The cesarean delivery rate in England was just under 23 percent for 2004-2005, according to the recent report, NHS Maternity Statistics, England: 2004–05. Of the cesareans, 11 percent were elective deliveries, 91 percent were repeat cesareans (70% planned), and 78 percent were for malpresentation of the fetus. Cesarean delivery rates have risen from 3 percent in the 1950s, to 12 percent in 1990–1991, and 22 percent in 2001–2002. Other key findings for 2004–2005 were that 20 percent of deliveries were induced; 11 percent were instrumental deliveries (68% by ventouse); an estimated 48 percent were “normal deliveries” (i.e., no surgical intervention, instruments, induction, epidural or general anesthetic); approximately 20 percent of women had an epidural, 12 percent spinal, and 2 percent general anesthetic; and 13 percent of women had an episiotomy.
In addition, women with spontaneous deliveries spent an average of 1 day in hospital postpartum, women with instrumental deliveries 1 or 2 days, and women with cesarean deliveries between 2 and 4 days. The vast majority of deliveries occurred in National Health Service (NHS) hospitals, 2 percent were home deliveries, and 0.5 percent occurred in private hospitals. In 2004–2005, approximately 36 percent of deliveries were conducted by hospital physicians and 64 percent by midwives (a shift since 1989–1990 from 24% and 76%, respectively). The full report is available at www.ic.nhs.uk/pubs/maternityeng2005.
Nearly 25 percent of Canadian babies were delivered by cesarean section in 2002–2003, up from 17 percent in 1992–1993. Hospitals typically spend over 60 percent more to care for a mother who has a cesarean section birth than for a mother who has a vaginal delivery, according to a new report Giving Birth in Canada: The Costs. The report is one of a series on the health and health care of Canada’s mothers and infants by the Canadian Institute for Health Information (CIHI) (CIHI News release, April 26, 2006). In 2002–2003, average hospital costs ranged from about Can$2,800 for vaginal deliveries to Can$4,600 for cesarean sections and Can$7,700 for major procedures, such as hysterectomies and surgical repairs following delivery. The average length of stay in 2003–2004 was about 2 days for vaginal births and 4 days for cesarean deliveries.
All provincial and territorial health insurance plans cover medically necessary hospital and medical care during pregnancy and childbirth. Public funding of other services varies across the country, sometimes even within a province or territory. For example, coverage for expanded prenatal screening for inherited disorders and for in vitro fertilization differs between jurisdictions. Likewise, midwifery services are publicly funded in British Columbia, Manitoba, Ontario, Quebec, the Northwest Territories and Nunavut. Some other provinces regulate midwifery, but families have to pay for the services out-of-pocket. In Alberta, where midwifery services are not usually publicly covered, typical costs are about Can$2,500 for such services. According to Statistics Canada, midwives provided care for 3 percent of mothers with children ages 0 to 11 months across Canada in 2000–2001. The full report is available free of charge at http//:secure.cihi.ca.
Starting to breastfeed immediately after birth significantly increases the chances of survival of babies, according to new research funded by the Department for International Development (DFID) (Press release, Mar 26, 2006). Four million babies in the developing world die each year in the first month of life. If mothers start breastfeeding within 1 hour of birth, 22 percent of babies who die in the first 28 days, the equivalent to almost 1 million newborn children each year, could be saved. If breastfeeding starts on the first day, 16 percent of lives could be saved. The likelihood of death increases significantly each day the start of breastfeeding is further delayed. The research is the first study to assess the effect on newborn survival rates of when mothers start to breastfeed. It was carried out by the Kintampo Health Research Centre in Ghana and the London School of Hygiene and Tropical Medicine (Pediatrics 2006;117(3):e380–e386) (doi:10.1542/peds.2005–1496). The analysis was based on 10,947 breastfeeding babies born between July 2003 and June 2004 in Ghana who survived to the second day. Babies who were fed only breastmilk were four times less likely to die than those who were also fed other milk or solids, confirming the health benefits of exclusive breastfeeding in the first month.
A landmark children’s study will be launched by the United States government to examine effects of environmental factors on the health and development of more than 100,000 children from before birth to age 21 years (ACOG Today Feb 2006). The National Children’s Study, authorized in the Children’s Health Act of 2000 and sponsored by the National Institute of Child Health and Human Development, National Institute of Environmental Health Sciences, Environmental Protection Agency, and Centers for Disease Control and Protection, is estimated to cost more than $2 billion and is currently awaiting congressional funding. Scheduled to begin recruiting participants in 2007, the study seeks to enroll 100,000 women, 75,000 during pregnancy and at least 25,000 before pregnancy. Women will be recruited from approximately 40 centers that will collect data from 105 sites around the country. The study is expected to answer key questions about topics such as obesity, asthma, autism, preterm birth, miscarriage, preeclampsia, medical complications during pregnancy, assisted reproductive technologies, and environmental factors and their effects on childhood health and development. The proposed study has been likened to the U.S. National Collaborative Perinatal Project, which in the 1950s and 1960s studied 65,000 pregnant women and their children to 7 years after the children’s birth. A wealth of data was obtained, leading to substantive changes is obstetrics practice.
Calling for a ban of misoprostol use in inducing labor, the advocacy group Women Educating Cytotec Awareness Nationwide protested outside the American College of Obstetricians and Gynecologists' (ACOG) 54th Annual Clinical Meeting in Washington, D.C., on May 9 (Howard Price, Wash Times, May 9, 20065/9). ACOG issued a Committee Opinion in November 2000 affirming use of misoprostol for induction of labor in response to an August 2000 letter from G.D. Searle & Co. (the maker of misoprostol then sold as an anti-ulcer drug under the brand name Cytotec) that warned physicians against the use of misoprostol in pregnant women for safety reasons. The Committee Opinion said that after reviewing published data and adverse outcomes reported to the U.S. Food and Drug Administration (FDA), it believes that misoprostol, “when used appropriately is a safe and effective agent for cervical ripening and labor induction as well as a resource for treating serious postpartum hemorrhage” (Kaiser Daily Women’s Health Policy Report, Dec 1, 2000). The FDA, which has approved Cytotec as a treatment for ulcers but not to induce labor, has issued alerts about the use of the drug in pregnant women since 2000. “There can be serious side effects, including a torn uterus (womb), when misoprostol is used for labor and delivery,” a May 2005 FDA alert says. It also says, “A torn uterus may result in severe bleeding, having the uterus removed (hysterectomy), and death of the mother or baby. These side effects are more likely in women who have had previous uterine surgery, a previous Cesarean delivery (C-section), or several previous births.” Pfizer, which currently produces Cytotec, earlier this year advised against pregnant women using the drug (Wash Times, May 9, 2006).
Doulas around the globe celebrated their profession during May 2006, offering public education seminars and other special events (DONA Press release, May 3, 2006). “The word is out and doulas are fast becoming a mainstay for birth and postpartum support,” said Susan Martensen of Ottawa, Canada, and President of DONA International, the world’s leading doula association. In fact, the word “doula” was added to some dictionaries in 2002, but is still not in the Oxford English Dictionary. Nevertheless, a growing number of women are seeking doulas as awareness of the benefits grows, says Martensen. Use of doulas in Canada, the United States, and Western Europe is increasing. DONA International has more than 6,200 professional doula members today, up from 4,900 just 2 years ago. This international, nonprofit organization supports doulas by providing quality training and certification, and now has doula members in more than 20 countries.
In the late 1980s and early 1990s, researchers found that women who had used doulas had shorter labors and fewer cesarean births. Recent research shows that women who have doula support also have increased rates of breastfeeding, more positive mother-infant relationships, greater satisfaction with their birth experience, and a more positive postpartum adjustment. The support they give is so beneficial that renowned pediatrician and researcher John Kennell says, “If a doula were a drug, it would be unethical not to use it.”
Approximately 640,000 children became infected with human immunodeficiency virus (HIV) worldwide in 2004, primarily through mother-to-child transmission of the virus. Transmission occurs in utero, at the time of childbirth, and postnatally through breastfeeding. However, the World Health Organization (WHO) recognizes that exclusive breastfeeding, rather than mixed feeding, remains the best option for many poor women with HIV who don’t have access to clean water or cannot afford artificial milk. The reality is that until women are able to know their HIV status before giving birth and until they can afford to give artificial feeds if they have HIV, breastfeeding is the only option. Current WHO recommendations on breastfeeding in poor countries are as follows: (1) For HIV-negative women and women whose status is unknown, it is recommended to breastfeed exclusively for 6 months (with early initiation) and to continue breastfeeding with adequate complementary feeding for 2 years of age or beyond. (2) For HIV-positive mothers, it is recommended that when replacement feeding is acceptable, feasible, affordable, sustainable and safe, all breastfeeding by HIV-infected mothers should be avoided. Otherwise, exclusive breastfeeding is recommended during the first months of life and should then be discontinued as soon as feasible. More information is available from the WHO at www.who.org.