title: State infant mortality: an ecologic study to determine modifiable risks and adjusted infant mortality rates.
abstract: OBJECTIVE
  To determine factors contributing to state infant mortality rates (IMR) and develop an adjusted IMR in the United States for 2001 and 2002.
  
  
  METHODS
  Ecologic study of factors contributing to state IMR. State IMR for 2001 and 2002 were obtained from the United States linked death and birth certificate data from the National Center for Health Statistics. Factors investigated using multivariable linear regression included state racial demographics, ethnicity, state population, median income, education, teen birth rate, proportion of obesity, smoking during pregnancy, diabetes, hypertension, cesarean delivery, prenatal care, health insurance, self-report of mental illness, and number of in-vitro fertilization procedures. Final risk adjusted IMR's were standardized and states were compared with the United States adjusted rates.
  
  
  RESULTS
  Models for IMR in individual states in 2001 (r2 = 0.66, P < 0.01) and 2002 (r2 = 0.81, P < 0.01) were tested. African-American race, teen birth rate, and smoking during pregnancy remained independently associated with state infant mortality rates for 2001 and 2002. Ninety five percent confidence intervals (CI) were calculated around the regression lines to model the expected IMR. After adjustment, some states maintained a consistent IMR; for instance, Vermont and New Hampshire remained low, while Delaware and Louisiana remained high. However, other states such as Mississippi, which have traditionally high infant mortality rates, remained within the expected 95% CI for IMR after adjustment indicating confounding affected the initial unadjusted rates.
  
  
  CONCLUSIONS
  Non-modifiable demographic variables, including the percentage of non-Hispanic African-American and Hispanic populations of the state are major factors contributing to individual variation in state IMR. Race and ethnicity may confound or modify the IMR in states that shifted inside or outside the 95% CI following adjustment. Other factors including smoking during pregnancy and teen birth rate, which are potentially modifiable, significantly contributed to differences in state IMR. State risk adjusted IMR indicate that other factors impact infant mortality after adjustment by race/ethnicity and other risk factors.
authors.affiliation: Pediatrics and Neonatology, Christiana Care Health Services, Christiana Hospital, 4745 Ogeltown-Stanton Road, MAP-1, Suite 217, Newark, DE 19713, USA. dpaul@christianacare.org
authors.forename: David A
authors.initials: DA
authors.lastname: Paul
authors.forename: Amy
authors.initials: A
authors.lastname: Mackley
authors.forename: Robert G
authors.initials: RG
authors.lastname: Locke
authors.forename: John L
authors.initials: JL
authors.lastname: Stefano
authors.forename: Charlan
authors.initials: C
authors.lastname: Kroelinger
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D007226:Infant Mortality / Q000208:ethnology / Q000639:trends*; D007231:Infant, Newborn; D016014:Linear Models; D011247:Pregnancy; D011253:Pregnancy in Adolescence; D018570:Risk Assessment; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012907:Smoking; D014481:United States / Q000453:epidemiology; D055815:Young Adult