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Trends in Preterm Birth,
Cesarean Delivery, and
Induction of Labor in Indiana
Statistics from Live Birth Data
1990-2006
Trends in Preterm Birth, Cesarean
Delivery, and Induction of Labor
in Indiana, 1990-2006
• Changes in gestational age distribution,
• Preterm rates by method delivery by gestational
age, race/ethnicity,
• Cesarean rate by total, primary and repeat,
• Rate of vaginal births after cesarean,
• Induction rate stratified by maternal race
/ethnicity, age and plurality,
• Index of occurrence by day of week and time of
day stratified by vaginal births, inductions,
primary and repeat cesareans.
Definitions
• Term: 39 weeks and 0 days through 42
complete weeks of gestation.
• Near Term: 37 to 38 weeks gestation.
• “Late Preterm”: 34 to 36 6/7 weeks gestation
• Preterm: <37 completed weeks gestation
The Prematurity Problem
• Serious health crisis that costs the United States
more than $26 billion annually.
• Key risk factor for infant death.
• High risk of serious and sometimes lifelong
health problems.
• Late preterm babies (34-36 weeks gestation) have
higher rates of death and disability than full-term
babies.
• Near term infants (born at 37-38 weeks) have
increased risk for problems compared to infants
born at 39 weeks.
Percent Preterm Births
Indiana and U.S, 1996-2006
Indiana
U.S.
15
10
5
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
0
In 2006, the preterm
birth rate in Indiana
was 13.4 percent
compared to 12.8
percent for the U.S.
Close to 12,000
babies were born
preterm.
More than 70 percent
were late preterm
births
Preterm Birth Rates:
Indiana, 2003-2006 Average
© March of Dimes Foundation, April 2009
Percent Distribution of Live Births
by Gestational Age: Indiana, 2006
•Nationally we are
seeing a shift in the
distribution of
gestational age from
40 weeks towards an
earlier gestation of
39 weeks.
•In Indiana the highest
number of births occur
at 37-38 weeks
gestation (near term)
not 40 weeks.
Percent Change by Gestational Age
in Weeks: Indiana 1990-2006
+63%
+38%
-20%
-46%
-54%
Looking at the
change in
distribution of
gestational age,
between 1990-2006,
we see a sharp
increase in late
preterm and near
term births with a
noticeable decline in
births at 40 weeks or
more.
Percent Preterm Births by
Gestational Age
<37 weeks
The preterm rate in Indiana
increased by 31 percent
from 10.2 in 1990 to 13.4 in
2006
Early preterm births have
remained fairly consistent over
time with a slight increase
among both 32-33 weeks and
< 32 weeks gestation.
Percent of Preterm Births by Race
and Hispanic Origin of Mother
Preterm rates remain
persistently higher
among non-Hispanic
blacks compared to nonHispanic whites and
Hispanics.
A 40% increase in the
white preterm rate has
shortened the disparity
gap not because of less
black babies being born
preterm but because
more white babies are
being born preterm.
Percent Late Preterm Births (34-36 wks)
by Race and Hispanic Origin of Mother
Late preterm births
increased sharply (by
48%) for non-Hispanic
whites and moderately
(16%) for Hispanics
while there was actually
a decrease among nonHispanic blacks since
2005.
Late Preterm Birth:
Indiana, 2003-2006 Average
Percent Distribution of Preterm
Births by Plurality
15% of preterm births
occur among multiples a
33% increase since 1990
85% of preterm births
occur among Singleton
births. a 26% increase
The remainder of this
report will report data
among singleton births
only.
Very Preterm:
Indiana, 2003-2006 Average
Very preterm is less than 32 completed weeks gestation.
© March of Dimes Foundation, April 2009
** Indicates less than five events or missing data. Not able to calculate a reliable rate.
Source: National Center for Health Statistics, final natality data. Retrieved October 26, 2009, from www.marchofdimes.com/peristats.
Total Cesarean Rate
In 2006, 29.3
percent of Indiana
births were
delivered by
cesarean, a 48%
increase from 19.8
percent in 1997.
Percent Preterm Births By Method
Of Delivery Among Singletons
This slide clearly
shows the
relationship of the
increase in cesarean
births to an increase
in preterm births in
Indiana.
Percent Preterm Births By
Gestational Age And Method
Delivery Among Singletons
there has been a 41%
increase in late preterm
births by cesarean
section compared to a
27% increase in late
preterm births among
vaginal deliveries
Total and Primary Cesarean Rate and
Vaginal Birth After Cesarean Rate
The rate of VBAC in
Indiana increased
from 16.5 percent in
1990 to an all time
high or 27.6 percent
in 1997, followed by
a dramatic decline to
5.8 percent.
Primary Cesarean Rate by Age of Mother
The 2006 rate for
women 35 years of age
and older (40.1%) was
double the rate for
mothers under 20
years of age (22.7%).
But
The largest increase
(66%) in primary
cesarean sections
occurred in the <20
year old, dooming
these young women to
a lifetime of repeat
cesareans and
increase risk of
complications.
Primary Cesarean Deliveries:
Indiana, 2003-2006 Average
St. Joseph
La Porte
Lake
Elkhart
Steuben
La Grange
Porter
Noble
De Kalb
Marshall
Kosciusko
Starke
Whitley
Jasper
Pulaski
Over 20.0 (31)
Miami
Benton
Wabash
Huntington
Wells
Cass
White
Carroll
Blac
kfor
d
Warren
Clinton
Adams
Grant
Howard
Tippecanoe
16.9-20.0 (32)
Allen
Fulton
Newton
Tipton
Madison
Jay
Delaware
Randolph
Fountain
Montgomery
Hamilton
Boone
Henry
Wayne
Parke
Under 16.9 (29)
Hendricks
Marion
Hancock
Putnam
Rush
Johnson
Clay
Vigo
Union
Fayette
Shelby
Morgan
Franklin
Owen
Decatur
Monroe
Brown
Bartholomew
Riple
y
Sullivan
Greene
Jennings
Lawrence
Ohio
Knox
Jefferson
Daviess
Martin
Washington
Scott
Orange
Clark
Pike
Dubois
Gibson
Crawford
© March of Dimes Foundation, April 2009
Posey
Vand
erburg
Dearborn
Jackson
Warrick
Perry
Spencer
Floyd
Harrison
Switzerland
Total Cesarean Deliveries:
Indiana, 2003-2006 Average
St. Joseph
La Porte
Lake
Elkhart
Steuben
La Grange
Porter
Noble
Marshall
Percent of live births
Whitley
Jasper
Allen
Fulton
Newton
Pulaski
Miami
Over 30.3 (30)
Benton
Wabash
Huntington
Wells
Cass
White
Carroll
Blac
kfor
d
Warren
Clinton
Adams
Grant
Howard
Tippecanoe
26.1-30.3 (35)
De Kalb
Kosciusko
Starke
Tipton
Madison
Jay
Delaware
Randolph
Fountain
Montgomery
Hamilton
Boone
Only 7 counties in
Indiana have a
Level III OB Hospital.
The majority of cesarean
deliveries are not
occurring in these
counties.
Henry
Wayne
Parke
Hendricks
Marion
Hancock
Putnam
Under 26.1 (27)
Rush
Johnson
Clay
Vigo
Union
Fayette
Shelby
Morgan
Franklin
Owen
Decatur
Monroe
Brown
Bartholomew
Riple
y
Sullivan
Greene
Jennings
Lawrence
Ohio
Knox
Jefferson
Daviess
Martin
Washington
Scott
Orange
Level III OB Hospital
Clark
Pike
Dubois
Gibson
Crawford
Posey
Vand
erburg
© March of Dimes Foundation, April 2009
Dearborn
Jackson
Warrick
Perry
Spencer
Floyd
Harrison
Switzerland
It is imperative that we
look more at this and
begin to develop a
perinatal system in
Indiana.
Top Ten Hospitals with the Highest Cesarean
Rate in 2006 Compared to Indiana State Rate
60
50
49.4 48.3 47.8
44.0 43.8 43.4
39.7 39.5 39.4 38.5
40
29.8
30
l/l
l/l
l/l
lll/lll
l/l
l/l
ll/ll
l/l
ll/ll
10
IN
20
10
0
2006
1
2
1/1
3
4
5
6
7
8
= Hospital Level of Care
9
l/l
ACOG Guidelines on the
Induction of Labor
“The new criteria for confirming a term pregnancy
provides clear and clinically relevant parameters to
accurately document when inductions might be
considered and cautions against inductions before 39
weeks in the absence of a medical indication,”
• The guidelines make clear that even mature lung
development is not a reason to induce delivery for
logistical reasons if the fetus is not at least 39 weeks old,
unless it is medically necessary.
• Risk of having a cesarean section doubles if labor is
induced and their cervix is not ready.
Comparison of Induced Labor Ending In Vaginal
Delivery And Cesarean Delivery by Day and Time
Inductions by Day and Time
50
Inductions in vaginal delivery show a
different pattern than inductions
resulting in cesarean delivery.
Inductions with vaginal deliveries occur
most often between noon-6PM on
Mondays and Thursdays during the
week
40
30
20
10
0
Mid-6am
6am-noon
noon-6pm
6pm-mid
Inductions Ending in Cesarean by Day and Time
Sun
Mon
Tue
Wed
Thu
Fri
Sat 50
40
Inductions with subsequent cesarean
occur most often during 6PM –
midnight and more often on Mondays
and Thursdays.
30
20
10
0
Mid-6am
6am-noon
noon-6pm
6pm-mid