The Institute of Medicine (IOM) released important preventive health services recommendations for women in the United States for federal health insurance coverage without out-of-pocket fees (no copayments). The IOM Panel’s report was released on July 20, 2011, and signed into law by the Obama administration on August 1. The IOM defined preventive health services as measures—including medications, procedures, devices, tests, education, and counseling—shown to improve well-being, and/or decrease the likelihood or delay the onset of a targeted disease or condition. The IOM recommends that women’s preventive services include:
- • Improved screening for cervical cancer, counseling for sexually transmitted infections, and counseling and screening for HIV.
- • A fuller range of contraceptive education, counseling, methods, and services so that women can better avoid unwanted pregnancies and space their pregnancies to promote optimal birth outcomes.
- • Services for pregnant women including screening for gestational diabetes and lactation counseling and equipment to help women who choose to breastfeed do so successfully.
- • At least one well-woman preventive care visit annually for women to receive comprehensive services.
- • Screening and counseling for all women and adolescent girls for interpersonal and domestic violence in a culturally sensitive and supportive manner.
Women’s health advocates and Democratic lawmakers, who have pushed for the policies for years, praised the panel’s recommendations. Some social and religious conservatives objected to the birth control mandate, however. Government officials said that the prevention services will be available from January 1, 2013, in most cases resulting in a slight increase in premiums. Tens of millions of women are expected to benefit initially from the health reform law, a number that is expected to grow with time.
Most babies are now breastfed in the United Kingdom according to a new report from the National Health Service (NHS; Smith D. FIGO News Report, June 23, 2011). Approximately 78 to 83 percent of women in England breastfed their babies between 2005 and 2010. The prevalence of women breastfeeding their children was slightly lower in Wales (67–71%) and Scotland (70–74%). The study from the NHS Information Centre, The Infant Feeding Survey 2010: Early Results, looked at the percentage of newborns who were initially breastfed by their mothers, examining the variation in rates in different countries in the United Kingdom, across age ranges and socioeconomic groups. In addition, according to the report, across the United Kingdom, the percentage of mothers smoking either before or during gestation dropped over the research period, falling from 33 to 26 percent between 2005 and 2010. “It is pleasing to see that a greater percentage of babies than in the previous survey are being breastfed initially by their mothers,” said Tim Straughan, chief executive of the NHS Information Centre.
Trial of labor is one of the new checkboxes reported on the revised 2003 U.S. Standard Certificate of Live Birth, and results for 27 reporting states in 2008 in the United States were reported recently by the U.S. Centers for Disease Control and Prevention (CDC) (Osterman M, et al. Expanded data from the new birth certificate, 2008. Natl Vital Stat Rep 2011;59(7):8, 21, 22). Fewer than 1 of 10 women with a previous cesarean section (8.4%) had a vaginal birth after a previous cesarean (VBAC) in the 27 states. VBAC rates varied with maternal age, ranging from 7.8 to 8.7 percent. Black women had the highest rate of VBAC (9.4%) compared with white (8.6%) and Hispanic (7.7%) women. A large variation in rates occurred by state; VBAC was nearly four times as common in Colorado (16.3%) as in California (4.4%).
The primary cesarean delivery rate for the 27 revised states was 23.8 percent in 2008. The primary cesarean rate has been increasing since the mid-1990s (13.28%), “and may be influenced by shifts in demographics, maternal choice, medicolegal pressures, and other nonclinical factors,” the report noted.
Data for the reporting area showed that just over one of four women delivering by cesarean (26.8%) experienced a trial of labor. Rates of attempted trial of labor increased with increasing maternal age. Women below 20 years of age were at least twice as likely to attempt a trial of labor as women aged 35 years and older (45% vs approximately 19%). Black women (30.2%) and white women (29.1%) were more likely to attempt a trial of labor than Hispanic women (21.4%).
External cephalic version (ECV) was performed in 2.1 per 1,000 births in the 24-state reporting area in 2008 in the United States, according to a recent government report (Osterman M, et al. Expanded data from the new birth certificate, 2008. Natl Vital Stat Rep 2011;59(7):6–7, 19). This obstetric procedure to change fetal position from nonvertex to vertex using external manipulation was reported for the first time on the revised 2003 U.S. Standard Certificate of Live Birth. White women were more likely to have ECV (2.5 per 1,000) compared with black (1.3) and Hispanic (1.7) women. Use of the procedure also rose with increasing age.
More than one-half of the procedures were successful (56.7%), and women with a successful ECV were more than five times as likely to have a vaginal delivery (77.8%) as women with a failed ECV (14.9%; data not shown). Success rates varied by maternal age; women aged 40 to 54 years had the lowest success rates (52.3%), and those aged 20 to 24 years had the highest success rates (60.8%). Hispanic women (69.4%) and black women (63.4%) were more likely to have a successful ECV than white women (50.6%).
A national survey of hospital practices that support breastfeeding was conducted by the CDC in 2007 and 2009 in the United States (MMWR, August 2, 2011). The CDC analyzed data from all U.S. hospitals and birth centers to describe the prevalence of facilities using maternity care practices consistent with the Ten Steps to Successful Breastfeeding (developed by WHO and UNICEF). U.S. hospitals are not doing enough to encourage mothers to breastfeed their infants, raising the risk of health conditions such as childhood obesity and diabetes, according to the report.
The report found that less than 4 percent of hospitals fully support breastfeeding. Infants born at nearly 80 percent of hospitals are given formula when there is no medical need. Only about one-third of hospitals have “rooming-in” policies allowing infants to stay with their mothers around the clock. About 75 percent of hospitals fail to provide adequate support for mothers after they leave the hospital, according to CDC Director Thomas Frieden. Most hospitals were implementing three to five recommended practices (60.5% in 2007 and 54.3% in 2009), with only 2.4 percent of hospitals implementing at least nine recommended practices in 2007 and 3.5 percent in 2009. Less than 1 percent implemented all 10 policies either year. Recommended maternity practices varied by region (highest prevalence in the northeast) and facility size (larger had better breastfeeding policies). The report concluded: “Most U.S. hospitals have policies and practices that do not conform to international recommendations for best practices in maternity care and interfere with mothers’ abilities to breastfeed.”
Recent trends in in-hospital newborn male circumcision during 1999–2010 in the United States have been reported by the CDC (MMWR, September 2, 2011;60(34):1167–1168). To monitor trends during this period the CDC used three independent data sources—the National Hospital Discharge Survey (NHDS) from the National Center for Health Statistics, the Nationwide Inpatient Sample (NIS) from the Agency for Healthcare Research and Quality, and the Charge Data Master (CDM) from SDIHealth. Each system collects discharge data on inpatient hospitalization. Incidence of newborn male circumcision decreased from 62.5 percent in 1999 to 56.9 percent in 2008 in the NHDS (average annual percentage change [AAPC] = −1.4%; p < 0.001); from 63.5 percent in 1999 to 56.3 percent in 2008 in the NIS (AAPC = −1.2%; p < 0.001); and from 58.4 percent in 2001 to 54.7 percent in 2010 in the CDM (AAPC = −0.75%; p < 0.001). The report noted that all three data sources underestimate the actual rate of newborn male circumcision because none of the data sets includes procedures performed in the community.
A recent government report, Childbearing Differences among Three Generations of U.S. Women, examined childbearing patterns of cohorts of women representing generations born at 25-year intervals in 1910, 1935, and 1960 (Kirmeyer SE, Hamilton BE, NCHS Data Brief, no. 68, August 2011). Women born in 1935 had the most children (on average 3.0 children per woman), and those born in 1960 had the fewest (2.0). Women born in 1910 and 1935 started their childbearing at the youngest ages with an “average” or median age at first birth of 21 years; more than 70 percent of their first births occurred to women below 25 years of age. The median age at first birth was oldest for the 1960 birth cohort (23 years). Of women born in 1935, 37 percent had four or more children; women born in 1960 were the most likely to have two children (35%); and women born in 1910 were equally likely to have no, one, or two children (approximately 22% each). Of these three cohorts, women born in 1910 were the most likely to be childless by 50 years of age (20%), whereas those born in 1935 were the least likely (11%).
The report noted that these distinct fertility patterns were a product of sociohistorical forces during these generations’ reproductive lives. The childbearing of the earliest cohort (1910) was largely affected by the Great Depression and World War II. The drop in marriages and uncertainty brought by those events lowered the likelihood of childbearing. Women in the middle cohort (1935) started their reproductive lives after the end of World War II, when the number of marriages jumped, and the economy prospered. For several reasons, including the increases in women’s educational and occupational opportunities and availability of reliable means of fertility control, the fertility of the last cohort (1960) was delayed and resulted in a smaller family size than that of the two earlier cohorts.