Breastfeeding in the United States has increased significantly since 1999, and more than 3 out of 4 new mothers now breastfeed their babies, according to a recent national government survey (Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Survey, 1999-2006, April 2008). Approximately 77 percent breastfed in 2005-2006, at least briefly, which is up from 60 percent in 1993-1994, the U.S. Centers for Disease and Prevention said. Breastfeeding rates increased significantly among non-Hispanic black women from 36 percent in 1993-1994 to 65 percent in 2005-2006. For white women the rate rose from 62 to 79 percent. Breastfeeding rates in 1999-2006 were significantly higher among those with higher income (74%) compared with those who had lower income (57%). Rates among mothers aged 30 years and older were significantly higher than those of younger mothers. The report noted that breastfeeding rates were lowest among women who were unmarried, poor, rural, younger than 20 years, and with a high school education or less. No significant change occurred in the rate of breastfeeding at 6 months of age for infants born between 1993 and 2004. The report is available free of charge at

A recent important report, Safe Births: Everybody’s Business, is “An Independent Inquiry into the Safety of Maternity Services in England.” It was published by an independent panel chaired by Professor Onora O’Neill of Cambridge University and set up in 2007 by the King’s Fund, which is a charitable foundation that works for better health (February 2008, 160 pp). The panel’s focus was primarily on the safety of mothers and babies during birth. It concluded that “giving birth in England in 2008 is likely to be safe in the overwhelming majority of women and babies”: the stillbirth rate of 5.4 per 1,000 total births has remained almost unchanged since the mid-1990s; rates of infant mortality fell from 6.1 per 1,000 live births in 1996 to 4.8 per 1,000 in 2006; maternal deaths (pregnancy and birth related) remained stable at just over 6 per 100,000 live births since the mid-1980s; however, safety “incidents” in maternity care are regularly reported.

The report notes that recent changes in the childbearing population have important implications for safe births. For example, there are higher numbers of births since 2002, which are projected to increase; more older mothers; more fertility treatments; more obese women; more women who survive serious childhood illness and who need extra care in pregnancy and birth; rising rates of intervention during labor, in particular in rates of cesarean section; and more women from diverse social and ethnic backgrounds.

In addition to finding that “the overwhelming majority of births in England are safe,” the report noted that some were less safe than they could and should be; that safety was the responsibility of each member of all the teams who worked and supported maternity services (midwives, obstetricians, anesthetists, support staff, managers, and trust boards); and that “safe teams” were the key to improving safety in birth. The report is available free of charge at

In 2005 the infant mortality rate was 6.87 deaths per 1,000 live births in the United States, and the neonatal mortality rate was 4.54 deaths, according to the U.S. National Center for Health Statistics (Deaths: Final Data for 2005. Natl Vital Stat Rep 2008;56(10:11-12, 95). According to race, in 2005 the rate for white infants was 5.73 deaths per 1,000 live births (compared with 5.66 in 2004 and 6.29 in 1995); for Hispanic infants 5.81 deaths; and for black infants 13.73 deaths (compared with 13.79 in 2004 and 15.12 in 1995).

The maternal mortality rate in 2005 was 15.1 deaths per 100,000 live births, which is up from 13.1 per 100,000 in 2004 and 12 per 100,000 in 2003, according to the National Center for Health Statistics. In terms of actual deaths, in 2005 a total of 623 women were reported to have died of maternal causes (540 in 2004 and 495 in 2003). The number of maternal deaths does not include all deaths occurring to pregnant women, but only those on the death certificate that were assigned to causes related to or aggravated by pregnancy or pregnancy management. Black women have a substantially higher risk of dying than white women. In 2005 the rate for black women was 36.5 deaths per 100,000 live births, which is approximately 3.3 times the rate for white women (11.1 deaths per 100,000 live births).

Canada has fallen “far behind other developed countries” in terms of access to in-vitro fertilization (IVF), according to a news release from the Society of Obstetricians and Gynaecologists that reports about an article by Dr. Jeff Nisker of the University of Western Ontario. The article, published in the Journal of Obstetrics and Gynaecology Canada (May 2008), exposes the clinical, ethical, and economic implications of the limited access for Canadian women to publicly funded IVF. “Only 15 percent of Canadian women who need in-vitro fertilization to conceive are able to afford the cost of IVF,” said Dr. Nisker. “Canada is one of the only developed countries where IVF is not publicly funded.” He noted that even many health maintenance organizations in the United States fund IVF. Adoption, often cited as an alternative, can also be prohibitively expensive, and long waiting lists and selection criteria may prevent women who are socially disadvantaged from successfully adopting a child through adoption agencies. Dr. Nisker believes that public funding of IVF and single embryo transfer would save the provinces money by offsetting the high costs of caring for twins and higher order multiple births that result from the use of fertility drugs.

The health status of American Indians and Alaska Natives is lower than that of other Americans (ACOG Today May/June, 2008). Infants die at a rate of nearly 12 per 1,000 live births compared with 7 per 1,000 among all races in the U.S. Although the health care needs of this population are growing, funding by the U.S. Indian Health Service (IHS) has not kept pace with either medical costs or growth of the population. On the Fort Apache Reservation in Arizona a pregnant woman who is a tribal member (Apache, Navajo, or Hopi Indian) can get free prenatal care at the Whiteriver Indian Hospital, but a woman who wants a tubal ligation cannot have one because the 40-bed IHS hospital has no surgical capabilities and cannot afford to pay for her to have the surgery elsewhere. The hospital receives about $10 million from IHS, but it costs about $35 million a year to run. The difference is made up by billing the federal programs of Medicaid and Medicare for low-income individuals, and since the community is impoverished, about 75 percent of women qualify for Medicaid. “The remote nature of the practice” is a major problem, said Dr. David Yost, the Whiteriver hospital’s clinical director. “About 25% of our patients have access to vehicles and there is no public transportation on the reservation.” To get to a clinic, women may walk 5 miles and then hitchhike. Geography is also a problem in Alaska, where women also live in primarily rural areas. Recruiting physicians and other health providers to these rural locations is difficult.

Reauthorization of the Indian Health Care Improvement Act is a critical and long-overdue step needed to address the health care needs of American Indians, but the last reauthorization in 1992 expired long ago. In February the U.S. Senate passed a reauthorization bill that would expand health coverage and services, and a similar bill is pending in the House of Representatives (H.R. 1328). The bill is supported by the American College of Obstetricians and Gynecologists, which urges U.S. health professionals to contact their congressional representatives. For information, go to Indian Health Service:; or go to, under “Women’s Issues,” and click on “Indian Health Service.”

Women who have had a previous cesarean delivery have recently been denied individual health coverage by some insurers in the United States because the women are more likely to have a repeat cesarean (D. Grady, NY Times June 1, 2008). A cesarean section costs on average $2,700 more than a vaginal delivery, according to the Times, and although many women can safely have a vaginal delivery after a previous cesarean, many physicians require them to have another cesarean. “Obstetricians are rendering large numbers of women uninsurable by overusing this surgery,” said Pamela Uddy, president of the International Caesarean Awareness Network, a nonprofit advocacy group. She added that women feel pressured into having cesareans that they might not need or want and then are denied coverage for the surgery. Insurers’ rules on cesareans vary by company and state, depending on state regulations said Susan Pisano of America’s Health Insurance Plans. Although some companies ignore the surgery, others treat it like a preexisting condition, and insurers who do accept women who have had a cesarean typically charge higher premiums. Some companies have provisions that qualify women for coverage if they have been sterilized after the cesarean, meet certain age requirements, or have not given birth for a period of time before applying. Insurers also “often accuse women and obstetricians of scheduling unneeded caesareans for their own convenience—to deliver the baby at a certain time, or to avoid labor,” the Times article noted.

“Providing Oral Nutrition to Women in Labor” is the recently published Clinical Bulletin of the American College of Nurse-Midwives (ACNM News Release May 20, 2008). The guidelines review the evidence on the topic and conclude that “drinking and eating during labor can provide women with the energy they need and should not be routinely restricted.” Most hospitals in the United States currently have policies that restrict women’s oral intake during labor. Debate on the issue has continued for many years, based on concern about possible detrimental effects of fasting in labor versus the risk of aspiration if general anesthesia is administered after food or fluid intake. “It is important that we don’t unnecessarily restrict a women’s ability to eat or drink during labor,” said Deborah Anderson, CNM, Associate Clinical Professor from the University of California, San Francisco. “In addition to providing hydration, nutrition, and comfort, self-regulating intake decreases a woman’s stress level and provides her with a feeling of control.” The Clinical Bulletin is published in the Journal of Midwifery & Women’s Health 2008;53(3):276-283, and can be purchased online at