Article

Changes in delivery methods at specialty care hospitals in the United States between 2006 and 2010

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Abstract

Objective: Given the increasing rates of labor induction and cesarean delivery, and efforts to reduce early term births, we examined recent trends in methods and timing of delivery. Study design: We identified delivery methods and medical indications for delivery from administrative hospital discharge data for 231 691 deliveries in 2006 and 213 710 deliveries in 2010 from 47 specialty care member hospitals of the National Perinatal Information Center/Quality Analytic Services. In a subset of 17 hospitals, we examined trends by gestational age. Result: From 2006 to 2010, there was an 11% increase in labor induction and a 6% increase in cesarean delivery, largely due to repeat cesareans. There was a 4 per 100 reduction in early term births (37 to 38 weeks), mostly due to a decline in non-medically indicated interventional deliveries. Conclusion: We report a shift in deliveries at 38 weeks, which we believe may be attributed to efforts to actively limit non-medically indicated early term deliveries.

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... 15 A recent study of specialty hospitals was the first to provide nationally representative data, reporting an 11% increase in induction from 2006 to 2010. 16 At the same time, the authors observed a substantial reduction in early-term iatrogenic delivery, including elective induction. It would be valuable to know whether these trends hold true for a broader range of U.S. hospitals, as well as those providing advanced perinatal care. ...
... 24 In terms of trends, Danilack et al. reported that at U.S. specialty hospitals, the overall prevalence of induction increased from 20% in 2006 to 22% in 2010 while at the same time induction declined slightly in preterm and early-term deliveries. 16 In contrast, Murthy et al. examined birth certificate data and reported that between 2001 and 2006, the prevalence of early-term induction increased. 12 None of these studies validated their measure of induction nor examined whether validity changed over time. ...
... 7-11 For example, at one hospital, induction prevalence decreased from 30% to 25%, 11 while at another, elective induction declined from 26% to 21%. 8 At U.S. specialty hospitals, from 2006 to 2010 there was a marked decrease in non-indicated iatrogenic delivery (including both induction and cesarean delivery) at 37 and 38 weeks' gestation. 16 Few studies have examined clinical outcomes accompanying these changes. Ehrenthal reported that after a local initiative to limit elective delivery before 39 weeks' gestation, NICU admissions decreased but macrosomia and stillbirth increased. ...
Article
Background: To describe trends in labor induction, including elective induction, from 2001 to 2007 for six U.S. health plans and to examine the validity of induction measures derived from birth certificate and health plan data. Methods: This retrospective cohort study included 339,123 deliveries at 35 weeks' gestation or greater. Linked health plan and birth certificate data provided information about induction, maternal medical conditions, and pregnancy complications. Induction was defined from diagnosis and procedure codes and birth certificate data and considered elective if no accepted indication was coded. We calculated induction prevalence across health plans and years. At four health plans, we reviewed medical records to validate induction measures. Results: Based on electronic data, induction prevalence rose from 28% in 2001 to 32% in 2005, then declined to 29% in 2007. The trend was driven by changes in the prevalence of apparent elective induction, which rose from 11% in 2001 to 14% in 2005 and then declined to 11% in 2007. The trend was similar for subgroups by parity and gestational age. Elective induction prevalence varied considerably across plans. On review of 86 records, 36% of apparent elective inductions identified from electronic data were confirmed as valid. Conclusions: Elective induction appeared to peak in 2005 and then decline. The decrease may reflect quality improvement initiatives or changes in policies, patient or provider attitudes, or coding practices. The low validation rate for measures of elective induction defined from electronic data has important implications for existing quality measures and for research studies examining induction's outcomes.
... Our results show a stabilisation in the rate of OI including C-sections through the period, a decrease in the use of forceps and an increase in the use of vacuum. These results are aligned with other studies [10] conducted after implementing clinical practical guidelines for decreasing unnec- essary interventions, which identified a decrease in instrumented births at the expense of an increase in C-sections. In our results, the decrease in the use of forceps is at the expense of the increase in the use of vacuum. ...
Article
Aim: To explore the effect of hospital's characteristics in the proportion of obstetric interventions (OI) performed in singleton fullterm births (SFTB) in Catalonia (2010-2014), while incentives were employed to reduce C-sections. Methods: Data about SFTB assisted at 42 public hospitals were extracted from the dataset of hospital discharges. Hospitals were classified according to the level of complexity, the volume of births attended, and the adoption of a non-medicalized delivery (NMD) strategy. The annual average change in the percentage for OI was calculated based on Poisson regression models. Results: The rate of OI (35% of all SFTB) including C-sections (20.6%) remained stable through the period. Hospitals attending less complex cases had a lower average of OI, while hospitals attending lower volumes had the highest average. Higher levels of complexity increased the use of C-sections (+4% yearly) and forceps (+16%). The adoption of the NMD strategy decreased the rate of C-sections. Conclusions: The proportion of OI, including C-sections, remained stable in spite of public incentives to reduce them. The adoption of the NMD strategy could help in decreasing the rate of OI. To reduce the OI rate, new strategies should be launched as the development of low-risk pregnancies units, alignment of incentives and hospital payment, increased value of incentives and encouragement of a cultural shift towards non-medicalized births.
... [5][6][7][8] Recently, declines in both spontaneous preterm births and preterm births that involved induction or cesarean delivery were documented in the United States over 2005-2012. 9 Several recent US-based hospital and regional studies have documented reductions in elective obstetric intervention at early term gestations, [10][11][12] but these trends have not been examined at the national level. The relationships between use of obstetric interventions and national-level late preterm and early term birth rates have not been examined in other high-income countries where obstetric intervention practices may be similar to the United States. ...
Article
Importance Clinicians have been urged to delay the use of obstetric interventions (eg, labor induction, cesarean delivery) until 39 weeks or later in the absence of maternal or fetal indications for intervention. Objective To describe recent trends in late preterm and early term birth rates in 6 high-income countries and assess association with use of clinician-initiated obstetric interventions. Design Retrospective analysis of singleton live births from 2006 to the latest available year (ranging from 2010 to 2015) in Canada, Denmark, Finland, Norway, Sweden, and the United States. Exposures Use of clinician-initiated obstetric intervention (either labor induction or prelabor cesarean delivery) during delivery. Main Outcomes and Measures Annual country-specific late preterm (34-36 weeks) and early term (37-38 weeks) birth rates. Results The study population included 2 415 432 Canadian births in 2006-2014 (4.8% late preterm; 25.3% early term); 305 947 Danish births in 2006-2010 (3.6% late preterm; 18.8% early term); 571 937 Finnish births in 2006-2015 (3.3% late preterm; 16.8% early term); 468 954 Norwegian births in 2006-2013 (3.8% late preterm; 17.2% early term); 737 754 Swedish births in 2006-2012 (3.6% late preterm; 18.7% early term); and 25 788 558 US births in 2006-2014 (6.0% late preterm; 26.9% early term). Late preterm birth rates decreased in Norway (3.9% to 3.5%) and the United States (6.8% to 5.7%). Early term birth rates decreased in Norway (17.6% to 16.8%), Sweden (19.4% to 18.5%), and the United States (30.2% to 24.4%). In the United States, early term birth rates decreased from 33.0% in 2006 to 21.1% in 2014 among births with clinician-initiated obstetric intervention, and from 29.7% in 2006 to 27.1% in 2014 among births without clinician-initiated obstetric intervention. Rates of clinician-initiated obstetric intervention increased among late preterm births in Canada (28.0% to 37.9%), Denmark (22.2% to 25.0%), and Finland (25.1% to 38.5%), and among early term births in Denmark (38.4% to 43.8%) and Finland (29.8% to 40.1%). Conclusions and Relevance Between 2006 and 2014, late preterm and early term birth rates decreased in the United States, and an association was observed between early term birth rates and decreasing clinician-initiated obstetric interventions. Late preterm births also decreased in Norway, and early term births decreased in Norway and Sweden. Clinician-initiated obstetric interventions increased in some countries but no association was found with rates of late preterm or early term birth.
Article
Purpose Evaluate the association between psychotropic medication use during pregnancy and gestational age at delivery, after adjusting for depressive symptom and perceived stress severity. Methods We analyzed data on singleton live births from 2,914 female PRESTO participants, aged 21-45, with a reported conception from 6/2013-6/2018. Women reported psychotropic medication use at 8-12 weeks and ∼32 weeks’ gestation. We measured depressive symptoms using the Major Depressive Inventory (MDI) and perceived stress using the 10-item Perceived Stress Scale (PSS). Data on gestational age at delivery were based on self-report and/or birth certificates. We used restricted mean survival time models, stratifying by severity of depressive symptoms (MDI <25 vs. ≥25) and perceived stress (PSS <20 vs. ≥20). Results Two hundred and ten (7.2%) participants reported using psychotropic medications during pregnancy. Mean gestational age at delivery among women who never used psychotropic medications was 38.2 weeks (95% CI: 37.7, 38.7), while it was 37.3 weeks (95% CI: 36.7, 37.9) among women who used psychotropic medications during pregnancy. Results were similar across strata of depressive symptoms and perceived stress. Conclusion Our data indicate that the association between psychotropic medication use and gestational age at delivery is not confounded by indication.
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Evidence-based care of women in labor requires a thorough understanding of both "normal" and abnormal labor progress. In response to the growing cesarean delivery rate for dystocia at our institution, a multidisciplinary team of attending physicians, nurse-midwives, resident physicians, and nurses was established to review the literature and create evidence-based guidelines. This article describes the background literature and consensus guidelines reached for the diagnosis of active phase labor, active phase arrest, second-stage arrest, protraction of the active phase, and failed induction of labor. Our review illustrates that slower labor patterns than traditionally described often result in a vaginal delivery without unacceptable increases in maternal or neonatal morbidity.
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This report presents 2009 data on U.S. births according to a wide variety of characteristics. Data are presented for maternal characteristics including age, live-birth order, race and Hispanic origin, marital status, hypertension during pregnancy, attendant at birth, method of delivery, and infant characteristics (period of gestation, birthweight, and plurality). Birth and fertility rates by age, live-birth order, race and Hispanic origin, and marital status also are presented. Selected data by mother's state of residence are shown, as well as birth rates by age and race of father. Trends in fertility patterns and maternal and infant characteristics are described and interpreted. Descriptive tabulations of data reported on the birth certificates of the 4.13 million births that occurred in 2009 are presented. Denominators for population-based rates are postcensal estimates derived from the U.S. 2000 census. The number of births declined to 4,130,665 in 2009, 3 percent less than in 2008. The general fertility rate declined 3 percent to 66.7 per 1,000 women aged 15-44 years. The teenage birth rate fell 6 percent to 39.1 per 1,000. Birth rates for women in each 5-year age group from 20 through 39 years declined, but the rate for women 40-44 years continued to rise. The total fertility rate (estimated number of births over a woman's lifetime) was down 4 percent to 2,007.0 per 1,000 women. The number and rate of births to unmarried women declined, whereas the percentage of nonmarital births increased slightly to 41.0. The cesarean delivery rate rose again, to 32.9 percent. The preterm birth rate declined to 12.18 percent; the low birthweight rate was stable at 8.16 percent. The twin birth rate increased to 33.2 per 1,000; the triplet and higher-order multiple birth rate rose 4 percent to 153.5 per 100,000.
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Preterm birth rates have increased substantially in the recent years mostly due to obstetric intervention. We studied the effects of increasing iatrogenic preterm birth on temporal trends in perinatal mortality and serious neonatal morbidity in the United States. We used data on singleton and twin births in the United States, 1995-2005 (n = 36,399,333), to examine trends in stillbirths, neonatal deaths, and serious neonatal morbidity (5-minute Apgar ≤3, assisted ventilation ≥30 min and neonatal seizures). Preterm birth subtypes were identified using an algorithm that categorized live births <37 weeks into iatrogenic preterm births, births following premature rupture of membranes and spontaneous preterm births. Temporal changes were quantified using odds ratios (OR) and 95% confidence intervals (CI). Among singletons, preterm birth increased from 7.3 to 8.8 per 100 live births from 1995 to 2005, while iatrogenic preterm birth increased from 2.2 to 3.7 per 100 live births. Stillbirth rates declined from 3.4 to 3.0 per 1,000 total births from 1995-96 to 2004-05, and neonatal mortality rates declined from 2.4 to 2.1 per 1,000 live births. Temporal declines in neonatal mortality/morbidity were most pronounced at 34-36 weeks gestation and larger among iatrogenic preterm births (OR = 0.75, CI 0.73-0.77) than among spontaneous preterm births (OR = 0.82, CI 0.80-0.84); P < 0.001. Similar patterns were observed among twins, with some notable differences. Increases in iatrogenic preterm birth have been accompanied by declines in perinatal mortality. The temporal decline in neonatal mortality/serious neonatal morbidity has been larger among iatrogenic preterm births as compared with spontaneous preterm births.
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Objectives—This report presents 2009 data on U.S. births according to a wide variety of characteristics. Data are presented for maternal characteristics including age, live-birth order, race and Hispanic origin, marital status, hypertension during pregnancy, attendant at birth, method of delivery, and infant characteristics (period of gestation, birthweight, and plurality). Birth and fertility rates by age, live-birth order, race and Hispanic origin, and marital status also are presented. Selected data by mother’s state of residence are shown, as well as birth rates by age and race of father. Trends in fertility patterns and maternal and infant characteristics are described and interpreted. Methods—Descriptive tabulations of data reported on the birth certificates of the 4.13 million births that occurred in 2009 are presented. Denominators for population-based rates are postcensal estimates
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To evaluate the distribution of births among United States (U.S.) hospitals in 2008 as part of the background for the Association of Women's Health, Obstetric and Neonatal Nurses' Guidelines for Professional Registered Nurse Staffing for Perinatal Units. Descriptive analysis of birth volumes in U.S. hospitals using American Hospital Association Annual Survey: 2008. U.S. hospitals providing obstetric (OB) services were identified based on information in any of three fields: OB services, OB beds, or number of births. Data were verified via telephone and/or website for the top 100 hospitals based on volume, hospitals with "Healthcare System" as part of their names, hospitals reporting births but no OB service, and hospitals reporting <100 births. Hospitals with <100 births were queried regarding nurse staffing. Descriptive statistics were used to analyze data. Approximately 3,265 U.S. hospitals offered OB services in 2008. The top 500 hospitals based on volume (15.3%) accounted for almost one half (47.4%) of births, the top 1,000 for 69.2%, and the remaining 2,265 for 30.8%. Fourteen percent of hospitals with <100 births in 2008 reported discontinuing OB services in 2010, in part due to lack of physician coverage and costs. Most hospitals (n=159, 72.3%) with <100 births routinely maintained two OB-skilled nurses in-house in 2010. U.S. births are unevenly distributed among hospitals; 15% have a disproportionate share of nearly one half of all births. Most hospitals (69.4%) are operating medium- to small-volume OB units. Most hospitals (72.3%) with <100 births annually reported currently meeting minimum staffing guidelines.
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To determine the trends and racial differences in early-term induction of labor in the United States. Data from the National Center for Health Statistics were used to identify women eligible for induction between 37-42 weeks' gestation in the United States from 1991-2006. Annual early-term induction rates were calculated, and maternal race/ethnicity was classified into 4 groups. The change in frequency and odds of early-term induction stratified by race/ethnicity over time was assessed. Among 39.2 million eligible women, early-term induction rates increased from 2.0% to 8.0% (P < .01) over 16 years. Cross-sectional and annual early-term induction rates were highest for non-Hispanic white women during the study period (P < .01). After adjusting for confounding factors, the odds of any early-term induction were highest (P < .01) and rose most rapidly (P < .01) among non-Hispanic white women compared with women from other racial/ethnic groups. In the United States, early-term induction rates rose significantly and were highest among non-Hispanic white women.
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We examined the relationship between obstetrical intervention and preterm birth in the United States between 1991 and 2006. We assessed changes in preterm birth, cesarean delivery, labor induction, and associated risks. Logistic regression modeled the odds of preterm obstetrical intervention after risk adjustment. From 1991 to 2006, the percentage of singleton preterm births increased 13%. The cesarean delivery rate for singleton preterm births increased 47%, and the rate of induced labor doubled. In 2006, 51% of singleton preterm births were spontaneous vaginal deliveries, compared with 69% in 1991. After adjustment for demographic and medical risks, the mother of a preterm infant was 88% (95% confidence interval [CI] = 1.87, 1.90) more likely to have an obstetrical intervention in 2006 than in 1991. Using new birth certificate data from 19 states, we estimated that 42% of singleton preterm infants were delivered via induction or cesarean birth without spontaneous onset of labor. Obstetrical interventions were related to the increase in the US preterm birth rate between 1991 and 2006. The public health community can play a central role in reducing medically unnecessary interventions.
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No studies exist that have examined the effectiveness of different approaches to a reduction in elective early term deliveries or the effect of such policies on newborn intensive care admissions and stillbirth rates. We conducted a retrospective cohort study of prospectively collected data and examined outcomes in 27 hospitals before and after implementation of 1 of 3 strategies for the reduction of elective early term deliveries. Elective early term delivery was reduced from 9.6-4.3% of deliveries, and the rate of term neonatal intensive care admissions fell by 16%. We observed no increase in still births. The greatest improvement was seen when elective deliveries at <39 weeks were not allowed by hospital personnel. Physician education and the adoption of policies backed only by peer review are less effective than "hard stop" hospital policies to prevent this practice. A 5% rate of elective early term delivery would be reasonable as a national quality benchmark.
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Key findings: Following a long period of fairly steady increase, the U.S. preterm birth rate declined for the second straight year in 2008 to 12.3 percent, from 12.8 percent in 2006. This marks the first 2-year decline in the preterm birth rate in nearly three decades. Preterm birth rates declined from 2006 to 2008 for mothers of all age groups under age 40, for the three largest race and Hispanic origin groups and for most U.S. states. The percentage of preterm births was down for all types of deliveries from 2006 to 2008, for cesareans and for induced and noninduced vaginal deliveries.
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To estimate the association of labor induction with the risk of a cesarean delivery for nulliparous women presenting at term at a regional hospital. This was a retrospective cohort study of cesarean delivery among nulliparous women delivering a live, singleton, vertex pregnancy at term. We used clinical data from electronic hospital obstetric records at a large, regional, obstetric hospital, approximating a population-based cohort. Multivariable logistic regression was used to explore risk factors associated with cesarean delivery, and the fraction of cesarean deliveries attributable to the use of labor induction was estimated. From a cohort of 24,679 women, 7,804 met inclusion criteria. Labor induction was used in 43.6% of cases, 39.9% of which were elective. Use of labor induction was associated with an increased odds of cesarean delivery (crude odds ratio 2.67, 2.40-2.96) and the association remained significant (adjusted odds ratio 1.93, 1.71-2.2) after adjustment for maternal demographic characteristics, medical risk, and pregnancy complications. The contribution of labor induction to cesarean delivery in this cohort was estimated to be approximately 20%. Labor induction is significantly associated with a cesarean delivery among nulliparous women at term for those with and without medical or obstetric complications. Reducing the use of elective labor induction may lead to decreased rates of cesarean delivery for a population. II.
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Key findings: Data from the Natality Data File, National Vital Statistics System. The cesarean rate rose by 53% from 1996 to 2007, reaching 32%, the highest rate ever reported in the United States. From 1996 to 2007, the cesarean rate increased for mothers in all age and racial and Hispanic origin groups. The pace of the increase accelerated from 2000 to 2007. Cesarean rates also increased for infants at all gestational ages; from 1996 to 2006 preterm infants had the highest rates. Cesarean rates increased for births to mothers in all U.S. states, and by more than 70% in six states from 1996 to 2007.
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To examine the effects that medical staff education and a new process for scheduling inductions had on decreasing inappropriate inductions. At our institution in 2004, guidelines were developed and shared with the medical staff and reinforced in 2005. The guidelines for elective induction required patients to have completed 39 weeks of gestation and to have a Bishop score of at least 8 for nulliparas and 6 for multiparas. In 2006, the induction scheduling process was changed and the guidelines were strictly enforced. All scheduled inductions during the same 3-month time period (June through August) in 2004 (n=533) and 2005 (n=454) and during a 13-month period from November 2006 to December 2007 (n=1,806) were compared. Outcomes included elective inductions less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and the overall induction rate. From 2004-2007, the overall induction rate dropped from 24.9% to 16.6%, a 33% reduction(P<.001); the elective induction rate dropped from 9.1% to 6.4%, a 30% reduction (P<.001); the percentage of elective inductions before 39 weeks of gestation dropped from 11.8% to 4.3%, a decrease of 64% (P<.001); and the frequency of cesarean delivery among nulliparas undergoing elective induction dropped from 34.5% to 13.8%, a decrease of 60%. (P=.01). Medical staff education and the development and enforcement of induction guidelines contributed to a decrease in inappropriate inductions, a lower cesarean birth rate for electively induced nulliparas, and a lower elective and overall induction rate. III.
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In 40,635 deliveries in 1978-85, unexplained stillbirths were an important component (nearly a quarter) of all perinatal deaths. The rate of unexplained stillbirth (unexplained stillbirths divided by total births) was highest among preterm deliveries, fell to a minimum at 39-40 weeks' gestation, then rose at 41-42 weeks. Rate is generally accepted as measuring risk, but since it is the population of undelivered, not delivered, infants that is at risk of intrauterine death, stillbirth risk would be better measured as the number of impending stillbirths divided by the total number of undelivered fetuses. With this measure the risk of unexplained stillbirth was least in preterm pregnancies, rising fourfold after 39 weeks to a maximum at 41 weeks. At this time, it was also four times higher than at 33 weeks, in contrast to the rate, which was nineteen times lower.
Article
The goal of this project was to study the increasing risk of induction of labor in a community hospital and to determine whether it had an adverse effect on the rate of cesarean delivery. Study Design: From January 1, 1990, through July 31, 1997, 18,055 consecutive singleton pregnancies in women who were candidates for labor were reviewed via a comprehensive perinatal database. The risk of and indication for induction were reviewed. Cesarean delivery rates were calculated for nulliparous and multiparous patients by indication for induction and were compared with rates for patients who had spontaneous labor. Overall trends in cesarean delivery were reviewed for the duration of the study period. The annual induction rate significantly rose from 32% to 43% at the conclusion of the study period. Labor was induced in nearly 40% of nulliparous patients. Postdate pregnancy was the most common indication for induction, although few patients were at or beyond 42 weeks' gestation. The cesarean delivery rate remained at or below 20% for the years of the study. No increase was noted in spite of the increasing risk of induction. However, for nulliparous patients who had elective induction of labor, the risk of cesarean delivery was twice that of nulliparous patients who had spontaneous labor. The use of induction methods has significantly increased in this community hospital. More than 40% of patients are now candidates for induction. The cesarean delivery rate remains low in this facility in spite of a marked increase in risk of operative delivery for nulliparous patients who undergo induction.
Article
To quantify the risk of cesarean delivery associated with elective induction of labor in nulliparous women at term. We performed a cohort study on a major urban obstetric service that serves predominantly private obstetric practices. All term, nulliparous women with vertex, singleton gestations who labored during an 8-month period (n = 1561) were divided into three groups: spontaneous labor, elective induction, and medical induction. The risk of cesarean delivery in the induction groups was determined using stepwise logistic regression to control for potential confounding factors. Women experiencing spontaneous labor had a 7.8% cesarean delivery rate, whereas women undergoing elective labor induction had a 17.5% cesarean delivery rate (adjusted odds ratio [OR] 1.89; 95% confidence interval [CI] 1.12, 3.18) and women undergoing medically indicated labor induction had a 17.7% cesarean delivery rate (OR 1.69; 95% CI 1.13, 2.54). Other variables that remained significant risk factors for cesarean delivery in the model included: epidural placement at less than 4 cm dilatation (OR 4.66; 95% CI 2.25, 9.66), epidural placement after 4 cm dilatation (OR 2.18; 95% CI 1.06, 4.48), chorioamnionitis (OR 4.61; 95% CI 2.89, 7.35), birth weight greater than 4000 g (OR 2.59; 95% CI 1.69, 3.97), maternal body mass index greater than 26 kg/m2 (OR 2.36; 95% CI 1.61, 3.47), Asian race (OR 2.35; 95% CI 1.04, 5.34), and magnesium sulfate use (OR 2.18; 95% CI 1.04, 4.55). Elective induction of labor is associated with a significantly increased risk of cesarean delivery in nulliparous women. Avoiding labor induction in settings of unproved benefit may aid efforts to reduce the primary cesarean delivery rate.
Article
Induction of labour is one of the fastest growing medical procedures in the United States. In 1998, 19.2% of all US births were a product of induced labour, more than twice the 9.0% in 1989. Induction of labour has been efficacious in the management of post-term pregnancy and in expediting delivery when the mother or infant is sufficiently ill to make continuation of the pregnancy hazardous. However, the recent rapid increase in induction, and particularly the doubling of the induction rate for preterm pregnancies (from 6.7% in 1989 to 13.4% in 1998), has generated concern among some clinicians. The present study uses vital statistics natality data to examine the epidemiology of induced labour in the US. Multivariable analysis is used to examine the probability of having an induced delivery in relation to a wide variety of socio-demographic and medical characteristics, and also in relation to relative indications and contraindications for induced labour as outlined by the American College of Obstetricians and Gynecologists (ACOG). Induction rates were higher for women who were non-Hispanic white, college educated, born in the US, primaparae and those with intensive prenatal care utilisation. Induction rates were also higher for women with various medical conditions including hypertension, eclampsia and renal disease. For non-Hispanic white women with singleton births, 59% of the increase in the preterm birth rate from 1989 to 1998 can be accounted for by the increase in preterm inductions. The adjusted odds ratio for neonatal mortality among preterm births with induced labour was 1.20 [95% confidence interval 1.11, 1.31]. The rapid increase in induction rates, particularly among preterm births, marks a shift in the obstetric management of pregnancy. More detailed studies are needed to examine physician decision-making protocols, particularly for preterm induction, and to assess the impact of these practice changes on patient outcomes.
Article
Despite widespread recognition that preventing preterm birth is the most important perinatal challenge facing industrialized countries, preterm birth has increased steadily in recent years. This article examines the relation between trends in preterm birth, preterm labor induction/cesarean delivery, stillbirth, and infant mortality. The recent rise in preterm birth in the United States and Canada has been mainly due to increases in mild preterm birth (34-36 weeks). Live births at 34 to 36 weeks' gestation have increased largely as a consequence of increases in preterm induction and preterm cesarean delivery among women at high risk for adverse pregnancy outcomes. Increased obstetric intervention at 34 to 36 weeks' gestation appears to have led to larger-than-expected temporal declines in stillbirth rates at this gestation. Infant mortality rates have declined overall and also among live births at 34 to 36 weeks' gestation. Obstetric intervention at preterm gestation, when indicated, can prevent stillbirth and reduce infant morbidity and mortality despite the increasing rates of preterm delivery.
Article
There is mounting evidence that infants born late preterm (34-36 weeks) are at greater risk for morbidity than term infants. This article examines the changing epidemiology of gestational length among singleton births in the United States, from 1992 to 2002. Analyzing gestational age by mode of delivery, the distribution of spontaneous births shifted to the left, with 39 weeks becoming the most common length of gestation in 2002, compared with 40 weeks in 1992 (P < 0.001). Deliveries at > or =40 weeks gestation markedly decreased, accompanied by an increase in those at 34 to 39 weeks (P < 0.001). Singleton births with PROM or medical interventions had similar trends. Changes in the distribution of all singleton births differed by race/ethnicity, with non-Hispanic white infants having the largest increase in late preterm births. These observations, in addition to emerging evidence of increased morbidity, suggest the need for investigation of optimal obstetric and neonatal management of these late preterm infants.
Article
Nationally and in New Jersey, the cesarean delivery rate has been increasing steadily for nearly a decade, and especially since 1999. The purpose of this study was to describe recent trends in cesarean section delivery in New Jersey. Data on delivery method, medical indications and patient characteristics were extracted from electronic birth certificate files. Cesarean section deliveries increased as a proportion of live births by 6 percent annually. Growth was roughly uniform across Robson's clinical classification. Repeat cesareans contributed only proportionately to the overall trend. The greatest acceleration was observed for procedures without trial of labor, and in medical situations where cesarean delivery had been relatively rare. Medical indications recorded on the birth certificate explained little of the rapid growth in utilization of cesarean delivery, since trends were comparable in most categories we examined. A sustained autonomous shift in practice patterns, patient preferences, or both seems the most likely driver of the overall trend.
Article
This report presents 2003 fetal and perinatal mortality data by a variety of characteristics, including maternal age, marital status, race, Hispanic origin, and state of residence; and by infant birthweight, gestational age, plurality, and sex. Trends in fetal and perinatal mortality are also examined. Descriptive tabulations of data are presented and interpreted. The U.S. fetal mortality rate in 2003 was 6.23 fetal deaths of 20 weeks of gestation or more per 1,000 live births and fetal deaths. Fetal and perinatal mortality rates have declined slowly but steadily from 1990 to 2003. Fetal mortality rates for 28 weeks of gestation or more have declined substantially, whereas those for 20-27 weeks of gestation have not declined. Fetal mortality rates are higher for a number of groups, including non-Hispanic black women, teenagers, women aged 35 years and over, unmarried women, and multiple deliveries. Over one-half (51 percent) of fetal deaths of 20 weeks of gestation or more occurred between 20 and 27 weeks of gestation.
Article
This report presents 2004 fetal and perinatal mortality data by a variety of characteristics, including maternal age, marital status, race, Hispanic origin and state of residence; and by infant birthweight, gestational age, plurality and sex. Trends in fetal and perinatal mortality are also examined. Descriptive tabulations of data are presented and interpreted. In 2004, there were 25,655 reported fetal deaths of 20 weeks of gestation or more in the United States. The U.S. fetal mortality rate was 6.20 fetal deaths of 20 weeks of gestation or more per 1,000 live births and fetal deaths, not significantly different from the rate of 6.23 in 2003. The fetal mortality rate for non-Hispanic black women (11.25) was 2.3 times the rate for non-Hispanic white women (4.98), whereas the rate for Hispanic women (5.43) was 9 percent higher than the rate for non-Hispanic white women. Fetal and perinatal mortality rates have declined slowly but steadily from 1990 to 2004. Fetal mortality rates for 28 weeks of gestation or more have declined substantially whereas those for 20-27 weeks of gestation have not declined. Fetal mortality rates are elevated for a number of groups, including teenagers, women aged 35 years and over, unmarried women, and multiple deliveries. In 2004, one-half of fetal deaths of 20 weeks of gestation or more occurred between 20 and 27 weeks of gestation.
Article
US births increased 3% between 2005 and 2006 to 4,265,996, the largest number since 1961. The crude birth rate rose 1%, to 14.2 per 1000 population, and the general fertility rate increased 3%, to 68.5 per 1000 women 15 to 44 years. Births and birth rates increased among all race and Hispanic-origin groups. Teen childbearing rose 3% in 2006, to 41.9 per 1000 females aged 15 to 19 years, the first increase after 14 years of steady decline. Birth rates rose 2% to 4% for women aged 20 to 44; rates for the youngest (10-14 years) and oldest (45-49) women were unchanged. Childbearing by unmarried women increased steeply in 2006 and set new historic highs. The cesarean-delivery rate rose by 3% in 2006 to 31.1% of all births; this figure has been up 50% over the last decade. Preterm and low birth weight rates also increased for 2006 to 12.8% and 8.3%, respectively. The 2005 infant mortality rate was 6.89 infant deaths per 1000 live births, not statistically higher than the 2004 level. Non-Hispanic black newborns continued to be more than twice as likely as non-Hispanic white and Hispanic infants to die in the first year of life in 2004. For all gender and race groups combined, expectation of life at birth reached a record high of 77.9 years in 2005. Age-adjusted death rates in the United States continue to decline. The crude death rate for children aged 1 to 19 years decreased significantly between 2000 and 2005. Of the 10 leading causes of death for children in 2005, only the death rate for cerebrovascular disease was up slightly from 2000, whereas accident and chronic lower respiratory disease death rates decreased. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.
Article
The increasing trend of delivering at earlier gestational ages has raised concerns of the impact on maternal and infant health. The delicate balance of the risks and benefits associated with continuing a pregnancy versus delivering early remains challenging. Among singleton live births in the United States, the proportion of preterm births increased from 9.7% to 10.7% between 1996 and 2004. The increase in singleton preterm births occurred primarily among those delivered by cesarean section, with the largest percentage increase in late preterm births. For all maternal racial/ethnic groups, singleton cesarean section rates increased for each gestational age group. Singleton cesarean section rates for non-Hispanic black women increased at a faster pace among all preterm gestational age groups compared with non-Hispanic white and Hispanic women. Further research is needed to understand the underlying reasons for the increase in cesarean section deliveries resulting in preterm birth.
Article
The percentage of United States cesarean births increased from 20.7% in 1996 to 31.1% in 2006. Cesarean rates increased for women of all ages, race/ethnic groups, and gestational ages and in all states. Both primary and repeat cesareans have increased. Increases in primary cesareans in cases of "no indicated risk" have been more rapid than in the overall population and seem the result of changes in obstetric practice rather than changes in the medical risk profile or increases in "maternal request." Several studies note an increased risk for neonatal and maternal mortality for medically elective cesareans compared with vaginal births.
Fetal and perinatal mortality
  • M F Macdorman
  • M L Munson
  • S Kirmeyer
  • MF MacDorman