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Cesarean deliveries reached an all-time high in 2002 in the United States, according to preliminary data from the National Center for Health Statistics (Natl Vital Stat Rep 2003;51(11):4–5). The total cesarean rate rose to 26.1 percent, an increase of 7 percent over the rate in 2001 (24.4%). The primary cesarean rate increased to 18.0 percent, also a 7 percent rise from the previous year. The rate of vaginal birth after previous cesarean (VBAC) continued to plummet, from 16.4 in 2001 to 12.7 in 2002 per 100 women with a previous cesarean. The VBAC rate has dropped 55 percent from the 1996 high of 28.3 percent.

The cesarean delivery rate increased from 21.5 to 22.3 percent in the United Kingdom between 2001 and 2002, according to information from the Hospital Episode Statistics system (Stat Bull, NHS Maternity Statistics, May 2003). Approximately 12 percent of the cesareans were emergency procedures and 10 percent were elective. During the same period, over 21 percent of deliveries were induced, and approximately 11 percent were instrumental deliveries (vacuum extraction, forceps), similar to the rates for these procedures in 2000–2001. During delivery approximately one-third of women had epidural, general, or spinal anesthesia, and 13 percent of women had an episiotomy. Home births accounted for 2 percent of deliveries in 2001–2002. Fifty-three percent of women had a spontaneous delivery without induction, instruments, or cesarean section. Women with spontaneous deliveries spent on average 1 day in hospital after delivery, women with instrumental deliveries 1 or 2 days, and women with cesarean deliveries 3 or 4 days.

The best countries in which to be a mother are Sweden, Denmark, and Norway, and the worst countries are Niger, Burkina Faso, and Ethiopia, according to the fourth annual State of the World's Mothers report (Kaiser Daily Reports May 7, 2003). The United States ranked 11th, after Canada, Australia, and Western European countries. The Mothers’ Index ranks 117 countries based on 10 factors related to women's and children's health and education and political status of women and children. The indicators specific to women include lifetime risk of maternal mortality, use of modern contraception, births attended by trained personnel, prevalence of anemia among pregnant women, female literacy and participation of women in national government; the indicators relative to children are infant mortality rate, primary school enrollment, nutritional status and access to safe water. According to the report, women who live in the countries ranked in the bottom 10 of the Mothers’ Index are 600 times more likely to die during childbirth than women who live in the countries ranked in the top 10.

A woman's level of education and access to family planning services were most closely linked to her well-being and her infant's survival. For example, in the United Kingdom, 82 percent of women use birth control, only 1 in 5,100 women die during childbirth, and only 6 of 1,000 infants do not live until their first birthday. However, in Guinea, where only 4 percent of women use birth control, 1 woman in 7 dies in childbirth, and more than 10 percent of infants die before their first birthday. More information on the State of the World's Mothers 2003 report, may be found on Save the Children's web site at http://www.savethechildren.org.

Pregnancy-related deaths are three to four times higher in black women than in white women in the United States, according to a report from the Centers for Disease Control and Prevention (CDC), Pregnancy-Related Mortality Surveillance—United States, 1991–1999, released in April 2003. The pregnancy-related mortality ratio for all women for the years 1991 through 1998 was 11.8 deaths per 100,000 live births. The nation's Healthy People 2010 objective proposes no more than 3.3 maternal deaths per 100,000 live births. Although pregnancy-related deaths are rare—525 occurred in 1999—during the 9-year study period, the ratio for black women was 30.0 deaths per 100,000 live births, compared with 8.1 for white women. This is the largest racial gap of any indicator in the field of maternal and child health and has persisted for more than 60 years. The CDC report also found a greater risk of pregnancy-related deaths among older women and those who received no prenatal care. The risk for pregnancy-related death increased sharply for women aged 35 years and older, and the risk for women 40 and older was four times that for women aged 30–34. For each age category, black women were at a higher risk of death than white women. Among all age groups, women who received no prenatal care were three to four times more likely to die of pregnancy-related causes than women who received any care; that risk was even higher for black women.

The data are based on the CDC's Pregnancy Mortality Surveillance System (PMSS), which collects data on pregnancy-related deaths through state health departments, maternal mortality review committees, the media, and individual providers. Although improved identification of these deaths in recent years has probably led to the reported increase in the pregnancy-related mortality ratio, the report authors say that such deaths are still underreported and that their number may increase significantly with more active surveillance. “Complete and consistent reporting involves a thorough review of the medical and social circumstances of every pregnancy-related death so that we can better understand the effects of medical care, socioeconomic status, prenatal care, social environment, and lifestyle,” said Jeani Chang, an epidemiologist with CDC's reproductive health program and senior author of the report.

Maternal morbidity during labor and delivery is a frequent occurrence in the United States (Am J Public Health 2003;93:631–634). In the first such report, researchers from the Centers for Disease Control and Prevention (CDC) used data from the National Hospital Discharge Survey from 1993 to 1997. During this period, almost 4 million women annually gave birth. Of these, approximately 43 percent (nearly 1.7 million women annually) had some kind of maternal morbidity, which included three categories: (1) an obstetric condition (caused by the pregnancy itself or its management); (2) a preexisting medical condition (an underlying condition that may be aggravated by the pregnancy); and (3) a cesarean delivery. Overall, 30.7 percent of women (nearly 1.2 million women annually) who gave birth had an obstetric complication, a preexisting medical condition, or both. Of the 1 million women who had at least one obstetric complication, the most common problems were third- and fourth-degree lacerations, other obstetric trauma including cervical lacerations and pelvic trauma, preeclampsia and eclampsia, gestational diabetes, genitourinary infection, postpartum hemorrhage, and amnionitis. The most common preexisting medical condition was chronic hypertension. The authors observed that the magnitude of the problem of maternal morbidity during labor and delivery is greater than had been previously recognized and it is often preventable. Only 57 percent of women had a delivery with no maternal morbidity.

Premature labor and delivery is the “most vexing problem in obstetrics” (NY Times Apr 8, 2003). Despite many reproductive health advances over the years, the problem of premature birth is still “essentially unsolved,” and nearly 500,000 infants (1 in 8 infants) are born prematurely each year in the United States. The rate of preterm births is increasing (11.9% in 2001, the highest level in two decades), and leaders in maternal-fetal medicine are struggling to improve understanding of its many causes and find more effective ways to prevent it. Only the hormone progesterone has been shown to delay premature birth among women who are at risk of, but who are not yet in the process of, preterm delivery. “Despite everything we've done—increased prenatal care, improved nutrition, various drugs to stop preterm labor—we've made no progress at all in stemming the growing tide of premature births. Almost all studies that have tried to reduce prematurity have failed. It's very discouraging,” said Dr. Robert Goldenberg, a leading researcher on premature birth at the University of Alabama at Birmingham. Some doctors are calling for increased regulation of fertility treatments as a way to prevent premature deliveries. Dr. Charles Lockwood, chair of obstetrics and gynecology at Yale Medical School, pointed to the actions of fertility specialists who “hyperstimulate” women with ovulation-inducing drugs or implant “way too many” embryos in a woman's uterus as part of the problem. The article also cited risk factors for premature labor and delivery, including age (<17 or >35 yr), poverty, lack of prenatal care, “chronic stress,” smoking, previous premature delivery, multiple-birth pregnancy, diabetes, high blood pressure, and “serious infections” (bacterial pneumonia, sexually transmitted diseases).

Researchers have discovered how an embryo initially attaches to the wall of the uterus in what appears to be one of the earliest steps needed to establish a successful pregnancy, according to the National Institute of Child Health and Human Development (NICHD) (NIH News Release Jan 16, 2003). The research was conducted by scientists at the University of California at San Francisco, the Nevada Center for Reproductive Medicine in Reno, the Lawrence Berkeley National Laboratory in Berkeley, California, and the University of Wisconsin, Madison. The researchers believe that 6 days after an egg is fertilized, the embryo, shaped like a sphere and called the blastocyst, attaches itself to the wall of the uterus. As the blastocyst travels along the uterine wall, L-selectin on its surface binds to the carbohydrates on the uterine wall, until the blastocyst gradually slows to a complete stop. After this happens the cells, which later become the fetus’ contribution to the placenta, develop. The placental tissue from the fetus then invades the uterine wall by sending fingerlike extensions into it. These projections make contact with the maternal blood supply, becoming the pipeline through which the fetus derives nutrients and oxygen, and rids itself of carbon dioxide and wastes. “This discovery opens up a promising new realm of research,” said Dr. Duane Alexander, Director of NICHD. “It may lead to insight into infertility, early pregnancy loss, and perhaps to an understanding of the life-threatening complication of pregnancy known as preeclampsia.”

A new female contraceptive device called FemCap , which could protect against human immunodeficiency virus ((HIV) and other sexually transmitted diseases (STDs) if used in conjunction with a microbicide, is now on the market in the United Sates (Los Angeles Times, May 12, 2003). FemCap is made from silicone rubber, which its developers said is less irritating than similar latex contraceptives, and can be worn for up to 48 hours, double the time recommended for similar birth control devices. A single FemCap can be reused for 2 years, costs approximately $2 per month, and comes in three sizes. The device, which works to prevent pregnancy by completely covering the cervix to stop sperm from reaching the uterus, is also equipped with a delivery system for microbicides and spermicides. Several companies are currently developing microbicides that could be used with FemCap to protect against STDs. Dr. Alfred Shihata a family physician at the Scripps Memorial Hospital in Chula Vista, California, developed FemCap, which was tested in clinical trials using funds from the United States Agency for International Development and approved by the Food and Drug Administration at the end of April.

Another new female contraceptive, the Today sponge, which is currently available in Canada, is expected to be available in the United States in 2004 (Philadelphia Inquirer April 24, 2003). The sponge, manufactured by Allendale Pharmaceuticals in New Jersey, is an over-the-counter disk of foam that protects against pregnancy for 24 hours. Customers in the United States can order it through two Canadian Internet sites (ObGyn News 2003;38(7):12.) The Today sponge was extremely popular between 1983 and 1995, when its manufacturer took it off the market after the discovery of bacterial contamination in the water used to make it. Since then, other birth control methods such as Depo-Provera, a hormone injection given every 3 months; Ortho Evra, an adhesive patched applied once a week that delivers hormones through the skin; and Nuva Ring, a thin ring inserted into the vagina each month that releases hormones, have become available. In light of these new products, some health professionals predict that the sponge could have an “uphill marketing battle” to appeal to younger women.

The number of abortions in Russia fell “dramatically” over the last 5 years, Russian Health Minister Olga Sharapova said, according to a recent report by Agence France-Presse (Kaiser Daily Reports Apr 7, 2003). In 1997, there were 3 abortions registered for every birth in Russia, compared with 1.3 abortions for every birth in 2002. The infant mortality rate also fell during the same period, and the number of miscarriages has dropped from 21,000 in 1997 to 12,000 in 2002, the report noted. However, Sharapova said that “unfortunately, the state of health of Russian children remains very difficult despite some recent improvements.” Sharapova said that 20 percent of Russian infants were born with defects during the 5-year period, and only 33 percent of infants born in Russia could be considered “completely healthy,” Approximately 80 percent of Russian women experience some complications during pregnancy, Sharapova added. The Russian health system fell apart following the fall of the Soviet Union in 1991, and many hospitals in rural areas are operating without basic medical equipment, according to Agence France-Presse.