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The infant mortality rate in the United States reached a record low of 6.8 per 1,000 live births in 2001, according to a recent report from the Centers for Disease Control and Prevention (National Center for Health Statistics News Release, Sept 15, 2003). Wide variation occurred by race of the mother, with the highest rate of 13.3 for infants of black mothers, which was 4 times greater than the lowest rate of 3.2 for infants of Chinese mothers. Rates were also high for infants of American Indian (9.7) and Hawaiian (7.3) mothers.

The three leading causes of infant death were congenital malformations, low birthweight, and sudden infant death syndrome, which together accounted for 44 percent of all infant deaths. Driving the decline in infant mortality was the substantial drop in sudden infant death syndrome (SIDS), down 11 percent from 2000 to 2001. SIDS was down 12 percent for white mothers, 21 percent for all Hispanic mothers, and 27 percent for Mexican-American mothers—the largest single decline. In 2001, the SIDS rate for infants of black and American Indian mothers was more than double that of non-Hispanic white mothers. Infant mortality rates were higher for infants whose mothers had no prenatal care, were teenagers, had less education, were unmarried, or smoked during pregnancy; they were also higher for male infants, multiple births, and infants born preterm or at low birthweight. Infant mortality rates varied greatly by state; they were generally higher for states in the South and lowest for states in the West and Northeast, ranging from 10.4 for Mississippi to 4.9 for Massachusetts.

New findings on maternal mortality, reported online by the World Health Organization (WHO), UNICEF, and UNFPA, show that a woman living in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth compared with a 1 in 2,800 risk for a woman from a developed region (WHO Maternal Mortality Report, Oct 20, 2003). Of the estimated 529,000 maternal deaths in 2000, 95 percent occurred in Africa and Asia, 4 percent (22,000) in Latin America and the Caribbean, and less than 1 percent (2,500) in the more developed regions of the world. Maternal deaths per 100,000 live births for 2000 in some developed countries include Australia 5, Canada 4, Denmark 3, Finland 6, France 8, Germany 5, Italy 4, Netherlands 11, New Zealand 7, Sweden 1, United Kingdom 7, United States 11.

The maternal mortality ratio, which measures the number of deaths to women per 100,000 live births due to pregnancy-related complications, was estimated to be 400 per 100,000 live births globally in 2000. In 2000, world leaders agreed to reduce maternal mortality by three-quarters by 2015, as part of the Millennium Development Goals. Most maternal deaths and disability occur as the result of one or more of three delays: a delay in recognizing complications, a delay in reaching a medical facility, or a delay in receiving good quality care. Efforts to address these delays are essential to save the lives of mothers and babies. Education on family planning and the provision of family planning services of high quality can also make a difference. “Skilled attendants are vital because they can recognise and prevent medical crises and provide or refer for life-saving care when complications arise. They also provide mothers with basic information about care for themselves and their children before and after giving birth.” said Dr Lee Jong-wook, Director-General of the WHO. “UNICEF Executive Director Carol Bellamy note, “These new estimates indicate an unacceptably high number of women dying in childbirth and an urgent need for increased access to emergency obstetric care, especially in sub-Saharan Africa. The widespread provision of emergency obstetric care is essential if we want to reduce maternal deaths.” As the focal agencies within the United Nations system for the health of women and children, WHO, UNICEF, and UNFPA have pledged to enhance—both individually and jointly in collaboration with their partners—their efforts in assisting countries strengthen their maternal health programs. Maternal mortality data are available at: http:www.whoreproductivehealthpublicationsmaternal_mortality_ 2000tables.html.

Elective cesarean delivery is judged to be ethical, even if the mother has no medical complication, according to a recent statement published by the American College of Obstetricians and Gynecologists (ACOG)(ACOG Committee Opinion No. 289, Nov 2003). On one side of the debate on “patient choice cesarean” or “cesarean on demand” are some physicians who believe women have the right to choose surgery without medical necessity and, on the other, are those who believe that a natural process should not be replaced with a major surgical procedure. Thus, according to the ACOG statement, if a physician thinks that a cesarean promotes the mother's and fetus’ health more than a vaginal birth, he or she is ethically justified in performing it; otherwise, if he or she thinks the procedure “would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery,” and should refer the woman to another practitioner. ACOG also stated, “given the lack of data, it is not ethically necessary to initiate discussion regarding the relative risks and benefits of elective cesarean birth versus vaginal delivery with every pregnant patient.”

The opinion by ACOG has alarmed several major women's health organizations, since it may deny women access to fully informed consent concerning a highly controversial obstetrical procedure. “With a U.S. cesarean rate exceeding 26 percent, and no definitive study on the benefits of cesarean delivery, it is startling to give physicians the go-ahead to perform non-medically justified surgery on women with normal pregnancies,” said a press release from Lamaze International (Nov 19, 2003). A group of women's health care organizations, including Lamaze International, American College of Nurse-Midwives, Doulas of North America, Coalition for Improving Maternity Services, and the Association of Nurse Advocates for Childbirth Solutions believes this opinion downplays the risks to mother and baby. “No evidence supports the idea that cesareans are as safe as vaginal births for mother or baby, and pregnant women should be given all of the facts they need to make an educated decision,” said Barbara Hotelling, president of Lamaze International. In addition, the Childbirth and Postpartum Professional Association (CAPPA) has organized nationwide demonstrations to unite childbirth professionals and women who wish to send a message to ACOG that they will protect and defend a woman's right to VBAC, and to be fully informed of her childbearing choices and the long-term consequences of her decisions (http:www.cappa.netrally.asp).

A Better Birth Environment Survey of nearly 2,000 women around the United Kingdom who had given birth during the past 5 years was recently conducted by the National Childbirth Trust (NCT)(New Generation Sept 2003). Nine of 10 women thought that the physical surroundings can affect how easy or difficult it is to give birth, including space for walking and moving around, a birthing pool or large bath, an en suite toilet, a comfortable adjustable bed, low light or adjustable lighting, and comfortable furniture for their partner. Women valued privacy and quiet, and being in control of their surroundings, in particular not being in sight of other people or overhearing other women in labor. They wanted to decide who came into their room during labor, and preferred not to have to move from one room to another halfway through labor. Overall, women who gave birth in hospital had less access to helpful facilities than women who gave birth at home or in free-standing, midwife-led units. Women who had access to good facilities were less likely to have an emergency cesarean delivery than those who had poorer facilities. The NCT survey findings will be used to ensure that women's views are taken into account, and the organization has published a report for architects and designers and for National Health Service managers, encouraging them to improve facilities for women and families.

Having a cesarean delivery may significantly increase the risk of having an unexplained stillbirth in a second pregnancy, according to a study by British and Scottish researchers (Lancet 2003;362:1779–1784). Principal researcher Gordon Smith, from Cambridge University, linked pregnancy discharge data from the Scottish Mortality Record and the Scottish Stillbirth and Infant Death Inquiry on 120,633 births in Scotland between 1992 and 1998. The risk of unexplained stillbirth associated with a previous cesarean differed significantly with the age of the fetus—the most dangerous time was at 34 weeks’ gestation. The risk was not reduced by factors such as the mother's age or outcome of her first pregnancy. “The absolute risk of unexplained stillbirth at or after 39 week's gestation was 1.1 per 1000 women who had had a previous caesarean section and 0.5 per 1000 in those who had not,” the study said. Doctors are not sure why the surgery increases the risk of stillbirth but they suspect that repairing the uterus after the surgery could affect the function of the placenta in a future pregnancy. “This is a factor that women should take into account when deciding to have a caesarean section,” Smith said. “Our results are of relevance for women considering caesarean delivery who are planning future pregnancies.” Commenting on the study, Australian researcher Judith Lumley, of the Centre for the Study of Women's and Children's Health in Victoria, said that the finding by Smith and colleagues “could redefine the nature of the debate about the place of caesarean delivery in maternity care.”

The first free-standing birth center in the United States closed its doors for good in August 2003—unable to afford the nearly $2 million per year needed to pay its malpractice insurance premiums (Network News Nov/Dec 2003). The Elizabeth Seton Childbearing Center of New York City opened its doors in 1975, providing midwife-assisted deliveries outside the hospital to women with low-risk pregnancies. It had a cesarean birth rate of only 10 percent, and 99 percent of its clients were breastfeeding when they left the center, compared with national rates of 26 and 67 percent, respectively. “This is about how malpractice insurance rates are threatening midwives and obstetricians,” said Deanne Williams, executive director of the American College of Nurse-Midwives to Long Island Newsday. “Pretty soon, there won’t be anyone left to deliver babies.”

Breastfeeding may help wound healing from childbirth, according to a study presented by researchers from Ohio State University, Columbus, Ohio, at the Annual Meeting of the Society for Neuroscience, New Orleans, November 2003 (Nature Science Update Nov 17, 2003). The study on rats showed that lactation speeds wound healing and lowers stress. Rats were given small skin wounds the day after they littered. Five days later, their injuries were 30 percent smaller than those of animals prevented from breastfeeding. After a mother gives birth, her prolactin and oxytocin levels increase. Prolactin boosts the number of circulating immune cells, which may speed repair, the researchers noted. Oxytocin, which prompts lactation, lowers the levels of stress hormones. “It's quite possible that mothers who breastfeed their newborns will have accelerated healing of tissue damage compared with mothers who bottle-feed,” said Tara Craft, who conducted the study. Natural and cesarean births can leave substantial wounds, said Craft, who now plans to study wound healing in human mothers. “The immune system is sensitive to just about every hormone in the body, so oxytocin may well be involved,” said Bruce McEwen from the Rockefeller University in New York, who studies the effects of hormones on the brain. Oxytocin is also thought to help animals form social bonds. Rodents that live in pairs are less vulnerable to stress and mend more quickly than do single animals, said Craft, citing this as further evidence for the hormone's involvement in wound healing.

A worldwide campaign to promote normal birth, based on Six Care Practices adapted from the World Health Organization, has been announced by Lamaze International (Press Release Oct 2, 2003). The purpose of the initiative is “to educate women, childbirth educators, and healthcare professionals about the benefits in safeguarding the normal, natural process of birth.” The Lamaze Institute for Normal Birth, which is central to the campaign, is a new online resource center (http:www.normalbirth.lamaze.org) that will make available evidence-based position papers and other reference materials that support normal birth. The papers on the Six Care Practices are available on the website above, and include (1) labor begins on its own; (2) freedom of movement throughout labor; (3) continuous labor support; (4) no routine interventions; (5) non-supine (e.g., side-lying, upright) positions for birth; and (6) no separation of mother and baby after birth. “The safety of birth is enhanced by respecting the normal, natural physiologic process of birth and not interfering unless there are compelling medical indications,” said Lamaze International President, Barbara Hotelling.

The Maternity Care Calendar and Guidelines (2003), second edition, has recently been published by the Children's and Women's Health Centre of British Columbia, Canada. This useful tool is designed for maternity caregivers, and combines a rotational calendar with an evidence-based checklist of clinical practice guidelines. The calendar provides both caregiver and pregnant woman with an at-a-glance, individualized view of the timing of important events in the pregnancy. This updated version of the wheel is accurate within plus or minus 1 day (other wheels have shown up to a 5-day error in calculating delivery dates). The calendar also shows the probability of delivery at different intervals around the due date, facilitating planning for delivery and discussion about induction for postdates between 41 and 42 weeks. The face of the calendar contains time-sensitive prompts for care. After being set to a client's dates, it is designed to be photocopied—one copy for the chart and one for the pregnant woman. The chart copy has space for adding ultrasound information and any time-specific notes. The Maternity Care Guidelines, on the other side of the wheel, provides an updated evidence-based checklist that outlines suggested interventions for preconception and prenatal care, displayed along a timeline along one axis under 3 headings of “Clinical,”“Investigations,” and “Issues for Discussion.” Interventions for which evidence is strong (Grade A or B) are shown in bold font; less compelling evidence is in plain font; and preconception interventions are in green print. A new website for 2003 (http:www. maternitycarecalendar.com) can be used for ordering the Maternity Care Calendar and Guidelines($US9.95 or $CDN14.95 plus tax/shipping, discounts on volume orders). The website also posts in-depth reviews of maternity topics of the evidence behind the checklist guidelines, references, and links to patient care resources.

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