Trends in Preterm Birth, Cesarean Delivery, and Induction of Labor in

IndianaStatistics from Live Birth

Data 1990-2006

Trends in Preterm Birth, Cesarean Delivery, and Induction

of Labor in Indiana, 1990-2006

• Changes in gestational age distribution,• Preterm rates by method delivery by

gestational age, race/ethnicity,• Cesarean rate by total, primary and repeat,• Rate of vaginal births after cesarean,• Induction rate stratified by maternal

race /ethnicity, age and plurality,• Index of occurrence by day of week and

time of day stratified by vaginal births, inductions, primary and repeat cesareans.

Definitions

• Term: 39 weeks and 0 days through 42 complete weeks of gestation.

• Near Term: 37 to 38 weeks gestation.

• “Late Preterm”: 34 to 36 6/7 weeks gestation

• Preterm: <37 completed weeks gestation

The Prematurity Problem

• Serious health crisis that costs the United States more than $26 billion annually.

• Key risk factor for infant death. • High risk of serious and sometimes lifelong

health problems.  • Late preterm babies (34-36 weeks

gestation) have higher rates of death and disability than full-term babies.

• Near term infants (born at 37-38 weeks) have increased risk for problems compared to infants born at 39 weeks.

Percent Preterm BirthsIndiana and U.S, 1996-2006

In 2006, the preterm birth rate in Indiana was 13.4 percent compared to 12.8 percent for the U.S.

Close to 12,000 babies were born preterm.

More than 70 percent were late preterm births

Preterm Birth Rates: Indiana, 2003-2006 Average

© March of Dimes Foundation, April 2009

Percent Distribution of Live Births by Gestational Age:

Indiana, 2006•Nationally we are seeing a shift in the distribution of gestational age from 40 weeks towards an earlier gestation of 39 weeks.

•In Indiana the highest number of births occur at 37-38 weeks gestation (near term) not 40 weeks.

Percent Change by Gestational Age

in Weeks: Indiana 1990-2006

Looking at the change in distribution of gestational age, between 1990-2006, we see a sharp increase in late preterm and near term births with a noticeable decline in births at 40 weeks or more.

+63%

+38%

-54%-46%-20%

Percent Preterm Births by Gestational Age

<37 weeks

Early preterm births have remained fairly consistent over time with a slight increase among both 32-33 weeks and < 32 weeks gestation.

The preterm rate in Indiana increased by 31 percent from 10.2 in 1990 to 13.4 in 2006

Percent of Preterm Births by Race and Hispanic Origin of

MotherPreterm rates remain persistently higher among non-Hispanic blacks compared to

non-Hispanic whites and Hispanics.

A 40% increase in the white preterm rate has shortened the disparity gap not because of less black babies being born preterm but because more white babies are being born preterm.

Percent Late Preterm Births (34-36 wks) by Race and Hispanic

Origin of Mother

Late preterm births increased sharply (by 48%) for non-Hispanic whites and moderately (16%) for Hispanics while there was actually a decrease among non-Hispanic blacks since 2005.

Late Preterm Birth: Indiana, 2003-2006 Average

Percent Distribution of Preterm Births by Plurality

15% of preterm births occur among multiples a 33% increase since 1990

85% of preterm births occur among Singleton

births. a 26% increase

The remainder of this report will report data among singleton births only.

Very Preterm: Indiana, 2003-2006 Average

© March of Dimes Foundation, April 2009Very preterm is less than 32 completed weeks gestation. ** Indicates less than five events or missing data. Not able to calculate a reliable rate.Source: National Center for Health Statistics, final natality data. Retrieved October 26, 2009, from www.marchofdimes.com/peristats.

Total Cesarean Rate

In 2006, 29.3 percent of Indiana births were delivered by cesarean, a 48% increase from 19.8 percent in 1997.

Percent Preterm Births By Method Of Delivery Among

Singletons

This slide clearly shows the relationship of the increase in cesarean births to an increase in preterm births in Indiana.

Percent Preterm Births By Gestational Age And Method Delivery Among Singletons

there has been a 41% increase in late preterm births by cesarean section compared to a 27% increase in late preterm births among vaginal deliveries

Total and Primary Cesarean Rate and Vaginal Birth After

Cesarean Rate

The rate of VBAC in Indiana increased from 16.5 percent in 1990 to an all time high or 27.6 percent in 1997, followed by a dramatic decline to 5.8 percent.

Primary Cesarean Rate by Age of Mother

The 2006 rate for women 35 years of age and older (40.1%) was double the rate for mothers under 20 years of age (22.7%).

But

The largest increase (66%) in primary cesarean sections occurred in the <20 year old, dooming these young women to a lifetime of repeat cesareans and increase risk of

complications.

 Primary Cesarean Deliveries: Indiana, 2003-2006 Average

© March of Dimes Foundation, April 2009

Elkhart

Newton

Jasper

Noble

Allen Whitley

Adams Wells

Huntington Wabash

Fulton

Miami

Cass

Pulaski

White

Benton

Warren

Tippecanoe

Carroll

Howard

Grant

Jay

Randolph

Delaware Madison Tipton

Hamilton

Henry

Hancock Marion

Boone

Clinton

Fountain Montgomery

Putnam Hendricks

Parke

Vigo

Sullivan

Clay

Greene

Owen

Morgan Johnson

Shelby

Monroe Brown Bartholomew

Lawrence Jackson

Orange

Washington

Posey

Gibson

Pike

Knox

Warrick

Dubois

Daviess Martin

Spencer

Perry

Crawford

Harrison

Floyd

Clark

Jennings

Jefferson

Decatur

Ripley

Dearborn

Wayne

Union Fayette

Switzerland

Rush

Franklin

Steuben

De Kalb

Lake Porter

La Porte St. Joseph

Marshall Kosciusko

La Grange

Vanderburg

Scott

Starke

Ver

mill

ion

Bla

ckf

or

d

Ohio

Over 20.0 (31)

16.9-20.0 (32)

Under 16.9 (29)

Total Cesarean Deliveries: Indiana, 2003-2006 Average

© March of Dimes Foundation, April 2009

Elkhart

Newton

Jasper

Noble

Allen Whitley

Adams Wells

Huntington Wabash

Fulton

Miami

Cass

Pulaski

White

Benton

Warren

Tippecanoe

Carroll

Howard

Grant

Jay

Randolph

Delaware Madison Tipton

Hamilton

Henry

Hancock Marion

Boone

Clinton

Fountain Montgomery

Putnam Hendricks

Parke

Vigo

Sullivan

Clay

Greene

Owen

Morgan Johnson

Shelby

Monroe Brown Bartholomew

Lawrence Jackson

Orange

Washington

Posey

Gibson

Pike

Knox

Warrick

Dubois

Daviess Martin

Spencer

Perry

Crawford

Harrison

Floyd

Clark

Jennings

Jefferson

Decatur

Ripley

Dearborn

Wayne

Union Fayette

Switzerland

Rush

Franklin

Steuben

De Kalb

Lake Porter

La Porte St. Joseph

Marshall Kosciusko

La Grange

Vanderburg

Scott

Starke

Ver

mill

ion

Bla

ckf

or

d

Ohio

Over 30.3 (30)

26.1-30.3 (35)

Under 26.1 (27)

Percent of live births

Level III OB Hospital

Only 7 counties in Indiana have a Level III OB Hospital. The majority of cesarean deliveries are not occurring in these counties.

It is imperative that we look more at this and begin to develop a perinatal system in Indiana.

49.4 48.3 47.844.0 43.8 43.4

39.7 39.5 39.4 38.5

29.8

0

10

20

30

40

50

60

2006

1 2 3 4 5 6 7 8 9 10 IN

Top Ten Hospitals with the Highest Cesarean Rate in 2006 Compared to

Indiana State Rate

l/l l/l l/l lll/lll l/l l/l ll/ll l/l ll/ll l/l

1/1 = Hospital Level of Care

ACOG Guidelines on the Induction of Labor

“The new criteria for confirming a term pregnancy provides clear and clinically relevant parameters to accurately document when inductions might be considered and cautions against inductions before 39 weeks in the absence of a medical indication,”

• The guidelines make clear that even mature lung development is not a reason to induce delivery for logistical reasons if the fetus is not at least 39 weeks old, unless it is medically necessary.

• Risk of having a cesarean section doubles if labor is induced and their cervix is not ready.

Comparison of Induced Labor Ending In Vaginal Delivery And Cesarean Delivery by

Day and Time

0

10

20

30

40

50

Mid-6am 6am-noon noon-6pm 6pm-mid

Inductions by Day and Time

Sun Mon Tue Wed Thu Fri Sat

0

10

20

30

40

50

Mid-6am 6am-noon noon-6pm 6pm-mid

Inductions Ending in Cesarean by Day and Time

Inductions in vaginal delivery show a different pattern than inductions resulting in cesarean delivery. Inductions with vaginal deliveries occur most often between noon-6PM on Mondays and Thursdays during the week

Inductions with subsequent cesarean occur most often during 6PM – midnight and more often on Mondays and Thursdays.