Cesarean deliveries rose to an unprecedented high of 27.6 percent in the United States in 2003, according to preliminary data from the National Center for Health Statistics (Natl Vital Stat Rep 2004;53(9):6). This is a marked 6 percent rise over the 2002 level of 26.1 percent. Following declines for 1989–1996, the cesarean delivery rate has risen each year; the current level is one-third higher than that for 1996 (20.7%). For 2002–2003, in keeping with the recent trend, the primary cesarean rate (percent of cesareans among women with no previous cesarean delivery) rose 6 percent, from 18.0 to 19.1 percent, whereas the rate of vaginal birth after previous cesarean (VBAC) dropped from 12.6 to 10.6, a 16 percent decline. The primary rate has climbed 31 percent and the VBAC rate has plunged 63 percent since only 1996. The cesarean rate was higher for non-Hispanic black (29.3%) than non-Hispanic white women (27.7), and lower for Hispanic (26.6%) and American Indian women (24.2%) than non-Hispanic white women.
The national study of vaginal birth after cesarean(VBAC) in birth centers reported that, despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management (Obstet Gynecol 2004;104(5) pt 1:933–942). This was the finding by the National Association of Childbearing Centers in its 10-year study of VBAC in birth centers in the United States to obtain data to formulate an evidence-based opinion on the outcomes for women attempting a VBAC in an out-of-hospital setting. The researchers prospectively collected data on pregnancy outcomes of 1,913 women intending to attempt VBACs in 41 participating birth centers between 1990 and 2000. Of 1,453 of the 1,913 women presenting to the birth center in labor, 24 percent were transferred to hospitals during labor, and 87 percent of these women had vaginal births. There were 6 uterine ruptures (0.4%), 1 hysterectomy (0.1%), 15 infants with 5-minute Apgar scores less than 7 (1.0%), and 7 fetal/neonatal deaths (0.5%). The study researchers concluded that birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery, and hospitals should increase access to in-hospital care provided by midwife/obstetrician teams during VBACs.
The crude birth rate rose to 14.1 births per 1,000 population in 2003 in the United States, an increase of 1 percent from 2002 (13.9)(Natl Vital Stat Rep 2004;53(9):1). The fertility rate also rose in 2003 by 2 percent to 66.1 births per 1,000 women aged 15–44 years. Since 1994, the rate has ranged from 63.6 to 66.1. The birth rate for teenagers continued to decline in 2003 to 41.7 births per 1,000 women aged 15–19 years, 3 percent lower than in 2002. Rates fell for teenagers in all groups, in many cases marking new record lows for the nation. Birth rates for teenagers 15–17 and 18–19 years continued to decline steadily. The rate for ages 15–17 was 22.4 per 1,000 in 2003, down 3 percent from 2002 and 42 percent from 1991, the recent peak. The rate for older teenagers 18–19 years in 2003 was 70.8 per 1,000, also 3 percent lower than in 2002. Among older mothers, the birth rate for women aged 30–34 years increased 4 percent to 95.2 births per 1,000 women compared with 2002. The rate rose 6 percent for women aged 35–39 years, between 2002 and 2003, and 5 percent for women aged 40–44 years. The rate for women aged 45–49 years remained unchanged. The proportion of mothers smoking during pregnancy continued to steadily decline in 2003, from 11.4 percent in 2002 to 11.0 percent. The percent of women who received prenatal care within the first 3 months of pregnancy edged upward for 2003, to 84.1 percent, compared with 83.7 percent in 2002.
Germany's total fertility rate continues to fall, entering its second generation of decline, and could imperil the country's “advanced social systems and public infrastructure” that were designed for larger populations (New York Times Nov 18, 2004). German women are having too few children to maintain the population level, and the number of “potential mothers” also is falling. Dr. Reiner Klingholz, director of the Berlin Institute for Population and Development, calculated that without new immigrants, Germany's population will drop from 82 million to 24 million by 2100, according to the Times report. Even with the current average number of 230,000 immigrants entering the country annually, Germany's population will decrease by 700,000 over the next 15 years, according to Klingholz. Some European countries have increased the average number of infants born to each woman by offering incentives to families to have more children, but Germany's government does not have the resources for similar programs. The decrease in the number of infants being born has “ignited a fierce competition” among German hospitals. Dr. Volker Mobus, chief of obstetrics and gynecology at Hochst hospital in Frankfurt, tries to persuade couples to deliver their infants at the hospital by promoting its neonatal intensive care unit, offering extra services such as massage therapy and performing cesarean deliveries for nonmedical reasons. “In every German city, you could close 20% of the hospitals and no one would notice. We have too many beds and too many hospitals,” Mobus said.
In Canada, pregnancy and childbirth accounted for 14 percent of all hospitalizations in 2001–2002, second only to circulatory diseases, according to a recent report by the Canadian Institute for Health Information, Giving Birth in Canada: A Regional Profile. Each year, approximately 330,000 babies are born, about 99 percent in hospitals. Approximately one-fourth of births in Canada in 2001–2002 occurred without surgical intervention (use of instruments, induction, or epidural/general anesthesia). Substantial variations occurred in practice across the country, with rates in some regions at least double the rates in other areas. Epidurals were used in 45.4 percent of all vaginal births, their use varying across the country from 3.9 to 74.6 percent. The proportion of vaginal deliveries assisted by vacuum extraction increased by 56 percent, whereas the use of forceps decreased by 45 percent during the same time period. Other countries, such as England, the United States, New Zealand, and Australia, have seen similar trends. Primary cesarean section rates varied across health regions from 7.6 to 25.5 percent of births. The medical induction rate rose to 19.7 percent in 2001–2002, up from 12.9 percent 10 years earlier. Episiotomy rates dropped from 49.1 percent in 1991–1992 to 23.8 percent in 2000–2001. The proportion of newborns admitted to neonatal intensive care units in Canada rose from 12.6 percent in 1994–1995 to 14.4 percent in 2001–2002. The report is available at http://www.cihi.ca.
The number of maternal deaths in 2002 dropped by 42 to 357 from the 2001 total, for a maternal mortality rate (MMR) of 8.9 deaths per 100,000 births in the United States (Natl Vital Stat Rep 2004;53(5):13). The MMR for black women was 24.9, however, which was 4.2 times the rate for white women (6.0 deaths per 100,000 live births). The MMR for Hispanic women was 7.1 deaths per 100,000 live births. The MMR in Canada is 6.1 per 100,000, according to a recent report from Health Canada (ObGyn News 2004;39(19). In both countries, pulmonary embolism and preeclampsia/pregnancy-induced hypertension were the leading direct causes of maternal mortality.
Labor progress is slower in pregnant women who are overweight or obese compared with normal weight women, according to a study by researchers at the University of North Carolina and the National Institute of Child Health and Human Development of the National Institutes of Health (News Release Oct 29, 2004). Since a longer labor is one consideration for whether or not a pregnant woman will have a cesarean section, the new finding also means that a physician may need to take a woman's weight into consideration before deciding whether or not to recommend her for the procedure, the authors cautioned. The study, which was published in the November 2004 issue of Obstetrics and Gynecology, analyzed pregnancy and birth records from 612 North Carolina women who gave birth to their first child. The researchers found that the median labor for overweight women was 7.5 hours, for obese women 7.9 hours, and for normal weight women 6.2 hours. When taken together with other findings showing that extra body weight during pregnancy can pose serious and even life-threatening complications for both mother and infant, the current finding underscored the need for overweight or obese women who were either pregnant or contemplating pregnancy to seek medical and nutritional attention.
A new birth training program in Afghanistan has graduated 40 Afghan women as traditional birthing assistants (TBAs), according to the U.S. Army's News Media Service (Oct 12, 2004). The 3-month program, the first of its kind in Qalat province in southern Afghanistan, teaches students how to care for women during pregnancy and how to assist women with the delivery. The program's founder Dr. Gulnar, a gynecologist and general surgeon who received her education at Kabul University, said the mortality rate among Afghan women and their babies during childbirth is very high, often because women are not allowed to see a doctor. Other contributory factors include early marriages for young women, back-to-back pregnancies, malnutrition, and anemia. Program funding from the Commander's Emergency Relief Program (CERP) funds paid for rent for classrooms, purchase of books and desks, a security team, and transportation for students, who also received two U.S. dollars for every class they attended. The main difficulty to overcome in teaching students was literacy, since Afghan women were not allowed to attend school under Taliban rule. To overcome reading deficiencies, Dr. Gulnar divided the group into two classes based on their level of education, using either written or visual materials. On completing training, those women who could not read were tested by personal interview by the instructors. The students, who ranged in age from 16 to 45 years, said they were proud of their achievement and looked forward to practicing as a TBA, which they said was “a good profession.” They also said they desired to see Afghanistan become a “peaceful, healthy community.”
Some pregnant women are prescribed drugs that may be unsafe, according to a recent study of data from 8 health maintenance organizations in a variety of geographic areas (Am J Obstet Gynecol 2004;191: 398–407). The study evaluated prescription drug use by 152,531 women who gave birth in a hospital from January 1, 1996, through December 31, 2000, based on the U.S. Food and Drug Administration's (FDA) risk classification of drugs used during pregnancy. Of 64 percent of women who were dispensed a medicine other than a vitamin or mineral supplement within 270 days before delivery, nearly 40 percent were dispensed a drug for which human safety has not been established, nearly 5 percent were dispensed drugs classified as having positive evidence of fetal risk, and another 5 percent dispensed from a groups of drugs for which evidence indicates definite fetal risks based on human or animal studies or based on human experience and for which the risk clearly outweighs any possible benefit. The remaining approximately 50 percent of prescriptions were classified as drugs with a remote risk to the fetus and drugs for which animal studies show no fetal risk and there are no controlled studies in women; or animal studies show risk, but controlled studies in women fail to show risk. The researchers concluded that routine medication audits, physician education, and new technologies may have the potential to reduce inappropriate prescribing for pregnant women.
Two new valuable on-line resources are the Contraception Resource Center and the updated Choosing a Birth Control Method tool–both available from the nonprofit Association of Reproductive Health Professionals (ARHP). The Contraception Resource Center(http://www.arhp.org/contraceptionresources) is a comprehensive source for information on contraception for health care providers and their patients. Choosing a Birth Control Method(http://www.arhp.org/choosing) is an interactive Web tool designed to help patients choose which birth control method is best for them. By asking a series of questions about their lifestyle, health, and preferences, the tool lists specific birth control options that may be appropriate for the user.