The cesarean birth rate rose again to 32.9 percent in 2009 in the United States, according to preliminary data from the National Center for Health Statistics (Births: Preliminary data for 2009. Natl Vital Stat Rep 2010;59(3):6)—an increase of 2 percent and another record high. The percentage of births delivered by cesarean has risen more than 50 percent since 1996, but the rate has slowed somewhat in the past few years. Increases in 2009 were seen among women of all age groups and race and ethnic groups.
The cesarean birth rate in Australia did not significantly increase for the second consecutive year, with a 0.2 percent rise from 30.9 percent in 2007 to 31.1 percent in 2008, according to the report of Australia’s Mothers and Babies 2008 from the Australian Institute of Health and Welfare (AIHW National Perinatal Statistics Unit, November 2010). The cesarean birth rate for first-time mothers was 32.0 percent in 2008. Approximately 83.2 percent of those who had a previous cesarean birth had a repeat cesarean, ranging from 74.9 percent in the Northern Territory to 87.6 percent in Western Australia. Cesarean section rates increased with maternal age; in 2008, they ranged from 16.7 percent for mothers aged less than 20 years to 46.9 percent for mothers aged 40 years and older. Of women who labored (defined as spontaneous or induced onset of labor), 74.6 percent received analgesia, most commonly nitrous oxide (50.3%), ranging from 68.5 percent in the Australian Capital Territory to 78.8 percent in Western Australia. Of first-time mothers who labored, 84.9 percent used analgesia for labor, compared with 66.2 percent in multiparous women. In 2008, the onset of labor was spontaneous for 57.0 percent of all women who gave birth. Labor was induced for 24.8 percent of mothers.
Three of every four new mothers now starts out breastfeeding in the United States, continuing a decades-long increase according to a recent report from the Centers for Disease Control and Prevention (CDC) (Breastfeeding Report Card: United States, 2010. August 2010, CDC, Atlanta, Georgia). The United States has now met the Healthy People 2010 national objective for breastfeeding initiation in early postpartum of 75 percent. However, rates of breastfeeding at 6 and 12 months as well as rates of exclusive breastfeeding at 3 and 6 months remain stagnated and low. Low breastfeeding rates at 3, 6, and 12 months show that mothers still face multiple barriers to breastfeeding. Across the United States, the average level of support that birth facilities provide to mothers and babies as they get started with breastfeeding is inadequate, and hospital practices and policies that interfere with breastfeeding remain common. In the United States, too few hospitals participate in the global program to recognize best practices in supporting breastfeeding mothers and babies, known as the Baby-Friendly Hospital Initiative. Although more babies in the United States are now born at Baby-Friendly facilities than ever before, those births represent less than 4 percent of all births. Breastfeeding rates differed depending on geographic location. Western states had the highest rates of breastfed infants, with Utah leading the nation with about 90 percent of mothers breastfeeding at least temporarily. Mississippi ranked the lowest with only about 50 percent of mothers attempting to breastfeed. The CDC Breastfeeding Report Card was first released in 2007 and is updated annually; it is available at http://www.cdc.gov/breastfeeding/data.
Global maternal mortality rates declined by one-third, from 546,000 to 358,000, over the past 20 years but remain higher than targets set by the United Nations (U.N.) Millennium Development Goal (MDG) for maternal health, according to a recent World Health Organization report (WHO, Trends in Maternal Mortality 1990 to 2008, September 2010). The report was released ahead of a New York summit on the MDGs. The maternal mortality rate would have to decline 5.5 percent per year from now until 2015 to hit the U.N.’s MDG target. The annual rate of decline since 1990 was 2.3 percent. About 1,000 women die from pregnancy- and childbirth-related causes every day, the report said. Women in poor countries are 36 times more likely to die from such causes than those in wealthy countries. According to the report, 99 percent of maternal deaths occurred in developing countries, with sub-Saharan Africa and South Asia accounting for 87 percent of the world’s maternal mortality. Asia showed the greatest progress in decreasing maternal mortality, cutting the number of deaths in half from 315,000 in 1990 to 139,000 in 2008. The report attributed the decrease in global maternal mortality to better training for midwives, improved post-delivery care in hospitals and health clinics, and improved family planning services.
More than $40 billion are expected to be committed by governments and private aid groups to improve global maternal and children’s health it was announced by United Nations Secretary General Ban Ki-moon at the close of a U.N. development summit held in September 2010. A statement announcing the plan called it “a roadmap that identifies the finance and policy changes needed as well as critical interventions that can and do improve health and save lives.” The program will be administered by four U.N. agencies and the World Bank. The World Health Organization will chair the program—called the Global Strategy for Women’s and Children’s Health—and deliver an annual progress report to the U.N. General Assembly. The program is designed to jumpstart progress toward the Millennium Development Goals of reducing pregnancy-related deaths among women and deaths of children before age 5 years. The goals include reducing by two-thirds the number of children who die before age 5 years and lowering by three-fourths the number of pregnancy-related deaths by 2015, using baseline measurements from 1990.
Pregnancy-related deaths have risen in the United States, in contrast to those worldwide (A. Norton, Reuters Dec 2, 2010). Researchers at the U.S. Centers for Disease Control and Prevention (CDC) found that between 1998 and 2005 the rate of pregnancy-related deaths was 12.5 per 100,000 live births. However, recent changes in how causes of death are officially reported by states may be partially responsible for the findings. According to the new data, deaths from chronic medical conditions, such as heart disease, seem to account for more deaths, whereas deaths from actual obstetric complications (e.g., hemorrhage and pregnancy-related high blood pressure disorders) are declining. The report also acknowledged that an increasing number of cesarean sections and maternal obesity could be partly to blame for the rise.
One in three first-time mothers give birth by cesarean section in the United States, and prelabor repeat cesareans contribute almost one-third of cesareans overall, according to a recent National Institutes of Health study (Zhang et al, Am J Obstet Gynecol 2010 [doi: 10.1016/j.ajog.2010.06.058]). In collaboration with the Consortium of Safe Labor, comprising 12 clinical centers nationwide, the researchers collected information on 206,969 births from 2002 through 2008. Dr. Zhang, the lead investigator, reported that of women attempting vaginal delivery, 43.8 percent had induced labor, 21.1 percent of whom had a cesarean delivery, a rate nearly twice as high as that among women who had spontaneous labor. In addition, one-third of cesarean deliveries at the second stage of labor were performed at less than 3 hours in nulliparas and one-fourth were performed at less than 2 hours in multiparas—waiting periods that appear to be shorter than those recommended in the American College of Obstetricians and Gynecologists’ guidelines (i.e., arrest of descent defined as > 3 hr in nulliparas with epidural analgesia and > 2 hr in multiparas with epidural analgesia). The researchers concluded:
To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.
The state of Minnesota is endeavoring to develop a policy against the use of induction of childbirth early just for the convenience of doctors or mothers (J. Olson, Star Tribune November 15, 2010). The state Department of Human Services has proposed that hospitals create plans by 2012 for reducing the use of elective inductions before 39 weeks’ gestation. The penalty for hospitals without plans would be to fill out onerous paperwork for every state-funded delivery. Medicaid, known in Minnesota as Medical Assistance, pays for 38 percent of births in the state. The policy would synchronize with a campaign by the March of Dimes to encourage women to continue their pregnancies to the full 40 weeks whenever possible. The policy would not limit inductions for medical reasons or conditions that might make continuing a pregnancy risky. Dr. Jeff Schiff, Medical Director of the Human Services Department, said the key to progress will be broad participation by hospitals and consistent information for mothers. “Then everyone will get the same message,” he said, “that convenience is less important than the health of the babies.”
In Ohio a statewide quality collaborative initiative reduced “inappropriate scheduled births” at 36- to 38-weeks’ gestation from 25 percent to less than 5 percent in 20 participating hospitals in 1 year, and the mean rate of inductions with no indication decreased significantly from 13 to 8 percent, according to a recent report (Am J Obstet Gynecol 2010;202(3):243.e1-8).