Cesarean Section on Demand

1
US Birth Outcomes in a Comparative Context
Update of Data from Birth By the Numbers. These
slides largely mirror those used in the video,
but update them with the most recent available
data as of January 1, 2012 Gene Declercq,
PhD NOTE There is a lag of 2-4 years in the
reporting of vital statistics from the US and
abroad
BirthByTheNumbers.org
2
Key Question

• Is the U.S. really doing as badly as it seems in
  international comparisons?

BirthByTheNumbers.org
3
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

4
Outcomes Comparative Neonatal Mortality Rates
Rank Country Rank Country Rank Country
1 Andorra (1) Greece Cuba
Iceland Ireland Hungary
Japan Italy Israel
Luxembourg Malta Lithuania
San Marino Monaco Malaysia
Singapore Norway Netherlands
7 Belgium (2) Portugal New Zealand
Cyprus Korea Slovakia
Czech Republic Slovenia Switzerland
Denmark Spain United Kingdom
Estonia Sweden 39 United States (4)
Finland 26 Australia (3) Canada, Croatia
France Austria Poland, Qatar
Germany Brunei Serbia, Un. Arab Emir.
Source World Health Statistics 2011.h
ttp//www.who.int/healthinfo/statistics/mortality_
neonatal/en/index.html
BirthByTheNumbers.org
5
Outcomes Comparative Neonatal Mortality Rates

• TWO PROBLEMS
• Comparisons Seven countries highlighted had
  fewer combined births than the state of Idaho
• Measurement Is neonatal mortality the best
  measure to use?

Rank Country Rank Country Rank Country
1 Iceland (1) Greece Cuba
Japan Ireland Hungary
Singapore Italy Israel
Andorra Malta Lithuania
San Marino Monaco Malaysia
Luxembourg Norway Netherlands
7 Belgium (2) Portugal New Zealand
Cyprus Korea Slovakia
Czech Republic Slovenia Switzerland
Denmark Spain United Kingdom
Estonia Sweden 39 United States (4)
Finland 26 Australia (3) Canada, Croatia
France Austria Poland, Qatar
Germany Brunei Serbia, Un. Arab Emir.
Source World Health Statistics
2011 http//www.who.int/healthinfo/statistics/mort
ality_neonatal/en/index.html
BirthByTheNumbers.org
6
Outcomes
Seven countries in red background share a
particular characteristic almost no one
actually lives there. Total Births in these
countries in 2009 were 23,549 or fewer than the
23,731 in Idaho in 09
Country 2009 Births
Andorra 828
Iceland 5,027
Luxembourg 5,639
San Marino 334
Malta 4,143
Monaco 298
Brunei 7,280
TOTAL 23,549
BirthByTheNumbers.org
7
Whats a Fair Comparison with the US?

• In the most recent year available (2009)
• 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.

8
Defining a Set of Countries to Compare with the U.S. Defining a Set of Countries to Compare with the U.S. Defining a Set of Countries to Compare with the U.S. Defining a Set of Countries to Compare with the U.S.
16 Comparison Countries (OECD, Health Data 2010) 2010 Total Births (000) 2009 Total exp. health PC, US PPP 2008 Births by Cesarean
Australia 296 3,445 30.8
Belgium 127 3,946 17.3
Canada 378 4,363 26.6
Czech Republic 117 2,108 20.5
France 829 3,809 19.9
Germany 681 4,218 29.4
Greece 118 2,679 NA
Italy 562 3,137 38.5
Japan 1,070 2,878 18.0
Korea 445 1,879 35.4
Netherlands 184 4,914 14.3
Portugal 101 2,508 32.7
Spain 480 3,067 24.6
Sweden 116 3,722 16.8
United Kingdom 779 3,487 23.4
United States 4,248 7,960 32.3
BirthByTheNumbers.org
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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
BirthByTheNumbers.org
10
Neonatal Mortality Rates (per 1,000 births),
2009, Industrialized with 100,000 Births
Source OECD Health Data 2011 and NCHS, Deaths
Final Data for 2007.
BirthByTheNumbers.org
11
Perinatal Mortality Rates (per 1,000 births),
2009, Industrialized Countries with 100,000
Births
2005 2008
Source OECD Health Data 2011 MacDorman MF,
Kirmeyer S. Fetal and perinatal mortality, United
States, 2005. National vital statistics reports
vol 57 no 8. Hyattsville, MD National Center for
Health Statistics. 2009.
12
Maternal Mortality Ratios
Maternal Mortality Ratio Maternal Deaths all causes X 100,000 _______________ Live births
13
Maternal Mortality Rates, (per 100,000 births),
2009, Industrialized Countries with 200,000
births
U.S. 2007 Black non-Hispanic
28.4 White non-Hispanic 10.5 Hispanic
8.9
2008 2007 2006
Maternal Mortality Rate
Sources OECD Health Data 2011 NCHS. 2009.
Deaths, Final Data, 2007.
14
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?
15
US Subgroups in Comparative Contextwith other
Industrialized Countries
US Subgroup U.S. IMR 2007 Rank (16 - 100K)
All 6.8 16




Source U.S. subgroups Mathews M. MacDorman.
2010. Infant mortality statistics from the 2006
period linked birth/infant death data set. NVSR
v. 58 (17).Hyattsville, MD NCHS, Table 2. Other
IMRs from OECD Health Data 2010.
16
US Subgroups in Comparative Contextwith other
Industrialized Countries
US Subgroup U.S. IMR 2007 Rank (16 - 100K)
All 6.8 16
White Non-Hispanic 5.6 16



Source U.S. subgroups Mathews M. MacDorman.
2010. Infant mortality statistics from the 2006
period linked birth/infant death data set. NVSR
v. 58 (17).Hyattsville, MD NCHS, Table 2. Other
IMRs from OECD Health Data 2010.
17
US Subgroups in Comparative Contextwith other
Industrialized Countries
US Subgroup U.S. IMR 2007 Rank (16- 100K)
All 6.8 16
White Non-Hispanic 5.6 16
White NH, Native Born 5.7 16


Source U.S. subgroups Mathews M. MacDorman.
2010. Infant mortality statistics from the 2006
period linked birth/infant death data set. NVSR
v. 58 (17).Hyattsville, MD NCHS, Table 2. Other
IMRs from OECD Health Data 2010.
18
US Subgroups in Comparative Contextwith other
Industrialized Countries
US Subgroup U.S. IMR 2007 Rank (16- 100K)
All 6.8 16
White Non-Hispanic 5.6 16
White NH, Native Born 5.7 16
White NH, Singleton Birth 4.9 15

Source U.S. subgroups Mathews M. MacDorman.
2010. Infant mortality statistics from the 2006
period linked birth/infant death data set. NVSR
v. 58 (17).Hyattsville, MD NCHS, Table 2. Other
IMRs from OECD Health Data 2010.
19
US Subgroups in Comparative Contextwith other
Industrialized Countries
US Subgroup U.S. IMR 2007 Rank (16- 100K)
All 6.8 16
White Non-Hispanic 5.6 16
White NH, Native Born 5.7 16
White NH, Singleton Birth 4.9 15
White NH, 30-34 yrs old 4.4 14
Source U.S. subgroups Mathews M. MacDorman.
2010. Infant mortality statistics from the 2006
period linked birth/infant death data set. NVSR
v. 58 (17).Hyattsville, MD NCHS, Table 2. Other
IMRs from OECD Health Data 2010.
20
Examining Trends over Time
21
Neonatal Mortality Rate, 2000-2009, U.S., Ave.
for Industrialized Countries
U.S.
8 decrease
4.6 per 1,000
4.2 per 1,000
Industrialized Countries 28 decrease
3.1 per 1,000
2.2 per 1,000
Countries with 100,000 births (2009)
Australia, Belgium, Canada, Czech Republic,
France, Germany, Greece, Italy, Japan,
Netherlands, Portugal, Spain, Sweden, U.K.
Source OECD Health Data, 2011
22
Neonatal Mortality Rate, 2000-2009, U.S., Ave.
for Industrialized Countries
U.S.
8 decrease
4.6 per 1,000
4.2 per 1,000
Industrialized Countries 28 decrease
3.1 per 1,000
2.2 per 1,000
If the U,S. neonatal mortality rate equaled the
current average rate of the other countries in
2009, that would mean almost 8,400 fewer deaths
to babies 28 days or younger annually.
Countries with 100,000 births (2009)
Australia, Belgium, Canada, Czech Republic,
France, Germany, Greece, Italy, Japan,
Netherlands, Portugal, Spain, Sweden, U.K.
Source OECD Health Data, 2011
23
Perinatal Mortality Rates, 2000-2008 , U.S.,
Ave. for Industrialized Countries
U.S. 5.6 decrease
Industrialized Countries 20.3 decrease
Countries with 100,000 births (2006)
Australia, Belgium, Canada, Czech Republic,
France, Germany, Greece, Hungary, Italy, Japan,
Netherlands, Portugal, S. Korea, Spain, Sweden,
United Kingdom
Source MacDormanM. Fetal and Perinatal
Mortality, U.S., 2005. 2009.NCHS V. 578 and
OECD Health Data 2011
24
Maternal Mortality Ratios (per 100,000 births),
2000-2008, U.S. Ave. Industrialized Countries
U.S. 30 Increase
Case Ascertainment??
Industrialized Countries 15 Decrease
Countries with 100,000 births (2007)
Australia, Belgium, Canada, Czech Republic,
France, Germany, Greece, Italy, Japan, S. Korea,
Netherlands, Portugal, Spain, Sweden, United
Kingdom
Sources OECD Health Data 2011 NCHS. 2010.
Deaths, Final Data, 2007.
25
Gestational Age, U.S. All Births, 1990, 2009
Only births occurring at home.
Source Vital Stats website
26
What about process?
27
US Cesarean Rates, 1989-2010
1,312,091

If the 2010 cesarean rate was the same as in
1996, there would have been 484,000 fewer
cesareans in the U.S. in 10.
Source National Center for Health Statistics
Annual Birth Reports
28
Cesarean Rates in Industrialized Countries with
100,000 Births, 2009
2008 2010
No data on cesarean rates in Greece
Sources OECD Health Data 2011 U.S. Natality
Data Japan sample Lancet 6736(09)61870-5.
29
Total cesarean rates by race/ethnicity, U.S.
1989-2010
1989 WNH 1.4percentage points
2010 BNH 2.9 percentage points
Source National Center for Health Statistics
Annual Birth Reports
30
Total Cesarean Rates (per 100 births) by Age of
Mother United States, 1996 and 2009
Overall increase, 1996-2009 58.5
Percent
Source National vital statistics system, NCHS,
CDC.
31
VBAC Rates, U.S.,1990-2009
NOTE Rates for 2005-2009 are unofficial
Number of VBACs among women with prior cesarean
Source NCHS Vital Stats. http//www.cdc.gov/nchs/
VitalStats.htm
32
VBAC Rates, Selected Countries, 2004
Source Adapted from Peristats, US Canadian Data
33
Do High Rates of Intervention Matter?1.
Outcomes (NMR GA)2. Costs
34
Cesarean Rates and Neonatal Mortality
Low Income
Medium Income
High Income
Source Althabe F.Cesarean Section Rates and
Maternal Neonatal Mortality Birth.200633270
35
Percent of singleton preterm (lt37 weeks) births
by method of delivery, United States, 1991-2006
11.0
9.7
6.7
5.7
Note Births with method of delivery and
induction of labor not stated are excluded.
Source MacDorman et al. AJPH, 2011.
36
National Costs and Hospitalizations
37
LEADING MAJOR DIAGNOSTIC CATEGORIES by NUMBER OF
HOSPITAL DISCHARGES, U.S., 2009
AHRQ. 2011. HCUPnet, Healthcare Cost
Utilization Project. Rockville, MD AHRQ.
http//hcupnet.ahrq.gov. Accessed 7/16/2011.
38
MEDIAN FACILITY LABOR BIRTH CHARGES BY SITE
MODE OF BIRTH, U.S., 2009
NOTE Hospital charges no physician costs
Charge in 2009
15,998
Increase in Charge in 2000-2009
13,549
Charge in 2000
9,644
8,037
Sources AHRQ. 2010. HCUPnet, Healthcare Cost
Utilization Project. Rockville, MD AHRQ.
http//hcupnet.ahrq.gov. Accessed 11/1/10
39
Estimated Total Charges, Hospital Birth, U.S.,
1993-2009 (000,000)
50,942
14,039
Sources AHRQ. 2009. HCUPnet, Healthcare Cost
Utilization Project. Rockville, MD AHRQ.
http//hcupnet.ahrq.gov. Accessed 7/16/11.
40

• Have maternal request cesareans played a major
  role in these increases?

41
Asking Mothers about Maternal Request Cesareans
http//www.childbirthconnection.org
42
Two Components to Maternal Request Primary
Cesarean

• 1. Mother made request for planned cesarean
  before labor

43
Two Components to Maternal Request Primary
Cesarean

• 1. Mother made request for planned cesarean
  before labor
• 2. Cesarean for no medical reason

44
Patient Choice Primary Cesareans

• Combining reason for cesarean and timing of
  decision found only 1 respondent of 252 (0.4)
  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 doesnt struggle to come out, the
baby is not pressed to come out I think that
everybody should have the baby by cesarean
section.
Studies from England and Canada confirm very low
rates of maternal request cesareans
45
Pressure to Accept Interventions by Method of
DeliveryDid you feel pressure from any health
professional to have a cesarean? yes
Source Declercq et al. 2006. Listening to
Mothers II.
46

• Have maternal request cesareans played a major
  role in these increases?
• NO!
• So what is the reason for the increasing cesarean
  rate?

47

• Have maternal request cesareans played a major
  role in these increases?
• NO!
• So what is the reason for the increasing cesarean
  rate?
• Practice Changes

48
Cesarean Rates, Low Risk, First-Time Mothers for
Medical Risk Factors Labor Complications
Singleton, Vertex, Full Gestation Births
49
US Cesarean Rates, 1989-2010

Source National Center for Health Statistics
Annual Birth Reports
50
Cesarean Rates, Low Risk, First-Time Mothers for
Medical Risk Factors Labor Complications
Singleton, Vertex, Full Gestation Births
51
Cesarean Rates, Low Risk, First-Time Mothers for
Medical Risk Factors Labor Complications
Source CDC Vital Stats. http//www.cdc.gov/nchs/V
italStats.htm Singleton, Vertex, Full Gestation
Births
52
Women have not changed nearly as much as practice
patterns have
53
For more information and additional resources
regularly checkBirthByTheNumbers.orgThe site
is updated as additional data becomes available.