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The cesarean delivery rate rose in 1999 for the third consecutive year in the United States, according to the National Center for Health Statistics (Natl Vital Stat Rep 2001;49(1):14–15). The rate increased to 22 percent (from 21.2% in 1998) after falling each year between 1989 and 1996 and remaining steady between 1996 and 1997. The primary rate increased to 15.5 per 100 live births for women who had no previous cesarean (14.9% in 1998), and vaginal births after previous cesarean (VBAC) declined to 23.4 (from 26.3% in 1998). Overall cesarean rates increased steadily by age of the mother and were more than twice as high for mothers 40 to 54 years of age (34.7%) as for teenagers (15.0%); black women had a higher rate (23.2%) than women who were white (22.1%), Hispanic (21.2%), American Indian (18.9%), and Asian or Pacific Islander (20.2%). Rates varied considerably among states, with the highest rate in Mississippi (27.3%) and the lowest in Hawaii (13.8%); however, the latter rate “is believed to be substantially underreported.” In addition, VBAC rates varied greatly among states, from 36.3 percent in New Hampshire to 11.3 in Louisiana.

Electronic fetal monitoring, ultrasound, induction of labor, and stimulation of labor are four of the six obstetric procedures reported on the birth certificate that have been rising steadily every year since 1989, according to the National Center for Health Statistics (Natl Vital Stat Rep 2001;49(1):13). In 1999 electronic fetal monitoring was reported for nearly 3.3 million births, or 84 percent of live births, a 15 percent increase over 1990. At least 66 percent of mothers received ultrasound in 1999, a 26 percent increase since 1990. The rates for induction and stimulation of labor in 1999 were 19.8 and 17.9 percent, respectively. The overall rate for tocolysis has been slowly increasing, from 1.6 percent in 1990 to 2.4 percent in 1999, and the overall rate for amniocentesis was 2.7 percent in 1999, down from 3.3 percent in 1990.

The risk for pregnancy-related death is significantly higher for black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women than for white women in the United States, according to a recent report from the Centers for Disease Control and Prevention that studied the period 1991 to 1997 (MMWR 2001:50(18):361–364). In all age groups the risk of death was highest among black women, with a risk three to four times greater than that for white women. A pregnancy-related death is defined as a death that occurred during pregnancy or within 1 year after the end of pregnancy, and the pregnancy-related mortality ratio (PRMR) is defined as the number of pregnancy-related deaths per 100,000 live births. During 1991 to 1997, 3,193 pregnancy-related deaths occurred, and the overall PRMR was 11.5. Among American Indians/Alaska native women, the PRMR was 12.2, among Asians/Pacific Islanders 11.3, among Hispanics 10.3, among whites 7.3, and among blacks 29.6. The report notes that in 1997 the Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native ethnic populations represented 16 percent of all reproductive-age females (age 15–49 yr), but accounted for 23.5 percent of all live births. By 2025, these populations are expected to represent approximately 25 percent of the females of reproductive age in the United States. The report points out that an important national health objective for 2010 is to eliminate racial disparities, including those in pregnancy-related death, necessitating ongoing surveillance of morbidity and mortality and implementation of effective prevention programs.

Triplet and other higher order multiple births dropped in the United States for the first time in a decade in 1999, after more than doubling between 1990 and 1998, according to the National Center for Health Statistics (CDC Press Release April 17, 2001). The report showed that 7,321 triplet/+ babies were born in 1999 compared with 7,625 in 1998, a decline of 4 percent, from 194 to 185 per 100,000 live births; by comparison in 1990 the rate was 73 per 100,000. The twin birth rate, however, continued to rise—from 110,670 in 1998 to 114,307 in 1999, which was up 3 percent from 28.1 per 1,000 live births in 1998 to 28.9 in 1999. The report also noted that the birth rate for teenagers 15 to 19 years declined 3 percent to 49.6 births per 1,000 teenaged women. This rate has fallen 20 percent since 1990 and is now at a record low. The birth rates for women in their 30s increased 2 to 3 percent between 1998 and 1999, and are at their highest level in more than three decades.

The percentage of United States births that occurred in hospital attended by a physician was slightly lower in 1999 (91.7%) than in 1998 (91.9%), and has declined from 98.4 percent in 1975 (Natl Vital Stat Rep 2001;49(1):14). For physician-attended births 4.4 percent were by doctors of osteopathy (DOs) and the remainder were by doctors of medicine (MDs). Although the number and percent of births attended by DOs are small, they have grown steadily since 1989, the first year the data appeared on the birth certificate. The number of births attended by midwives continues to grow, and in 1999 was 7.7 percent compared with 7.4 percent in 1998 and 1.0 percent in 1975. Certified nurse-midwives attended about 95 percent of these births. Approximately 99 percent of births occurred in hospital, virtually unchanged for the past several decades. Of the out-of-hospital births, 65 percent occurred in a home and 27 percent in a free-standing birth center. As in 1998, Hispanic women were more likely to have midwife-attended hospital births (9%) than non-Hispanic white or black women, (6 and 7%, respectively).

The average number of births on any given day in 1999 was 10,948, but as in the past, considerable variation occurred in the number of births by day of the week. For the most popular day, Tuesday, the average was 12,424 births and for the least popular day, Sunday, the average was 7,731.

It is illegal to test pregnant women for drugs without their knowledge or consent, according to a recent decision handed down by the U.S. Supreme Court in a 6 to 3 vote (Nation's Health May 2001:27). The decision was a victory for patient privacy and the doctor-patient relationship. The court ruled that the actions of a South Carolina hospital violated the Fourth Amendment protection from unreasonable searches. The case, Ferguson v City of Charleston, grew out of actions taken by medical professionals at the University of South Carolina, local police, and prosecutors. Beginning in 1989, select pregnant women who sought medical care were subjected to unauthorized urine tests for cocaine use. The results were then handed over to police, who arrested 30 women during a 5-year period. “This decision slams the door against police searches or private medical information in your doctor's office,” said Priscilla Smith, of the Center for Reproductive Law and Policy. Seventy-five groups had signed friend-of-the-court briefs urging that Supreme Court justices rule against the actions of the hospital.

Poor women will have limited access to the abortion pill, mifepristone (RU 486), as a result of a recent order from the U.S. Department of Health and Human Services written in a letter to state Medicaid directors in March 2001 (BMJ 2001;322:1015). Mifepristone will be covered for Medicaid women only when a pregnancy results from rape or incest or if the woman's life is endangered. “Because this is an abortion drug, the same restrictions have to apply for it,” a department spokesperson explained. “This is just taking the law and applying it as we're required to do.” The drug was reviewed and recommended for approval by the Advisory Committee on Reproductive Health Drugs in July 1996, but the Food and Drug Administration (FDA) did not approve the drug until September 2000 after a lengthy battle with abortion opponents for 12 years to keep the drug from being approved. The Health and Human Services secretary, Tommy Thompson, said that he would order a review of the FDA's decision. Republicans in the U.S. House of Representatives have “opened a coordinated campaign to begin imposing new restrictions on abortion,” according to an article published by the Washington Post (March 16, 2001). A possible forerunner to the campaign was a bill introduced into the Kentucky state senate in February to permit pharmacists in that state to deny patients drugs on the basis of the pharmacist's moral or religious concerns.

International News

Several multinational baby food companies are continuing to violate the International Code of Marketing of Breastmilk Substitutes, reports the International Baby Food Action Network (IBFAN), a coalition of more than 150 citizen and consumer groups in more than 90 countries (IBFAN Press Release, May 15, 2001). The report is based on a survey of company compliance with the Code that was conducted by IBFAN groups in 14 countries. The World Health Organization discussed the progress of the Code in May. The Code prohibits all direct and indirect promotion of baby foods by the companies. The worst violators listed by IBFAN are Nestlé, Mead-Johnson, Wyeth, Abbott-Ross, and Milupa, and others include Gerber, Heinz, Danone, Dumex, Friesland, Hipp, Humana, and Meiji. Among the bottle and teat companies the worst violators were Gerber, Evenflo, Playtex, and Chicco. IBFAN regularly monitors the marketing practices of baby food companies and also monitors Code implementation by governments. To date, 51 countries have incorporated all or most of the code's provisions into law. The IBFAN report identifies Nestlé, Gerber, Milupa, Wyeth, Heinz, Mead-Johnson, and Abbott-Ross as companies that have employed new approaches to circumvent marketing curbs. For example, they establish “baby clubs” to contact mothers directly to distribute promotional material, free samples, and enticing gifts. Another new avenue to contact mothers directly is via the Internet. IBFAN also reports an “alarming resurgence” of donations of free supplies of milks, baby foods, and feeding bottles to health care facilities.

The abortion of female fetuses in India is “tipping scales sharply against girls,” according to a recent news report (NY Times April 22, 2001). Although India outlawed sex-determination tests in 1994, their use has become commonplace as traveling doctors carry ultrasound machines from clinic to clinic in small towns throughout the country. One woman, Gurjit Kaur, is reported as saying that she paid 500 rupees, or about $11, for an ultrasound test a year ago and after learning that she was carrying a girl, she had the fetus aborted for 2,000 rupees, or $44. “Our elders wanted a boy,” she explained. “Boys are important because they have to look after all the property.” Early figures from the 2001 census indicated that female fetuses are being regularly aborted, continuing a trend from the 1980s, when ultrasound technology became available. The number of girls per 1,000 boys dropped to 927 from 945 in 1991 and 962 in 1981. The fall in the ratio of girls to boys since 1990, when India's population grew “by a staggering 81 million,” is greatest in the richest states of the north and west, where more people can afford the prenatal tests and abortions. The trend also occurs elsewhere in Asia. “India is catching up with other sexist, modern societies like South Korea and China in sex-selective abortions,” said the Nobel Prize–winning economist Amartya Sen of Trinity College in Cambridge, England. Although a variety of medical and nonprofit groups in India are campaigning against the sex-selective abortions, enforcement of the 1994 law against sex-determination tests is weak and no one has ever been convicted of violating it.

The cesarean delivery rate in New Zealand has soared from 12 percent in 1989 to almost 20 percent in 1999, according to a national news report about cesarean childbirth (April 27, 2001). The rate was 25 percent in 2000 at National Women's Hospital in Auckland, which is Australasia's largest maternity facility, and was at least 30 percent at some other large New Zealand hospitals. The Health Ministry wants cesarean guidelines developed in an effort to reduce the rate. National Women's Hospital's clinical leader Rob Buist is reported as saying that women's choice was paramount, and they should be allowed to have cesareans even without medical need after being informed of the risks.

At the Australia-New Zealand Perinatal Society annual conference, held in Canberra in March, Professor Nicholas Fisk, professor of fetal and maternal medicine at London's Queen Charlotte's and Chelsea Hospital, was reported to predict that by 2010 more than one-half of women having babies would opt for a cesarean delivery. The news report said that Fisk noted that it was wrong to deny women the choice when research indicated that attempting a vaginal birth could be riskier for the mother or baby. He stated, “Patient choice is all important in maternity care and, given this, I believe efforts to reduce caesarean deliveries are doomed.” Health leaders in New Zealand expressed concern, however, and sounded warnings about the risks of cesarean delivery, “which, they emphasized, was a major operation.”

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