PublhI
ref
HealthBriefs
Effects
of
Maternal
Education,
Age,
and
Parity
on
Fatal
Infant
Accidents
KRISTINE
WICKLUND,
PHD,
SHEILA
MOSS,
MA,
AND
FLOYD
FROST,
PHD
Abstract:
Accidents
are
a
major
cause
of
death
among
children.
Using
computerized
linked
birth
and
death
record
information,
this
study
examined
the
relationship
of
selected
parental
factors
to
the
risk
of
infant
accidental
death.
The
analyses
suggest
that
maternal
age
and
education
are
inversely
related
to
infant
accident
mortality
while
mother's
parity
is
directly
related.
Accident
mortality
rate
differentials
by
educational
level
were
more
evident
for
certain
categories
of
accidents.
(Am
J
Public
Health
1984;
74:1150-1152.)
Accidents
are
a
major
cause
of
death
to
children
under
the
age
of
20.
A
number
of
risk
factors
have
been
identified
as
influencing
the
distribution
of
fatal
childhood
accidents.
These
include
host
factors
such
as
age
and
sex;
environmen-
tal
factors
such
as
hazardous
play
equipment,
flammable
clothing,
and
accessible
poisons;
and
parental
characteris-
tics
such
as
socioeconomic
status.
This
study
examines
the
relationship
of
selected
paren-
tal
factors
with
accident
mortality
rates
for
children
under
one
year
of
age.
An
attempt
is
made
to
determine
the
independent
effects
of
three
variables-maternal
education,
age,
and
parity.
These
factors
may
be
of
utmost
importance
in
understanding
accidental
deaths
to
children
less
than
one
year
of
age,
since
infants
depend
almost
entirely
upon
parental
care
for
their
safety
and
well-being.
Methods
Our
data
consist
of
linked
birth
and
death
records
from
North
Carolina
and
Washington
State
for
the
years
1968
through
1980.
Overall
infant
accident
mortality
rates
were
calculated
for
both
states,
stratified
by
race
and
year
of
birth.
Causes
of
death
were
identified
according
to
the
8th
revision,
International
Classification
of
Diseases,
Adapted
(ICDA-8),
for
deaths
between
1968-1978.
The
9th
revision
of
the
International
Classification
of
Diseases
was
used
for
1979-1980
deaths.
Inclusion
of
the
educational
level
of
the
mother
on
the
North
Carolina
birth
certificates
enabled
North
Carolina
accident
mortality
rates
to
be
calculated
for
each
of
three
maternal
educational
groups:
8
years
or
less
of
schooling,
9
through
12
years,
and
more
than
12
years.
Birth
certificates
in
Washington
State
did
not
include
information
on
maternal
educational
level.
Address
reprint
requests
to
Kristine
Wicklund,
PhD,
Health
Services
Division,
Department
of
Social
and
Health
Services,
Public
Health
Labora-
tory,
1409
Smith
Tower,
Seattle,
WA
98104.
Dr.
Frost
is
also
with
the
Health
Services
Division;
Ms.
Moss
is
with
Children's
Orthopedic
Hospital
and
Medical
Center,
Seattle.
This
paper,
submitted
to
the
Journal
January
10,
1983,
was
revised
and
accepted
for
publication
February
27,
1984.
c
1984
American
Journal
of
Public
Health
0090-0036/84
$1.50
To
determine
the
independent
effects
of
maternal
age
and
parity
on
infant
accident
mortality,
unconfounded
sum-
mary
accident
mortality
rates
for
maternal
age
groups
and
parity
groups
were
obtained
using
a
convergent
iterative
procedure
developed
by
Mantel
and
Stark.'
The
procedure
provided
maternal
age-specific
mortality
rates
standardized
for
parity,
as
well
as
parity-specific
mortality
rates
standard-
ized
for
maternal
age.
Twenty
separate
mortality
rates
were
provided
by
stratifying
maternal
age
into
five
groups
(under
20,
20-24,
25-29,
30-34,
and
35
and
older)
and
parity
into
four
groups
(1,
2,
3,
and
4
and
over).
This
procedure
was
conducted
with
North
Carolina
data
for
Blacks
and
Whites
in
each
educational
group
and
with
Washington
State
data
only
for
Whites.
Results
The
overall
accident
mortality
rates
among
children
during
the
first
year
of
life
were
5.48
per
10,000
live
births
in
North
Carolina,
and
3.12
per
10,000
live
births
in
Washing-
ton,
from
1968-80
(Table
1).
In
North
Carolina,
the
rates
were
higher
among
Black
children
than
among
White
chil-
dren.
A
fairly
steady
and
dramatic
decline
in
fatal
accident
rates
is
evident
in
both
states.
The
particularly
large
decline
in
fatal
accidents
among
North
Carolina
Black
infants
has
sharply
narrowed
the
differential
between
Blacks
and
Whites.
The
risk
of
a
fatal
accident
among
infants
during
the
first
year
of
life
was
directly
related
to
the
level
of
the
mother's
schooling
for
White
as
well
as
Black
children
(Table
2).
Infants
whose
mothers
completed
8
or
fewer
years
of
education
had
nearly
double
the
rate
of
fatal
accidents
as
infants
whose
mothers
had
some
high
school
education.
The
independent
effects
of
maternal
age
and
parity
on
infant
accident
mortality
were
considered
within
each
educa-
tional
group
for
White
and
Black
children
in
North
Carolina
(Tables
3
and
4).
Among
White
women
of
each
educational
group
and
Black
women
who
had
completed
9-12
years
of
schooling,
maternal
age
was
inversely
related
to
the
child's
risk
of
a
fatal
accident,
while
parity
was
directly
related.
In
Washington,
a
three-fold
increase
in
accident
rates
was
evident
with
decreasing
maternal
age
and
a
two-fold
increase
in
rates
was
observed
with
increasing
parity
(Table
5).
The
two
leading
causes
of
infant
accident
mortality
in
North
Carolina
were
suffocation
by
inhalation
and/or
inges-
tion
of
food,
and
suffocation
by
mechanical
means
(e.g.,
in
bed
or
cradle,
by
plastic
bag,
etc.).
Transport
accidents
followed
closely
as
the
third
leading
cause
of
accidental
death.
For
all
types
of
accidents,
an
inverse
relationship
existed
between
mortality
and
mother's
educational
level
(Table
6).
Suffocation
rate,
either
by
ingestion
of
food
and
AJPH
October
1984,
Vol.
74,
No.
10
1150
PUBLIC
HEALTH
BRIEFS
objects
or
by
mechanical
means,
showed
particularly
large
differences
by
maternal
education,
as
did
risk
of
death
by
fire.
Rates
of
transport
accidents,
poisonings,
and
falls
demonstrated
smaller
differences
when
stratified
by
mater-
nal
education.
In
Washington,
transport
accidents
were
the
leading
cause
of
accidental
infant
mortality,
followed
by
mechanical
suffocation
and
food
suffocation.
Of
the
37
mechanical
suffocation
deaths,
16
were
the
result
of
an
TABLE
1-Accident*
Mortality
Ratest
(Deaths)
for
Infants
during
the
First
Year
of
Life,
North
Carolina
and
Washington
1968-1980,
by
Year
and
Race
North
Carolina
Washingtont
All
Children
White
Black
All
Children
White
1968
9.89
7.08
16.84
4.20
4.32
1969
8.04
5.35
14.75
5.22
4.54
1970
7.54
5.10
13.64
4.63
3.58
1971
6.61
4.53
12.03
4.52
4.54
1972
6.20
4.14
11.74
3.32
3.39
1973
4.71
4.50
5.61
2.52
2.07
1974
4.80
3.40
7.76
2.99
3.07
1975
5.00
4.29
6.68
2.16
1.73
1976
3.91
2.32
6.37
2.64
2.50
1977
4.42
3.92
5.17
2.10
2.33
1978
2.98
1.76
5.99
3.07
2.28
1979
3.17
2.94
3.55
1.86
1.74
1980
2.79
2.56
3.17
1.47
1.55
1968-80
5.48
(631)
4.04
(323)
8.80
(289)
3.12
(228)
2.83
(188)
*Accidents:
ICDA-8
E8000-9299,
E9400-9499,
ICD-9
E8000-9299.
tRates
per
10,000
live
births.
$The
number
of
Black
infants
was
too
small
to
calculate
rates.
TABLE
2-Accident*
Mortality
Ratest
(Deaths)
for
Infants
during
the
First
Year
of
Life,
North
Carolina
1968-
1980
by
Maternal
Education
and
Race
Maternal
Education
(years)
<8
9-12
>12
All
Children
11.96
(99)
5.85
(480)
2.12
(52)
White
Children
9.57
(48)
4.24
(232)
1.75
(43)
Black
Children
16.38
(47)
9.10
(235)
2.50
(7)
*Accidents
ICDA-8
E8000-9299,
9400-9499;
ICD-9
E8000-9299.
tRates
per
10,000
live
births.
TABLE
3-Matemal
Age-Specific
Accident*
Mortality
Rates"
(Deaths)
Standardized
for
Parity,
North
Carolina,
1968-1980
by
Race
and
Maternal
Education
Matemal
Age
(years)
Mother's
Education
<20
20-24
25-29
30-34
35+
WHITE
CHILDREN
-8
yearst
1.253
(15)
1.392
(21)
0.521
(7)
0.315
(3)
0.214
(2)
9-12
yearst
0.735
(70)
0.467
(106)
0.212
(38)
0.136
(13)
0.104
(5)
>12
yearst
0.820
(2)
0.206
(11)
0.243
(23)
0.138
(6)
0.080
(1)
BLACK
CHILDREN
-8
years
1.458
(21)
2.414
(12)
1.965
(7)
1.407
(4)
0.891
(3)
9-12
yearst
1.143
(105)
0.524
(95)
0.274
(27)
0.135
(7)
0.030
(1)
>12
years
0.663
(2)
0.119
(2)
0.197
(2)
0.084
(1)
0.000
(0)
'Accidents:
ICDA-8
E8000-9299,
9400-9499,
ICD-9
E8000-9299.
"Rates
per
10,000
live
births.
tFor
educational
group
-8
yrs:
Test
for
independent
effect
of
matemal
age:
G2=40.0,
1
Test
for
interaction
of
matemal
age
and
parity:
G
=8.0,
12
tFor
educational
group
9-12
yrs:
Test
for
independent
effect
of
matemal
age:
G2=70.0,
1
Test
for
interaction
of
maternal
age
and
parity:
G2=6.0,
12
tFor
educational
group
>12
yrs:
Test
for
independent
effect
of
matemal
age:
G2=28.0,
1
Test
for
interaction
of
maternal
age
and
parity:
G2=6.0,
12
$Test
for
independent
effect
of
maternal
age:
G2=
144.0,
16df,
Test
for
interaction
of
matemal
age
and
parity:
G2-52.0,
12df,
p
16df,
p<0.001
2df,
p>0.05
16df,
p<0.001
2df,
p>0.05
16df,
p<0.05
2df,
p>0.05
,
p<0.001
p<0.001
AJPH
October
1984,
Vol.
74,
No.
10
1151
PUBLIC
HEALTH
BRIEFS
TABLE
4-Parity-Specific
Accident*
Mortalfty
Rates"
(Deaths)
Standardized
for
Matemal
Age,
North
Carolina,
1968-1980
by
Race
and
Maternal
Education
Parity
Mother's
Education
1
2
3
4+
WHITE
CHILDREN
-8
yearst
0.516
(12)
0.631
(11)
0.891
(9)
1.869
(16)
9-12
yearst
0.240
(89)
0.419
(79)
0.539
(32)
1.215
(32)
>12
yearst
0.171
(19)
0.258
(18)
0.153
(3)
0.499
(3)
BLACK
CHILDREN
-8
years
1.787
(17)
2.421
(12)
0.242
(1)
1.612
(17)
9-12
yearst
0.303
(80)
0.474
(63)
1.234
(44)
1.942
(48)
>12
years
0.223
(6)
0.000
(0)
0.000
(0)
0.551
(1)
*Accidents:
ICDA-8
E8000-9299,
9400-9499,
ICD-9
E8000-9299.
**Rates
per
10,000
live
births.
tFor
educational
group
-8
yrs:
Test
for
independent
effect
of
matemal
age:
G2=34.0
1
df,
p<0.001
Test
for
interaction
of
matemal
age
and
parity:
G2
80
12df,
p>0.05
tFor
educational
group
9-12
yrs:
Test
for
independent
effect
of
matemal
age:
G2
600
15df,
p<0.201
Test
for
interaction
of
maternal
age
and
parity:
G2
=6.0,
12df,
p>0.05
tFor
educational
group
>12
yrs:
Test
fo
independent
effect
of
matemal
age:
G2=28.0,
15df,
p<0.05
Test
for
interaction
of
maternal
age
and
parity:
G=6.0,
12df,
p>0.05
*Test
for
independent
effect
of
matemal
age:
G2
152.0,
15df,
p<0.001
Test
for
interaction
of
matemal
age
and
parity:
G2
=52.0,
12df,
p<0.001
TABLE
5-Maternal
Age-Specific
Accident*
Mortality
Rates"
(Deaths)
and
Parity-Specific
Accident
Mortality
Rates
(Deaths),
Wash-
ington,
1968-1980,
White
Children
Maternal
Age-Specific
Rates
Standardized
for
Parityt
Maternal
Age
(years)
<20
20-24
25-29 30-34
35+
White
Children
.665
(51)
.320
(76)
.153
(36)
.149
(16)
.208
(8)
Parity-Specific
Rates
Standardized
for
Maternal
Age*
Parity
1
2
3
4+
White
Children
.213
(80)
.235
(47)
.547
(39)
.433
(21)
*Accidents:
ICDA-8
E8000-9299,
E9400-9499,
ICD-9
E8000-9299.
**Rates
per
10,000
live
births.
tTest
for
independent
effect
of
maternal
age:
G
=
57.3,
16df,
p
<
0.001.
tTest
for
interaction
of
maternal
age
and
parity:
G2
=
16.5,
12df,
p
>
0.05.
fTest
for
independent
effect
of
parity:
G2
=
36.2,
15df,
p
<
0.005.
*Test
for
interaction
of
maternal
age
and
parity:
G2
=
16.5,
12df,
p
>
0.05.
infant's
head/neck
being
caught
in
crib
slats
or
between
the
mattress
and
slats.
Five
infants
died
from
falling
out
of
a
crib
and
being
caught
between
the
crib
and
the
wall.
Four
others
suffocated
while
sleeping
with
parents.
Of
the
34
infants
who
died
as
a
result
of
food
suffocation,
all
aspirated
vomitus
or
mucous,
most
often
in
bed.
Discussion
Our
analyses
suggest
that
three
parental
factors
have
an
effect
on
infant
accident
mortality.
An
inverse
relationship
was
demonstrated
with
maternal
education
and
age,
while
a
direct
relationship
was
observed
with
mother's
parity.
Limited
to
data
on
death
certificates,
we
were
unable
to
pursue
other
variables
of
interest
related
to
our
findings.
The
declining
rates
of
accident
mortality
may
reflect
the
exten-
sive
work
of
the
Consumer
Product
Safety
Commission
in
TABLE
B-Type-Specific*
Mortality
Rates**
(Deaths)
for
Infants
during
the
First
Year
of
Life,
North
Carolina
1968-1980,
by
Matemal
Education,
All
Races
Matemal
Education
(years)
Type
of
Accident
All
Educational
Groups
(Deaths)
<8
9-12
>12
Transport
1.00
(115)
1.09
1.11
0.61
Poisoning
0.20
(23)
0.48
0.19
0.12
Falls
0.23
(26)
0.24 0.23
0.20
Fire
0.72
(83)
1.81
0.77
0.20
Drowning
0.22
(25)
0.60
0.23
0.04
Food
Suffocation
1.14
(131)
2.66
1.19
0.45
Object
Suffocation
0.47
(54)
1.09
0.54
0.04
Mechanical
Suffocation
1.08
(124)
2.66
1.15
0.33
Other
0.44
(50)
1.33
0.44
0.12
*Accidents:
ICDA-8
E8000-9299,
9400-9499;
ICD-9
E8000-9299.
*^Rates
per
10,000
live
births.
forcing
the
redesign
of
cribs,
the
child-proofing
of
bottle
caps,
and
the
recall
of
unsafe
toys.
Limited
access
to
medical
care,
and
exposure
to
environmental
hazards
associ-
ated
with
poverty
and
isolation
may,
in
part,
explain
why
maternal
educational
differentials
are
observed
with
the
rates
of
specific
types
of
accidents.
As
an
example,
improper
use
of
portable
heaters
in
crowded
living
quarters
may
contribute
to
the
differential
in
infant
deaths
due
to
fires.
Although
the
causes
for
the
relationships
are
specula-
tive,
mothers
whose
children
are
at
high
risk
of
fatal
acci-
dents
have
been
identified.
An
approach
to
prevention
can
focus
on
the
environmental
hazards
that
endanger
the
under-
privileged
and
on
educational
efforts
and
social
supports
directed
particularly
toward
young
mothers
with
little
formal
education.
REFERENCE
1.
Mantel
N,
Stark
CR:
Computation
of
indirect-adjusted
rates
in
the
pres-
ence
of
confounding.
Biometrics
1%8;
24(4):997-1005.
1152
AJPH
October
1984,
Vol.
74,
No.
10
