The cesarean delivery rate rose to 31.1 percent of all births in the United States in 2006, a 3 percent increase over the 2005 rate of 30.3 percent. It was another record high, according to preliminary data released by the National Center for Health Statistics (Natl Vital Stat Rep 2007;56(7):4). The percentage of all births delivered by cesarean section has climbed 50 percent over the past decade, from 20.7 percent in 1996.

Unacceptably high rates of maternal mortality persist in many countries, despite some improvements in developed regions, according to researchers from the WHO, UNICEF, the World Bank, and other centers reporting recently in The Lancet (2007;370:1311-1319). These new data from 2005 indicate that the maternal mortality ratio will not fall far enough to reach the target of the Millennium Development Goal 5 (MDG5), which is to reduce the ratio by 75 percent between 1990 and 2015, an average decrease of 5.5 percent each year. Most maternal deaths in 2005 occurred in sub-Saharan Africa (270,000 deaths, 50% of deaths worldwide) and Asia (240,000 deaths, 45% of deaths worldwide). Almost half of all maternal deaths occurred in only five countries: India (117,100 deaths), Nigeria (58,800 deaths), the Democratic Republic of Congo (32,300 deaths), Afghanistan (26,000), and Ethiopia (22,200 deaths). In a joint news release issued to coincide with the Lancet paper, the WHO, UNICEF, UNFPA, and World Bank stated:

To achieve MDG5 and reduce the maternal mortality ratio by three-quarters before 2015, improving healthcare for women and providing universal access to reproductive health services must be prioritized. This includes access to family planning, prevention of unplanned pregnancies, and provision of high-quality pregnancy and delivery care, including emergency obstetric care…However, health services can only help when women are able to make use of them. When obstetric emergencies arise during pregnancy and delivery, the importance of recognizing danger signs and seeking care quickly is critical. Transportation must be available, and appropriately staffed and equipped facilities must be within reach. Increasing female education, improving gender equality, and strengthening empowerment for making decisions about seeking care are essential elements of strategies to reduce maternal mortality.

A new recommendation about consumption of fish by pregnant women has been issued in the United States by the National Healthy Mothers, Healthy Babies Coalition (HMHB, Oct 4, 2007). The coalition has recommended that pregnant, breastfeeding, and postpartum women consume a minimum of 12 ounces of seafood weekly, especially oily ocean fish like salmon and sardines. Six of the 12 ounces may come from albacore tuna. The recommendation, which was written for the coalition by 14 scientists who made up the Maternal Nutrition Group, is consistent with recommendations from scientific groups and governments from many other countries. The group emphasized the importance of omega-3 fatty acids for pregnant women because of their benefit to the development of the fetal nervous system, and stated that “recent studies indicate the nutritional benefits of fish consumption during pregnancy greatly outweigh potential risks from trace methyl mercury consumption.”

The recommendation is at odds with the 12-ounce limit advised by the U.S. Food and Drug Administration (FDA) and U.S. Environmental Protection Agency. In 2004, these groups advised that women who were pregnant, breastfeeding, or planning a pregnancy consume up to 12 ounces of lower-mercury seafood (e.g., shrimp, canned light tuna) weekly, with albacore limited to 6 ounces. They also recommend that these women avoid high-mercury fish (e.g., shark, swordfish). The federal seafood warning has led to 56 percent of pregnant women reducing their seafood consumption to levels well below beneficial amounts, according to a 2007 study from the Medical University of South Carolina (Washington Post Oct 4, 2007). The FDA plans to review the information from the Maternal Nutrition Group, but is not ready to change its current stance.

Nine out of 10 mothers whose babies died from sudden infant death syndrome (SIDS) smoked during pregnancy, according to a recent analysis of evidence from 21 studies (Early Hum Dev 2007;83:721-725). Authors Peter Fleming and Peter Blair of the University of Bristol, United Kingdom, noted that although smoking among pregnant women has fallen from 30 to 20 percent in the last 15 years in the U.K., the prevalence of maternal smoking during pregnancy rose from 57 to 86 percent among SIDS mothers. Recent studies showed a fourfold increased risk for SIDS mortality associated with in utero tobacco exposure. Moreover, researchers reported a dose-response effect, with the risk for SIDS-related deaths increasing with the number of cigarettes smoked by the pregnant mother. The risk for SIDS was also associated with postnatal tobacco exposure, including infants co-sleeping with habitually smoking parents, the number of smokers in the household, and the daily duration of the infant’s exposure to tobacco smoke. The investigators concluded: “Thus exposure to tobacco smoke, either prenatally or postnatally will lead to a complex range of effects upon normal physiological and anatomical development in fetal and postnatal life, together with an increased incidence of acute viral infection that places infants at greatly increased risk of SIDS.” Speaking about the report, Dr. Blair said, “If smoking is a cause of SIDS, and the evidence suggests it is, we think that if all parents stopped smoking tomorrow more than 60 percent of SIDS deaths would be prevented.” (The Independent Nov 28, 2007.)

A comprehensive global study of induced abortion has concluded that rates are similar in countries where it is legal and those where it is not, suggesting that outlawing the procedure does little to deter women seeking it (NY Times Oct 11, 2007). The study, published recently in The Lancet (2007;370:1338-1345), was a collaboration between scientists from the World Health Organization (WHO) in Geneva and the Guttmacher Institute in New York, a reproductive rights group. The researchers used national data for 2003 from countries where abortion was legal and therefore tallied. WHO scientists estimated abortion rates from countries where it was outlawed, using data on hospital admissions for abortion complications, interviews with local family planning experts, and surveys of women in those countries. The researchers found that abortion was safe in countries where it was legal, but dangerous in countries where it was outlawed and performed clandestinely; unsafe abortion is concentrated in developing countries. Globally, abortion accounts for 13 percent of women’s deaths during pregnancy and childbirth, and there are 31 abortions for every 100 live births, the study said. In 2003 the abortion rate declined worldwide, an estimated 42 million abortions were induced compared with 46 million in 1995. In 2003, abortion rates were lowest in western Europe (12 per 1,000 women), which has legal abortion and widely available contraception. Rates were 17 per 1,000 women in northern Europe, 18 per 1,000 in southern Europe, and 21 per 1,000 in northern America (USA and Canada). Anti-abortion groups have criticized the research, saying that the scientists had jumped to conclusions from imperfect tallies and that data were biased according to the agenda of those who organized the data. The study researchers concluded that “Ensuring that the need for contraception is met and that all abortions are safe will reduce maternal mortality substantially and protect maternal health.”

Midwife-attended home births in some states are under new and intense scrutiny in the United States, where approximately 40,000 babies are born outside a hospital, the great majority attended by midwives, according to the Midwives Alliance of North America (Chicago Tribune Nov 25, 2007). Missouri, where a midwife who attends a home birth can be arrested as a felon, has long been especially hostile to midwives, but a new development has thrust it into the national spotlight. A state lawmaker, whose wife was aided in pregnancy by a midwife, pushed through legislation in 2007 that would allow midwives to practice freely in the state. Although the state governor signed it into law, opponents quickly filed a lawsuit to overturn it, and the law cannot go into effect until the state Supreme Court rules on its legality, probably in early 2008. In 40 states some form of home birth midwifery is legal, but Missouri and nine other states, including Illinois, Iowa, and Indiana, outlaw “professional certified midwives,” practitioners who are not registered nurses but have undergone 3 to 5 years of study and national certification. All 50 states, however, allow “certified nurse-midwives” (registered nurses or nurse practitioners with advanced midwifery training) to practice, and in recent years more than 300,000 babies a year have been delivered by nurse-midwives in hospitals, according to the American College of Nurse-Midwives. Currently in Missouri, an underground network of “black market” midwives practices quietly outside the law. What happens in Missouri is being closely watched across the country, especially in Illinois where the Coalition for Illinois Midwifery is pushing for new legislation that would allow nationally certified midwives to practice in that state, and in Delaware, where regulatory changes are under consideration to allow certified professional midwives to practice in freestanding birth centers. Midwife-assisted home births are “strongly opposed” by the American College of Obstetricians and Gynecologists—in contrast to the United Kingdom, where “home birth is now a real alternative,” writes Sheila Kitzinger in her “Letter from Europe” in this issue of Birth.

Obesity is a risk factor for cesarean delivery in women who are obese before becoming pregnant, irrespective of whether they have had a previous cesarean, a large Canadian study has found (BJOG 2007;114:1088-1096). A team of investigators from Montreal Children’s Hospital Research Unit in Quebec prospectively studied 63,390 singleton term deliveries in women with cephalic presentation, 58,039 of whom had a previous cesarean delivery and 5,351 had no previous cesarean. “It could be that physicians encourage women with high pregravid body mass to undergo elective caesarean delivery simply because of concerns about the likelihood of achieving vaginal birth,” said lead investigator Adam Sherrard and colleagues. A body mass index of at least 30 kg/m2 doubled the likelihood of a primary cesarean delivery both before and after the onset of labor. A high rate of gestational weight gain, at more than 0.50 kg/week, increased the risk of cesarean, but only after the onset of labor. Among women with a previous cesarean, high weight gain modestly increased the risk for cesarean only before labor, but obesity increased the risk both before and after the onset of labor. The increased risks could not be attributed to gestational diabetes, pregnancy-induced hypertensions, macrosomia, socioeconomic factors, parity, or maternal age.

Evenflo Company, a leading manufacturer of infant products including baby feeding bottles and supplies, has purchased Ameda Breastfeeding Products, a major manufacturer of breast pumps and accessories (Evenflo press release, Oct 18, 2007). To underscore its commitment to breastfeeding, Evenflo has pledged to become the first baby bottle manufacturer in the U.S. to achieve compliance with the World Health Organization (WHO) International Code of Marketing of Breast-Milk Substitutes. The WHO code was created in 1981 as a guide for marketing practices of infant formula, bottle, and nipple manufacturers to protect and promote breastfeeding and ensure proper use of breastmilk substitutes, feeding bottles, and nipples when these are necessary. As part of its pledge, Evenflo states that it will immediately: “(1) discontinue all bottle/nipple advertising directed to consumers; (2) change our feeding packaging to align with WHO code guidelines; and (3) remove bottle/nipple images from our Web site.” At the same time, Evenflo states that it will continue to innovate in its core bottle and nipple products, and work closely with retail partners to ensure broad-scale availability for mothers who do not breastfeed or do not breastfeed exclusively. Ameda already meets all the requirements of the WHO code. Marsha Walker, Executive Director of the National Alliance for Breastfeeding Advocacy, commented “I believe Evenflo’s actions will help encourage moms and remove barriers to breastfeeding in the U.S. I’m gratified to see Evenflo and Ameda delivering on their promise to develop and market products in a manner that will not interfere with or impede breastfeeding.”