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The cesarean delivery rate increased to 28.5 percent in Australia in 2003, compared with 27.4 percent in 2002 and 19.4 percent in 1994, according to Australia’s Mothers and Babies 2003(AIHW National Perinatal Statistics Unit, Dec, 2005). Cesarean delivery rates were higher among older mothers (ranging from 15.9% for women age <20 yr to 43.2% for women age 40 yr and more) and among women admitted to private hospitals. The proportion of cesarean deliveries varied by state and territory, from 25.2 percent in the Australian Capital Territory to 30.9 percent in Western Australia. Three states, Queensland, Western Australia, and South Australia, reported cesarean rates of 30.7, 30.9, and 30.0 percent, respectively. Of women with a previous cesarean delivery, 81.4 percent had a repeat cesarean in 2003, 14.9 percent had a spontaneous vaginal delivery, and 3.5 percent had an assisted delivery. In 2003, the rate of vacuum extractions was 6.8 percent and the rate of forceps was 3.9 percent nationally. The full report (Perinatal Statistics Series No. 16) is available at http://www.npsu.unsw.edu.au/ps16.pdf.

Fourteen states in the United States achieved the national Healthy People 2010 objective of 75 percent of mothers initiating breastfeeding in 2004, according to a recent report from the US Centers for Disease Control and Prevention (2004 National Immunization Survey). Only 3 and 5 states achieved the objective of having 50 percent of mothers breastfeeding their children at 6 months of age and 25 percent of mothers breastfeeding their children at 12 months of age, respectively. Two states—Oregon and Utah—achieved all three of these Healthy People 2010 objectives. Consistent with previous research, the NIS breastfeeding data reveal that non-Hispanic black and socioeconomically disadvantaged groups have lower breastfeeding rates. The American Academy of Pediatrics recommends that an infant be breastfed without supplemental foods or liquids for the first 6 months of age (i.e., exclusive breastfeeding). However, no US state achieved an exclusive breastfeeding rate of 25 percent or greater through 6 months of age. The states with the highest percentage of ever breastfeeding were Alaska (88%), Idaho (86%), Oregon (86%), Washington (85.9%), Utah (84.8%), California (82.2%), Arizona (80.9%), Colorado (80.5%), Hawaii (80.2%), and Nevada (80.2%). Washington and Utah had the highest rates of exclusive breastfeeding at 6 months, 23 and 22.3 percent, respectively.

In a groundbreaking step for mothers and babies, Massachusetts may become the first state in the United States to prohibit hospitals from giving out free formula company diaper bags to new parents (Massachusetts Breastfeeding Coalition News, Dec 20, 2005; http://www.massbfc.org/news). Giving out these bags reduces the duration and exclusivity of breastfeeding, and is considered unethical by many national and international groups, including the World Health Organization. For decades, formula companies have used hospitals to hand out diaper bags stocked with coupons and free samples. Most parents see these as a “free gift,” but the bags are a marketing technique that implies that the hospital endorses the product, successfully boosting sales of formula at the expense of breastfeeding. The new rules on formula marketing are part of a much larger update of existing perinatal regulations written by the Massachusetts Department of Public Health (DPH) and approved by the Public Health Council. Hospitals must follow DPH regulations to be allowed to operate in the state. The regulations contain many other mandates that help promote and support breastfeeding and otherwise limit formula marketing. Most hospitals in Massachusetts and the US give out free diaper bags containing formula to new mothers, and also accept free formula for in-hospital use. “We’d never tolerate the thought of hospitals giving out coupons for Big Macs on the cardiac unit,” said Melissa Bartick, MD, Chair of the Massachusetts Breastfeeding Coalition. Since lack of breastfeeding is clearly associated with multiple adverse health outcomes in children and mothers, distribution of formula marketing materials by hospitals and health care providers has been recognized as unethical since at least 1981, when the World Health Organization approved the International Code of Marketing of Breastmilk Substitutes.

The story continues, however. Governor Mitt Romney then proposed that the new regulation be rescinded, but in a surprise setback for the Governor, the Public Health Council decided on February 21 to study the proposed ban on formula gift bags for 3 more months, rather than completely rescind it. The Massachusetts Breastfeeding Coalition has condemned the Governor’s action and called on the Public Health Council to override pressure from him and save the proposed ban on infant formula gift bags. Dr. Bartick noted, “This is the third time Governor Romney has tried to overrule the recommendations of his own public health agency. In this case, he caved in to industry pressure and put the interests of formula makers above the health of mothers and babies, while camouflaging it in the language of freedom of choice. The American Academy of Pediatrics and the Centers for Disease Control and Prevention have both called for an end to this distribution of industry-sponsored bags. It is unethical, and it should be stopped.”

The American Academy of Pediatrics (AAP) has released controversial new recommendations aimed at further reducing the incidence of sudden infant death syndrome (SIDS)(Massachusetts Breastfeeding Coalition News, Oct 15, 2005). Press coverage emphasized new recommendations on the avoidance of bedsharing and the recommendation to use pacifiers, and downplayed widespread concerns among researchers, infant sleep and breastfeeding experts. The Academy of Breastfeeding Medicine, an international organization of physicians, also released a statement noting that breastfeeding itself is protective against SIDS, and strongly disagreed with the AAP regulations, which were contrary to even the recommendations of its own Section on Breastfeeding. Recommendations that advise against parent-infant bed-sharing and support the generic use of pacifiers imply a “truly astounding triumph of ethnocentric assumptions over common sense and medical research,” according to Nancy Wight, MD, president of The Academy of Breastfeeding Medicine. Many health care providers, breastfeeding authorities, and infant sleep experts question the strength of some of the underlying evidence of the new recommendations on which so much attention has been focused. Pacifiers are linked with dental problems, fungal infections, ear infections, gastrointestinal infections, and breastfeeding difficulties. Bedsharing has been found to facilitate breastfeeding.

The global safe abortion program will receive a contribution from the United Kingdom government of 3 million pounds over the next two years (BMJ 2006;332:322). The program, developed by the International Planned Parenthood Federation, aims to help meet an internationally agreed target to reduce mortality among mothers in many of the world’s poorest countries. It will help member associations do more to stop unsafe abortions as well as help halt the decline in family planning and reproductive services in some countries, such as Peru. The UK government’s contribution flies in the face of restrictions introduced by the United States government on funding of such organizations. The US’s “global gag rule” prevents federal funding of any organization that is involved in work promoting or discussing safe abortion services, even when that work is funded from non-US sources. The rule even applies to organizations working in countries where abortions are legally available.

Placentas were collected from as many as 700 women without their knowledge from hospitals in Oregon, California, and Washington between 1996 and 2003 by the Cascadia Placenta Registry (Oregonian, Feb 16, 2006). Cascadia, which was started in 1995 and financed by Northwest Physicians Mutual Insurance Company, Oregon’s largest malpractice insurance provider, received and analyzed placentas from several hospital districts on the West Coast. “Its purpose was rather idealistic—to gather more information about the physiology of the placenta and how it related to birth injury,” Bob Taylor, former medical director of Northwest Physicians Mutual, said. However, promotional materials released by Cascadia suggested the research could be used to fight malpractice lawsuits, the Oregonian reports. “The burden on the physician can be eased when placental pathology provides evidence in court that poor outcomes are not the result of clinical care,” one brochure said.

The Oregonian article also profiled Angela Desbiens, who alleged that she did not learn of the report analyzing her placenta until after she sued Providence St. Vincent Medical Center, Portland, Oregon, for improper care. Desbiens claims she was never asked to consent to the placental analysis, calling it “a violation of privacy.” Experts say the hospitals may not have broken any state or federal laws, but their association with Cascadia, which closed in 2003, raises ethical questions about the clarity needed when seeking consent from patients. Arthur Caplan, a medical ethicist, said, “If you’re going to take things from patients, … subjects have an absolute right to know that and must consent”(Goldsmith, Oregonian, Feb 12, 2006).

The practice of shackling prisoners in labor continues to be relatively common in the United States, despite sporadic complaints and occasional lawsuits (A. Liptak, NY Times Mar 2, 2006). Only two states, California and Illinois, have laws forbidding the practice. The California law, which came into force in January 2006, was prompted by widespread problems, said Sally J. Lieber, a Democratic assemblywoman from Mountain View. “It presents risks not only for the inmate giving birth, but also for the infant.” The California law prohibits shackling prisoners by the wrists or ankles during labor, delivery, and recovery.

Corrections officials say they must strike a balance between security and the well-being of the pregnant woman and her child. Twenty-three state corrections departments, along with the federal Bureau of Prisons, have policies that expressly allow restraints during labor, according to a recent report by Amnesty International USA (Abuse of Women in Custody: Sexual Misconduct and Shackling of Pregnant Women, Mar 1, 2006). The corrections departments of five states, including Connecticut, and the District of Columbia, the report found, prohibit the practice. The remaining states do not have laws or formal policies, although some corrections departments told the group that they did not use restraints as a matter of informal practice. Many states justify restraints because the prisoners remain escape risks, although no instances of escape attempts by women in labor have occurred.

Illinois enacted the first law forbidding some restraints during labor, in 2000. “Under no circumstances,” it says, “may leg irons or shackles or waist shackles be used on any pregnant female prisoner who is in labor.” Before that, said Gail T. Smith, the executive director of Chicago Legal Advocacy for Incarcerated Mothers, the standard practice was to chain the prisoner to a hospital bed. “What was common,” Ms. Smith said, “was one wrist and one ankle.” In most cases, people who have studied the issue said, women are shackled because prison rules are unthinkingly exported to a hospital setting. “This is the perfect example of rule-following at the expense of common sense,” said William F. Schulz, the executive director of Amnesty International USA. “It’s almost as stupid as shackling someone in a coma.” The Amnesty International USA report is available at: http://www.amnestyusa.org/women/custody.