Home births are becoming more popular in the United States, according to a recent government report by the National Center for Health Statistics (MacDorman MF, et al. Home births in the United States, 1990–2009. NCHS Data Brief 2012;84:1–7). After declining from 1990 to 2004, the percentage of births that occurred at home increased by 29 percent, from 0.56 percent of births (23,150) in 2004 to 0.72 percent (29,650) in 2009 (Fig. 1). Approximately 1 in 90 births for non-Hispanic white women is now a home birth. In this group of women, home births increased by 36 percent, from 0.80 percent in 2004 to 1.09 percent in 2009. Home births are less common in other racial or ethnic groups. They are also more common among women aged 35 years and older, and among those with several previous children. In 2009 the percentage was generally higher in the northwestern states (e.g., 2.55% in Montana and 1.96% in Oregon) and lower in the southeastern states (e.g., 0.2% in Louisiana and Washington, DC).
The report concluded that “Women may prefer a home birth over a hospital birth for a variety of reasons, including a desire for a low-intervention birth in a familiar environment surrounded by family and friends, and cultural or religious concerns. Lack of transportation in rural areas and cost factors may also play a role, as home births cost about one-third as much as hospital births.”
Unprecedented collaboration by leading health care organizations in obstetrics-gynecology, family medicine, and pediatrics in the United States has created a joint “Call to Action” for the nation's health care providers and administrators (Society for Maternal-Fetal Medicine News Release November 30, 2011). The collaboration, which includes the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Nurse-Midwives, the American College of Obstetricians and Gynecologists, the American College of Osteopathic Obstetricians & Gynecologists, the Association of Women's Health, Obstetric and Neonatal Nurses, and the Society for Maternal-Fetal Medicine, was brought about by the need to develop an interdisciplinary collaborative approach to patient care to optimize maternal and fetal health outcomes.
The “Call to Action” includes the following recommendations for health care providers and administrators:
- Ensure that patient-centered care and patient safety are organizational priorities that guide decisions for policies and practices.
- Foster a culture of openness by promoting the active communication of good outcomes and opportunities for improvement. Develop forums to facilitate communication and track issues of concern.
- Provide resources for clinicians to be trained in the principles of teamwork, safety, and shared decision-making.
- Develop methods to systematically track and evaluate care processes and outcomes.
- Facilitate cross-departmental sharing of resources and expertise.
- Ensure that quality obstetric care is a priority that guides individual and team decisions.
- Identify and communicate safety concerns, and work together to mitigate potential safety risks.
- Disseminate and use the best available evidence, including individual and hospital-level data, to guide practice patterns.
The joint endeavor underscores the collective belief among health care providers that ongoing collaboration is a key element to improving health care outcomes.
In Australia the cesarean birth rate rose again to 31.5 percent in 2009, a 0.4 percent rise from 2008, according to the recent report by Australia's Mothers and Babies 2009 from the Australian Institute of Health and Welfare (AIHW National Perinatal Statistics Unit, December 21, 2011). The cesarean section rate has shown an upward trend over the last 10 years, increasing from 23.3 percent nationally in 2000 to a peak of 31.5 percent in 2009. In contrast, the proportion of instrumental deliveries has remained stable at approximately 11.0 percent throughout this period. The proportion of cesarean deliveries varied by state and territory, ranging from 27.9 percent in the Australian Capital Territory to 33.3 percent in both Queensland and Western Australia. Cesarean section rates increased with advancing maternal age, ranging from 17.5 percent for mothers younger than 20 years to 47.2 percent for mothers aged 40 years and over in 2009. A history of repeat/previous cesarean section was the leading reason reported for cesarean section (range 32.7% to 37.0%). In 2009, 13.3 percent of mothers who had previously had a cesarean section had a noninstrumental vaginal birth, and 3.1 percent had an instrumental vaginal birth. Repeat cesarean sections occurred for 83.6 percent of mothers with a history of cesarean section, and ranged from 71.8 percent in the Northern Territory to 87.1 percent in Western Australia.
In 2009, the onset of labor was a spontaneous vaginal birth for 56.1 percent of all women, 18.4 percent of mothers experienced no labor, and labor was induced for 25.3 percent. Approximately 1 in 3 mothers (29.5%) had an intact perineum following vaginal birth, and a total of 15.6 percent of women who had a vaginal birth had an episiotomy. In 2009, of all women who gave birth, 285,460 women (96.9%) gave birth in hospitals; 6,395 women (2.2%) gave birth in birth centers; and 863 women (0.3%) had planned home births.
More than $40 million in grants to test ways to reduce preterm births and early elective deliveries in America have been awarded by the U.S. Department of Health and Human Services (HHS) in a Strong Start initiative (HHS News Release February 8, 2012). “Preterm births are a growing public health problem that has significant consequences for families well into a child's life,” said HHS Secretary Kathleen Sebelius. “The Strong Start initiative will help give expectant mothers the care they need for a healthy delivery and a healthy baby.” More than half a million infants are born prematurely in America each year, a trend that has skyrocketed by 36 percent over the last 20 years. To tackle this problem, the Centers for Medicare and Medicaid Services (CMS) will award grants to health care providers and coalitions to improve prenatal care to women covered by the federal Medicaid program for low-income women. The grants will support the testing of enhanced prenatal care through several approaches under evaluation, including through group visits with other pregnant women, at birth centers providing case management, and at maternity care homes where pregnant women have expanded access to better coordinated, enhanced prenatal care. As part of the Strong Start campaign, CMS will also work with hospitals across the country that have joined the Partnership for Patients—–a national, voluntary effort to improve safety and reduce avoidable harm, including obstetric harm that may stem from early elective deliveries. The Strong Start initiative cuts across many agencies within HHS and will also work with a variety of professional organizations including the March of Dimes, American College of Obstetricians and Gynecologists, and other organizations.
One in every 30 infants born in 2009 was a twin in the United States, according to a recent report from the National Center for Health Statistics (Martin JA, et al. Three decades of twin births in the United States, 1980–2009, NCHS Data Brief 2012;80:1–8). Twin birth rates increased in all states from 1980 through 2009 and doubled among non-Hispanic white mothers over the three decades. Twin birth rates rose by nearly 100 percent among women aged 35 to 39 years and more than 200 percent among women aged 40 and over. Older maternal age accounted for only about one-third of the rise in twinning over the 30 years. Another factor related to the rise in twinning in recent years is the increased use of infertility treatments, both assisted reproductive technologies (ART) (e.g., in vitro fertilization) and non-ART treatments (ovulation stimulation), the report noted. Similar increasing trends in multiple births associated with both maternal age and infertility therapies have been observed in Western Europe and other countries during the 1980s and 1990s.