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The total cesarean delivery rate jumped sharply to 24.4 percent in the United States in 2001, according to preliminary data from the National Center for Health Statistics (Natl Vital Stat Rep 2002;50(10):4-5). This was a 7 percent increase, and the highest rate ever reported from this data source. The primary rate of cesareans rose 5 percent to 16.9 percent, and the rate of vaginal birth after previous cesarean (VBAC) tumbled 20 percent from 16.5 percent in 2000 to a new low of 16.5 percent in 2001. Increases were seen in every state and the District of Columbia, with Louisiana (29.9%), Mississippi (29.6%), and New Jersey (28.9%) showing the highest rates in 2001; the rate in Puerto Rico jumped to 41.7 percent (39.1% in 2000). The 2001 cesarean rates were the highest levels reported for non-Hispanic white, black, and Hispanic women—24.5, 25.8, and 23.5 percent, respectively.

Reproductive health and children's rights issues came under attack at the 10-year review of the 1990 World Summit for Children at a UN General Assembly Special Session on Children, held at the United Nations in New York in May, according to a recentcommentary by Canadians Jennifer Kitts andKatherine McDonald (CMAJ 2002;166(9)). At numerous UN conferences in the 1990s, the international community made a commitment to improve and promote the sexual and reproductive health of adolescents. It was agreed that all people, regardless of age, have the right to access the information, education, and services they need to protect their sexual and reproductive health, including contraceptives, prenatal care, intrapartum and postpartum care, and prevention of sexually transmitted diseases. Many countries, including Canada, the European Union, Switzerland, and a bloc of 18 Latin American countries, are working to maintain these commitments. In contrast, the Bush Administration, lining up with countries including Sudan, Libya, Iran, Pakistan, and the Holy See, continues to advance its conservative agenda on the international stage in trying to roll back earlier agreements on the rights of adolescents tosexual and reproductive health information, education, and services. The United States delegation,reportedly ‘‘pro-family and pro-life,‘’ supports abstinence as the primary strategy to prevent unintended pregnancies and HIV/AIDS, and has campaigned to have the phrase ‘‘reproductive health services’’ removed from the wording of the final UN document. The Children's Special Session will set the direction for international policy for children over the next decade. Any weakening of the language evolving from that Special Session could ‘‘set a dangerous precedent for future agreements, and encouragefurther and more aggressive activism by socially conservative interest groups,‘’ noted Kitts and McDonald.

Racial and ethnic disparities were reported in the infant mortality rates among the 60 largest cities in the United States during the period 1995 to 1998, according to the Centers for Disease Control and Prevention (MMWR April 19, 2002). Overall rates ranged from 4.5 to 15.4 in deaths per 1000 live births (median=7.8). Infant mortality rates varied by race and ethnicity, and the median black rate of 13.9 per 1000 live births was substantially higher than both white and Hispanic rates (6.4 and 5.9, respectively). Wide differences also existed within each racial and ethnic group. The city with the highest rate in each group had a rate at least twice that of the city with the lowest rate in that group. Cities with the highest infant mortality rates tended to have a larger proportion of black births and a smaller proportion of Hispanic births; conversely, cities with the lowest rate tended to have a smaller proportion of black births and a larger proportion of Hispanic births. Cities with higher rates were more common in the Midwest, Southeast, and Northeast, and those with lower rates were clustered in the Pacific East and West Central regions. Because urban communities are targets for many local, state, and federal initiatives, reporting and comparing city-specific infant mortality rates are important for understanding city-level differences in child health.

Overall prevalence of any alcohol use among pregnant women in the United States declined to 12.8 percent by 1999, down from 16.3 percent in 1995, thus reversing a rise throughout the early 1990s, according to a survey by the Centers for Disease Control and Prevention (MMWR April 5, 2002). One of the national health objectives for 2010 is to decrease alcohol consumption among pregnant women to 94 percent. However, rates of binge drinking (i.e., ≥5 drinks on any one occasion) and frequent drinking (i.e., ≥7 drinks per week or ≥5 drinks on any one occasion) during pregnancy have not declined, and these rates also have not declined among nonpregnant women of childbearing age. Prenatal drinking patterns are highly predictive of alcohol use during pregnancy. For pregnant women the binge and frequent drinking rates remain higher than the 2010 national health objectives. Pregnant women who reported alcohol use were more likely to be older than 30 years, unmarried, and employed. Investigators said that physicians should routinely screen women for alcohol use, and warn those of childbearing age about the links of alcohol with birth defects, mental retardation, and developmental disorders.

The decline of human fertility begins at an earlierage than previously believed, according to a recent British study published in Human Reproduction (Rochester Democrat Chronicle April 30, 2002). Until now, it was thought that women's fertility started to drop significantly in their early 30s, with a large decline after age 35 years. However, this new study indicates that, on average, female fertility begins to drop at age 27 years. In addition, men's fertility starts to decline after age 35 years. The study involved healthy couples from across Europe who were using only the rhythm method of birth control. Women in the 27- to 29-age group had lower pregnancy chances on average than women at ages 19 to 26 years. The likelihood of pregnancy did not noticeably decline between the age groups 27 to 29 and 30 to 34 years, but then dropped again from age 35 years. Nevertheless, experts said that the findings should not raise undue concern. The results mean that it may take a month or two longer to conceive than it does for younger people.

An oversupply of neonatal doctors was reported in a recent study conducted at Dartmouth Medical School in Hanover, New Hampshire, and published in the New England Journal of Medicine(NY Times May 15, 2002). The study found that areas where the supply of neonatal specialists ranged widely—from 4.3 to 11.6 per 10,000 births—all had about the same newborn death rates, and suggested that far too many doctors and hospital units specialize in intensive care of premature or sick infants. Even the most premature babies were found to die at roughly the same rate in these areas. The supply of neonatal intensive care beds made no difference in death rates around the country. The researchers observed that this oversupply was not only a waste of medical resources but might even be harmful, because it might subject babies to unnecessary test and treatments. The findings ‘‘raise disturbing issues regarding the nation's unquestioning acceptance that more is always better with respect to the supply of specialist physicians and hospital technology,‘’ said Dr. Kevin Grumbach, a public health researcher at the University of California at San Francisco, who wrote an editorial to accompany the findings. ‘‘If I have a healthy full-term baby, I actually don't want anyone messing around with that baby,‘’ Dr. Grumbach said. ‘‘There's a downside where we meddle too much.‘’

Exclusive breastfeeding for the first 6 months of life gives full-term infants who are born small the advantage of an average of 11 points higher on IQ tests compared with those who are given formula or solids early on, according to research published in the March Acta Paediatrica (NIH News Release March 20, 2002). The study was conducted by researchers at the National Institute of Child Health and Human Development (NICHD) and the Norwegian University of Science and Technology.The finding is consistent with earlier reports that full-term infants who were of normal size for their age scored 3 points higher on IQ tests at 5 years of age when breastfed exclusively for the first 6 months than did infants who either stopped breastfeeding before 6 months or had supplements such as formula or solids introduced into their diets. The finding also discredits the widely held belief that supplementary feedings of formula and cereal, in addition to breastmilk, will help these smaller infants reach normal size faster than they would on breastmilk alone. Ten percent of all births in the United States are small for gestational age, or less than 6 pounds when born full term. ‘‘This study provides strong evidence that exclusive breast feeding for the first six months benefits the cognitive development of both small and normal-size infants,‘’ said Duane Alexander, M.D., Director of the NICHD. ‘‘Also noteworthy is the observation that exclusive breast feeding does not compromise growth.‘’ The scientists conducted the study in Norway and Sweden because mothers in those countries exclusively breastfeed their infants for longer durations than women in the United States. The most recent U.S. statistics from the Third National Health and Nutrition Examination Survey indicate that whereas only 21 percent of infants are still being exclusively breastfed for 4 months, this percentage drops to 16 percent by 6 months of age.

Home uterine monitors are not useful for predicting preterm birth, according to a study by the National Institute of Child Health and Human Develop-ment (NICHD) (NIH News Release Jan 23, 2002). Although they are widely prescribed for women at risk of giving birth prematurely, the NICHD study confirmed earlier findings that the monitors are not useful for predicting or preventing preterm birth and also confirmed that several other methods being assessed as ways to predict preterm labor were of little value. ‘‘The study found that while women who gave birth prematurely did have slightly more contractions throughout pregnancy than did women who gave birth at term, there was no detectable pattern that would predict premature birth,‘’ said Duane Alexander, M.D., Director of the NICHD. The study of 306 women was conducted at the 11 centers participating in the NICHD Network of Maternal-Fetal Medicine Units and was published in the January 25 New England Journal of Medicine. The portable monitors, which relay information to a central office, where any potential signs of early labor can be passed on to a physician, cost up to $100 a day and may be worn for up to 10 weeks. The researchers also found little value for some other techniques in predicting preterm labor, including measuring the cervix and collecting fetal fibronectin from the cervix. ‘‘Our data indicate that ambulatory monitoring of uterine contractions does not identify women destined to have preterm delivery,‘’ the authors concluded.

The Postpartum Doula's Role in Maternity Care is a position paper that was recently published by the Doulas of North America (DONA). The paper presents the position of DONA on the benefits of a doula's support in the weeks after birth, with 36 references to the medical and social sciences literature. It explains the role of the doula with the family, and within the context of postpartum health care. Terminology relating to doula care, information about training and certification of doulas, and questions to ask someone who provides postpartum support are also described. Copies of this position paper as well as the paper, The Doula's Contribution to Maternity Care, are both available online from www.DONA.org, and permission is granted to make free copies in whole or in part with attribution to DONA.

The cesarean delivery rate rose to 21.5 percent in the United Kingdom for 2000–2001, and more than half of the country's deliveries involve some type of intervention (London Daily Telegraph May 1, 2002). In addition, according to new figures released by the U.K. Health Department's Hospital Episodes Statistics, another 21 percent of infants are delivered after induced labor and 11.5 percent are delivered using instruments such as forceps and vacuum extraction. The U.K.‘s cesarean rate, which has nearly doubled over the past decade, is now almost twice as high as the rate recommended by the World Health Organization, which recommends that cesarean sections account for no more than 10 to 15 percent of all births in a country. Whereas 10 percent of British women decide in advance that they want to deliver by means of cesarean, slightly more than 50 percent of all the procedures are performed as emergency interventions.

The National Childbirth Trust (NCT) ‘‘condemned’’ the U.K.‘s high cesarean rate, particularly criticizing the common use of emergency procedures (London Independent, May 1, 2002). Mary Newburn, head of policy research at the NCT, said that hospitals should help keep women upright and mobile during labor and should employ appropriate clinical checks before opting for emergency surgery. Newburn added that full midwifery support during labor can reduce the rates of cesareans and other interventions, but U.K. midwives say that severe shortages in their profession have resulted in some women not receiving necessary care during labor, leading to a rise in complications. A spokesperson for the U.K. health department said that the National Health Service hopes to recruit 2000 midwives over the next four years but added that there is no direct evidence linking the shortage of midwives to the increase in cesareans. U.K. Public Health Minister Yvette Cooper issued new national standards for maternity units to the Royal College of Midwives in April, and the National Institute for Clinical Excellence next year plans to issue guidelines to hospitals outlining the circumstances in which cesarean sections should be performed.

Fertility clinics in the United Kingdom may have to subsidize care costs of twins and triplets created through in vitro fertilization (IVF) under a plan by the National Health Service (NHS) (BBC News April 13, 2002). Two hundred eighty-five sets of twins were born in the United Kingdom in 2000, compared with only 105 sets in 1985, a rise that is largely attributed to assisted reproductive services. Twins and triplets are three and seven times more likely, respectively, to need intensive care after birth than singleton infants, and the NHS states that multiple births cost the government about $86 million a year. Former U.K. Human Fertilization and Embryology Authority Chair Ruth Deech told the Times of London that penalties are needed to ‘‘curb’’ the high rate of multiple births to relieve NHS from ‘‘carry[ing] the burden’’ of costly neonatal care. U.K. fertility clinics are currently not insured for the treatment of ‘‘sick or disabled’’ infants, and researchers estimate that a mandatory insurance program to supplement the care of premature twins and triplets could save the NHS $10.8 million a year in costs. Many leading fertility specialists have criticized the plan, however, saying that penalizing clinics for creating multiple pregnancies would ‘‘wreck the hopes’’ of women seeking IVF treatment whose odds of conception using only two implanted embryos may be rather small.