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Understanding Contemporary US Birth and the Role of Midwives Eugene Declercq, PhD

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.

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Understanding Contemporary US Birth and the Role of Midwives Eugene Declercq, PhD

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  1. 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

  2. Three Trends of Interest

  3. Total U.S. Births, 1990-2012 Source: Adapted from CDC VitalSTATS. http://www.cdc.gov/nchs/VitalStats.htm

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

  5. Percent of all births occurring outside a hospital, at home, or in a birthing center, United States, 1990-2012 43% Increase 2004-2013 50,761 (1.28%) 46,956 (1.13%) 35,587 (0.87%) Total out of hospital Home Birthing center

  6. Key Question Is the U.S. really doing as badly as it seems in international comparisons? BirthByTheNumbers.org

  7. 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

  8. Outcomes: Comparative Neonatal Mortality Rates Source: State of the World’s Children2013. http://www.unicef.org/sowc2013/statistics.html BirthByTheNumbers.org

  9. 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 BirthByTheNumbers.org

  10. 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.

  11. * 2010 BirthByTheNumbers.org

  12. 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, Greeceand Hungary

  13. Neonatal Mortality Rates (per 1,000 births), 2010, Industrialized Countries with 100,000+ Births Source: OECD Health Data 2013 and NCHS, Deaths Final Data for 2007. BirthByTheNumbers.org

  14. Neonatal Mortality Rates (per 1,000 births), 2010, Industrialized Countries with 100,000+ Births Source: OECD Health Data 2013 and NCHS, Deaths Final Data for 2007. BirthByTheNumbers.org

  15. Maternal Mortality Ratios

  16. Maternal Mortality Rates, (per 100,000 births), 2010, Industrialized Countries with 300,000+ births U.S. 2007: Black non-Hispanic 28.4 White non-Hispanic 10.5 Hispanic 8.9 *2009; #2008; **2007; ^Estimate Maternal Mortality Rate Sources: OECD Health Data 2013; NCHS. 2009. Deaths, Final Data, 2007.

  17. 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?

  18. US Subgroups in Comparative Contextwith other Industrialized Countries 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.

  19. US Subgroups in Comparative Contextwith other Industrialized Countries 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.

  20. US Subgroups in Comparative Contextwith other Industrialized Countries 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.

  21. US Subgroups in Comparative Contextwith other Industrialized Countries 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.

  22. US Subgroups in Comparative Contextwith other Industrialized Countries 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.

  23. US Subgroups in Comparative Contextwith other Industrialized Countries 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.

  24. Examining Trends over Time

  25. Neonatal Mortality Rate (per 1,000 births), 2000-2011, U.S., & Ave. for Industrialized Countries* 4.6 U.S. 13% decrease 4.0 Industrialized Countries 23% decrease 3.1 2.3 * 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. 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.

  26. Neonatal Mortality Rate (per 1,000 births), 2000-2011, U.S., & Ave. for Industrialized Countries* 4.6 U.S. If the U,S. neonatal mortality rate equaled the current average rate of the other countries in 2011, that would mean almost 6,955fewer deaths to babies 28 days or younger annually. 4.0 3.1 2.3 * 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. 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.

  27. Maternal Mortality Ratios (per 100,000 births), 2000-2011, U.S. & Ave. Industrialized Countries* U.S. 71% Increase Industrialized Countries 3 % Increase * Countries with 300,000+ births (2011): Australia, Canada, France, Germany, Italy, Japan, S. Korea, Spain, United Kingdom NOTE: 2008-2010 US rates unofficial Sources: OECD Health Data 2014; NCHS. 2010. Deaths, Final Data, 2007.

  28. But Gene, you’ve only looked at outcomes What about process?

  29. US Cesarean Rates, 1989-2012 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. Source: National Center for Health Statistics Annual Birth Reports

  30. BirthByTheNumbers.org

  31. Do High Rates of Intervention Matter?1. Outcomes 2. Costs

  32. Gestational Age, U.S. All Births, 1990 * Only births occurring at home. Source: Martin JA, Hamilton BE, OstermanMJK, 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.

  33. Gestational Age, U.S. All Births, 1990, 2012 * Only births occurring at home. Source: Martin JA, Hamilton BE, OstermanMJK, 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.

  34. Gestational Age, U.S. All Births, 1990, 2012 * Only births occurring at home. Source: Martin JA, Hamilton BE, OstermanMJK, 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.

  35. Cesarean Rates and Neonatal Mortality Low Income Medium Income High Income Source: Althabe F.Cesarean Section Rates and Maternal & Neonatal Mortality Birth.2006;33:270

  36. 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.

  37. LEADING MAJOR DIAGNOSTIC CATEGORIES by NUMBER OF HOSPITAL DISCHARGES, U.S., 2011 5,258,172 4,237,975 3,941,545 AHRQ. 2014. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1/2014.

  38. MEDIAN FACILITY LABOR & BIRTH CHARGES BY MODE OF BIRTH, U.S., 2011 NOTE: Hospital charges; no physician costs 72% • Sources: AHRQ. 2011. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1/14;

  39. Estimated Total Charges, Hospital Birth, U.S., 1993-2011 (000,000) $ 52,734 $ 14,039 • Sources: AHRQ. 2009. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1614.

  40. Can Midwives Make a Difference?

  41. December, 2013 Benefits of midwifery Midwife-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

  42. CNMs per births & Cesarean Rate in State 2011 LA NJ FL TX NY GA CA MI MA NH Cesarean Rate WA VT AZ CO ID NM UT AL CNM per 1,000 births in state

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

  44. OBGYN per 100K, 2011 3,142 U.S. Counties 1,459 (46%) U.S. Counties with no OB SOURCE: Area Resource File

  45. CNMs per 100K, 2011 3,142 U.S. Counties 1,758 (56%) U.S. Counties with no CNM SOURCE: Area Resource File

  46. CNMs & OBs per 100K, 2011 3,142 U.S. Counties 1,263 (40%) U.S. Counties with no OB or CNM SOURCE: Area Resource File

  47. Childbirth Advocacy Led by Mothers www.birthbythenumbers.org www.childbirthconnection.org

  48. Extra Slides

  49. Percent of singleton preterm (<37 weeks) births by method of delivery, United States, 1991-2012 11.1% 10.0% 9.7% 3.9% Cesarean 2.3% 3.6% Induced Vaginal 6.7% Cesarean post induction 5.7% 4.8% Spontaneous Vaginal Source: Adapted from MacDorman et al. AJPH, 2011.

  50. Cesarean Rates in Industrialized Countries* with 100,000+ Births, 2011 *2010 * No data on cesarean rates in Greece Sources: OECD Health Data 2013; U.S. Natality Data; Japan – sample; Lancet6736(09)61870-5.

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