August 04, 2003

US birth statistics

The latest edition of Birth - Issues in Perinatal Care has some interesting birth outcome statistics from the US, for the year 2001. The birthrate has fallen 1%, the first fall after 3 years of increases and now stands at 4,029,330. The teenage pregnancy rate has fallen by 26% since 1991 and the rate of low-birth weight babies has climbed slightly, (up 13% since the mid-80s) and the twin birth rate has risen 33% since 1990.

Breastfeeding rates are rising at the rate of about 2% each year and now stand at a 69.5% initiation rate and a 32.5% rate at 6 months of age.

The induction rate is up again to 20.5%, and EFM was again the most frequently reported obstetric procedure in 2001 (84.8%). Episiotomy has declined from 32.7% in 2000 to 29.2% in 2001, manually assisted birth (not sure what this term refers to) was 32.8% (31.3% in 2000), vacuum extraction was down to 8.0% (8.4% in 2000) and forceps declined from 4.00 in 2000 to 3.4% in 2001. Caesarean birth rates are not given but have been reported as up to around 22%.

Midwife attended births are up to 8 % in 2001 and the percentage of babies delivered by doctors in hospitals declines very slowly to 91.3% of all births. Almost all babies are born in hospitals (99%) and of the rest, 65% were in the home and 28% in a birth centre.

These figures would not differ markedly from those in Australia, except for a big difference in midwife attended births. Here, all maternity unit staff must be midwives and all catch babies, especially for hospital clients (as distinct from private obstetric clients). It is hard to see how birth can ever change dramatically in the US unless there are more midwives staffing hospitals. By the same token, it is hard to see how our birth outcome statistics will drop in Australia until we get staff specialist obstetricians in our hospitals, and limit their practice to emergencies and complications - those births that cannot be handled by midwives. In Australia, we know it is the private obstetric component of our care that is pushing up our rising interventions rates. In this we are slavishly following the American model, which is an example of how not to provide humanised, woman-centred and baby friendly maternity care!

Posted by andrea at August 04, 2003 04:39 PM

Comments

Andrea: I have hesitated to write a comment because I remain amazed at your perception of North American midwifery be it in the USA, Canada, or Mexico. All midwives who are licensed in these nations catch babies, all practice some variation of caseload midwifery and all provide humanised, woman centred, baby friendly care. Only some midwives in the USA are able to practise in all 3 settings: home, hospital, and birth centre (free-standing).At the moment except for maybe 2 or 3 states where some DEM's (direct entry midwives) have hospital privileges(they can accompany their clients to hospital and catch their babies) only CNM's (certified nurse midwives) are allowed by law to work in hospitals. These midwives do not work shifts as most midwives do here in hospital but rather various forms of caseload with a shared on-call rostering system. The wards: antenatal, gyne, postpartum and NICU are all staffed by specialist nurses who care for the clients of both doctors and nurse midwives. These specialist nurses do NOT catch babies BUT they are not nurse midwives. Not all hospitals employ nurse midwives, this is because of hospital policies NOT decisions by midwives. For DEM's to work in hospitals as nurse midwives they would have to undertake further education at a Masters level. This is prohibitive to many and deemed unnecessary to their lives. Both the MANA website: www.mana.org and the ACNM website at www.acnm.org can provide further information on North American midwifery.

marilyn

Posted by: Marilyn Kleidon on August 6, 2003 08:06 PM

Comments

Marilyn,

I think I have failed to make my point clear.... I do undertstand
that there are nurse midwives in the US etc as you have explained
and I have met many of them. My point is that there are relatively
few of them and they work primarily in the home, birth centres and
a few hospitals. The vast majority of the care for women having
babies in US hospitals is undertaken by obstetric nurses, who are
not allowed to catch babies, as you pointed out. These nurses work
under the direct supevision of doctors, and therefore the system
tends to be medicalised.

If all the maternity hospitals in the US were staffed by nurse midwives
instead of obstetric nurses, then there would be a chance that
alternatives to the medicalised approach may become a reality. When
I spoke at the MANA Conference, the figures I was given for the
number of nurse midwives in the US was around 10,000. This seemed
very low for a country with a population of 250 million and 4 million
births per year.

The only hospital that I know of in the US that is completely staffed
by midwives (not obstetric nurses) in the South Central Bronx Hospital
in New York and its birth outcome statisitics are legendary. There
may be other hospitals by now that have followed their lead, but
even so, they will be few and far between.

Another of the barriers to improving birth in the US is the plethora
of regulations around midwifery that vary between States. It must
be hard to get a consensus and difficult to forge national policies
when the laws make it impossible for programs and personnel to flow
easily across State borders.

For all these reasons, I think it will be a long time before birth
practices change much in the US, midwifery gains the recognition
it deserves and women have true choice freely available to them in
their maternity hospitals.

Have I clarified what I was getting at or so you think I still have it
wrong?

Posted by: Andrea Robertson on August 7, 2003 10:27 AM

Comments

I think you have it Andrea. I was sure you were aware of the many different kinds of midwives including CNM's in the USA, however, I am not sure that most Australian Midwives do and I didn't think your critique of US health care or birth stats did either. It is difficult to look at a nation of 50 sovereign states many such as California with populations the size of Australia. You do have to be aware that the medical profession did a pretty good job of eliminating midwifery in these 50 states up until the natural chilbirth movement of the late 1950's early 1960's. I am sure you are aware.

You are so right that labour and delivery nurses work under the direction/supervision of doctors whereas midwives are autonomous practitioners.

You should also be aware that even in New York city (the bastion of Nurse Midwifery) Nurse Midwifery is under threat by the medical profession. It is an ongoing battle to simply hold the ground they have gained since 1954 when the ACNM was founded.

Nurse Midwives are the true public health midwives serving the poor and oppressed of the USA since the 1930's with a small group that came to Kentucky from Britain after World War 1.

MANA midwives are equally dedicated, but by and large these are the midwives of the homebirth/out of hospital birth movements of the 1960's-80's and continuing; many are also CNM's, but not all.

I am not so sure that the USA changing to a system such as we have here is the way to go where I have to wonder about our autonomy. Unless we work independently or in the few but very special hospital group practices of midwives scattered around the country but perhaps clustered around Sydney, Adelaide, and Melbourne, we seem to be under obstetric supervision ie obstetric nurses who can catch the occassional baby. Sorry that that is so cynical.

You seemed to be saying that USA midwives don't want to work in a hospital setting (and of course like here, some don't). I just wanted to make it clear that for many it isn't an option. Where they do it is true midwifery care. If you want to compare midwifery care here with there it probably should be done on a hospital by hospital basis. Where there aren't nurse midwives working in a US hospital then it truly is pure unadulterated obstetric care.

I want to make it clear that i am NOT an advocate for US obstetrics but I am an advocate for american midwives of any stripe (from both the north and south continents of course). They have long been an oppressed group but are slowly but surely making in roads. As midwives we need to stand together supporting each other, but perhaps we do need to know who we truly are first.

marilyn

Posted by: Marilyn Kleidon on August 7, 2003 04:12 PM

Comments

"The Union for the Collaboration of Childbirth Professionals" doesn't that sound nice?

I am a student preparing to enter Seattle Midwifery School. I believe that it is necessary for Obstetricians and Midwives to unite: wouldn't it be grand if we were able to work side by side, and our clients have the choice to birth in a hospital or at home? Midwives provide such a woman-and-infant centered atmosphere and doctors are essential to have as allies when serious complications arise.

Unfortunately, the United States hospital world is governed primarily by patriarchial figures who are not interested above all in what is best for the populace they serve, but rather in avoiding law suits.

I don't mean to sound as though I think the medical community is all bad, but I do believe they are jaded.

I have enjoyed what you have written thus far...I am currently writing a hefty research paper on the "Medicalization of Childbirth", if you have any suggestions, I would love to hear them!

Posted by: Aimee Stilts on December 7, 2003 11:37 AM