The 2005 cesarean delivery rate reached an all-time high of 30.2 percent in the United States, according to preliminary data from the National Center of Health Statistics (Births: Preliminary Data for 2005, Nov 21, 2006). This rate is up from 29.1 percent in 2004. The cesarean delivery rate declined somewhat during the early and mid-1990s, but rose 46 percent since 1996 (from 20.7%). Rates were up in 2005 for all races (non-Hispanic white, non-Hispanic black, American Indian or Alaska Native, Asian or Pacific Islander, and Hispanic women), and also for each 5-year age group. Since 1996, rates have risen by more than 40 percent for all age groups, including for young women under 20 years of age.
Surrogate motherhood is a new role being outsourced to India, where rent-a-womb services are far cheaper than in the West (Reuters 6 February, 2007). “In the US a childless couple would have to spend anything up to $50,000. In India, it’s done for $10,000-$12,000,” said Gautam Allahbadia, a fertility specialist who has helped couples obtain a child through an Indian surrogate. It is estimated between 100 and 150 surrogate babies are born each year in India, although the number of failed attempts may be far higher. Yashodhara Mhatre, a fertility consultant at Mumbai’s Centre for Human Reproduction, says that although no comprehensive figures are available perhaps 500 to 600 surrogate babies are born each year throughout the world. Allahbadia is presently handling 14 cases with prospective parents from India, Britain, the USA, Singapore, France, Portugal, and Canada. But the practice is not without its critics in India, with some calling it the “commoditisation of motherhood” and an exploitation of the poor by the rich. For the surrogates—usually lower middle-class housewives—money is the primary motivator. For their clients it is infertility or, some claim, educated working women turning to hired wombs to avoid a pregnancy affecting their careers. However, a social dimension to the surrogate’s service exists, experts say, an empathy with the childless in a society that views reproduction as a sacred obligation, and believes good deeds performed in this life are rewarded in the next one.
Preterm births in the United States rose from 12.5 to 12.7 percent for 2004-2005, according to the National Center for Health Statistics (Births: Preliminary Data for 2005, Nov 21, 2006). The percentage of infants delivered at less than 37 completed weeks’ gestation has risen 20 percent since 1990 (from 10.6%). Preterm rates rose significantly for non-Hispanic white (11.7% for 2005), non-Hispanic black (18.4%), and Hispanic infants (12.1%) between 2004 and 2005. Rates for non-Hispanic white and Hispanic births have been rising for more than a decade, increasing 38 percent for non-Hispanic white, and 10 percent for Hispanic infants since 1990. The preterm rate for black infants declined modestly during the 1990s, but has been on the rise since the year 2000. Although the upswing in multiple births has had an important influence on recent trends in preterm birth rates, shorter gestations have also risen among singleton deliveries. The percentage of infants born low birthweight also increased in 2005, to 8.2 percent of all births, up from 8.1 percent in 2004. The percentage of infants born low birthweight (< 2,500 g) has increased more than 20 percent since the mid-1980s (from 6.7); the 2005 level is the highest level reported since 1968. Low birthweight rates rose 1 to 2 percent for non-Hispanic white, non-Hispanic black, and Hispanic infants between 2004 and 2005.
Fewer boys were born after the 9/11 terrorist attacks on the World Trade Center in New York City, supporting similar results from California, according to researchers from the University of California in Berkeley, whose study was published recently (Hum Reprod 2006, Aug 26, doi: 10.1093/humrep/del283). The sex ratio in California fell 3 months, but not 8, 9, or 10 months, after the terrorist attacks of September 11, 2001. California’s distance from the attacks raised questions of whether the results arose from chance and would be found elsewhere. In an effort to replicate the California findings, Catalano and colleagues applied interrupted time-series methods, which controlled for seasonality, secular trends, and other forms of autocorrelations. Based on more than 700,000 births in New York City between January 1996 and June 2002, the study showed that the birth sex ratio for the city dropped to below 1 in the January after the attacks—its lowest level—and significantly below the value expected from history. One theory is that the stress of the attack, particularly in women in the second and early third trimesters of their pregnancy, resulted in a disproportionate loss of male fetuses, so lowering the odds of a male birth. The authors noted, “The human secondary sex ratio reportedly falls in populations subjected to exogenous stressors such as earthquakes or political and social upheavals. Explanations of the association include reduced conception of males and increased fetal deaths among males.” They concluded, “Our findings support the male fetal loss explanation of the association between exogenous population shocks and the secondary sex ratio.”
Fear of lawsuits and increasing professional liability premiums continue to cause obstetrician-gynecologists in the United States to change their practice, according to the American College of Obstetricians and Gynecologists (ACOG) 2006 ACOG Survey on Professional Liability (ACOG Today Nov/Dec 2006). Seventy percent of obstetrician-gynecologists surveyed by ACOG made practice changes because of lack of available or affordable professional liability insurance and 65 percent made changes because of the fear or risk of liability claims or lawsuits. In both instances nearly 29 percent reported increasing the number of cesarean deliveries, 26 percent decreased the number of high-risk patients under their care, and 26 percent stopped performing or offering vaginal birth after a previous cesarean section (VBAC). About 8 percent stopped practicing obstetrics entirely. The average age for stopping the practice of obstetrics was 48 years—once considered to be near the midpoint of a professional’s career in the field. Eighty-nine percent of respondents had at least one claim filed against them in their professional careers for an average of 2.62 claims per obstetrician-gynecologist, and of the claims, 62 percent were for obstetric care and 38 percent for gynecologic care. The results represented 10,659 survey respondents, and the survey covered the period from 2003 to 2005. It was the ninth such survey conducted by ACOG.
All pregnant women, regardless of their age, should be offered screening for Down syndrome, according to a guideline by the American College of Obstetricians and Gynecologists (ACOG) in a new Practice Bulletin issued in January (ACOG Press Release, Jan 2, 2007). Previously, women were automatically offered genetic counseling and diagnostic testing for Down syndrome by amniocentesis or chorionic villus sampling (CVS) if they were 35 years and older. The new ACOG guidelines recommend that all pregnant women consider less invasive screening options for assessing their risk for Down syndrome, and such screening should occur before the 20th week of pregnancy. “This new recommendation says that the maternal age of 35 should no longer be used by itself as a cut-off to determine who is offered screening versus who is offered invasive diagnostic testing,” noted Deborah Driscoll, MD, a lead author of the document. ACOG also advises that all pregnant women, regardless of their age, should have the option of diagnostic testing. The goal is to offer screening tests with high detection rates and low false positive rates that also provide patients with diagnostic testing options if the screening test indicates that the woman is at an increased risk for having a child with Down syndrome. The guidelines discuss the advantages and disadvantages of each screening test and some of the factors that determine which screening test should be offered, including gestational age at first prenatal visit, number of fetuses, previous obstetric and family history, and availability of various screening tests.
LactMed is a free online database that provides reliable, up-to-date information on drugs and lactation available at http://toxnet.nlm.nih.gov/lactmed. It is a new addition to the TOXNET collection of resources covering toxicology, chemical safety, and environmental health produced by the National Library of Medicine of the National Institutes of Health. The database focuses on the effects of medication on the nursing mother, the infant, and the physical process of lactation. LactMed covers over 500 drugs (with new ones being added regularly), and is peer-reviewed, fully referenced, and easily searchable. The user can search by generic name (e.g., “aspirin”), brand name (e.g., “Tylenol”) type (e.g., “laxative”), chemical name or CAS number. Professionals working in maternal and neonatal health will find current information about the effects of drugs on breastfeeding, with links to PubMed citations. LactMed is also sufficiently straightforward to be used effectively by consumers, with helpful features such as a glossary and links to breastfeeding sites.
Scores of mothers breastfed their babies at airports around the United States on November 21, 2006, in a show of support for a woman who was ordered off a Delta Air Lines and Freedom Airlines flight for breastfeeding her daughter and reportedly not “covering up” (Rochester Democrat& Chronicle Nov 22, 2006). The mother, Emily Gillette, filed a complaint against the two airlines with the Vermont Human Rights Commission; the state of Vermont allows a mother to breastfeed in public (Associated Press Nov 16, 2006). She said that she was discreetly breastfeeding her daughter as their flight prepared to leave Burlington for New York City. She was sitting by the window in the next-to-last row, her husband was seated between her and the aisle, and no part of her breast was showing. Telling her to cover up, a flight attendant tried to hand her a blanket, which she declined. The family was then asked to leave the flight and, not wanting to make a fuss, they complied.