pregnancy & natality sectionhd.ingham.org/portals/hd/data book template 2017-03-06 (pregnancy)...
TRANSCRIPT
1
1
InghamCountyHealthSurveillanceBook2015
Pregnancy & Natality
Section
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-3
Datelastu
Pregnancy & Natality
Thehealthofwomenandchildreniscentraltothepublichealthofacommunity.Ahealthypregnancy
andchildbirthpavesthewaytoahealthierchildhoodandadultlife.Therefore,itisimportanttoun-
derstandfactorsaffectingpregnancyandnatalityandrelatedoutcomedataatthecounty,stateand
nationallevels.
Todothatforalocalcounty,itisimportanttoscreentherelevantdatafromvitalrecordsstatistics
collectedbystateornationaldatasources.Theprimarypurposeforcollectionofvitalrecordsisto
recordinformationonvitaleventsforlegalpurposes;vitalrecords�ilesalsoserveasanimportant
sourceforstatisticalinformation.
Thissectionofthereportisintendedtoassistpolicymakers,programmanagers,andotherinterest-
edpersonsunderstandhealthfactorsandtrendsaffectinghealthypregnanciesandnatality.Thisre-
port includesanumberofpregnancyandnatalityindicators forInghamCounty,Michigan.Mostof
thedatawasgleanedfromtheStateofMichigan“Natality,PregnancyandAbortionStatistics”forthe
years2005-2015intrendsor2015forlateststatistics.
Theindicatorsselectedfallunderoneofthefollowingbroadcategoriesofvitalevents,andincludea
comparisonofcountyandstatedata.
Fertility(includesgraphoftrendsandestimatedpregnancies)
Abortiongraphandtrends
Livebirthtrendsandrates
Maternalcharacteristics,includingdemographics,prenatalcare,educationandbehav-
ioralriskssuchassmoking
Infantcharacteristics,includingpregnancyterms,birthweight
Eachsectionincludes:
An‘IndicatorExplanation’sectionwhichdescribeswhythisindicatorwasrelevant
AdescriptionofcurrentstatusinInghamCountyandMichigan
TablesandgraphsbasedonStateofMichiganrecords
Speci�icdatasourceslinkswillbeplacedbeloweachofthetablesandgraphs.Alsocitationswithin
textswillbelistedattheendofthisdocumentsection.
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-4
Datelastupdated:April2017
Refreshcycle:annually
Fertility
Fertilityistheactualreproductiveperformanceofanindividual,acouple,agrouporapopulation(1).Agrowing
populationofbabiesandyouthsleadstoworkingadultsandtaxpayerstosupportanagingpopulation.Acommu-
nitycanseeitspopulationgrowthwithincreasedfertilityofmothers,orwithadults’jobmobilitybetweencities,
orinternationalmigrationsbringingyoungfamiliestosettleandeventuallyreproducingthere.Whenfertilityis
lowinacommunity,theneedtoattractmoreworkingadultsandfamiliesfromothercitiesandcountriesgrows.
This is whyunderstanding fertility trends and the factorscontributing tohigher or lower fertilityare ways to
helppredictthefutureregenerationofcommunitiesthroughpregnancyandnewbirths(2).
IndicatorExplanation
Fertility refers to the number of live births that occur toawomanduringchildbearingagerangeusually15-44
years.Fertilityrateisnumberoflivebirthsper1000childbearingagewomeninacertainyearandgeographic
location.Notallwomenhaveexactlythesamepotentialtogivebirthtokidsduringtheirchildbearingyears,and
it varies signi�icantly across a population or countries, which contributes to difference in overall population
growth.
KeyFindings
Between2005and2015, InghamCountyhasmaintained fertilityrates thatareslightly lower thantheoverall
StateofMichiganfertilityrates.TherehasbeenaslightdeclineinfertilityratesinbothInghamcountyandthe
StateofMichiganfrom2008to2013andthenasmallincreasein2014thatwasnotsustainedin2015;this
trendfollowsasimilartrendintheUnitedStates.The2008Economicrecession hasbeenassociatedwiththe
Source:table1MichiganDepartmentofHealthandHumanServices,MichiganHealthStatistics,PregnanciesbyOutcomeandFertility,AbortionandPregnancyRatesbyCounty,EstimatedPopulationforFemales,MichiganResidents,2015;Retrievedfromhttp://www.mdch.state.mi.us/pha/osr/abortion/pregbyco.asp
Figure1.FertilityRatebyGeography,2015 Figure2.PregnancyRatebyGeography,2015
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-5
Datelastupdated:April2017
Refreshcycle:annually
Fertility
Figure4.FertilityRateTrendInghamCountyandMichigan,2005-2015
Source3:http://www.mdch.state.mi.us/osr/CHI/Births14/frame.html
Figure3.FertilityRateinInghamCountyandMichigan,2015
lowerfertilityrates(2).ThepeakfertilityrateforInghamintheyears2005-2015wasin2006,at49.9per1000
women15-44andthelowestwasin2015at45.6.
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-6
Datelastupdated:April2017
Refreshcycle:annually
Abortion
Abortionisaninterventionperformedbyalicensedclinician(e.g.,aphysician,nurse-midwife,nursepractition-
er,orphysicianassistant)thatisintendedtoterminateanongoingpregnancy(3).Understandingabortionrates
helpspolicymakersandhealthproviderstopreservematernalhealthandlife;Compilingmaternalandlifedata
andmonitoringallabortionshelpstoensurethattheyaredoneonlyunderandinaccordancewiththeprovi-
sionsofthelawtominimizetherisksincurredtomothersfromunsafeabortion.
IndicatorExplanation
TheAbortionrateisthetotalnumberofabortionsper1,000womenaged15–44yearsinacertainyearandgeo-
graphiclocation.TheStateofMichigancompiledtheabortiontrends.Thisreportusestrendsfrom2005-2015
bycountyofresidence.
KeyFindings
InghamCountyabortionrateshavedeclinedintheyearsfrom2005to2015reachingalowof6per1000wom-
enin2013butstartedincreasingagainin2014and2015;ThetrendfortheStateofMichiganhasincreaseddur-
ingthesameperiodfrom11.9to13.8per1000women.
Figure5.AbortionRateTrendInghamCountyandMichigan,2005-2015
FigureSource:MichiganDepartmentofHealthandHumanServices,MichiganHealthStatistics,PregnanciesbyOutcomeandFertility,AbortionandPregnancyRatesbyCounty,EstimatedPopulationforFemales,MichiganResidents,2015;Retrievedfromhttp://www.mdch.state.mi.us/osr/Abortion/AbortionRates.asp
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-7
AccordingtotheWorldHealthOrganization(4),Livebirthisde�inedasthe“completeexpulsionorextractionof
aproductofconceptionfromitsmother,irrespectiveofthedurationofthepregnancy,which,aftersuchsepara-
tion,breathesorshowsanyotherevidenceoflife,suchasbeatingoftheheart,pulsationoftheumbilicalcord,or
de�initemovementofvoluntarymuscles,whetherornottheumbilicalcordhasbeencutortheplacentaisat-
tached.UnderstandingLiveBirthdataforwomenofacertainagegrouporpopulationgroupsallowscommuni-
ties to plan ahead for increasing supportof healthier pregnancies. Live Birth data forspecial subgroups help
communities understand how to deter stressful factors that might contribute to reduce healthy live births
amongsubgroups.
IndicatorExplanation
Crudebirthrateisde�inedintheStateofMichiganasthenumberofbirthsper1,000populationforacertain
geographicareainthiscasecountyorstate,orinaspeci�iedagecohortorraceorancestrysuchasHispanicor
AraborigingroupsinMichigan.
KeyFindings
InghamCountybirthrateshavebeengraduallydecliningbetween2005and2015andfollowtheexacttrendas
theStateofMichigan.From2003to2013theCrudeBirthrateinInghamCountyfollowedthegeneralpatternas
inthestateofMichigan;therewasageneraldeclinefrom13in2004to11.6in2011andthenitstabilizedatthis
ratefrom2011through2013.
Figure6.CrudeBirthRatesinInghamCountyandMichigan,2005-2015
Datelastupdated:April2017
Refreshcycle:annually
Live Birth
Source:MichiganHealthStatistics,PregnanciesbyOutcomeandFertility,AbortionandPregnancyRatesby
County,CrudeBirthRates,Retrievedfromhttp://www.mdch.state.mi.us/osr/Natality/BirthRateTrends.asp
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-8
Datelastupdated:April2017
Refreshcycle:annually
Live Birth
Table2.LiveBirthsandFertilityRateper1000
inInghamCountyandMichigan,2015
KeyFindings(cont’d)
Thehighestbirthratewasforwomen25-29yearsfollowedby30-34yearsrangeinbothInghamandMichi-
ganinthatsametimespan.TeenpregnancywasslightlyhigherinInghamCountythanMichiganin2015,
6.36%comparedto5.7%.(Table2).InrecentyearstheUnitedStateshasseenadropinbirthratesamong
theyoungerageasmoreyoungadultsdecidetopostponehavingchildren,andanincreaseintherateamong
womenintheir30sand40s.(5)WomeninInghamCountyarefollowingthattrend,therateforolderwomen
30-34is93.4almostthreetimesastherateforwomen20-24yrsold32.6.
Amongthevariousracialgroups,ArabandHispanicancestrywomenhadthehighestbirthratesinboth
InghamandMichigan,followedbyBlackthenAsian&Paci�icIslandersin2015(Figure5)andalsowhenwe
lookedattrendsfrom2005to2015.Thetrendoflivebirthsforwhitefemales15-44yearswasslightlyhigh-
eroverallthanthatofAsianPaci�icIslanders(Figure6).
Source:MichiganHealthStatistics,PregnanciesbyOutcome
andFertility,AbortionandPregnancyRatesbyCounty,
BirthRatesbyAgeofMother,retrievedfromhttp://
www.mdch.state.mi.us/pha/osr/Chi/births14/frame.html
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-9
Datelastupdated:April2017
Refreshcycle:annually
Maternal Characteristics Prenatal Care (PNC)
Prenatalvisitsstartinginthe�irsttrimesterareimportantforthehealthofbothinfantandmothertoincrease
chancesofhealthydeliveryandbirthweight.Duringtheprenatalcarevisits,healthcareproviderseducatemoth-
ersonimportanthealth issuesrelatedtopregnancyandchildbirthandthe importanceofcarefollowingbirth.
Topicsincludedietandnutrition,exercise,immunizations,weightgain,andabstainingfromdrugsthatareharm-
fulforthepregnancyandalcohol.Expectantparentsalsolearnaboutnutritionfortheirnewborn,thebene�itsof
breastfeeding,injuryandillnessprevention,aswellasmonitorforhealth-compromisingconditions,andprepar-
ingforthenewemotionalchallengesofcaringforaninfant.(6)
IndicatorExplanation
PrenatalCareistheregularvisitsofapregnantwomantoseekhealthcareandsupportbeforebirth.Inthisre-
portweusethe“Koteichuckindex,as theAdequacyPrenatalCareIndex(APNCU). It isbasedonAdequacyof
InitiationofPrenatalCareandAdequacyofReceivedservices. (7)Adequacyofcare,hasbeencorrelatedwith
positivebirthoutcomesandmayalsoconferbene�itssuchasreducedlikelihoodofpost-partumdepressionand
infantinjuries.Theindicatorislinkedtosomemothercharacteristics.Higherincome,bettereducatedmothers
aremorelikelytouseprenatalcareservicesandsomeracialorethnicgroupshavetraditionallybeenlesslikely
toenrollinprenatalcare.Itisimportanttounderstandfactorsleadingtolowerparticipationinprenatalcarein
order to provide services to subgroups that encourage such participation. Maternal health behavior such as
whetherornotsheisasmokerorlivesinahouseholdwhereherexposureofsmokingcompromisesherpreg-
nancyandmaternaleducationsaresomeofthecharacteristicsincludedinthissection.
KeyFindings
Between2005and2015theproportionofpregnantwomenparticipating inPrenatalcareby the4thmonthof
pregnancyformorethan80%ofrequiredtotalappointmentshasbeensteadilyincreasinginbothMichiganand
Inghamcounty,atasimilarpacetill2009butsince2010InghamCountyhassurpassedMichiganbyat least5
digitpointsontheKotelchuckIndex.Thepercentofwomenjoiningprenatalcareinthe�irsttrimesterhasslight-
lydeclinedforMichiganandInghamCounty.In2015Whitewomenwereatleast10%morelikelytoparticipate
inprenatalcarethananyotherraces.BlackwomenhadthelowestpercentageofparticipantsinPNCduringthe
�irst trimester comparedto other races,. Black women rates were at 56.6% in Ingham and 62.2%in Michigan
comparedto75.5%WhitewomeninbotherInghamandMichigan.
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-10
Datelastupdated:April2017
Refreshcycle:annually
Maternal Characteristics > PNC
Figure7.InadequatePNC(KotelchuckIndex),2015
Figure8.PercentWomenentryinPrenatalCareintheir1sttrimesterByRaceandEthnicAncestry,in
InghamCountyandMichigan,2015
Source:MichiganHealthStatistics,PregnanciesbyOutcomeandFertility,AbortionandPregnancy.Retrievedfrom:http://
www.mdch.state.mi.us/pha/osr/Chi/births14/frame.html
Source:MichiganHealthStatistics,PregnanciesbyOutcomeandFertility,AbortionandPregnancyRetrievedfrom:http://
www.mdch.state.mi.us/pha/osr/Chi/births14/frameBxChar.html
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-11
Datelastupdated:April2017
Refreshcycle:annually
Maternal Characteristics > Tobacco Use
Tobaccouseandexposureisanotherfactorthatisincludedinthisreportunderprenatalcare.Accordingtothe
Centers for Disease Control and Prevention,smoking reduces a woman’s chances of getting pregnant, causes
unnecessarycomplicationsinpregnancyandisharmfultothebabybeforeandafterbirth(8)
IndicatorExplanation
Tounderstandpatternsofmotheruseorexposuretotobacco,thereportusedornotthepregnantmotherused
tobacco,andwhetherornotthehouseholdhadanyoneregularlysmoking.
KeyFindings
Thepercentof livebirthsborntomotherswhosmokehasbeentrendingupwardfrom2005to2015inboth
InghamCounty(from13.7to17.0%)anditdoubledinMichigan(9.1%to18.2%).Raceisnotasigni�icantfac-
torinInghamcountyasitrangesbetween19.3%forwhite,20.4%forHispanicancestry,and22.6%forblack.
Dataforothergroupswerenotavailable.
InMichiganthepercentforHispanicswasmuchlowerthaneitherWhiteorBlackraces.ArabsandPaci�icIs-
landershaveamuchsmallerpercent(2.6%and1.7%,respectively)comparedtowhite18.3,black16.3andHis-
panic11.6%. LivebirthsinhouseholdswithsmokersorsecondhandsmokingisthehighestamongHispanic
ancestry,followedbyBlackandWhiteinInghamCounty,withnearlyaquarteroflivebirthsatriskofsmoke
exposureintheirhouseholds.
Figure9.TrendofthePercentofLiveBirthstoMotherswhousedTobaccoinInghamCountyandMichi-gan,2005-2015
Figures9,10,11Source:MichiganDepartmentofHealthandHumanServices,MichiganHealthStatistics,PregnanciesbyOutcomeandFertility,AbortionandPregnancy,PercentofLiveBirthstoMotherswhousedTobacco.Retrievedat:http://www.mdch.state.mi.us/pha/osr/Chi/births14/frameBxChar.html
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-12
Figure11.PercentofLiveBirthswithHouseholdSmokinginInghamCountyandMichigan,2015
Datelastupdated:April2017
Refreshcycle:annually
Maternal Characteristics > Tobacco Use
Figure10.PercentofLiveBirthstoMotherswhousedTobaccobyRaceGroupinInghamCounty
andMichigan,2015
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-13
Datelastupdated:April2017
Refreshcycle:annually
Maternal Characteristics > Education
Maternaleducationisthenumberofyearsamotherhasattendedformaleducationpriortogivingbirth.Itisone
ofthesocio-economicfactorsthatcontributetoadheringtogoodprenatalcarethatleadstoahealthyweightfull
term pregnancy and to infant care following birth. Lower levels of maternal education were associated with
higher maternal mortality even amongst women able to access facilities providing intrapartum care
(9).Understandingthematernaleducationlevelsacrossvariousraceorethnicgroupscanhelppredicttherisks
andaddressthemaccordinglytoimprovethechancesoffulltermhealthymotherandbabyatbirth.
IndicatorExplanation
Motherswithlessthan12yearsofeducationistheindicatorusedbytheStateofMichigan,thatmeansthemoth-
erwasnotahighschoolgraduatewhenshegavebirth.
KeyFindings
Since2005thepercentageofbirthstomothersoflessthan12yearseducationisthehighestamongthe15-19
years old age bracket in Ingham (56%) and Michigan (47.8%). This �igure has continued to drop in Ingham
Countyfrom16.2%to13.2%in2015whilethistrendisgoingupwardsfortheStateofMichiganfrom13.7%in
2005toreachapeakof19.7%in2013.Whenbrokendownbyracialandethnicancestry,theHispanicancestry
had the highest percent of births to mothers with less than 12 years education, both in Ingham (24.2%) and
Michigan(30.7%)comparedtoalltheotherracialandethnicgroups.
Table3.PercentofLiveBirthstoMotherswithlessthan12yrsofeducationbyMaternalAgeGroupin
InghamandMichigan,2015
Age of Mother Ingham County
Michigan
total 13.2% 12.1%
<15 years no data no data
15-19 years 56% 47.8%
20-24 years 22% 17%
25-29 years 8.3% 8.7%
30-34 years 5%% 6.3%
35-39 years 6.8 7.8%
40+ years 9.8% 9.7%
Table3andFigures12,13Source:MichiganDepartmentofHealthandHumanServices,MichiganHealthStatistics,PregnanciesbyOut-comeandFertility,AbortionandPregnancy,MaternalCharacteristics,Education,Retrievedat:http://www.mdch.state.mi.us/pha/osr/Chi/births14/frame.html
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-14
Figure13.PercentLiveBirthstoMotherswithlessthan12yearseducationinInghamCountyand
Michigan,2005-2015
Datelastupdated:April2017Refreshcycle:annually
Maternal Characteristics > Education
Figure12.PercentLivebirthstomotherswithlessthan12yearseducationByRacialandEthnic
groups,InghamCountyandMichigan,2015
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-15
Datelastupdated:April2017
Refreshcycle:annually
Infant Characteristics > Low Birthweight
Aninfant’sbirthweightisrecordedshortlyafterbirthandregisteredonthebirthcerti�icate.Aggregatebirthcer-
ti�icatedataonbirthweightsarethenusedtostudycommunitytrends.Loworverybirthweightinfantsaremore
likelytobeprematureoraresultofmothersufferingfromhealthissuesthataffectedfetalgrowth.Theyareata
higher risk of death in the �irst year of life. Understanding the factors associated with low birth weights is im-
portant to help minimize physical and developmental risks and to address the socio-economic maternal health
riskspriorandduringpregnancy.
IndicatorExplanation
Infantsbornatlowbirthweightarethosewhoweighlessthan2,500gramsor5pounds8ounces,andverylow
birthweightarethosebornlessthan1,500gramsor3.25pounds.
KeyFindings
The2015dataforbirthweightisbasedon2013birthcerti�icates.TheNationalaverageLowBirthweightreported
in2015was8%.Nationallythetrendsince2005hasbeengoingupwhichmeansmoreinfantsarebornatLBW.In
Michiganthetrendfrom2005-2015hasbeenstablearound8per100livebirths.Inghamhasseenaslight�luctua-
tioninthetrendduringthattime,intherangeof7.3%and9.2%butmostly8%orless.TheBlackandAsianPaci�ic
IslanderracialgroupsinInghamCountyhadthehighestLBWinfantsper1000birthsin2015,135.5and106.6re-
spectively. These rates for Black infants are nearly double that of the white racial group rates 69.6of LBW per
1000orthatofHispanicethnicgroupat65.4.
Figure14.LowBirthWeightbyMaternalAgeGroupinIngham
CountyandMichigan,2015
Table4andFigures14,15Source:MichiganDepartmentofHealthandHumanServices,MichiganHealthStatistics,Pregnan-ciesbyOutcomeandFertility,AbortionandPregnancy,RateofLowBirthweightper1000livebirths,Retrievedat::http://www.mdch.state.mi.us/pha/osr/Chi/births14/frameBxChar.html
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-16
Figure16.LowBirthWeightTrendinInghamCountyandMichigan,2005-2015
Datelastupdated:April2017
Refreshcycle:annually
Infant Characteristics > Low Birthweight
Figure15.LowBirthweightByRacialandEthnicGroupsinInghamCountyandMichigan,2015
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-17
Datelastupdated:April2017
Refreshcycle:annually
Infant Characteristics > Preterm Birth
IntheUnitedStates,1in10infantswerebornbeforethemothercompleted37weeksofpregnancy,orpreterm
birthin2015.Pretermbirthratesdecreasedfrom2007to2014,andCDCresearchshowsthatthisdeclineisdue,in
part,todeclinesinthenumberofbirthstoteensandyoungmothers(11).Understandingfactorsthatleadtopre-
termbirthisimportanttoaddressthemandpreventpotentialcomplicationsthatcanoccurasaresultofpreterm
birth;suchasrespiratorydistress,jaundice,anemia,andinfectionshortlyafterdelivery.Long-termcomplications
canincludelearningandbehavioralproblems,cerebralpalsy,lungproblems,andvisionandhearingloss.
IndicatorExplanation
Preterm babies are born before 37 completed weeks of gestation, and are at increased risk of immediate life-
threateninghealthproblems,aswellaslong-termcomplicationsanddevelopmentaldelays.
KeyFindings
Thepre-termratetrendshavebeengoingdownnationallysince2007andMichiganandInghamCountyfollowed
thistrendfrom2005to2013withaslightrisein2014and2015.Thelowernumberofteenpregnancieshasbeen
attributedtolowerpreterminfantbirths.Thetworacialgroupsathigherriskofpre-termbirthsinInghamCounty
were theBlackandAsian/Paci�ic Islandergroups,withratesofpre-termbirthper1000 livebirthsat135.5and
101.5respectivelyin2015.TheoverallrateinInghamCounty(96.6)wasslightlylowerthanthatinMichigan(98.4
pretermper1000livebirths).
Table4.PretermBirthByMaternalAgeGroupInghamCountyandMichigan,2015
Age of Mother Ingham County Michigan
All Ages 96.6 98.4
<15 years No data No data
15-19 years 18 95.9
20-24 years 95.5 98.5
25-29 years 76.2 90.1
30-34 years 98 96.2
35-39 years 43 117
40+ years 7 149.3
Table5andFigures16,17Source:MichiganDepartmentofHealthandHumanServices,MichiganHealthStatistics,PregnanciesbyOut-comeandFertility,AbortionandPregnancy,RateofPretermBirthsper1000livebirths,Retrievedat:http://www.mdch.state.mi.us/pha/osr/Chi/births14/frame.html
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-18
Figure18.Pre-termBirthTrendsinInghamCountyandMichigan,2005-2015
Datelastupdated:April2017
Refreshcycle:annually
Infant Characteristics > Preterm Birth
Figure17.PretermBirthbyRaceandEthnicgroupInghamCountyandMichigan,2015
InghamCountyHealthSurveillanceBook2015Pregnancy&Natality-19
Datelastupdated:April2017
Refreshcycle:annually
References
GlossaryofDemographicTerms;PopulationReferenceBureau,GlossaryofDemographicTerms,retrievedfromhttp://www.prb.org/Publications/Lesson-Plans/Glossary.aspx
Mather,Mark;WSJLivesegment,"IstheU.S.'s'BabyRecession'Over?";PopulationReferenceBureauvideo,re-trievedfrom:http://www.prb.org/Publications/Articles/2015/mather-wsj-baby-recession.aspx
Mather,Mark;TheDeclineofUSfertility,PopulationReferenceBureau,2012WorldfactSheet,Retrievedfromhttp://www.prb.org/publications/datasheets/2012/world-population-data-sheet/fact-sheet-us-population.aspx
DivisionofReproductiveHealth,NationalCenterforChronicDiseasePreventionandHealthPromotion,Abor-tionSurveillanceSystemFAQs;Retrievedfrom:https://www.cdc.gov/reproductivehealth/data_stats/abortion.htm
Worldhealthorganization,healthStatisticsandInformationSystem,MaternalMortalityissues.Retrievedat:http://www.who.int/healthinfo/statistics/indmaternalmortality/en/
Childtrends,databankIndicators,LateofNoPrenatalCare.December2015Retrievedat:https://www.childtrends.org/indicators/late-or-no-prenatal-care/
MichiganDepartmentofHealthandHumanServices,MichiganHealthStatistics,PregnanciesbyOutcomeandFertility,AbortionandPregnancy,http://www.mdch.state.mi.us/pha/osr/natality/tab1.8perc.asp
CenterforDiseasecontrolandPrevention,SmokingDuringPregnancy.Retrievedathttps://www.cdc.gov/to-bacco/basic_information/health_effects/pregnancy/
Therelationshipbetweenmaternaleducationandmortalityamongwomengivingbirthinhealthcareinstitu-tions:AnalysisofthecrosssectionalWHOGlobalSurveyonMaternalandPerinatalHealth;BMCPublicHealth,2011,Volume11,Number1,Page1SaffronKarlsen,LaleSay,Joao-PauloSouza,CarolJHogue,DinorahLCalles,AMetinGulmezoglu,RosalindRaine;retrievedfrom:http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-11-606
CenterforDiseasecontrolandPrevention,Pre-termBirth.Retrievedfrom:https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm