NEWS


A new revision of the United States certificates of live birth and death and the report of fetal death are currently being drafted by the National Center for Health Statistics of the Centers for Disease Control (CDC/NCHS). This process is carried out every 10 to 15 years, and the most recent revisions were implemented in 1989. The next revisions will be going into effect in the states beginning in 2003. Fundamental changes are being implemented in the way the data are collected, especially for births, thus requiring states to re-engineer their vital statistics systems to adapt to the revisions.

The revision of the U.S. live birth certificate has been expanded to a total of 58 items, compared with 43 in the 1989 version. Several topic areas have been changed and expanded, including the mother's and father's education, race, and Hispanic origin. The title for the person attending and certifying the birth, formerly listed as MD, DO, CNM, and other midwife, has been changed to include CM (certified midwife). Under place of birth, the option of home birth now asks, “Home birth: Planned to deliver at home? Yes/No.” The draft certificate requests new information on date of last prenatal care visit; cigarette smoking before and during pregnancy; onset of labor; epidural or spinal anesthesia during labor; method of delivery/vaginal (separated into spontaneous, forceps, or vacuum); method of delivery/cesarean (separated into “If cesarean, was a trial of labor attempted? Yes/No”); principal source of payment for this delivery; neonatal intensive care unit admission; Apgar score at 10 minutes; the obstetric procedures of cervical cerclage, tocolysis, and external cephalic version (Successful/Failed); and “Is infant being breastfed? Yes/No.” The draft revisions of the live birth and death certificates and the report of fetal deaths are now available on the CDC/NCHS web site: www.cdc.gov/nchs.

The folate status of U.S. women has improved since public health measures were implemented in January 1998 mandating that all enriched cereal grain products be fortified with folic acid (National Center for Health Statistics Press Release, Nov 13, 2001). In 1992 the U.S. Public Health Service first recommended that women of childbearing age increase their consumption of the vitamin folic acid to reduce spina bifida and anencephalus, which was followed in 1996 by the U.S. Food and Drug Administration's mandate for folic acid fortification in enriched cereal grain products. Birth certificate data in the United States have been available for selected birth defects since 1989. The 10-year trend for the two neural tube defects shows that the rate for spina bifida in 2000 was 21.03 per 100,000 live births, significantly lower than in 1997. After a decline in the early 1990s, the anencephalus rate has been stable since 1994. The rate in 2000 was 10.12 per 100,000 live births. The numbers and rates for all years exclude data for Maryland, New Mexico, and New York, which in various years had incomplete reporting or did not report these defects. Both of these neural tube defects are considered to be underreported on the birth certificate.

The percentage of new mothers in the workplace fell in 2000 for the first time in the United States since the government began tracking the figures nearly three decades ago, thus signaling a social trend that has had a broad impact on the nation's economy, culture, and daily life (Washington Post Oct 18, 2001:A2). The Census Bureau report said that of the 3.9 million women age 15 to 44 years who had babies between July 1999 and June 2000 (i.e., younger than 12 mo), about 55 percent were working in 2000, down from 59 percent in 1998. The decline was among women most likely to be able to afford the break from outside employment—older mothers, white women, married women living with their husbands, and women with at least a year of college. No significant decline occurred among younger mothers, black or Hispanic women, or those with a high school education or less. The percentage of mothers with infants working outside the home has risen steadily since 1976, from 31 percent to more than half by 1988, to the high of nearly 60 percent in 1998. The latest data match those of the U.S. Bureau of Labor statistics.

Leading causes of infant death in 1999 in the United States were, in rank order, congenital anomalies (accounted for nearly one-fifth of all infant deaths); disorders related to short gestation and low birthweight; followed by sudden infant death syndrome (SIDS); maternal complications of pregnancy; respiratory distress of the newborn; cord and placental complications; unintentional injuries; bacterial sepsis; circulatory diseases, and atelectasis (Natl Vital Stat Rep 2001;49(8):11). For neonatal death (< 28 days after birth) the leading cause of death was disorders related to short gestation and low birthweight, and for postneonatal death (between 28 days and 11 months), SIDS was the leading cause. Congenital anomalies ranked second as the cause of  death for both the neonatal and postneonatal periods. The infant mortality rate of 7.1 per 1000 live  births, although the lowest rate ever recorded for  the United States, was not statistically different from 1998.

The maternal mortality rate was 9.9 deaths per 100,000 live births in the United States in 1999 (a total of 391 deaths) (Natl Vital Stat Rep 2001; 49(8):11). The number of maternal deaths refers only to those with causes related to or aggravated by pregnancy or pregnancy management, and excludes those due to external causes (unintentional injuries, homicides, suicides). Black women have a substantially higher risk of maternal death than white women. In 1999 the rate for black women was 25.4, which was 3.7 times the rate for white women (6.8).

Midwives and obstetricians in the United States recently issued a “revised”Joint Statement of Practice Relationships Between Obstetrician-Gynecologists and Certified Nurse-Midwives/Certified Midwives. This statement by the American College of Nurse-Midwives (ACNM) and the American College of Obstetricians and Gynecologists, issued on September 1, 2001, clarifies their relationships and professional responsibilities and is designed to increase women's access to care and to promote communication and collaboration. This is the third modification of the original statement, written in 1971, and according to ACNM President Mary Ann Shah, not only does the wording show the medical community's greater acceptance of the midwifery profession than in the past, but also the physician supervision clause of the earlier statements has been “nullified, placing responsibility for the outcomes of care where it belongs…with the provider of that care” (Quickening 2001;32(5):3).In addition, the new statement recognizes the certified midwife (CM) throughout the statement. Shah notes that “It is my hope (and dream) that this joint reaffirmation of interdependence, mutual respect, and trust will translate into very tangible benefits within the clinical arena so that every CNM and CM is enabled to truly provide the safe and personalized care that women need, want, and so deserve.”

A recent analysis of male fertility has resulted in new recommendations questioning current standards for determining whether a semen sample is normal or abnormal (NIH News Release, Nov 7, 2001). Under the new recommendations, many men formerly considered fertile may, in fact, have difficulty fathering a child; conversely, men who fall below the threshold of the current standards may be capable of fathering a child. The study was conducted by University of Rochester, New York, researchers sponsored by the National Institute of Child Health and Human Development (NICHD), and was published in the Nov 8, 2001, issue of the New England Journal of Medicine. Current standards for estimating the fertility of semen samples were established by the World Health Organization, and according to their criteria, normal semen contains 20 million sperm per milliliter, with at least 50 percent motility. Dr. David Guzik and his co-workers found that men were most likely to be fertile if their semen had more than 48 million sperm per milliliter, more than 63 percent motility, and more than 12 percent having a normal appearance. A “gray zone” was also identified, in which men had borderline fertility, yet could still establish a pregnancy. The researchers found that men were most likely to be infertile if their sample contained fewer than 13.5 million sperm per milliliter, less than 32 percent motility, and fewer than 9 percent of normally shaped sperm. “Every treatment for infertility depends upon first establishing what's normal and what's abnormal,” Dr. Guzik said. “Up until now, we've just been using guidelines without rigorously testing them. We hope specialists will use these revisions in their counseling of infertile couples and in tailoring treatments to individual patient circumstances.”

The first month-long contraceptive was approved by the Food and Drug Administration (FDA) in October 2001 (Washington Post Oct 4, 2001:10A). The hormone-based device, called NuvaRing, consists of a flexible, transparent, and colorless ring about 3 inches in diameter that women insert vaginally once a month. The ring releases a continuous dose of estrogen and progestin, the same hormones used in oral contraceptives. Each ring remains in the vagina for 21 days, and is then removed and discarded. A new ring is inserted on or before the fifth day of the menstrual period. The device is produced by the Dutch company Organon, Inc., and will require a prescription. It will be available by mid-2002. Dena Hixon, a medical officer with the FDA's division of reproductive and urologic products, stated that “It has the same effectiveness as oral contraceptives and has the same risks and side effects.”

International News

In Brazil, contrary to popular belief, middle and upper  class women do not want to deliver by cesarean section, according to recent research (BMJ 2001;323:1155–1158). The study assessed and compared the preferences of 1612 pregnant women in the public (n= 1093) and private (n= 519) sectors. Women were questioned in face-to-face structured interviews early in their pregnancy, about 1 month before their due date, and about 1 month postpartum. Despite large differences in the cesarean section rates in the two sectors, 222/717 (32%) among public patients and 302/419 (72%) among private patients, no differences in preferences occurred in the two groups. In the two antenatal interviews, preferences in both groups for type of delivery were nearly identical, and strongly favored vaginal births. The study concluded that the large difference in the rates of cesarean section between the two groups is due to more unwanted cesareans among private patients rather than to a difference in preferences for delivery, and noted that “high or rising rates of cesarean births  do not necessarily reflect demand for surgical delivery.”

The WHO/UNICEF Baby Friendly Initiative in the United Kingdom is crucial in promoting an increase in breastfeeding initiation, according to a report from the National Health Service Centre for Reviews and Dissemination. In a recent letter to the Editor (BMJ 2001:322:555), Andrew Radford, Programme Director of the Unicef UK Baby Friendly Initiative, advised that although breastfeeding rates in the U.K. have remained the same since 1980, a survey of 21 Baby Friendly hospitals showed an increase of more than 10 percent in breastfeeding initiation. The percentage of babies who were breastfed rose from 60 percent 2 years before the units were awarded Baby Friendly status to 70.6 percent a year after accreditation. Some of the largest increases occurred in hospitals in inner city or deprived areas that generally have low rates. Currently in the U.K. 31 maternity units have the full Baby Friendly status and 68 have a certificate of intent.

High-risk pregnant women in New Zealand may have to be flown to Australia to deliver their babies because of overcrowding at National Women's Hospital in Auckland (New Zealand Herald Oct 17, 2001). The largest women's hospital in the Australia-Pacific region, it has a birth rate of approximately 8000 babies each year. However, this year the hospital's newborn unit has experienced an “unprecedented crush” of infants requiring intensive care. A nursing shortage, increasing numbers of multiple births, and the advent of technologies that enable caring for very premature babies have contributed to the overcrowding problem. The hospital had to close its 59-bassinet newborn unit to babies from other regions for several days at least three times in 2001 because of overcrowding. Dr. Rob Buist, clinical leader at the hospital, said that the lack of beds left “no alternative” but to fly pregnant women to Australia for care. He noted that the plan was “very disturbing” because the women who were being transferred would be likely to have complications, such as preeclampsia or prematurity. They would most likely take the 3-hour trip on commercial flights while accompanied by doctors and nurses at a cost of approximately US$12,600 per flight, which would be covered by the hospital. The New Zealand Ministry of Health, however, maintained that there were enough hospital beds in New Zealand to accommodate the demand, and reportedly had refused to provide extra money if patients had to be sent to Australia.

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