Open Access Research article

A parsimonious explanation for intersecting perinatal mortality curves: understanding the effects of race and of maternal smoking

K S Joseph1*, Kitaw Demissie2, Robert W Platt3, Cande V Ananth4, Brian J McCarthy5 and Michael S Kramer3

Author Affiliations

1 Perinatal Epidemiology Research Unit, Departments of Obstetrics and Gynaecology and of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada

2 Department of Environmental and Community Medicine, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, USA

3 Departments of Pediatrics and of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada

4 Section of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive Sciences, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, USA

5 Centers for Disease Control and Prevention, Atlanta, Georgia, USA

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BMC Pregnancy and Childbirth 2004, 4:7  doi:10.1186/1471-2393-4-7

Published: 16 April 2004



Neonatal mortality rates among black infants are lower than neonatal mortality rates among white infants at birth weights <3000 g, whereas white infants have a survival advantage at higher birth weights. This finding is also observed when birth weight-specific neonatal mortality rates are compared between infants of smokers and non-smokers. We provide a parsimonious explanation for this paradoxical phenomenon.


We used data on births in the United States in 1997 after excluding those with a birth weight <500 g or a gestational age <22 weeks. Birth weight- and gestational age-specific perinatal mortality rates were calculated per convention (using total live births at each birth weight/gestational age as the denominator) and also using the fetuses at risk of death at each gestational age.


Perinatal mortality rates (calculated per convention) were lower among blacks than whites at lower birth weights and at preterm gestational ages, while blacks had higher mortality rates at higher birth weights and later gestational ages. With the fetuses-at-risk approach, mortality curves did not intersect; blacks had higher mortality rates at all gestational ages. Increases in birth rates and (especially) growth-restriction rates presaged gestational age-dependent increases in perinatal mortality. Similar findings were obtained in comparisons of smokers versus nonsmokers.


Formulating perinatal risk based on the fetuses-at-risk approach solves the intersecting perinatal mortality curves paradox; blacks have higher perinatal mortality rates than whites and smokers have higher perinatal mortality rates than nonsmokers at all gestational ages and birth weights.