Post on 22-Feb-2016
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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
BirthByTheNumbers.org
Key Question
Is the U.S. really doing as badly as it seems in
international comparisons?
BirthByTheNumbers.org
BirthByTheNumbers.org
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
Outcomes: Comparative Neonatal Mortality RatesRank Country Rank
Country Rank Country
1 Andorra (1) Greece CubaIceland Ireland HungaryJapan Italy IsraelLuxembourg Malta Lithuania
San Marino Monaco MalaysiaSingapore Norway Netherlands
7 Belgium (2) Portugal New ZealandCyprus Korea SlovakiaCzech Republic Slovenia SwitzerlandDenmark Spain United KingdomEstonia Sweden 39 United States (4)Finland 26 Australia (3) Canada, CroatiaFrance 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
Outcomes: Comparative Neonatal Mortality RatesRank Country Rank
Country Rank Country
1 Iceland (1) Greece CubaJapan Ireland HungarySingapore Italy IsraelAndorra Malta Lithuania
San Marino Monaco MalaysiaLuxembourg Norway Netherlands
7 Belgium (2) Portugal New ZealandCyprus Korea SlovakiaCzech Republic Slovenia SwitzerlandDenmark Spain United Kingdom
Estonia Sweden 39 United States (4)Finland 26 Australia (3) Canada, CroatiaFrance Austria Poland, Qatar
Germany Brunei Serbia, Un. Arab Emir.Source: World Health Statistics 2011http://www.who.int/healthinfo/statistics/mortality_neonatal/en/index.html
TWO PROBLEMS(1) Comparisons – Seven countries
highlighted had fewer combined births than the state of Idaho
(2) Measurement – Is neonatal mortality the best measure to use?
BirthByTheNumbers.org
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 2009Births
Andorra 828Iceland 5,027Luxembourg 5,639San Marino 334Malta 4,143Monaco 298Brunei 7,280TOTAL 23,549
BirthByTheNumbers.org
BirthByTheNumbers.org
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 $1,500 in US dollars.
Defining a Set of Countries to Compare with the U.S.16 Comparison Countries (OECD, Health Data 2010)
2010 Total Births
(000)
2009Total exp. health –
PC, US$ PPP
2008% Births by
CesareanAustralia 296 3,445 30.8Belgium 127 3,946 17.3Canada 378 4,363 26.6Czech Republic 117 2,108 20.5France 829 3,809 19.9Germany 681 4,218 29.4Greece 118 2,679 NAItaly 562 3,137 38.5Japan 1,070 2,878 18.0Korea 445 1,879 35.4Netherlands 184 4,914 14.3Portugal 101 2,508 32.7Spain 480 3,067 24.6Sweden 116 3,722 16.8United Kingdom 779 3,487 23.4United States 4,248 7,960 32.3
BirthByTheNumbers.org
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
Neonatal Mortality Rates (per 1,000 births), 2009, Industrialized with 100,000+ Births
1.21.61.6
22.1
2.32.3
2.42.52.5
2.62.8
33.2
3.43.8
4.2
0 1 2 3 4 5
JapanCzech Republic
SwedenGreece
SpainGermany
ItalyKorea
BelgiumPortugal
FranceNetherlands
AustraliaUnited Kingdom
U.S. WhiteCanada
United States
Source: OECD Health Data 2011 and NCHS, Deaths Final Data for 2007. BirthByTheNumbers.org
Perinatal Mortality Rates (per 1,000 births), 2009, Industrialized Countries with 100,000+ Births
2.93.2
3.63.63.6
4.44.64.6
5.25.3
5.66.0
6.46.6
7.613.9
0 5 10 15
JapanKorea#
Australia*Czech Republic
SpainItaly#
GreecePortugalSweden
GermanyNetherlands
Belgium*Canada#
United States*United Kingdom
France
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.
*2005; #2008
Maternal Mortality Ratios
Maternal Mortality Ratio
Maternal Deaths all causes X 100,000
_______________Live births
Maternal Mortality Rates, (per 100,000 births), 2009, Industrialized Countries with 200,000+ births
22
3.45
5.36.5
7.68
10.512
12.7
2 15
Australia*
Italy^
Spain
Japan
Germany
Canada
France#
United Kingdom
US WNH#
Korea*
United States#
Sources: OECD Health Data 2011; NCHS. 2009. Deaths, Final Data, 2007.
U.S. 2007:Black non-Hispanic 28.4White non-Hispanic 10.5Hispanic 8.9
Maternal Mortality Rate
*2008; #2007; ^2006
BirthByTheNumbers.org
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?
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.
US Subgroups in Comparative Contextwith other Industrialized Countries
US Subgroup U.S. IMR 2007
Rank (16 - 100K)
All 6.8 16White 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.
US Subgroups in Comparative Contextwith other Industrialized Countries
US Subgroup U.S. IMR 2007
Rank (16- 100K)
All 6.8 16White Non-Hispanic 5.6 16White 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.
US Subgroups in Comparative Contextwith other Industrialized Countries
US Subgroup U.S. IMR 2007
Rank (16- 100K)
All 6.8 16White Non-Hispanic 5.6 16White NH, Native Born 5.7 16White 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.
US Subgroups in Comparative Contextwith other Industrialized Countries
US Subgroup U.S. IMR 2007
Rank (16- 100K)
All 6.8 16White Non-Hispanic 5.6 16White NH, Native Born 5.7 16White 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.
Examining Trends over Time
Neonatal Mortality Rate, 2000-2009, U.S., & Ave. for Industrialized Countries*
2
3
4
5
Rat
e pe
r 1,0
00 li
ve b
irths
Source: OECD Health Data, 2011
U.S.
* Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Italy, Japan, Netherlands, Portugal, Spain, Sweden, U.K.
2.2 per 1,000
4.2 per 1,0004.6 per 1,000
3.1 per 1,000
Industrialized Countries
28% decrease
8% decrease
Neonatal Mortality Rate, 2000-2009, U.S., & Ave. for Industrialized Countries*
2
3
4
5
Rat
e pe
r 1,0
00 li
ve b
irths
Source: OECD Health Data, 2011
U.S.
* Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Italy, Japan, Netherlands, Portugal, Spain, Sweden, U.K.
2.2 per 1,000
4.2 per 1,0004.6 per 1,000
3.1 per 1,000
Industrialized Countries
28% decrease
8% decrease
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.
Perinatal Mortality Rates, 2000-2008 , U.S., & Ave. for Industrialized Countries*
5
5.5
6
6.5
7
7.5
2000 2001 2002 2003 2004 2005 2006 2007 2008
Rat
e pe
r 1,0
00 li
ve b
irths
+ fe
tal d
eath
s
Source: MacDormanM. Fetal and Perinatal Mortality, U.S., 2005. 2009.NCHS V. 57#8 and OECD Health Data 2011
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
Maternal Mortality Ratios (per 100,000 births), 2000-2008, U.S. & Ave.
Industrialized Countries*
4
8
12
16
2000 2001 2002 2003 2004 2005 2006 2007 2008
Dea
ths
per 1
00,0
00 li
ve b
irths
Industrialized Countries
15 % Decrease
U.S.30%
Increase
* 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.
Case Ascertainment??
Gestational Age, U.S. All Births, 1990, 2009
0%
5%
10%
15%
20%
25%
30%
<32 32-33 34-36 37 38 39 40 41 42+
19902009
* Only births occurring at home. Source: Vital Stats website
BirthByTheNumbers.org
What about process?
US Cesarean Rates, 1989-2010
2022242628303234
% Tot US 23 22.7 22.622.3 21.8 21.2 20.820.7 20.8 21.2 22.0 23 24 26 28 29 30 31 32 32 33 33
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10
%
Source: National Center for Health Statistics Annual Birth Reports
%
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.
14.3%17.1%17.3%
18.0%20.0%
21.2%23.7%
24.9%26.6%
30.3%
33.0%
38.4%
32.8%
31.8%
30.8%
10% 45%
*NetherlandsSweden
*BelgiumJapan
FranceCzech RepublicUnited Kingdom
Spain*Canada
Germany*Australia
**United StatesPortugal
KoreaItaly
Sources: OECD Health Data 2011; U.S. Natality Data; Japan – sample; Lancet 6736(09)61870-5.
Cesarean Rates in Industrialized Countries* with 100,000+ Births, 2009
*2008; **2010
* No data on cesarean rates in Greece
18202224262830323436
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
WNH BNH Hisp
Total cesarean rates by race/ethnicity, U.S. 1989-2010
Source: National Center for Health Statistics Annual Birth Reports
1989 WNH +1.4percentage
points2010 BNH
+2.9 percentage points
BirthByTheNumbers.org
Total Cesarean Rates (per 100 births) by Age of Mother: United States, 1996 and 2009
14.517.4
20.623.8
27.431.6
23.128.5
31.736.3
42.8
49.5
0
10
20
30
40
50
60
<20 20-24 25-29 30-34 35-39 40-54
1996 2009
59% 64% 54% 53% 56% 57%%
Source: National vital statistics system, NCHS, CDC.
Per
cent
Overall increase, 1996-2009: 58.5%
VBAC Rates*, U.S.,1990-2009
5%
10%
15%
20%
25%
30%
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Source: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm
* Number of VBACs among women with prior cesarean
NOTE: Rates for 2005-2009 are unofficial
VBAC Rates, Selected Countries, 2004
0 10 20 30 40 50 60
NetherlandsNorwayFinland
SwedenGermany
Czech RepDenmark
FranceBelg-Flanders
ScotlandSpain-Valencia
SloveniaMalta
EstoniaCanada
LithuaniaLatvia
U.S. VBACs
51
41
45
5155
25
2732
3539
41
919
24
25
25
20
8
Source: Adapted from Peristats, US & Canadian Data
BirthByTheNumbers.org
Do High Rates of Intervention Matter?
1. Outcomes (NMR & GA)2. Costs
Source: Althabe F.Cesarean Section Rates and Maternal & Neonatal Mortality Birth.2006;33:270
Cesarean Rates and Neonatal Mortality
Low Income
Medium Income
High Income
Percent of singleton preterm (<37 weeks) births by method of delivery, United States,
1991-2006
0
2
4
6
8
10
12
1991 1996 2001 2006
Perc
ent
Cesarean noinduction
Cesarean afterinductionattemptInducedvaginal
Spontaneousvaginal
Note: Births with method of delivery and induction of labor not stated are excluded.Source: MacDorman et al. AJPH, 2011.
9.7%
5.7%
6.7%
11.0%
National Costs and Hospitalizations
LEADING MAJOR DIAGNOSTIC CATEGORIES by NUMBER OF HOSPITAL DISCHARGES, U.S., 2009
1,274,786
1,490,050
1,621,592
2,210,056
3,370,140
3,429,592
3,964,889
4,300,390
4,591.5155,801,081
0
1,00
0,00
0
2,00
0,00
0
3,00
0,00
0
4,00
0,00
0
5,00
0,00
0
6,00
0,00
0
7,00
0,00
0
Endocrine, Nutritional & Metabolic
Mental Diseases & Disorders
Kidney & Urinary Tract
Nervous System
Musculoskeletal System
Digestive System
Respiratory System
Newborns & Other Neonates
Pregnancy, Childbirth
Diseases of The Circulatory System
AHRQ. 2011. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 7/16/2011.
MEDIAN FACILITY LABOR & BIRTH CHARGES BY SITE & MODE OF BIRTH, U.S., 2009
$5,003$7,419 $8,726
$3,956$4,614
$6,130$7,272
$4,081
$0
$18,000
Hospital Vaginalno Complications
Hospital VaginalComplications
Hospital CesareanNo Complications
Hospital CesareanComplications
Sources: AHRQ. 2010. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 11/1/10;
$8,037$9,644
$15,998
$13,549
NOTE: Hospital charges; no physician costs
Charge in 2000
Increase in Charge in 2000-2009
Charge in 2009
Estimated Total Charges, Hospital Birth, U.S., 1993-2009 (000,000)
0
10,000
20,000
30,000
40,000
50,000
60,00019
93
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Vag no Compl.Vag w Compl.Ces no Compl.Ces w/ Compl.
Sources: AHRQ. 2009. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 7/16/11.
$ 50,942
$ 14,039
BirthByTheNumbers.org
Have maternal request cesareans played a major role in these
increases?
http://www.childbirthconnection.org
Asking Mothers about Maternal Request Cesareans
BirthByTheNumbers.org
Two Components to Maternal Request Primary Cesarean
1. Mother made request for planned cesarean before labor
BirthByTheNumbers.org
Two Components to Maternal Request Primary Cesarean
1. Mother made request for planned cesarean before labor
2. Cesarean for no medical reason
BirthByTheNumbers.org
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
Pressure to Accept Interventions by Method of Delivery
Did you feel pressure from any health professional to have a cesarean? % yes
1%
35%
26%
25%
0% 10% 20% 30% 40%
Vaginal
VBAC
PrimaryCesarean
RepeatCesarean
Source: Declercq et al. 2006. Listening to Mothers II.
BirthByTheNumbers.org
Have maternal request cesareans played a major role in these increases?
NO!So what is the reason for the
increasing cesarean rate?
BirthByTheNumbers.org
Have maternal request cesareans played a major role in these increases?
NO!So what is the reason for the
increasing cesarean rate?
Practice Changes
Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications
30
35
40
45
50
1991 1996 2009
DiabetesEclampsiaPregAss HypertensionChronic HypertensionProlonged LaborBirthweight > 4000g
*Singleton, Vertex, Full Gestation Births
US Cesarean Rates, 1989-2010
2022242628303234
% Tot US 23 22.7 22.622.3 21.8 21.2 20.820.7 20.8 21.2 22.0 23 24 26 28 29 30 31 32 32 33 33
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10
%
Source: National Center for Health Statistics Annual Birth Reports
%
30
35
40
45
50
1991 1996 2009
DiabetesEclampsiaPregAss HypertensionChronic HypertensionProlonged LaborBirthweight > 4000g
Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications
*Singleton, Vertex, Full Gestation Births
30
35
40
45
50
1991 1996 2009
DiabetesEclampsiaPregAss HypertensionChronic HypertensionBirthweight > 4000g
Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications
Source: CDC Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm*Singleton, Vertex, Full Gestation Births
Women have not changed nearly as much as practice patterns have
For more information and additional resources regularly
check:
BirthByTheNumbers.org
The site is updated as additional data becomes available.