Norway came first on the list of the best countries for mothers and infants in the 12th annual Mothers Index compiled by Save the Children (Snow AP/Miami Herald May 3, 2011). The index measures the well-being of mothers and infants by analyzing maternal and child indicators and other published information on 164 countries. The United States ranked 31st, and Afghanistan came in last place. The U.S.’s rank was based largely on having one of the highest maternal mortality rates among industrialized nations at 1 maternal death per 2,100 births, Save the Children said. A woman in the U.S. is seven times more likely to die from pregnancy-related causes than a woman in Italy or Ireland and 15 times more likely than a woman in Greece. Eight of every 1,000 children born in the U.S. die before age 5 years, about the same as Latvia. Norway has a low maternal mortality rate, a female life expectancy of 83 years old, and a child mortality rate of one death before age 5 for every 175 children. By contrast, a woman in Afghanistan has a life expectancy of 45 years, and 1 in every 11 women dies during childbirth in the country; 1 in every 5 children dies before age 5 years. In Norway, almost every delivery is attended by skilled health personnel, compared with just 14 percent of births in Afghanistan.
The report called for governments and international agencies to improve educational, health care, and economic opportunities for women in developing countries. “The human despair and lost opportunities represented in these numbers demand mothers everywhere be given the basic tools they need to break the cycle of poverty and improve the quality of life for themselves, their children, and for generations to come,” the report said.
Most (61%) women with a vaginal birth received epidural or spinal anesthesia for labor pain in the United States in 2008, according to a recent report by the Centers for Disease Control and Prevention (CDC), Epidural and Spinal Anesthesia Use During Labor: 27-State Reporting Area, 2008 (Natl Vital Stat Rep 2002;59(5):1–16). Of the 27 states reporting, labor anesthesia rates ranged from 21.9 percent in New Mexico and 42.5 percent in California to 78.2 percent in Kentucky. Non-Hispanic white women received epidural/spinal anesthesia more than other racial groups. Levels increased with the mother’s increasing educational attainment, early initiation of prenatal care, and attendance of birth by a physician. Women with chronic and gestational diabetes were more likely to have an epidural or spinal anesthesia than women with no risk factors. The likelihood of having an epidural or spinal anesthesia decreased with advancing maternal age and when infants were born before 34 weeks of gestation or weighed less than 1,500 g. The report noted that the results cannot be generalized to the U.S. as a whole, and are limited by lack of information about other forms of pain relief. “However, there is some evidence that receipt of epidural/spinal anesthesia is increasing from year to year at the state level,” the report stated.
The rate of newborn circumcision for boys in the United States appears to be declining, according to data presented at the International AIDS Conference in July 2010 (R.C. Rabin, New York Times Aug 16, 2010). Charbel E. El Bcheraoui, a researcher from the U.S. Centers for Disease Control and Prevention (CDC), presented information that the circumcision rate for infant boys had dropped significantly from 56 percent in 2006 to 32.5 percent in 2009. The numbers, which have not yet been published, were based on calculations from SDI Health, a health care data analytics company, but they do not include Jewish ritual circumcisions or procedures not reimbursed by insurance. An SDI Health spokesperson noted that measuring the circumcision rate was not the purpose of the study, which instead, was to measure the rate of complications from the procedure; the study found a very low rate of complications associated with newborn circumcisions. Officials at the CDC were not involved in collecting the data and cautioned that the figures were not definitive; however, they did confirm that circumcision rates for male infants have declined in this decade. Both the CDC and the American Academy of Pediatrics (AAP) have plans to issue new policy recommendations about circumcision. Currently, the AAP does not recommend routine neonatal circumcision. The World Health Organization endorsed male circumcision in 2007 as “an important intervention to reduce the risk of heterosexually acquired H.I.V.”
Improvements in delivery room safety have been introduced in some United States hospitals by using a series of best practice protocols named “care bundles” (L. Landro, Wall Street Journal March 30, 2011). The protocols have been developed by a North Carolina alliance of 2,400 hospitals called Premier, and implemented in 16 hospitals in 2008. The changes have led to a dramatic decrease in birth injuries and infant deaths. Premier found that five recurring issues cause most delivery-related problems: failure to initiate a timely cesarean section; failure to detect signs of infant distress; failure to properly resuscitate an infant; inappropriate use of labor-inducing drugs; and misuse of vacuums and forceps. Hospitals using the care bundles reduced infant birth injuries by 11.6 percent and cases of insufficient oxygen by 31.4 percent compared with rates in 2006 and 2007. The federal Agency for Healthcare Research and Quality has awarded grants of $3 million each to two groups in Minnesota working on improving obstetrics safety by using the Premier protocols.
In addition to the care bundles, hospitals are using robots and video cameras in delivery room simulation training to help physicians and nurses prepare for all possible high-risk scenarios and are encouraging all team members to speak up when they see problems. Dr. Stanley Davis, who is overseeing the new phase of the Premier program, said the program will emphasize teamwork. Poor communication between caregivers has been cited in most of the reports on infant deaths or injury.
Rates of infant mortality and neonatal mortality in the United States both dropped slightly in 2009, according to preliminary data from the National Center for Health Statistics (K.D. Kochanek et al. Deaths: Preliminary data for 2009. Natl Vital Stat Rep 2011;59(4):8–9). In 2009 the infant mortality rate was 6.42 deaths per 1,000 live births, a 2.6 percent drop from 2008. Similarly, the rate of deaths for infants younger than 28 days fell from 4.27 per 1,000 live births in 2008 to 4.19 deaths in 2009, but the decrease was not statistically significant. The infant mortality rate for white infants decreased in 2009 by 4.0 percent, from 5.54 infant deaths per 1,000 live births in 2008 to 5.32 in 2009. The mortality rate for black infants was 2.4 times the rate for white infants. However, because of inconsistencies in the reporting of race groups on birth and death certificates (especially for races other than white and black and for Hispanic origin), infant mortality rates for these groups are likely to be underestimated, the report noted.
Fewer deaths were caused by maternal complications of pregnancy in 2009. The infant mortality rate for pregnancy complications decreased 7.5 percent from 2008 to 2009.
A concern that hospital neonatal intensive care units (NICUs) in Texas are being overbuilt and overused has been expressed by the Texas Health and Human Services Commission (E. Ramshaw, Texas Tribune March 20, 2011). State health officials believe that the state could save $36.5 million over the next biennium, “curbing so-called convenience C-sections and refusing to finance elective inductions before the 39th week of pregnancy.” Births in Texas have increased nearly 18 percent since 1998, but the number of NICU beds in Texas hospitals has surged approximately 87 percent, from 1,365 in 1998 to 2,510 in 2009, according to state health statistics. Neonatologist Dr. Charles Hankins suggested that pure profit is not the only reason, but with low reimbursement rates and high malpractice costs for routine obstetric care, “A lot of facilities realize that if they had a Level 3 nursery, they could help offset their costs,” he said. In contrast, Amanda Engler, spokesperson for the Texas Hospital Association, said “The services exist because they fill a need.” The average routine hospital delivery costs Medicaid (the joint state-federal health program) $2,500, according to state records, whereas the average NICU stay costs $45,000. Dr. Frank Mazza, chief patient safety officer and vice president for the Seton Family of Hospitals, said that state health officials are right to consider birth inefficiencies. “We should have in Texas the safest health care and the most cost-effective health care,” he said, “By keeping babies out of the NICU, you accomplish both.”
Infertility treatments in the United States resulted in more than 56,000 live births in 2009, according to the latest data from the Society for Assisted Reproductive Technology (SART) (M. Schneider, ObGyn News 2001;46(4):9). Infertility specialists are continuing a trend to transfer fewer embryos in each cycle. More women are also choosing to have single embryo transfer (SET) in 2009 compared with 2003. In 2009, for example, 7.2 percent of cycles in women under age 35 years involved elective SET, and approximately 4 percent of cycles in women aged 35 to 37 years versus 0.7 percent and 0.4 percent in 2003, respectively. Fertility experts agree that this trend of transferring fewer embryos is encouraging. However, although SET is the safest approach, it results in a lower pregnancy rate, and therefore is less popular with women.