The lowest birth rate since national data have been available (13.9 per 1,000 population) was reported in 2002 for the United States, according to preliminary data from the National Center for Health Statistics (Natl Vital Stat Rep 2003;51(11):1–5). The fertility rate was also down 1 percent to 64.8 births per 1,000 women aged 15 to 44 years, and the teenage birth rate continued to decline in 2002, down 5 percent to 42.9 births per 1,000 women aged 15 to 19 years. The teenage birth rate has dropped 28 percent since 1990. Birth rates for older women (35–39 and 40–44 yr) continued to rise, however, increasing 2 percent for both. The number of births to unmarried women increased by 1 percent, but births to unmarried teenagers declined by 4 percent. Prenatal care use continued to improve slowly—83.8 percent of women began prenatal care in the first trimester of pregnancy in 2002 (vs 83.4% in 2001). Preterm (12.0%) and low-birthweight (7.8%) rates were up slightly for 2002. The low-birthweight rate is the highest reported in over three decades.

Vaginal Birth After Cesarean (VBAC) is an important new United States government report (March 2003), issued in two volumes, “Evidence Report and Appendices” and “Evidence Tables.” Its purpose is to provide “a framework for comparing the harms and benefits of delivery options for women with prior cesarean delivery” and to provide information that will help consumers, providers, payers, and policymakers make decisions about repeat cesarean or trial of labor. The first group of questions compared outcomes of a trial of labor (TOL) and an elective repeat cesarean delivery (ECRD), and the second group addressed factors influencing the decision to have a trial of labor. One general finding was that “there is no direct evidence regarding the benefits and harms of TOL relative to ECRD in women who are similar in every respect except choice of delivery route.” The researchers also found that data were insufficient to allow conclusions about the best delivery choice for a given woman, that definitions for important outcomes were inconsistent and imprecise in studies, and that studies often failed to ensure comparability between TOL and ERCD groups. The report and summary are available online at the website of the Agency for Healthcare Research and Quality (AHRQ) at Printed copies may be obtained in the United States free of charge by calling (800) 358–9295 and asking for Evidence Report/Technology Assessment No. 71.

Inequality in Access to Maternity Services and Choicein MaternityServices are titles of two major new government reports in the United Kingdom (BMJ 2003;327:249). A House of Commons committee criticized UK maternity services as patchy, and urged more healthcare trusts to support women who want to give birth at home and to provide independent midwives where needed. The committee estimated that up to 10 times as many women would want to give birth at home, if given the choice, but that this choice was either not provided or taken away. “We heard evidence that women who chose home births had this option withdrawn from them at a late stage in their pregnancies, on the grounds that sufficient staffing could not be guaranteed to support the birth,” says the report. “We found this practice wholly unacceptable. We call on the government to take action to stop this practice.”

Women also have little choice in the type of maternity service they want, which the report blamed on staffing shortages and the closing of smaller maternity units. The committee recommended that the government to “allocate resources to maternity units so that staff can plan and implement change without fear of further staffing shortages.” In its report on access to maternity services, the committee said that not all families get access to the services they need. The committee also identified prejudice among maternity care staff relating to race, class, or disability, and recommended that trusts should recruit midwives from a greater range of ethnic groups and communities to redress the imbalance. In particular the report highlighted problems faced by homeless women, asylum seekers, women whose first language is not English, and deaf women. It called on the government to take action and recommended that “continuity of carer” schemes be developed and that qualified interpreters be provided, including British sign language interpreters. The two reports can be accessed online at

Rates of trisomy 21 (Down syndrome) have not been reduced by folic acid fortification of foods, according to recent Canadian research, published in the August 2003 American Journal of Medical Genetics (Toronto Globe & Mail, Aug 5, 2003).“We were hoping fortification would have other benefits aside from those that are already established, but we didn't see any decline in the rate of trisomy 21,” said Dr. Joel Ray, an obstetrical medicine internist at St. Michael's Hospital in Toronto. Fortifying foods such as flour and pasta with folic acid has dramatically reduced the rate of children with major birth defects, including spina bifida. Researchers were thus led to believe the incidence of Down syndrome would also fall, since it has also been linked to the body's failure to process folic acid. However, the prospect that further benefits of folic acid may not be seen for a generation still exists, because it will ensure that baby girls born today have healthier eggs and will be less likely to give birth to children with genetic disorders. “It could be that a woman who takes folic acid today could be preventing her granddaughter from being born with trisomy 21,” Dr. Ray said. “But we just don't know.” Despite the disappointing findings about short-term prevention of Down syndrome, women of childbearing age should be sure to get adequate levels of folic acid, in their diets, and by taking supplements. Folate, also known as vitamin B-9, is found in leafy green vegetables like spinach, and in legumes such as lentils and kidney beans. Since fortification of flour, pasta, and cornmeal became mandatory in 1998, the rate of neural tube defects in Canada has fallen by one-half. The new study showed that, before fortification, 1.7 per 1,000 women whose fetus was tested for Down syndrome had the condition. After fortification was introduced, the rate was identical. Because women are having babies later, there is tremendous interest in research about Down syndrome, but little is known about why it occurs, or how to prevent it.

An infant formula manufacturer was recently fined for illegally advertising directly to consumers (BMJ 2003;327:307). SMA Nutrition, part of Wyeth, one of the world's largest infant formula manufacturers, was fined a total of £26 000 ($41 900; EUR37 200), and ordered to pay costs of more than £34 000 after being convicted of six separate breaches of The Infant Formula and Follow On Formula Regulations 1995 and the Food Safety Act. In what may be the first case of its kind, the company was prosecuted by Birmingham Trading Standards at Birmingham Magistrates Court, after a mother drew their attention to the advertisement. Judge Rod Ross described the company's breaches as “cynical and deliberate.” The company placed the advertisement (which it claimed to be an “information piece”) six times in British parenting magazines in 2001. Regulations require that advertisements for infant formula for babies up to 6 months be published or displayed only through the healthcare system, in a scientific publication, in a publication not widely available to the public, or for purposes of trade before retail.

Professor Alan Lucas, an honorary consultant at Great Ormond Street Hospital for Children, called by the defense, said he found the SMA article “unexceptional” and that GPs and primary healthcare workers have a “poor understanding of infant feeding issues” and that “first time mothers often receive advice from the written media.” However, Judge Ross said SMA Nutrition had “deliberately crossed the line to advertise to a vulnerable section of the public.” He refused to accept its argument that the regulations as applied in this case restricted free movement of goods within the European Union.

The outcome was welcomed by breastfeeding and pressure groups. Mike Brady, campaigns and networking coordinator of Baby Milk Action, said, “It's a stunning victory for infants and mothers in this country, which I believe sets an important precedent and a warning to other companies with similar advertisements.”

An announcement that nurse-midwife attended births would be halted on October 1 at one of the oldest midwifery programs in the United States shocked birth and midwife advocates (NY Times June 15, 2003). In making the announcement, Cynthia Sparer, senior vice president of New York-Presbyterian Hospital, said, “We needed to move to a model that would have our deliveries being performed by obstetricians.” The nurse-midwives at the hospital serve mostly women of Dominican descent, along with African-Americans and low-income women of other ethnicities. New York-Presbyterian Hospital contends that nearly all expectant mothers served by this practice are considered high risk. However, New York Health Department statistics show that the infant mortality and low-birthweight rates among Latinos in the area served by New York-Presbyterian Hospital are far lower than, and in some cases, one-half that of the New York city average.

Several of the midwives appealed the decision to local officials and to the American College of Nurse-Midwives (ACNM). Deanne Williams, ACNM executive director, called the decision “beyond comprehension” and a threat to the “survival of the profession” of midwifery.“After almost half a century of midwifery care, Presbyterian has not explained why this group of patients is too high risk for nurse-midwife assisted births. If they really believe that these women are at risk, why wait until October to make the change?” she asked. In a July 1 news release the ACNM noted, “The end of nurse-midwife attended births at Presbyterian benefits no one. Expectant mothers from lower income brackets, and the public at large, will be left with higher healthcare costs, fewer women's healthcare professionals, and a loss of trusted healthcare providers.” The announcement by the hospital has drawn wide publicity and community support, and it is hoped that the hospital may reconsider its decision.

Risk of miscarriage is increased by use of nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen) or aspirin during pregnancy, especially when taken around the time of conception, according to a recent California study (BMJ 2003;327:368). Dr. De-Kun Li, lead author and epidemiologist, and colleagues obtained information on NSAID use, other drug use, history of miscarriage, smoking status, caffeine and alcohol use, age, ethnicity, income, general health, and other factors associated with an increased risk of miscarriage from 1,005 pregnant women who were seen at Kaiser Permanente's San Francisco location and South San Francisco medical centers. The 5 percent of study participants who reported using NSAIDs during pregnancy or around the time they conceived were 80 percent more likely than women who did not report using NSAIDs to miscarry by 20 weeks’ gestation. In addition, risk of miscarriage was even greater among women who took the drugs around the time of conception and women who used NSAIDs for longer than a week. The risk of miscarriage among women who took aspirin was 60 percent, although the number of women reporting using aspirin was so small that the data could be unreliable. Acetaminophen use had no effect on risk of miscarriage. The study results are similar to findings reported in a Danish study, which also noted an increased risk of miscarriage among pregnant women taking NSAIDs (BMJ 2001;322:266). Li said that NSAID use could be linked to miscarriage because the drugs inhibit prostaglandin synthesis, which is necessary for embryo implantation. Unlike NSAIDs, which inhibit prostaglandin synthesis in most organ systems of the body, acetaminophen inhibits prostaglandin synthesis only in the central nervous system. Li advised that until further studies on the subject can be conducted, pregnant women and women who wish to become pregnant avoid using NSAIDs.

The use of cervical cerclage is not effective in preventing preterm delivery or miscarriage in women at moderate risk of preterm birth or second-trimester pregnancy loss, according to a recent meta-analysis of randomized controlled trials (Obstet Gynecol 2003;102:621–627). The meta-analysis by researchers at the University of Liverpool involved 6 trials of 2,175 women in whom cerclage (inserting a prophylactic cervical stitch) was used either to prevent miscarriage or preterm labor in pregnant women or to treat women with cervical problems before pregnancy. They found that the procedure did not significantly reduce a pregnant woman's risk of preterm delivery or miscarriage or was convincing evidence available to support the use of cerclage in women with cervical problems who desired future pregnancies. Although cervical cerclage does not cause serious maternal or fetal health complications, the study found that it was consistently associated with increased risk of maternal infection and minor health problems often resulting in hospital admission. Women with cerclage were also more likely to require drugs to manage contractions and prolong gestation.