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US Birth Outcomes in a Comparative Context
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  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 Source: World Health Statistics 2011.h ttp://www.who.int/healthinfo/statistics/mortality_neonatal/en/index.html BirthByTheNumbers.org

  5. TWO PROBLEMS • Comparisons– Seven countries highlighted had fewer combined births than the state of Idaho • Measurement – Is neonatal mortality the best measure to use? Outcomes: Comparative Neonatal Mortality Rates Source: World Health Statistics 2011 http://www.who.int/healthinfo/statistics/mortality_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 BirthByTheNumbers.org

  7. What’s 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. BirthByTheNumbers.org

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

  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 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 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 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 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 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 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. 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

  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. 57#8 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; Lancet6736(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.2006;33:270

  35. Percent of singleton preterm (<37 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 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.” 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