US Birth Outcomes in a Comparative Context

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


Key Question

Is the U.S. really doing as badly as it seems in

international comparisons?



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?


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



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


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


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


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.



Rank (16 - 100K)

All 6.8 16White Non-Hispanic 5.6 16




Rank (16- 100K)

All 6.8 16White Non-Hispanic 5.6 16White NH, Native Born 5.7 16




Rank (16- 100K)

All 6.8 16White Non-Hispanic 5.6 16White NH, Native Born 5.7 16White NH, Singleton Birth 4.9 15




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


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


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


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


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


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


1989 WNH +1.4percentage

points2010 BNH

+2.9 percentage points


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


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

http://hcupnet.ahrq.gov/

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

http://hcupnet.ahrq.gov/


Have maternal request cesareans played a major role in these

increases?

http://www.childbirthconnection.org

Asking Mothers about Maternal Request Cesareans


Two Components to Maternal Request Primary Cesarean

1. Mother made request for planned cesarean before labor


Two Components to Maternal Request Primary Cesarean

1. Mother made request for planned cesarean before labor

2. Cesarean for no medical reason


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.


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

NO!So what is the reason for the

increasing cesarean rate?


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

%


%

30

35

40

45

50

1991 1996 2009

DiabetesEclampsiaPregAss HypertensionChronic HypertensionProlonged LaborBirthweight > 4000g


*Singleton, Vertex, Full Gestation Births

30

35

40

45

50

1991 1996 2009

DiabetesEclampsiaPregAss HypertensionChronic HypertensionBirthweight > 4000g


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:


The site is updated as additional data becomes available.

US Birth Outcomes in a Comparative Context

Documents

health data

total births

outcomesseven countries

set of countries

comparison countries

world health statistics

us birth outcomes

health pc