3 tables omitted
Persons born outside the 50 states and the District of Columbia (DC)*
comprised an estimated 11.1% (31.1 million) of the U.S. population in 2000,1 and approximately one fifth of all U.S. births
in 2000 were to women in this population. Racial/ethnic disparities in U.S.
health outcomes are of public health concern,2 and
the increasing cultural and linguistic diversity of the U.S. population poses
challenges to the delivery of maternal and child health services. This report
presents state-specific comparisons of live births in 1990 and 2000 to women
born outside the 50 states and DC and compares maternal characteristics and
live-birth outcomes for these women with those of state-born mothers (i.e.,
women born inside the 50 states and DC). The findings indicate that women
born outside the 50 states and DC had better birth outcomes than their state-born
racial/ethnic counterparts. However, a larger percentage of these women began
prenatal care later and had other problems accessing health care, which might
reflect economic, cultural, and language barriers. The U.S. public health
system and maternal health-care providers should understand and address the
health needs of an increasingly diverse population.
Data for 1990 and 2000 were obtained from CDC's National Center for
Health Statistics natality files, which are based on birth certificates for
all births occurring in the 50 states and DC. These certificates record the
mother's place of birth. Previous analyses indicated that maternal characteristics
and birth outcomes differed for women born in the 50 states and DC compared
with those born elsewhere.3,4 Because
maternal characteristics and birth outcomes for state-born Puerto Ricans differed
from those born elsewhere, results for these two groups are reported separately.
Records with missing information on the mother's place of birth (0.2% of all
U.S. live births in 1990 and 0.3% in 2000) were excluded from the analysis.
Data were analyzed by race/ethnicity. Reported birth outcomes analyzed were
preterm (i.e., <37 weeks' gestation) and low birthweight (i.e., <2,500
g). Late prenatal care was defined as care received in the third trimester
of pregnancy. Gestational age was computed from the date of the mother's last
menstrual period; when the date was missing or inconsistent with birthweight,
the clinical estimate of gestation was used.5 Unless
otherwise noted, all differences reported in this report are statistically
significant at p<0.0001.
In 1990, a total of 15.6% of all live births in the United States were
to women born outside the 50 states and DC; in 2000, such births represented
21.4% of all U.S. births. In both 1990 and 2000, births to Hispanics comprised
the majority of U.S. births to women born outside the 50 states and DC (57.2%
in 1990 and 58.6% in 2000); Mexicans accounted for 65.5% of Hispanic births
in 1990 and 72.2% in 2000. From 1990 to 2000, among women born outside the
50 states and DC, the percentages of live births to Mexicans increased from
5.7% to 9.0% of all U.S. live births, and births to Central and South Americans
increased from 1.9% to 2.5%. Births to Puerto Ricans declined from 0.6% to
0.5% of all U.S. births, and births to Cubans and other Hispanics born outside
the 50 states and DC remained the same. Births to non-Hispanics increased
from 6.7% to 8.8% overall; births to whites increased from 2.7% to 3.2%, births
to blacks increased from 1.1% to 1.6%, and births to Asians/Pacific Islanders
(APIs) increased from 2.8% to 4.1%.
In 1990, six states (California, Florida, Illinois, New Jersey, New
York, and Texas) accounted for 75.7% of live births to women who were born
outside the 50 states and DC. These states accounted for 65.8% of Hispanic
births in 2000. During 1990-2000, the percentage of births to women born outside
the 50 states and DC increased ≥10% in six states (Arizona, Colorado, Georgia,
Nevada, North Carolina, and Oregon); births to Hispanics accounted for the
majority of these increases.
In 2000, births to women born outside the 50 states and DC represented
a substantial proportion of all births in some population groups. At the state
level, approximately 66% of births to APIs in 49 states, >50% of births to
Hispanics in 42 states, and >33% of births to non-Hispanic blacks in six states
were to women born outside the 50 states and DC. Among non-Hispanics born
outside the 50 states and DC, the largest absolute increases in births occurred
among whites in New Hampshire (3.4%) and Vermont (2.4%), blacks in DC (2.5%)
and Florida (2.5%), and APIs in New York City (4.9%), New Jersey (4.5%), and
Because lower levels of education are associated with poor birth outcomes,
CDC compared maternal education levels of women who gave birth in 2000. The
analysis indicates that women born outside the 50 states and DC were more
than twice as likely as their state-born racial/ethnic counterparts to have
less than a high school education (38.9% versus 17.0%) and were less likely
to have completed 12 years of education (26.2% versus 33.4%). Approximately
59% of Hispanic women born outside the 50 states and DC had less than a high
school education compared with 33.4% of state-born Hispanic women. State-born
API women did not differ significantly from API women born outside the 50
states and DC in having less than a high school education (11.7% versus 11.3%).
However, Chinese women born outside the 50 states and DC were four times as
likely as their state-born counterparts to have less than a high school education
(12.5% versus 2.9%). State-born women overall, state-born API women, and state-born
Hispanic women were more likely than those born outside the 50 states and
DC to have completed ≥1 year of college. Puerto Rican, white, black, Filipina,
and other API women† born outside the 50 states and DC were more likely
than their state-born counterparts to have completed college.
State-born women were more likely than those born outside the 50 states
and DC to be teenagers when they gave birth (12.8% versus 8.1%). The magnitude
of the difference varied by race/ethnicity, with the largest intragroup differences
occurring among other APIs (19.7% versus 2.8%), blacks (21.5% versus 5.8%),
and Filipinas (13.2% versus 3.1%). State-born women were more likely to be
unmarried than those born outside the 50 states and DC (34.1% versus 29.7%).
This finding was consistent across all racial/ethnic groups, with the largest
intragroup differences occurring among blacks (72% versus 41%), Filipinas
(34.4% versus 16.1%), and whites (22.7% versus 10.7%). Except for Puerto Ricans,
Cubans, Filipinas, and other APIs, women born outside the 50 states and DC
were more likely than their state-born counterparts to begin prenatal care
late or to have no prenatal care.
Overall, state-born women were more likely to give birth to a preterm
infant (11.9% versus 10.5%) or an infant with low birthweight (7.9% versus
6.4%) than were those born outside the 50 states and DC. For preterm delivery,
this finding was consistent for all racial/ethnic populations except Filipinas,
Cubans, and Central/South Americans born outside the 50 states and DC. Among
Mexicans, who comprised the largest group of Hispanics, the difference was
11.9% versus 10.5%. For low birthweight, this finding was consistent for all
racial/ethnic groups except for Cubans and Puerto Ricans born outside the
50 states and DC. The largest intragroup difference occurred between state-born
blacks and those born outside the 50 states and DC, for both preterm births
(17.8% versus 14.0%) and low birthweight (13.5% versus 9.8%). The preterm
difference among Mexicans was 6.8% versus 5.5%.
B Sappenfield, MD, C Ferré, MA, S Iyasu, MMBS, Div of Reproductive
Health, National Center for Chronic Disease Prevention and Health Promotion;
JA Martin, MPH, SJ Ventura, MA, National Center for Health Statistics; DR
Allen, PhD, EIS Officer, CDC.
Approximately one in five live births in the United States in 2000 were
to women born outside the 50 states and DC. State-specific comparisons of
the number and distribution of such births from 1990 and 2000 reveal a shift
to states in the West and the South; births to Hispanic women accounted for
most of this increase.
Overall, women born outside the 50 states and DC had better birth outcomes
than their state-born racial/ethnic counterparts. Previous research has indicated
similar differences, even after adjustment for differences in age, education,
and marital status.3,4 Although
better birth outcomes among immigrants might reflect a "healthy immigrant
effect" (i.e., healthier persons might be more likely to immigrate), immigrant
status also might serve as a proxy for various protective behavioral, cultural,
and psychosocial factors that influence pregnancy outcome positively.3 For example, immigrants might have more extensive
social support networks to draw upon during their pregnancies. The process
of acculturation, which includes the adoption of new values, attitudes, and
behaviors that affect health, such as tobacco use and pregnancies at an earlier
age, might reduce these protective benefits and result in poorer pregnancy
outcomes among immigrants over time.
An analysis of pregnancy-related mortality in the United States during
1991-1997 indicated an increased risk for maternal death among Hispanic and
API immigrants compared with nonimmigrant whites.6 Although
few studies have focused specifically on access to maternal health-care services
among immigrant women in the United States, studies indicate that recent immigrants
face various economic, cultural, and language barriers when trying to access
health care.7 Recent epidemiologic investigations
underscore the need for maternal and child health services that are responsive
to changing immigration patterns. Studies have demonstrated an increased prevalence
of congenital rubella syndrome among infants born to women who migrate from
countries that have no mandatory rubella vaccination programs8 and
an association between the consumption of raw milk products and poor pregnancy
outcomes among a community of recent immigrants.9
The findings in this report are subject to at least two limitations.
First, how race/ethncity and mother's place of birth are reported might vary
between 1990 and 2000. Second, caution should be used when comparing some
reported estimates because of the small numbers of births in some states and
among some racial/ethnic populations.
This report highlights the need for U.S. maternal health services to
adapt to changing immigration patterns by providing culturally competent maternal
and child health services to an increasingly diverse population. Such services
should include language interpretation; cross-cultural training to increase
health practitioners' awareness of the impact of health beliefs, cultural
practices, and perceptions of health risks on health outcomes; and programs
that educate patients to access care and participate in treatment decisions.2,10
*This terminology is used instead of "foreign-born" because persons
who were born in U.S. territories and in Puerto Rico are U.S. citizens and
thus by definition are not "foreign-born."
†"Other API women" include Asians/Pacific Islanders other than
Chinese, Japanese, and Filipinas (e.g., Asian Indians, Koreans, and Vietnamese).
State-Specific Trends in US Live Births to Women Born Outside the 50 States and the District of Columbia—United States, 1990 and 2000. JAMA. 2003;289(12):1503-1505. doi:10.1001/jama.289.12.1503