understanding contemporary us birth and the role of midwives eugene declercq, phd boston university...

Understanding Contemporary US Birth and the Role of

Midwives

Eugene Declercq, PhD

Boston University School of Public Health

Grantmakers in Health Annual Meeting

Atlanta, Georgia

March 6, 2014

BirthByTheNumbers.org

Three Trends of Interest

Total U.S. Births, 1990-2012

19901992

19941996

19982000

20022004

20062008

20102012

3,800,000

3,900,000

4,000,000

4,100,000

4,200,000

4,300,000

4,400,000

3,952,937

4,316,233

Net Decrease 2007-2012363,296 or 8.4%

Source: Adapted from CDC VitalSTATS. http://www.cdc.gov/nchs/VitalStats.htm

Prematurity and Low Birthweight, U.S., 1981-2012

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

6

7

8

9

10

11

12

13

Prematurity

Low Birthweight

Percent of all births occurring outside a hospital, at home, or in a birthing center, United States,

1990-2012

19901995

20002005

20102012

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Total out of hospital

Home

Birthing center

46,956(1.13%) 35,587

(0.87%)

50,761(1.28%)

43% Increase 2004-2013


Key Question

Is the U.S. really doing as badly as it seems in

international comparisons?



Is the U.S. really doing that badly?

How Do we Compare Outcomes?Neonatal Mortality Rate

Infant Deaths in First 28 days

X 1,000________________

Live Births

Outcomes: Comparative Neonatal Mortality RatesRank Country Rank Country Rank Country

1 San Marino (1) 14 Israel 27 Belarus

Andorra Monaco Netherlands

IcelandRepublic of Korea Greece

Japan Ireland Cuba

Singapore Belgium Lithuania

Cyprus Czech Republic New Zealand7 Luxembourg (2) France United Kingdom

Slovenia Germany Switzerland

Sweden Italy Croatia

Finland Denmark Malaysia

Estonia 24 Austria (3) 37 United States (4)

Norway Spain Canada, Hungary, U.A.E.

13 Portugal 26 Australia Poland, Qatar, Serbia

Source: State of the World’s Children2013. http://www.unicef.org/sowc2013/statistics.html


Outcomes

Five countries in red background share a particular characteristic – almost no one actually lives there. Total Births in these countries in 2012 were 11,429 or fewer than the 11,450 in Alaska in 2011

Country 2012Births

Andorra 757

Iceland 4,146

Luxembourg 6,034

San Marino 285

Monaco 207

TOTAL 11,429



What’s a Fair Comparison with the US?

In the most recent year available (2010):

• Countries with at least 100,000 births

• Countries with a total per capita annual expenditure on health of at least $1,500 in US dollars.

Defining a Set of Countries to Compare with the U.S.17 Comparison Countries (SOURCE: OECD, Health Data 2012 & State of World’s Children)

2011 Total Births

(000)

2011Total exp. health –

PC, US$ PPP

2011% Births by

Cesarean

Australia 302 *3,800 *31.2

Belgium *129 4,061 *19.7

Canada 377 4,521 *26.1

Czech Republic 109 1,966 23.3

France 792 4,118 20.2

Germany *678 4,495 31.4

Greece 106 2,361 NA

Israel 166 2,239 19.9

Italy *557 3,012 37.7

Japan 1,051 *3,213 18.0

Korea 471 2,198 34.6

Netherlands *184 5,099 *15.6

Portugal 97 2,619 33.3

Spain 471 3,072 24.9

Sweden 112 3,925 16.2

United Kingdom 808 3,406 24.1

United States 3,954 8,508 32.8

BirthByTheNumbers.org* 2010


IOM chose 16 peer countries. 13 are same as the one’s we’ve used. They use 3 countries (Denmark, Finland, Switzerland) that have 100,000 births. We include Belgium, Czech Republic, Greece and Hungary

Neonatal Mortality Rates (per 1,000 births), 2010, Industrialized Countries with 100,000+ Births

1.2

1.6

1.6

2

2.1

2.3

2.3

2.4

2.5

2.5

2.6

2.8

3

3.2

3.8

4.2

0 1 2 3 4 5

Japan

Czech Republic

Sweden

Greece

Spain

Germany

Italy

Korea

Belgium

Portugal

France

Netherlands

AustraliaUnited Kingdom

Canada

United States

Source: OECD Health Data 2013 and NCHS, Deaths Final Data for 2007. BirthByTheNumbers.org

Neonatal Mortality Rates (per 1,000 births), 2010, Industrialized Countries with 100,000+ Births

1.2

1.6

1.6

2

2.1

2.3

2.3

2.4

2.5

2.5

2.6

2.8

3

3.2

3.4

3.8

0 1 2 3 4

Japan

Czech Republic

Sweden

Greece

Spain

Germany

Italy

Korea

Belgium

Portugal

France

Netherlands

AustraliaUnited Kingdom

U.S. White

Canada

Source: OECD Health Data 2013 and NCHS, Deaths Final Data for 2007. BirthByTheNumbers.org

Maternal Mortality Ratios

Maternal Mortality Ratio

Maternal Deaths all causes X 100,000

_______________Live births

Maternal Mortality Rates, (per 100,000 births), 2010, Industrialized Countries with 300,000+ births

2.4

3.4

4.1

4.2

5

5.5

7.7

9

10.5

14.7

16.8

2 17

Australia*

Italy*

Spain

Japan

United Kingdom

Germany

France#

Canada#

US WNH**

Korea*

United States^

Sources: OECD Health Data 2013; NCHS. 2009. Deaths, Final Data, 2007.

U.S. 2007:Black non-Hispanic 28.4White non-Hispanic 10.5Hispanic 8.9

Maternal Mortality Rate

*2009; #2008; **2007; ^Estimate


Other countries do better because the U.S. is different: -- more diversity, -- weaker social support system, -- inequality in our health care

system.

What if we compared subgroups in the U.S. to other countries?

US Subgroups in Comparative Contextwith other Industrialized Countries

US Subgroup U.S. IMR 2010

Rank (17- 100K)

All 6.1 17

Source: U.S. subgroups: Mathews & M. MacDorman. 1/24/13. Infant mortality statistics from the 2009 period linked birth/infant death data set. NVSR v. 61 (8).Hyattsville, MD: NCHS, Table 2. *Other IMRs from OECD Health Data 2013.



Rank (17- 100K)

All 6.1 17

White Non-Hispanic 5.2 17




Rank (17- 100K)

All 6.1 17


White NH, Native Born 5.4 17




Rank (17- 100K)

All 6.1 17



White NH, Singleton Birth 4.6 16




Rank (17- 100K)

All 6.1 17




White NH, 30-34 yrs old 4.1 15




Rank (17- 100K)

All 6.1 17




White NH, 30-34 yrs old 4.1 15

White NH, 39-41 weeks 1.8 1


Examining Trends over Time

Neonatal Mortality Rate (per 1,000 births), 2000-2011, U.S., & Ave. for Industrialized Countries*

2.0

3.0

4.0

5.0

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Rate

per

1,0

00 l

ive b

irth

s

Source: OECD Health Data, 2014 & MacDorman MF, et al. Recent declines in infant mortality in the United States, 2005–2011. NCHS data brief, no 120. Hyattsville, MD: NCHS. 2013.

U.S.

* Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Israel, Italy, Japan, Netherlands, Portugal, Spain, S. Korea, Sweden, U.K.

2.3

4.0

4.6

3.1

Industrialized Countries

23% decrease

13% decrease

Neonatal Mortality Rate (per 1,000 births), 2000-2011, U.S., & Ave. for Industrialized Countries*

2.0

3.0

4.0

5.0

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Rate

per

1,0

00 l

ive b

irth

s

Source: OECD Health Data, 2014 & MacDorman MF, et al. Recent declines in infant mortality in the United States, 2005–2011. NCHS data brief, no 120. Hyattsville, MD: NCHS. 2013.

U.S.

* Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Israel, Italy, Japan, Netherlands, Portugal, Spain, S. Korea, Sweden, U.K.

2.3

4.0

4.6

3.1

If the U,S. neonatal mortality rate equaled the current average rate of the other countries in 2011, that would mean almost 6,955 fewer deaths to babies 28 days or younger annually.

Maternal Mortality Ratios (per 100,000 births), 2000-2011, U.S. & Ave.

Industrialized Countries*

4

8

12

16

20

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Dea

ths

per

100

,000

live

bir

ths


3 % Increase

U.S.71%

Increase

Sources: OECD Health Data 2014; NCHS. 2010. Deaths, Final Data, 2007.

* Countries with 300,000+ births (2011): Australia, Canada, France, Germany, Italy, Japan, S. Korea, Spain, United Kingdom NOTE: 2008-2010 US

rates unofficial


But Gene, you’ve only looked at outcomes

What about process?

US Cesarean Rates, 1989-2012

20

22

24

26

28

30

32

34

% Tot US 23 22.722.622.321.821.220.820.720.821.222.0 23 24 26 28 29 30 31 32 32 33 33 33 33

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12

%

Source: National Center for Health Statistics Annual Birth Reports

%

1,296,070

If the 2012 cesarean rate was the same as in 1996, there would have been 478,000 fewer cesareans in the U.S. in ’12.


Do High Rates of Intervention Matter?

1. Outcomes 2. Costs

Gestational Age, U.S. All Births, 1990

2% 1%

7%

20%

14%

11%

22% 23%

0%

5%

10%

15%

20%

25%

30%

<32 32-33 34-36 37-38 39 40 41 42+

* Only births occurring at home. Source: Martin JA, Hamilton BE, Osterman MJK, Curtin S and Mathews TJ. Births: Final data for 2012. National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2014.

Gestational Age, U.S. All Births, 1990, 2012

2% 1%

8%

25%

30%

20%

9%

6%

0%

5%

10%

15%

20%

25%

30%

<32 32-33 34-36 37-38 39 40 41 42+


Gestational Age, U.S. All Births, 1990, 2012

2% 1%

20%22%

14%

11%

25%

30%

7%

23%

9%6%

2% 1%

8%

20%

0%

5%

10%

15%

20%

25%

30%

<32 32-33 34-36 37-38 39 40 41 42+

19902012


Source: Althabe F.Cesarean Section Rates and Maternal & Neonatal Mortality Birth.2006;33:270

Cesarean Rates and Neonatal Mortality

Low Income

Medium Income

High Income

But Gene, while our foundation focuses on health, we’ve never prioritized birth.

Why should we start now?

Economics of Childbirth in the U.S.

LEADING MAJOR DIAGNOSTIC CATEGORIES by

NUMBER OF HOSPITAL DISCHARGES, U.S., 2011

1,414,881

1,501,170

1,769,080

2,304,938

3,458,314

3,503,892

3,839,213

0

1,00

0,00

0

2,00

0,00

0

3,00

0,00

0

4,00

0,00

0

5,00

0,00

0

6,00

0,00

0

7,00

0,00

0

Endocrine, Nutritional & Metabolic

Mental Diseases & Disorders

Kidney & Urinary Tract

Nervous System

Musculoskeletal System

Digestive System

Respiratory System

Newborns & Other Neonates

Pregnancy, Childbirth

Diseases of The Circulatory System

AHRQ. 2014. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1/2014.

5,258,172

4,237,975

3,941,545

MEDIAN FACILITY LABOR & BIRTH CHARGES BY MODE OF BIRTH, U.S., 2011

$9,072

$15,632

$10,985

$18,781

$0

$19,000

Vaginal noComplications

Cesarean NoComplications

VaginalComplications

CesareanComplications

Sources: AHRQ. 2011. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1/14;

NOTE: Hospital charges; no physician costs

72%

http://hcupnet.ahrq.gov/

Estimated Total Charges, Hospital Birth, U.S., 1993-2011 (000,000)

0

10,000

20,000

30,000

40,000

50,000

60,000

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

Vag no Compl.

Vag w Compl.

Ces no Compl.

Ces w/ Compl.

Sources: AHRQ. 2009. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1614.

$ 52,734

$ 14,039

http://hcupnet.ahrq.gov/

Can Midwives Make a Difference?


Benefits of midwiferyMidwife-led continuity of care was associated with several benefits for mothers and babies, and had no identified adverse effects compared with models of medical-led care and shared care.

• Reduction in epidurals, episiotomies & instrumental births

• Increase in spontaneous vaginal births

• Less preterm birth

• Less miscarriage

• No difference in cesareans or stillbirths

December, 2013


CNMs per births & Cesarean Rate in State 2011

0.00 2.00 4.00 6.00 8.00 10.00 12.0020%

25%

30%

35%

40%

45%

r = -.28

CNM per 1,000 births in state

Ces

area

n R

ate

LA

UT

FL

NJ

VT

NH

ID

TX

MICANYGA

MA

NMAL

CO

WAAZ


Proportion of all U.S. Births Attended by Midwives, 1989-2012

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012-1%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

% Other MW%CNM

OBGYN per 100K, 2011

SOURCE: Area Resource File

1,459 (46%) U.S. Counties with no OB

3,142 U.S. Counties

CNMs per 100K, 2011


3,142 U.S. Counties

1,758 (56%) U.S. Counties with no CNM


CNMs & OBs per 100K, 2011 3,142 U.S.

Counties

1,263 (40%) U.S. Counties with no OB or CNM

Childbirth Advocacy Led by Mothers

www.birthbythenumbers.org

www.childbirthconnection.org


Extra Slides

Percent of singleton preterm (<37 weeks) births by method of delivery, United States,

1991-2012

0

2

4

6

8

10

12

1991 1996 2001 2006 2012

Per

cen

t

Source: Adapted from MacDorman et al. AJPH, 2011.

9.7%

5.7%

6.7%

11.1%

10.0%

4.8%

3.6%

3.9%

2.3%

Spontaneous Vaginal

Cesarean

Cesarean post induction

Induced Vaginal

15.6%16.2%

18.0%19.8%19.90%20.2%

23.3%24.1%

24.9%26.1%

34.6%37.7%

32.8%31.4%

33.4%

30.8%

10% 45%

*NetherlandsSweden

JapanIsrael

*BelgiumFrance

Czech RepublicUnited Kingdom

Spain*Canada

*AustraliaGermany

United States*Portugal

KoreaItaly

Sources: OECD Health Data 2013; U.S. Natality Data; Japan – sample; Lancet 6736(09)61870-5.

Cesarean Rates in Industrialized Countries* with 100,000+ Births, 2011

*2010

* No data on cesarean rates in Greece


Are mothers & babies the cause of these

changes?


Is it Older Mothers?Total Cesarean Rates (per 100 births) by Age of Mother:

United States, 1996 and 2012

14.517.4

20.623.8

27.431.6

22.3

27.931.5

35.8

42.1

49.1

0

10

20

30

40

50

60

<20 20-24 25-29 30-34 35-39 40-54

1996 2012

54% 60% 53% 50% 54% 55%%

Source: National vital statistics system, NCHS, CDC.

Per

cent

Overall increase, 1996-2012: 58.5%

Are Babies Getting Bigger?% Singleton Babies by Birthweight, U. S.,

1991-2012

11% 11% 10% 8% 8%

30% 30% 29%28% 28%

0%

10%

20%

30%

40%

50%

1991 1996 2001 2006 2012

3500-3999gms

4000+gms41% 41% 39%

36% 36%



Prepregnancy Obesity, U.S.2003, 2006, 2009

2003 2006 20090%

5%

10%

15%

20%

25%

17.6%19.5%

20.5%

Source: S. Fisher. Is obesity still increasing among pregnant women?Preventive Medicine 2013; 56: 372-378.

Induction No53%

Epidural No39%

Epidural Yes61%

Induction Yes47%

Epidural No22%

Epidural Yes78%

First-time mothers who experienced labor

Cesarean Yes20%

Cesarean Yes5%

Cesarean Yes31%

Cesarean Yes19%

Cascade of intervention in first-time mothers who experienced laborBase: first-time mothers with full term births who experienced labor n=821

Note: in this group, which included 93% of first-time mothers, the overall epidural rate was 71% and overall cesarean rate was 19%



Perinatal Mortality Rates, 2000-2011 , U.S., & Ave. for Industrialized Countries*

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20115

5.2

5.4

5.6

5.8

6

6.2

6.4

6.6

6.8

7 U.S. 6 %

decrease


14% decrease

* Countries with 100,000+ births (2011): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Israel, Italy, Japan, Netherlands, Portugal, S. Korea, Spain, Sweden, United Kingdom

18202224262830323436

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

WNH BNH Hisp

Total cesarean rates by race/ethnicity, U.S. 1989-2012

Source: National Center for Health Statistics Annual Birth Reports

1989 WNH +1.4percentage

points

2011 BNH +3.5 percentage

points

VBAC Rates, Selected Countries, 2004

0 10 20 30 40 50 60

NetherlandsNorwayFinland

SwedenGermany

Czech RepDenmark

FranceBelg-Flanders

ScotlandSpain-Valencia

SloveniaMalta

EstoniaCanada

LithuaniaLatvia

U.S. VBACs

51

41

45

5155

25

2732

3539

41

919

24

25

25

20

8

Source: Adapted from Peristats, US & Canadian Data


Have maternal request cesareans played a major role in these

increases?


Two Components to Maternal Request Primary Cesarean

1. Mother made request for planned cesarean before labor


Two Components to Maternal Request Primary Cesarean

1. Mother made request for planned cesarean before labor

2. Cesarean for no medical reason


Patient Choice Primary Cesareans• Combining reason for cesarean and timing of

decision found only about 1% of respondents had a planned primary cesarean for no medical reason.

“I think that [cesarean] is… the best way … to give birth. It is a planned way, no hassle, no pain, the baby doesn’t struggle to come out, the baby is not pressed to come out …I think that … everybody should have the baby by cesarean section.” (quote from LtM2)

Studies from England and Canada confirm very low rates of maternal request cesareans

Pressure to Accept Interventions by Method of Delivery

Did you feel pressure from any health professional to have a cesarean? % yes

7%

28%

28%

22%

0% 5% 10% 15% 20% 25% 30%

Vaginal

VBAC

PrimaryCesarean

RepeatCesarean

Source: Declercq et al. 2013. Listening to Mothers III.BirthByTheNumbers.org

Inductions in Vaginal Births, U.S., 1990-2012

5%

10%

15%

20%

25%

30%

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

Source: Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. http://www.cdc.gov/nchs/vitalstats.htm. BirthByTheNumbers.org

http://www.cdc.gov/nchs/vitalstats.htm

U.S. Fertility Rates (per 1,000) by Race/Ethnicity, 1989-2012

50

60

70

80

90

100

110

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

AllWNHBNHHisp

Fertility rates computed by relating total births, regardless of age of mother, to women 15-44 years. BirthByTheNumbers.org

Proportion of Births to Older Mothers, U.S. 1990-2012

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

NOTE: Since 2003Cesarean Rate Increased by 20%

> 35> 35

>30


Are Babies Getting Bigger?% Singleton Babies by Birthweight, U. S.,

1991-2011

11% 11% 10% 8% 8%

30% 30% 29%28% 27%

0%

10%

20%

30%

40%

50%

1991 1996 2001 2006 2011

3500-3999gms

4000+gms41% 41% 39%

36% 36%


Rates of Multiple Births (proportion of all babies in multiple births), U.S., 1980-2012

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012


Primary Cesarean and VBAC Rates, U.S., 1989-2011

5%

10%

15%

20%

25%

30%

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

Prim Ces Rate

VBAC

r = -.95

Source: NCHS. Annual Birth Reports & Vital Stats

Note: 2005-2011 unofficial

VBAC Rates*, U.S.,1990-2011

5%

10%

15%

20%

25%

30%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Source: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm

* Number of VBACs among women with prior cesarean

NOTE: Rates for 2005-2011 are unofficial


Perinatal Mortality Rates (per 1,000 births), 2010, Industrialized Countries 100,000+ Births

JapanKorea

Czech RepublicPortugal

Australia*SpainItaly#Israel

SwedenGreece

GermanyNetherlands

Belgium#Canada#

United States*United Kingdom

0 1 2 3 4 5 6 7 8

2.93.33.43.53.6

3.84.44.5

4.85.0

5.45.6

6.06.2

6.67.3

*2005; #2008

How is the U.S. doing relative to comparison countries?

Neonatal Mortality Rate

Infant Deaths in First 27 days

X 1,000_____________

Live Births

Perinatal Mortality Rate

Fetal deaths + deaths in the first week

X 1,000 _______________Live births + fetal

deaths


understanding contemporary us birth and the role of midwives eugene declercq, phd boston university...

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