A new policy controlling the timing of elective cesarean sections in New South Wales, Australia, was issued in April by the state health department (NSW Health Policy Directive Apr 3, 2007). Under these guidelines, “Maternal request on its own is not an indication for elective caesarean section and specific reasons for the request must be explored, discussed and recorded.” Pregnant women must be given evidence-based information on which they can make informed decisions, including risks and benefits for mother and baby compared with vaginal birth, indications for cesarean section, and implications for future pregnancies and births after cesarean section. The Policy Directive cites a United States study by MacDorman et al (Birth 2007;33(3):175–182) of more than 5 million births, which found that newborns born by a medically unnecessary cesarean were three times as likely to die as those born vaginally. The directive notes that since the risk of respiratory problems increases in babies born by cesarean section before 39 weeks’ gestation, elective cesarean section must not routinely be done before this time. Studies have also shown the adverse long-term outcomes for women planning to have additional children after a cesarean section, as mentioned by Andrew Child, a member of the NSW Health Maternal and Perinatal Committee, which drafted the directive. He said that “while first caesareans were generally safe, dangers escalated steeply with subsequent births” (J. Robotham, The Age, April 7, 2007). The complete Policy Directive, “Maternity—Timing of Elective or Pre-Labour Caesarean Section,” is available at http://www.health.nsw.gov.au/policies.
The deaths of two women after cesarean sections at Underwood-Memorial Hospital in Woodbury, New Jersey, USA, sparked a demonstration of protesters, some from the International Cesarean Awareness Network (ICAN), outside the Statehouse in Trenton to draw attention to their deaths and to the state’s high cesarean section rate (C.A. Campbell, Star- Ledger, May 18, 2007). In New Jersey, more than 1 of every 3 births, or 37 percent, were delivered by cesarean section in 2005, according to state health officials. The U.S. Centers for Disease Control and Prevention said New Jersey had the nation’s highest cesarean rate in 2004, according to the latest nationwide data. The women who died (on March 28 and April 12, 2007) were co-workers at the same elementary school. Both women, who were transferred to other hospitals before their deaths, had given birth to healthy infants. After the women’s deaths, hospital spokesman Richard Bellamente said Underwood-Memorial conducted an in-depth investigation and “we found that everything in terms of protocol of care is consistent with appropriate treatment.” Attorneys for the two women are awaiting autopsy results. Maternal deaths are rare in the United States, and in 2005, the figure in New Jersey was 8 deaths, according to state health officials.
Several participants at the rally acknowledged that facts surrounding the women’s deaths remained unclear, but they nonetheless said risk of maternal death is higher during cesarean sections. They are pushing for laws requiring all maternity health professionals to provide their cesarean section rates to potential patients.
The United Kingdom’s stillbirth rate has stopped declining in recent years, and even current rates of perinatal mortality may be hard to maintain because the average age of British mothers continues to rise, according to a recent report from the Confidential Enquiry into Maternal and Child Health (BMJ 2007;334:871, 28 April). Mandated by the government to collect confidential statistics from National Health Service trusts and neonatal networks, the research groups report recorded stillbirths and perinatal deaths for 2005 in England, Wales, and Northern Ireland. Slightly more than 1 in 200 pregnancies ended in a stillbirth, and about 1 in 300 babies died in the first 4 weeks of life. These numbers, although low, represent “the tip of an iceberg” of morbidity, the report argues. Social deprivation remains closely linked to perinatal risk, with mothers from the most deprived fifth of residential areas about twice as likely as mothers from the richest areas to experience stillbirth or neonatal mortality. Ethnicity is also a factor. Although the stillbirth rate among white mothers was 4.8 per 1,000, among black mothers it was 11.6 per 1,000, and among Asian women 8.9 per 1,000. Stillbirth and neonatal mortality were most likely when the mother was age under 20 or over 40 years. The report calls for better reporting of the causes of perinatal death. In 2005 more than half of stillbirths were listed as “unexplained,” and 48 percent of neonatal deaths were classified as caused by “immaturity.” Only 39 percent of perinatal deaths were investigated by postmortem examination in 2005, compared with 58 percent in 1993. The report, Perinatal Mortality 2005: England, Wales, and Northern Ireland, is at www.cemach.org.uk.
The shortage of practicing obstetricians and the closing of maternity wards in Japan have led some rural cities to adopt a system that examines pregnant women remotely using real-time data transmitted to a physician’s cell phone (Onishi, New York Times, April 8, 2007). According to Japan’s Ministry of Health, Labor and Welfare, the number of practicing obstetricians dropped by 40 percent from 1992 to 2004. Some physician groups attribute the decline in part to local and national governments’ failure to address the leading causes of the shortage. Japan’s medical system also does not allow obstetricians, who often work longer hours than other physicians, to receive additional compensation for their extra work. Approximately one half of the obstetricians in the country are age 50 years or older, and the number of medical students choosing an obstetrics specialty has “plummeted” since 2004. Four cities last fall adopted a remote examination system, in which if a physician judges that a pregnant woman is about to go into labor using the system, she is instructed to go to the nearest city with a maternity ward. Fourteen women in the city of Tono have given birth using the system, and 5 pregnant women currently are using it. After a 3-year evaluation of the system, it is expected to be expanded to other areas of Japan.
Long periods of bed rest can be harmful to the health of a pregnant woman, according to increasing evidence from the National Aeronautics and Space Administration (NASA) (G. Reynolds, New York Times, March 22, 2007). NASA scientists used bed rest to simulate weightlessness in space, and found that complete immobility during a long period of time can cause degeneration of a person’s musculoskeletal and cardiovascular systems. Such degeneration can begin within 48 hours of bed rest, but it usually is “after birth that many bedridden mothers realize the extent of their deconditioning.” According to data, about 700,000 pregnant women annually in the United States are advised to go on bed rest, including nearly all women pregnant with more than one fetus. Women often are told to go on bed rest if they are having blood spotting, contractions before 37 weeks’ gestation, high blood pressure, or a history of preterm labor, as well as if the fetus appears to be growing abnormally. Most of the women rest at home, whereas others are hospitalized. It is standard medical advice to assign these women to bed rest, said Dr. Raul Artal, the chairman of the department of obstetrics and gynecology at St. Louis University School of Medicine, even though the evidence that bed rest actually prevents preterm births in women with multiple fetuses is, he said, “flimsy, at best.” The American College of Obstetricians and Gynecologists no longer advises bed rest to prevent preterm births because no large-scale, double-blind studies have proved that the method is effective. According to the Times, four high-risk pregnancy specialists interviewed recommended that women on bed rest see a physical therapist and begin a light exercise program, if appropriate.
The 2003 revision of the U.S. Standard Certificate of Live Birth was used by seven states (Idaho, Kentucky, New York [excluding NY City], Pennsylvania, South Carolina, Tennessee, Washington) to report data on maternal, labor and delivery, and newborn items in 2004, according to a new report, Expanded Health Data from the New Birth certificate, 2004, from the National Center for Health Statistics (Martin et al, Natl Vital Stat Rep 2007;55(12):1–24). The report does not present data on all items new to the certificate, including breastfeeding, sources of payment for the delivery, maternal morbidity, and receipt of Women, Infants, and Children (WIC) food for the pregnancy. Some selected new data from 2004 for the seven-state reporting area include the following rates per 1,000 live births: pregnancies initiated by infertility treatment 14 (just over 1% of deliveries); cervical cerclage 4.4; external cephalic version 3.4 (<1% of deliveries, 58% successful); nonvertex presentation 28.7 (3% of deliveries); epidural or spinal anesthesia 680.5 (68% of deliveries). Trial of labor was attempted before cesarean delivery by 36.2 percent of women who had a cesarean delivery; trial of labor before first (primary) cesarean delivery by 47.7 percent; and trial of labor before repeat cesarean delivery by “only” 9.1 percent. The report pointed out that the findings from these seven states may not be generalizable to the total United States.
New evidence that breastfeeding decreases infants’and mothers’ risk of having many short-term and chronic diseases was released by the U.S. Agency for Healthcare Research and Quality in a new report (AHRQ Electronic Newsletter, Issue #226, April 23, 2007). The report found good evidence that breastfeeding reduced infants’ risk of ear infections by up to 50 percent, serious lower respiratory tract infections by 72 percent, and a skin rash similar to eczema by 42 percent. Children with a family history of asthma who had been breastfed were 40 percent less likely to have asthma, and children who were not susceptible to asthma had a 27 percent reduced risk compared with those children who were not breastfed. The risk of developing type 1 diabetes was reduced by about 20 percent. These benefits were seen in infants who were breastfed for 3 or more months. Breastfeeding also reduced the risk of type 2 diabetes by 39 percent compared with those who were not breastfed. The report found no clear relationship between breastfeeding and improvement in IQ.
For health outcomes in mothers, women who breastfed their infants had up to a 12 percent reduced risk of type 2 diabetes for each year they breastfed. Breastfeeding decreased the risk of ovarian cancer by up to 21 percent, and breast cancer by up to 28 percent in those whose lifetime duration of breastfeeding was 12 months or longer. The report is available at http://www.ahrq.gov/clinic/tp/brfouttp.htm.