The influence of the wider use of surfactant therapy on neonatal mortality among blacks and whites

N Engl J Med. 1996 Jun 20;334(25):1635-40. doi: 10.1056/NEJM199606203342504.


Background: Surfactant therapy reduces morbidity and mortality among premature infants with the respiratory distress syndrome (RDS). Fetal pulmonary surfactant matures more slowly in white than in black fetuses, and therefore RDS is more prevalent among whites than among blacks. We reasoned that the increased use of surfactant after its approval by the Food and Drug Administration (FDA) in 1990 might have reduced neonatal mortality more among whites than among blacks.

Methods: We merged vital-statistics information for all 1563 infants with very low birth weights (500 to 1500 g) born from 1987 through 1989 or in 1991 and 1992 to residents of St. Louis with clinical data from the four neonatal intensive care units in the St. Louis area; we then compared neonatal mortality during two periods, one before and one after the FDA's approval of surfactant for clinical use (1987 through 1989 and 1991 through 1992).

Results: The use of surfactant increased by a factor of 10 between 1987 through 1989 and 1991 through 1992. The neonatal mortality rate among all very-low-birth-weight infants decreased 17 percent, from 220.3 deaths per 1000 very-low-birth-weight babies born alive (in 1987 through 1989) to 183.9 per 1000 (in 1991 through 1992; P = 0.07). This decrease was due to a 41 percent reduction in the mortality rate among white newborns with very low birth weights (from 261.5 per 1000 to 155.5 per 1000; P = 0.003). In contrast, among black infants, the mortality rate for very-low-birth-weight infants did not change significantly (195.6 per 1000 and 196.8 per 1000). The relative risk of death among black newborns with very low birth weights as compared with white newborns with similar weights was 0.7 from 1987 through 1989 and 1.3 from 1991 through 1992 (P = 0.02). The differences in mortality were not explained by differences in access to surfactant therapy, by differences in mortality between black and white infants who received surfactant, or by differences in the use of antenatal corticosteroid therapy.

Conclusions: After surfactant therapy for RDS became generally available, neonatal mortality improved more for white than for black infants with very low birth weights.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use
  • African Continental Ancestry Group*
  • European Continental Ancestry Group*
  • Female
  • Health Services Accessibility
  • Humans
  • Infant Mortality / trends
  • Infant, Newborn
  • Infant, Very Low Birth Weight*
  • Missouri / epidemiology
  • Pregnancy
  • Prenatal Care
  • Pulmonary Surfactants / therapeutic use*
  • Respiratory Distress Syndrome, Newborn / drug therapy
  • Respiratory Distress Syndrome, Newborn / ethnology
  • Respiratory Distress Syndrome, Newborn / mortality*


  • Adrenal Cortex Hormones
  • Pulmonary Surfactants