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Over-the-counter access to emergency contraception has been denied by the United States government (FDA News, May 7, 2004), but in contrast, has been endorsed by the Canadian government (SOGC Press Release, May 19, 2004). The U.S. Food and Drug Administration's (FDA) decision to refuse to make Plan B emergency contraceptive pills available over the counter is opposed by over 70 leading health and medical organizations, including the American Medical Association and American College of Obstetricians and Gynecologists. Supporters of the ban cite fears of teen promiscuity and low confidence in teens’ abilities to take pills without clinical supervision. The Association of Reproductive Health Professionals (ARHP) is concerned that women's timely access to a safe and effective backup method of birth control has been denied based on political pressures and not the FDA's medical and scientific review process. “The FDA has done a terrible disservice to the public with this decision and continues to manifest a pattern of disregard for science from the current administration. There is unprecedented support for over-the-counter (OTC) access to emergency contraception among the medical community and the public,” says Dr. Felicia Stewart, ARHP board member, and co-director of the Center for Reproductive Health Research & Policy at University of California at San Francisco. “The medical evidence overwhelmingly shows Plan B is safe, effective, and appropriate for OTC use by women of all ages. This product's potential to reduce unintended pregnancy offers a significant public health benefit.” Plan B emergency contraceptive pills, also known as the morning after pill, are an FDA-approved backup contraceptive method effective for up to 72 hours after unprotected sex that have the potential to prevent up to one-half of the 3 million unintended pregnancies in the U.S. each year.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) is joined by many leading health and medical organizations and by the public in strongly supporting the Canadian government's decision to allow access to levonorgestrel (the “morning after pill”) without a doctor's prescription. “Yesterday's announcement demonstrates the Government's commitment to women's health. Providing timely access to a safe and effective back-up method of birth control can reduce the number of unwanted pregnancies and abortions in Canada,” stated Dr. André Lalonde, Executive Vice-President of the SOGC. On average, every day in Canada, almost 300 pregnancies end in abortion (about 25% of all pregnancies) and 115 teenage girls become pregnant. It is estimated that about 50 percent of all pregnancies are unintended. According to 2001 Statistics Canada figures, emergency contraception has the potential to prevent 106,418 abortions (including 19,936 teen abortions) each year in Canada. The SOGC states that there is no evidence linking emergency contraception with an increase in teen promiscuity, unprotected sex, or sexually transmitted infections. Medical evidence cited by the World Health Organization demonstrates the safety and effectiveness of emergency contraception as a backup method of contraception. It has a long-term safety record in women of all ages.

As this journal went to press, a new report revealed that the “FDA (is) likely to reverse decision on OTC status for emergency contraceptive Plan B,”(Kaiser Daily Reproductive Health Report June 9, 2004). However, some critics of the FDA's decision on Plan B “remain skeptical” about whether the agency will reverse its ruling (Cusack, The Hill 6/9/04).

Pregnant women who request a cesarean section should not automatically get one if no medical reasons support it, say new evidence-based guidelines for maternal health professionals issued in the United Kingdom by the National Collaborating Centre for Women's and Children's Health for the National Institute for Clinical Excellence (NICE) and published by the Royal College of Obstetricians and Gynaecologists. The organization issued its clinical guidance on cesarean section in April 2004 to the National Health Service in England and Wales in a 160-page report, Caesarean Section: Clinical Guideline. In England, cesarean rates have increased from 9 percent of deliveries in 1980 to 21.5 percent in 2001. The four major indications for cesarean delivery have remained the same over the last 10 to 15 years: fetal compromise (22%), “failure to progress” in labor (20%), repeat cesarean (14%), and breech (11%). However, “The fifth most common reason given for performing a CS has changed and is now reported to be ‘maternal request’(7%),” the report states.

So that pregnant women can make a fully informed choice about the best care for themselves and their baby, the report recommends that they should be given information based on the best research evidence about indications for cesarean section, benefits and risks of cesarean section compared with vaginal birth specific to the woman and her pregnancy, procedures involved, how labor will be managed, and implications for future pregnancies and birth after cesarean. If a woman requests a cesarean and the doctor thinks that it is not appropriate, the request can be declined, but the woman should be referred to another doctor. In addition, “A competent pregnant woman is entitled to refuse the offer of treatment such as CS, even when the treatment would clearly benefit her or her baby's health,” the report states. The guidelines also suggest management strategies for reducing cesarean rates—for example, by fetal blood sampling along with fetal heart monitoring, or by using external cephalic version at 36 weeks’ gestation for women with a breech presentation. The guidelines can be accessed at http://www.rcog.org.uk or http://www.nice.org.uk

Significant increases in the number of births in the western United States have occurred, despite a nationwide decline in the number of births over the past decade, according to a comprehensive new analysis by the National Center for Health Statistics, Trends in Characteristics of Births by State: United States, 1990, 1995, and 2000–2002. This western shift is partly due to a growing population as well as the age and race composition of residents in those states. States with the largest increases were Arizona, Colorado, Idaho, Nevada, and Utah; increases were also noted in Texas, Oklahoma, Oregon, Georgia, and North Carolina. The greatest declines in births were primarily in the Northeast and included Maine, New Hampshire, Vermont, New York, Connecticut, and Pennsylvania; decreases were also noted in North Dakota, Michigan, and Alaska. In 2002, the birth rate ranged from 10 births per 1,000 population recorded in Maine and Vermont to 21 per 1,000 in Utah. The report documents the changes in births, birth rates, and other fertility measures and demographic patterns. Data are based on birth certificates filed in state vital statistics offices and reported to the Centers for Disease Control's National Center for Health Statistics. Births are tabulated for each state and the nation by race, ethnicity, marital status, age, and education of mothers; birth order; and sex ratios of births. Nationwide and in all states, birth rates decreased for women under age 30 years and increased for women 30 years and over between 1990 and 2002. Each year more boys than girls are born, and nationwide this sex ratio has stabilized at about 1,050 boys for every 1,000 girls. Nationwide just over one-third of births were to unmarried women in 2002, and this proportion has increased in every state since 1990 but still varies considerably by state. The highest proportion of unmarried births is in the Southeast. In general, women with higher educational levels have more favorable pregnancy outcomes. From 1990 to 2002, the percentage of births to women with 16 or more years of education increased in nearly every state. However, some states—all with rapidly growing Hispanic populations—experienced an increase in the percentage of births to women with fewer than 12 years of education.

The vaginal-versus-cesarean-birth controversy was the subject of a forum, “Cesarean Section: Exposing the Myths and Reducing the Risks,” on April 14 in New York City, sponsored by the nonprofit organization Maternity Center Association (MCA). As part of its ongoing research and work to improve maternity care in the United States, the organization conducted an in-depth review of the relevant research to examine all outcomes for mothers and babies that may be affected by the decision about performing a vaginal or cesarean delivery. Experts compared the effects of vaginal and cesarean birth based on the evidence, addressing mothers and babies’ short- and long-term outcomes, physical and emotional outcomes, safety issues, and prevention of pelvic floor problems. MCA found that women who undergo a cesarean section are at significantly higher risk than women who have a vaginal birth for infection, re-hospitalization, and poor birth experience; the evidence also shows increased likelihood of infertility, ectopic pregnancy, placenta problems, breathing problems and asthma in childhood, and fetal death.

In conjunction with the meeting, MCA also released an important new booklet, What Every Pregnant Woman Needs to Know About Cesarean Section, to help pregnant women understand key results from the research review, together with the risks of cesarean delivery, so they can make an informed decision about the method of childbirth best for them. The booklet is available on the MCA web site, http://www.maternitywise.org, along with descriptions of the investigative process, outcomes examined, sources, and summaries of individual studies; quantity discounts are available. The work by MCA was carried out in partnership with many national nonprofit organizations and childbirth educators, consumers, doctors, labor support professionals, midwives, nurses, and researchers, who helped shape the content of the booklet and ensure its accuracy.

Improving the availability and safety of vaginal birth after a cesarean (VBAC) is the goal of a successful new initiative that was developed by the Vermont/New Hampshire VBAC Project (ACOG Today Apr 2004). The collaborative effort of more than 200 health professionals and 35 of 37 hospitals in Vermont and New Hampshire included input from obstetricians, nurse-midwives, nurse managers, anesthesia personnel, administrators, and insurers from throughout the region. Concern over the decline in the number of hospitals offering VBACs led to the project's formation and establishment of guidelines for the management of VBAC, which can be used to re-institute VBACs in hospitals that no longer offer them. “There's still clearly a demand for VBACs,” said Dr. Peter Cherouny, Chairman of the Vermont section of the American College of Obstetricians and Gynecologists. He noted that women in the region who wanted VBACs had difficulty finding hospitals that would perform them. After identifying clinical risk characteristics of women at low, medium, and high risk for uterine rupture, the project then developed a regional institutional classification that includes specific recommendations for the care of VBAC patients at each risk level. Women at low risk, for example, show fetal and maternal risks common to those regularly seen in obstetric patients in all hospitals, Cherouny pointed out. Three documents were developed and disseminated—a patient VBAC education form, a patient consent form for VBAC, and regional guidelines for hospital management of VBAC. The support for the project data and new documents has led to the re-institution for VBAC in some hospitals, and is being considered by others. Based on the project's success, the hospitals have created the Northern New England Perinatal Quality Improvement Network, whose first job will be to collect patient outcome data on VBAC.

A national campaign to market baby formula to Hispanic mothers in the United States is underway by Nestlé(M. Jordan, Wall Street J Mar 4, 2004). The company has begun promoting Nan, a leading brand in Latin America, just as the U.S. government is poised to launch a major campaign to persuade low-income, minority mothers to breastfeed. At issue is whether companies should market baby formula to low-income immigrant mothers when health experts and government officials agree that breastfeeding is healthier, and saves in long-term health care costs. “We have launched Nestlé Nan in the U.S. with a fully bilingual label so that U.S. Hispanic moms, who choose not to or cannot breastfeed, can make an informed choice with regard to their child's nutrition,” says Lisbeth Armentano, a spokeswoman for Nestlé's U.S. unit in Glendale, California.

The numbers help explain why Nestlé is focusing on the 38 million Hispanics in the U.S. Currently they make up 13 percent of the total population—a percentage that is expected to grow to 20 percent by 2020. “Hispanic households tend to be larger and have growing birth rates,” Ms. Armentano said. In addition, Hispanic mothers in the U.S. tend to be less educated, and research suggests that less educated mothers are more likely to bottle-feed their babies, making them a desirable marketing target for formula companies. Critics say that also means Hispanic mothers, who lack fluency in English, will not get enough medical advice to make an informed choice between formula and breastfeeding their infants. For many immigrant women from deprived backgrounds, bottle-feeding has an aura of acculturation and prosperity. “Nestlé is using a vulnerable population for a grab at market share,” says Marsha Walker, executive director of the National Alliance for Breastfeeding Advocacy. Critics point out that a mother who supplements with formula is likely to wean her baby from the breast early. At 6 months of an infant's life, 36 percent of white mothers breastfed, 32.7 percent of Hispanic mothers, and 19.2 percent of black mothers according to a 2002 national study by Abbott Laboratories’ Ross Products Division. The U.S. government's campaign plans to promote breastmilk with public-service announcements, targeting minorities and low-income women.

Major changes in obstetric practice due to the liability crisis are reported in the latest professional survey of the American College of Obstetricians and Gynecologists (ACOG) for the period 1999–2003 (ACOG Today Mar 2004). The national survey of obstetrician-gynecologists reports that one in seven has stopped practicing obstetrics because of the risk of liability claims; over 76 percent have had a malpractice claim against them and 57 percent two or more claims. Obtaining and paying for liability insurance is the other major problem—as of October 2003, the national average premium had increased 53 percent since 1999. Asked what changes in practice were made due to the risk of being sued, 22 percent of respondents decreased the number of obstetric patients they would take, and 14 percent stopped practicing obstetrics entirely. In response to the liability insurance market and the litigation climate, respondents also changed the types or number of procedures they did, referred more patients to subspecialties, increased the laboratory tests ordered, and increased the amount of consulting they sought. Claiming the liability crisis as ACOG's number one priority, Dr. Ralph W. Hale, ACOG Executive Vice President stated, “Our specialty is in danger of extinction if we cannot resolve this problem.”