greenfield Groton Groveland Hadley Halifax Hamilton Hampden Hancock Hanover Hanson Hardwick Harvard Harwich Hatfield Haverhill Hawley Heath Hingham Hinsdale Holbrook Holden

COUNTY Middlesex Franklin Hampshire Berkshire Essex Bristol Norfolk Franklin Barnstable Bristol Worcester Norfolk Middlesex Worcester Middlesex Plymouth Plymouth Worcester Hampden Barnstable Hampshire Bristol Dukes Berkshire Franklin Essex Middlesex Bristol Bristol Barnstable Worcester Berkshire Norfolk Middlesex Norfolk Bristol Worcester Essex Franklin Essex Hampshire Dukes Worcester Hampshire Hampden Berkshire Franklin Middlesex Essex Hampshire Plymouth Essex Hampden Berkshire Plymouth Plymouth Worcester Worcester Barnstable Hampshire Essex Franklin Franklin Plymouth Berkshire Norfolk Worcester

CHNA POPULATION1 15 2 3 1 14 26 18 2 27 24 6 18 10 5 10 23 22 5 4 27 3 22 27 1 2 13 16 26 25 27 9 1 7 7 6 26 9 12 2 13 3 27 8 3 4 1 2 9 12 3 23 13 4 1 23 23 9 9 27 3 12 2 2 20 1 22 8 16,858 1,902 986 6,697 25,999 31,371 23,681 4,786 15,914 6,648 7,861 5,634 28,805 10,787 3,142 14,655 13,832 2,111 14,845 5,550 15,994 22,995 3,934 1,355 1,542 3,342 37,100 16,223 92,117 33,620 40,514 666 16,288 65,651 30,748 8,963 20,955 8,023 1,392 30,671 956 86 16,783 6,332 1,644 7,440 17,888 10,396 6,591 4,820 7,805 8,334 5,312 1,018 14,077 9,915 2,655 6,116 12,673 3,280 60,032 345 805 21,470 1,811 10,765 16,571

16,305 20,539 10,535 8,456 28,547 400 16,617 34,721 32,838 362 41,273 5,970 2,926 1,824 15,431 11,690 43,364 16,393 4,345 7,212 47,902 5,375 1,783 12,486 13,897 15,735 23,453 6,352 2,683 2,237 39,833 39,812 9,051 1,266 4,428 558,435 19,355 5,032 8,162 4,253 33,658 10,242 25,769 3,627 100,366 3,096 56,422 1,995 23,265 101,529 21,481 4,823 11,552 1,387 12,447 6,833 33,728 34,128 3,356 1,320 1,271 54,599 944 1,663 13,997 7,219 1,858

112

Table A1 (contd). Population Estimates for Massachusetts Communities: 2005

TOWN NAME Holland Holliston Holyoke Hopedale Hopkinton Hubbardston Hudson Hull Huntington Ipswich Kingston Lakeville Lancaster Lanesborough Lawrence Lee Leicester Lenox Leominster Leverett Lexington Leyden Lincoln Littleton Longmeadow Lowell Ludlow Lunenburg Lynn Lynnfield Malden Manchester Mansfield Marblehead Marion Marlborough Marshfield Mashpee Mattapoisett Maynard Medfield Medford Medway Melrose Mendon Merrimac Methuen Middleborough Middlefield Middleton Milford Millbury Millis Millville Milton Monroe Monson Montague Monterey Montgomery Mt. Washington Nahant Nantucket Natick Needham New Ashford New Bedford New Braintree COUNTY Hampden Middlesex Hampden Worcester Middlesex Worcester Middlesex Plymouth Hampshire Essex Plymouth Plymouth Worcester Berkshire Essex Berkshire Worcester Berkshire Worcester Franklin Middlesex Franklin Middlesex Middlesex Hampden Middlesex Hampden Worcester Essex Essex Middlesex Essex Bristol Essex Plymouth Middlesex Plymouth Barnstable Plymouth Middlesex Norfolk Middlesex Norfolk Middlesex Worcester Essex Essex Plymouth Hampshire Essex Worcester Worcester Norfolk Worcester Norfolk Franklin Hampden Franklin Berkshire Hampden Berkshire Essex Nantucket Middlesex Norfolk Berkshire Bristol Worcester CHNA 5 7 21 6 7 9 7 20 21 13 23 24 9 1 11 1 8 1 9 2 15 2 15 15 4 10 21 9 14 14 16 13 24 14 26 7 23 27 26 7 7 16 6 16 6 12 11 24 3 11 6 8 7 6 20 2 4 2 1 4 1 14 27 7 18 1 26 9
POPULATION1

TOWN NAME New Marlborough New Salem Newbury Newburyport Newton Norfolk North Adams North Andover North Attleboro North Brookfield North Reading Northampton Northborough Northbridge Northfield Norton Norwell Norwood Oak Bluffs Oakham Orange Orleans Otis Oxford Palmer Paxton Peabody Pelham Pembroke Pepperell Peru Petersham Phillipston Pittsfield Plainfield Plainville Plymouth Plympton Princeton Provincetown Quincy Randolph Raynham Reading Rehoboth Revere Richmond Rochester Rockland Rockport Rowe Rowley Royalston Russell Rutland Salem Salisbury Sandisfield Sandwich Saugus Savoy Scituate Seekonk Sharon Sheffield Shelburne Sherborn Shirley

COUNTY Berkshire Franklin Essex Essex Middlesex Norfolk Berkshire Essex Bristol Worcester Middlesex Hampshire Worcester Worcester Franklin Bristol Plymouth Norfolk Dukes Worcester Franklin Barnstable Berkshire Worcester Hampden Worcester Essex Hampshire Plymouth Middlesex Berkshire Worcester Worcester Berkshire Hampshire Norfolk Plymouth Plymouth Worcester Barnstable Norfolk Norfolk Bristol Middlesex Bristol Suffolk Berkshire Plymouth Plymouth Essex Franklin Essex Worcester Hampden Worcester Essex Essex Berkshire Barnstable Essex Berkshire Plymouth Bristol Norfolk Berkshire Franklin Middlesex Middlesex

CHNA 1 2 12 12 18 7 1 11 24 5 16 3 7 6 2 24 20 20 27 9 2 27 1 5 4 8 14 3 23 9 1 2 2 1 3 7 23 23 9 27 20 20 24 16 24 19 1 26 23 13 2 12 2 4 9 14 12 1 27 14 1 20 24 20 1 2 7 9

POPULATION1

2,529 13,830 41,089 6,234 14,048 4,340 18,847 11,279 2,180 13,285 12,435 10,618 7,069 2,951 81,591 5,882 10,953 5,149 42,120 1,769 30,452 815 7,935 8,561 15,556 105,749 21,835 10,008 92,186 11,540 56,730 5,332 22,933 20,285 5,316 37,163 24,879 14,159 6,477 10,221 12,328 53,801 12,780 26,366 5,743 6,350 44,532 21,153 549 9,077 27,523 13,443 7,949 2,938 26,243 100 8,744 8,416 959 743 135 3,591 10,095 31,895 28,445 247 94,502 1,090

1,522 986 6,990 17,395 83,346 10,506 14,031 27,137 28,078 4,812 13,930 28,803 14,652 14,184 3,226 19,106 10,382 28,472 3,794 1,892 7,659 6,459 1,391 13,710 12,895 4,556 50,954 1,415 18,069 11,386 836 1,282 1,753 43,949 600 7,994 54,781 2,777 3,520 3,444 90,458 32,552 13,428 23,161 11,229 45,551 1,618 5,295 17,842 7,761 350 5,832 1,366 1,723 7,406 41,647 8,264 830 20,707 26,867 724 18,119 13,660 17,269 3,360 2,054 4,220 7,361

113

Table A1 (contd). Population Estimates for Massachusetts Communities: 2005

TOWN NAME Shrewsbury Shutesbury Somerset Somerville South Hadley Southampton Southborough Southbridge Southwick Spencer Springfield Sterling Stockbridge Stoneham Stoughton Stow Sturbridge Sudbury Sunderland Sutton Swampscott Swansea Taunton Templeton Tewksbury Tisbury Tolland Topsfield Townsend Truro Tyngsborough Tyringham Upton Uxbridge Wakefield Wales Walpole Waltham Ware Wareham Warren COUNTY Worcester Franklin Bristol Middlesex Hampshire Hampshire Worcester Worcester Hampden Worcester Hampden Worcester Berkshire Middlesex Norfolk Middlesex Worcester Middlesex Franklin Worcester Essex Bristol Bristol Worcester Middlesex Dukes Hampden Essex Middlesex Barnstable Middlesex Berkshire Worcester Worcester Middlesex Hampden Norfolk Middlesex Hampshire Plymouth Worcester CHNA 8 2 25 17 3 3 7 5 4 5 4 9 1 16 22 7 5 7 2 6 14 25 24 9 10 27 4 13 9 27 10 1 6 6 16 5 7 18 3 26 5
POPULATION1

TOWN NAME Warwick Washington Watertown Wayland Webster Wellesley Wellfleet Wendell Wenham West Boylston West Bridgewater West Brookfield West Newbury West Springfield West Stockbridge West Tisbury Westborough Westfield Westford Westhampton Westminster Weston Westport Westwood Weymouth Whately Whitman Wilbraham Williamsburg Williamstown Wilmington Winchendon Winchester Windsor Winthrop Woburn Worcester Worthington Wrentham Yarmouth

COUNTY Franklin Berkshire Middlesex Middlesex Worcester Norfolk Barnstable Franklin Essex Worcester Plymouth Worcester Essex Hampden Berkshire Dukes Worcester Hampden Middlesex Hampshire Worcester Middlesex Bristol Norfolk Norfolk Franklin Plymouth Hampden Hampshire Berkshire Middlesex Worcester Middlesex Berkshire Suffolk Middlesex Worcester Hampshire Norfolk Barnstable

CHNA 2 1 17 7 5 18 27 2 13 8 22 5 12 4 1 27 7 21 10 3 9 18 25 18 20 2 22 4 3 1 15 9 15 1 19 15 8 3 7 27

POPULATION1

33,171 1,843 18,564 75,372 17,071 5,828 9,511 17,503 9,512 12,087 156,358 7,761 2,256 21,594 26,782 6,159 8,825 17,035 3,853 8,974 14,283 16,243 56,348 7,474 28,990 3,819 446 6,178 9,273 2,162 11,297 352 6,374 12,377 24,553 1,818 23,067 59,564 9,988 21,274 5,040

763 546 32,255 13,015 16,853 26,975 2,821 1,035 4,643 7,708 6,819 3,896 4,301 27,938 1,450 2,666 18,781 40,432 21,369 1,566 7,358 11,591 15,053 13,902 53,708 1,584 14,424 13,960 2,433 8,276 21,431 10,085 21,139 858 17,067 37,074 179,839 1,291 11,066 24,663

1. Massachusetts (Department of Public Health) Modified Age, Race/Ethnicity, & Sex Estimates 2005 (MMARS05), released October 2006.

114

Table A2. Population Estimates for Massachusetts Community Health Network Areas (CHNAs) and Counties: 2005
CHNA POPULATION
1

COUNTY

POPULATION

1. Community Health Network of Berkshire County 2. Upper Valley Health Web (Franklin County) 3. Partnership for Health in Hampshire County (Northampton) 4. The Community Health Connection (Springfield) 5. Community Health Network of Southern Worcester County 6. Community Partners for Health (Milford) 7. Community Health Network of Greater Metro West (Framingham) 8 .Community Wellness Coalition (Worcester) 9. Fitchburg/Gardner Community Health Network 10. Greater Lowell Community Health Network 11. Greater Lawrence Community Health Network 12. Greater Haverhill Community Health Network 13. Community Health Network North (Beverly/Gloucester) 14. North Shore Community Health Network 15. Greater Woburn/Concord/Littleton Community Health Network 16. North Suburban Health Alliance (Medford/Malden/Melrose) 17. Greater Cambridge/Somerville Community Health Network 18. West Suburban Health Network (Newton/Waltham) 19. Alliance for Community Health (Boston/Chelsea/Revere/Winthrop) 20. Blue Hills Community Health Alliance (Greater Quincy) 21. Four (For) Communities (Holyoke, Chicopee, Ludlow, Westfield) 22. Greater Brockton Community Health Network 23. South Shore Community Partners in Prevention (Plymouth) 24. Greater Attleboro-Taunton Health & Education Response 25. Partners for a Healthier Community (Fall River) 26. Greater New Bedford Health & Human Services Coalition 27. Cape and Islands Community Health Network

131,965 88,506 151,801 299,490 119,141 160,521 379,658 303,669 261,369 272,893 195,176 148,557 119,378 287,352 209,597 257,235 273,883 253,138 711,603 372,309 161,454 242,404 188,787 252,919 141,977 199,955 252,204

Barnstable Berkshire Bristol Dukes Essex Franklin Hampden Hampshire Middlesex Nantucket Norfolk Plymouth Suffolk Worcester

226,505 131,965 547,711 15,605 750,463 72,415 466,739 153,981 1,464,179 10,095 656,472 497,687 655,181 787,943 6,436,940

STATE

1. Massachusetts (Department of Public Health) Modified Age, Race/Ethnicity, & Sex Estimates 2005 (MMARS05), released October 2006.

115

Glossary

Adequacy of Prenatal Care Utilization (APNCU) Index The Adequacy of Prenatal Care Utilization Index, developed by Dr. Milton Kotelchuck, is the measure used in this publication to classify the adequacy of prenatal care received by Massachusetts resident mothers. (Please note: Prior to the Births 2001 publication, the Kessner Index was used to measure adequacy of prenatal care; please see definition for Kessner Index below.) The APNCU Index has five categories (adequate intensive, adequate basic, intermediate, inadequate, and unknown), based on the month of pregnancy in which prenatal care begins and the percent of expected prenatal care visits for the time period during which a woman receives prenatal care services. Please see Technical Notes for more details. Birthweight The weight of an infant recorded at the time of delivery. It may be recorded in either pounds/ounces or grams. If recorded in pounds/ounces, it is converted to grams for use in this report. 1 pound = 453.6 grams 1,000 grams = 2 pounds and 3 ounces Birthweight Categories Normal birthweight (NBW): Low birthweight (LBW): An infant's weight of 2,500 grams (approximately 5.5 pounds) or more recorded at birth. An infant's weight of less than 2,500 grams (5.5 pounds) recorded at birth.

Very low birthweight (VLBW): An infant's weight of less than 1,500 grams (3.3 pounds) recorded at birth. Cesarean Delivery or Cesarean Section (C-Section) Primary: A mother's first cesarean delivery. Repeat: A cesarean delivery that has been preceded by at least one Cesarean delivery. Community Health Network Areas (CHNAs) The Department of Public Health, in collaboration with health service providers, coalition members, and interested citizens, has designated 27 areas for community health planning. It is the Department's intention to foster in each of these areas the development of Community Health Networks consortia of health care providers, human service agencies, schools, churches, youth, parents, elders, advocacy groups, and individual consumers to address the health needs of the community. These community coalitions will participate in monitoring outcomes and progress of strategies and responses to those health needs. It is hoped the Networks will mobilize around key health issues affecting the community, promote prevention efforts, enhance access to care, provide opportunities for more collaboration among agencies, and create a client-centered, outcome-oriented health service delivery system. Community Health Networks will also promote efficiency in service delivery by working to reduce duplication and overlap, and by identifying gaps in service. 116

A Community Health Network Area (CHNA) is defined as an aggregation of cities and towns. In the current publication, we have presented some data by CHNA. To determine which cities and towns make up a particular CHNA, Table A1 provides the appropriate CHNA code for each city and town. The data published in this volume reflect the definitions of CHNAs instituted in January 1997 and the corresponding CHNA names. Confidence Intervals The confidence interval (CI) for the infant mortality rate (IMR) is a range of values that has a 95% chance of including the underlying risk of an infant death. Observed rates are subject to statistical variation; even if the underlying risk of infant death is identical in two subpopulations, the observed IMRs for the subpopulations may differ because of random variation. The confidence interval describes the precision of observed IMR as an estimate of the underlying risk of infant death, with a wider interval indicating less certainty about this estimate. The width of the interval reflects the size of the subpopulation and the number of infant deaths; smaller subpopulations with fewer infant deaths lead to wider confidence intervals. Death Cohort Linked File or Linked Birth and Infant Death File Death Cohort All infant deaths occurring in a specific year have been linked to their corresponding birth certificates, whether the birth occurred during the same year or in the previous one. This is in contrast to a birth cohort linked file, in which infant deaths may have occurred in the same year or in the year following the year of birth. Delivery A delivery may consist of one or more live born or stillborn fetuses. The number of deliveries in a given period will be equal to or less than the number of births because multiple births (twins, triplets or higherorder births) are counted as single deliveries. EOHHS Regions The six regions delineated by the commonwealth's Executive Office of Health and Human Services and used by the Department of Public Health for statistical, care coordination and administrative purposes. The regions - Western, Central, Northeast, Metro West, Boston and Southeast - are based on geographical groupings of cities and towns. Ethnicity Also known as mothers ancestry. See the section in the Technical Notes of the Appendix entitled: Changes in the Collection of Race and Ethnicity Information. Fetal Death A stillbirth delivered, extracted or expulsed at 20 weeks gestation or more or weighs 350 grams or more. Feto-Infant Mortality Rate The combined number of fetal deaths and infant deaths per 1,000 live births and fetal deaths. Gestational Age (GA) The developmental period of a fetus from time of conception to time of birth, measured in weeks. Some groups of GA used in this report are: Preterm: infant born with less than 37 weeks of gestation Late Preterm: infant born between 34th and 36th week of gestation Term: infant born at 37th week of gestation or later Early Term: infant born between 37th and 38th week of gestation

117

Healthy Start A Massachusetts-funded program providing services and financing for prenatal care to lowincome pregnant women who lack health insurance, but do not qualify for Medicaid. Infant A child whose age is less than one year (365 days). Infant Death Death of a child whose age is less than one year. Kessner Index (Adequacy of Prenatal Care) A measure of adequacy of prenatal care, used in Advance Data: Births and Massachusetts Births publications prior to 2001. The Kessner Index classifies prenatal care as one of 5 categories (adequate, intermediate, inadequate, no prenatal care, and unknown), based on the trimester in which prenatal care began and the number of prenatal visits. The classification adjusts for gestational age to allow for proper classification of premature births, and is as follows:
Category Adequate Intermediate Inadequate Trimester Care Began 1 1 2 1 2 3 -Unknown Number of Visits 9 or more 5-8 5 or more 1-4 1-4 1 or more 0 Unknown

No prenatal care Unknown

Live Birth A live birth is any infant who breathes or shows any other evidence of life (such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles) after separation from the mother's uterus, regardless of the duration of gestation. Low Birthweight (LBW) See Birthweight Categories. Maternal Death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes. Mothers Birthplace In this publication, birth characteristics are presented according to mothers birthplace: those who were born in the 50 states and District of Columbia, or US States / D.C.; those who were born in Puerto Rico, the US Virgin Islands, and Guam, or Puerto Rico/US Territories; and those who were born outside of the US and Puerto Rico/US territories, or Non-US-born. Neonatal Infants under 28 days of age. Neonatal Death Death of a child whose age is less than 28 days. 118

Non-US-born Women See Mothers Birthplace. Occurrence Birth A birth occurring in the Commonwealth of Massachusetts, regardless of the residency of the mother. For individual cities/towns, an occurrence birth represents any birth occurring in that city/town, regardless of the residence of the mother. See Resident Birth. Parity The total number of live infants ever born to a woman, including the current birth. Perinatal Referring to the time period immediately before and after birth (28 weeks of gestation to 7 days after birth). Perinatal Death Death to a fetus of 28 weeks gestation or older or a live-born infant less than 7 days old. Plurality The number of births to a woman produced in the same gestational period. A singleton is the birth of one infant; twins represent the births of two infants, etc. Post Neonatal A child whose age is at least 28 days, but less than one year. Post Neonatal Death Death of a child whose age is at least 28 days, but less than one year. Prenatal Care Source of Payment Categories used in this publication include: Public = Government programs including CommonHealth, Healthy Start, Medicaid/MassHealth, and Medicare (may be HMO or managed care), or free care; Private = Commercial indemnity plan, commercial managed care (HMO, PPO, IPP, IPA, and other), or other private insurance; Other = Worker's Compensation and other sources; Self-paid. Pregnancy-Associated Death The death of a woman while pregnant or within one year of termination of pregnancy, irrespective of cause. Race See the section in the Technical Notes in the Appendix entitled: "Changes in the Collection of Race and Ethnicity Information." Resident Birth The birth of an infant whose mother reports that her usual place of residence is in Massachusetts. In Massachusetts, a resident is a person with a permanent address in one of the 351 cities or towns. Vital statistics data may be presented in terms either of residence or occurrence. All data in this publication are resident data unless otherwise stated. Resident data include all events that occur to residents of the Commonwealth, wherever they occur. 119

Occurrence data include all events that occur within the state, whether to residents or nonresidents. There is an exchange agreement among the 50 states, District of Columbia, Puerto Rico, Virgin Islands, Guam, and Canadian provinces that provides for exchange of copies of birth and death records. These records are used for statistical purposes only, and allow each state or province to track the births and deaths of its residents. Vaginal Birth After Cesarean (VBAC) A vaginal delivery of an infant to a mother who has had at least one prior cesarean delivery. Very Low Birthweight (VLBW) An infant's weight of less than 1,500 grams (3.3 pounds) recorded at birth.

120

Massachusetts Birth Certificate: 2009

SAMPLE

121

Massachusetts Births 2009 Evaluation Form TO OUR READERS: In an attempt to better serve our users, we are enclosing this evaluation form. Please take the time to complete this questionnaire and return it to the address at the bottom of the page. Thank you. What tables and charts do you find most useful?

What tables and charts do you find least useful?

Are there other tables and charts that you would like added to this publication? If yes, please describe them in detail.

Do you have other comments or suggestions?

Name (optional): Address: (For those who received the publication by mail) Is the mailing label address correct? If not, please correct the address. Thank you.

Please return your comments to: Division of Research and Epidemiology Bureau of Health Information, Statistics, Research and Evaluation Massachusetts Department of Public Health 250 Washington Street, 6th floor, Boston, MA 02108

123

------------------------------------------------------------------------------------------------------------------------Place stamp here

Isabel A. Cceres Division of Research and Epidemiology Bureau of Health Information, Statistics, Research & Evaluation Massachusetts Department of Public Health 250 Washington Street, 6th floor Boston, MA 02108

-------------------------------------------------------------------------------------------------------------------------