The overall improvement in the health of Americans over the 20th century is best exemplified by dramatic changes in 2 trends: 1) the age-adjusted death rate declined by about 74%, while 2) life expectancy increased 56%. Leading causes of death shifted from infectious to chronic diseases. In 1900, infectious respiratory diseases accounted for nearly a quarter of all deaths. In 1998, the 10 leading causes of death in the United States were, respectively, heart disease and cancer followed by stroke, chronic obstructive pulmonary disease, accidents (unintentional injuries), pneumonia and influenza, diabetes, suicide, kidney diseases, and chronic liver disease and cirrhosis. Together these leading causes accounted for 84% of all deaths. The size and composition of the American population is fundamentally affected by the fertility rate and the number of births. From the beginning of the century there was a steady decline in the fertility rate to a low point in 1936. The postwar baby boom peaked in 1957, when 123 of every 1000 women aged 15 to 44 years gave birth. Thereafter, fertility rates began a steady decline. Trends in the number of births parallel the trends in the fertility rate. Beginning in 1936 and continuing to 1956, there was precipitous decline in maternal mortality from 582 deaths per 100 000 live births in 1935 to 40 in 1956. Since 1950 the maternal mortality ratio dropped by 90% to 7.1 in 1998. The infant mortality rate has shown an exponential decline during the 20th century. In 1915, approximately 100 white infants per 1000 live births died in the first year of life; the rate for black infants was almost twice as high. In 1998, the infant mortality rate was 7.2 overall, 6.0 for white infants, and 14.3 for black infants. For children older than 1 year of age, the overall decline in mortality during the 20th century has been spectacular. In 1900, >3 in 100 children died between their first and 20th birthday; today, <2 in 1000 die. At the beginning of the 20th century, the leading causes of child mortality were infectious diseases, including diarrheal diseases, diphtheria, measles, pneumonia and influenza, scarlet fever, tuberculosis, typhoid and paratyphoid fevers, and whooping cough. Between 1900 and 1998, the percentage of child deaths attributable to infectious diseases declined from 61.6% to 2%. Accidents accounted for 6.3% of child deaths in 1900, but 43.9% in 1998. Between 1900 and 1998, the death rate from accidents, now usually called unintentional injuries, declined two-thirds, from 47. 5 to 15.9 deaths per 100 000. The child dependency ratio far exceeded the elderly dependency ratio during most of the 20th century, particularly during the first 70 years. The elderly ratio has gained incrementally since then and the large increase expected beginning in 2010 indicates that the difference in the 2 ratios will become considerably less by 2030. The challenge for the 21st century is how to balance the needs of children with the growing demands for a large aging population of elderly persons.
The number of births in the United States decreased by 3% between 2008 and 2009 to 4 130 665 births. The general fertility rate also declined 3% to 66.7 per 1000 women. The teenage birth rate fell 6% to 39.1 per 1000. Birth rates also declined for women 20 to 39 years and for all 5-year groups, but the rate for women 40 to 44 years continued to rise. The percentage of all births to unmarried women increased to 41.0% in 2009, up from 40.6% in 2008. In 2009, 32.9% of all births occurred by cesarean delivery, continuing its rise. The 2009 preterm birth rate declined for the third year in a row to 12.18%. The lowbirth-weight rate was unchanged in 2009 at 8.16%. Both twin and triplet and higher order birth rates increased. The infant mortality rate was 6.42 infant deaths per 1000 live births in 2009. The rate is significantly lower than the rate of 6.61 in 2008. Linked birth and infant death data from 2007 showed that non-Hispanic black infants continued to have much higher mortality rates than non-Hispanic white and Hispanic infants. Life expectancy at birth was 78.2 years in 2009. Crude death rates for children and adolescents aged 1 to 19 years decreased by 6.5% between 2008 and 2009. Unintentional injuries and homicide, the first and second leading causes of death jointly accounted for 48.6% of all deaths to children and adolescents in 2009.
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