Peru’s success in reducing maternal deaths by building“casas maternas” has been hailed as a model for the developing world, and has attracted the attention of United States officials, according to a recent news report (PBS Newshour, April 1, 2010). The United Nations has identified reducing maternal mortality as one its main public health objectives, but still worldwide approximately 500,000 women die in childbirth each year, and experts estimate that about one-tenth of those deaths are preventable.

In Peru’s rural areas, the journey to a hospital can take several hours by car and days by foot, and traditionally, most Peruvian women deliver at home, attended by family members or midwives. When complications arise, the lack of trained birth attendants and the long distance from health care facilities increases the risk that childbearing women will die. A centerpiece of the government’s strategy is constructing birthing homes (450 to date), or “casas maternas,” staffed 24 hours a day, where pregnant women in remote regions can live as their due dates approach. The birthing homes accommodate traditional rituals, such as allowing women to give birth in certain positions or consume customary herbs or teas. The report noted that the maternal mortality rate in the remote region of Ayacucho dropped 50 percent from 1999 to 2005 under the strategy. The nationwide program was launched by the international aid organization CARE but is now a joint effort between local and national government officials and nongovernmental organizations. A network of casas maternas has also been established since 2006 in Nicaragua to care for high-risk women in rural areas.

The preterm birth rate has declined in the United States for the second straight year, according to the National Center for Health Statistics (NCHS Data Brief, 2010;39:1–8). It is the first 2-year decline in nearly three decades. After a long period of steady increase, the preterm birth rate dropped in 2008 to 12.3 percent from 2.8 percent in 2006. The rates declined for mothers of all age groups under age 40 years, for the three largest race and Hispanic origin groups, and for most U.S. states; only one state, Hawaii, reported an increase in preterm births. The percentage of preterm births was also down for all types of deliveries from 2006 to 2009, for cesarean births, and for induced and noninduced vaginal deliveries. “Although lower in 2008, the U.S. preterm rate remains higher than in any year from 1981 to 2002, with large differences still evident by race and Hispanic origin,” the report noted. “Further research is necessary to explain the factors behind the current downturn and to develop approaches to ensure its continued decline.”

Wide regional disparities in rates of cesareans, epidurals, and forceps deliveries are described in a recent report of the Canadian Institute for Health Information (CIHI), titled Highlights of 2008–2009 Selected Indicators Describing the Birthing Process in Canada ( The highest primary cesarean section rates among the Canadian provinces were in Newfoundland and Labrador (23.1%) and British Columbia (22.3%) and the lowest in Quebec (15.7%) and Manitoba (13.5%) in 2008–2009. Of the total number of hospital births in Canada last year (approximately 374,000), 18.5 percent were cesarean and 81.5 percent were vaginal births (A. Picard, Globe and Mail, May 18, 2010). Epidural analgesia rates also varied greatly; for example, 69 percent of vaginal births in Quebec and 60 percent in Ontario had the highest rates, compared with 38.5 percent in Manitoba and 30 percent in British Columbia. In 2008–2009 the rates of overall assisted delivery, vacuum-assisted delivery, and forceps-assisted delivery in Canada were 14, 9.9, and 3.3 percent, respectively. “The bottom line is that there are a lot of obstetrical interventions in Canada,” said Gisela Becker, President of the Canadian Association of Midwives (A. Picard, Globe and Mail, May 18, 2010).

Substantial racial and ethnic differences in breastfeeding were reported in a United States analysis of breastfeeding from 2004 to 2008, according to the Centers for Disease Control and Prevention (CDC) (Morbidity and Mortality Weekly Report, March 26, 2010). The CDC National Immunization Survey is an ongoing, random-digit-dialed survey of the 50 states and the District of Columbia that contains questions about breastfeeding initiation and duration. National estimates for breastfeeding initiation and duration to 6 months and to 12 months were 73.4, 41.7, and 21.0 percent, respectively. For all but two states (Minnesota and Rhode Island), prevalence of breastfeeding was lower among non-Hispanic blacks than non-Hispanic whites and was far from the Healthy People 2010 targets of 75, 50, and 25 percent for initiating breastfeeding, breastfeeding to 6 months, and breastfeeding to 12 months, respectively. Most states were not meeting these targets for any racial or ethnic group the report said.

A “little-noticed provision” in the new health reform law (PL 111–148), passed by President Obama on March 23, requires employers to provide breastfeeding women with break times and a private location—other than a bathroom—to express milk or breastfeed (M. Pounds, South Florida Sun-Sentinel, April 9, 2010). The provision, which amends the Fair Labor Standards Act, is applicable until the child’s first birthday. Employers with 50 or fewer workers could be exempt from the requirement if they prove “undue hardship,” according to Andrew Rodman, partner with the Miami-based Stearns Weaver Miller law firm, which sent an advisory about the new law to clients. Rodman said that a partition with a curtain likely would not pass legal muster under the new law. The location must be completely “free from intrusion” and “public viewing,” he said. The law does not detail how many daily or weekly breaks are permitted.

Doulas are slated to receive $1.5 million for community-run doula programs in the United States as a result of the health care reform legislation passed by the U.S. Congress earlier this year (ABC News Release, May 22, 2010). Senator Dick Durbin (D-Illinois) inserted the funding for community doula programs into the health care reform legislation, citing the success of the Health Connect program in Chicago, a program that provides doulas to low-income families and teen clients at no cost. “We’re thrilled that doulas are getting more recognition for the important work that they do and that so many people are now realizing the benefits that thousands of women have experienced for many years,” said Susan Toffolon, President of DONA International, the organization that provides training and certification for doulas.

Birth centers in the United States are celebrating the passage of health care reform legislation, signed by President Obama on March 23, 2010 (American Association of Birth Centers News, May 2010). This bill is expected to have far-reaching benefits for sustaining birth centers and developing new birth centers in underserved communities. “This historic law includes guaranteed payment to birth centers by Medicaid for a facility fee, a necessary component to the survival of the birth center model. We have much to celebrate and be proud of as we look back at the hard work and lobbying efforts of many within our organization and the successful partnering with others that led to the bill’s passage,” said Linda Cole, President of the American Association of Birth Centers. Medicaid is a program, funded by the U.S. federal and state governments, which pays for medical care for those who cannot afford it.

The International MotherBaby Childbirth Initiative (IMBCI): 10 Steps to Optimal Maternity Care was created and developed in 2008 by the International MotherBaby Childbirth Organization, a nonprofit, nongovernmental agency that grew out of the United States-based Coalition for Improving Maternity Services. The overall purpose of the IMBCI 10 Steps is to improve care throughout the childbearing continuum; to save lives, prevent illness and harm from the overuse of obstetric technologies; and to promote health for mothers and babies around the world. The educational and instrumental purposes of the IMBCI 10 Steps are to establish and call global attention to the “motherbaby” (midwifery) model of care—a woman-centered, noninterventive approach that promotes the health and well-being of all women and babies during pregnancy, birth, and breastfeeding, setting the gold standard for excellence and superior outcomes in maternity care. The IMBCI acknowledges that women’s rights are human rights and that women have a right to informed decision making and to receive care that is evidence-based for themselves and their babies. It recognizes “motherbaby” as one unit, not to be separated. For information about this initiative, please see

Two important new educational tools about cesareansections are available from the Coalition for Improving Maternity Services (CIMS), which is a nonprofit coalition of individuals and national organizations concerned about the care and well-being of mothers, babies, and families. Their mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. The organization is concerned about the dramatic increase and overuse of cesarean sections in the United States and other countries. CIMS recommends that cesarean surgery be reserved for situations when potential benefits clearly outweigh potential harms. To educate pregnant women about cesarean sections, CIMS has developed an evidence-based document titled, The Risks of Cesarean Section Fact Sheet. This new resource includes an important companion tool, About the Risks of Cesarean Section: A Checklist for Expectant Mothers to Read During Pregnancy. Both resources are available for free download at