Transcript Birth By the Numbers 2015 Part I: Is there a problem? Gene Declercq, PhD www.birthbythenumbers.org With support from: The Transforming Birth Fund BirthByTheNumbers.org.

Birth By the Numbers 2015
Part I: Is there a problem?
Gene Declercq, PhD
www.birthbythenumbers.org
With support from:
The Transforming Birth Fund
BirthByTheNumbers.org
12,104
1,296,070
9.2%
BirthByTheNumbers.org
Total U.S. Births, 1990-2014
4,400,000
4,316,233
4,300,000
4,200,000
4,100,000
4,000,000
3,900,000
Net Decrease 2007-2013
330,309 or 7.7%
3,985,924
3,800,000
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
Source: Adapted from CDC VitalSTATS. http://www.cdc.gov/nchs/VitalStats.htm
BirthByTheNumbers.org
U.S. Fertility Rates (per 1,000) by
Race/Ethnicity, 1989-2013
All
WNH
BNH
Hisp
110
100
90
80
70
60
20
13
20
11
20
09
20
07
20
05
20
03
20
01
19
99
19
97
19
95
19
93
19
91
19
89
50
Fertility rates computed by relating total births, regardless of age of mother,
to women 15-44 years.
Prematurity and Low Birthweight,
U.S., 1981-2014
13
12
Prematurity
11.6%
Decrease
2006-14
11
10
%
9
Low Birthweight
8
7
6
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013
Year
BirthByTheNumbers.org
Percent of all births at home, or in a birthing
center, United States, 1990-2013
55% Increase
2004-2013
1.6
1.4
1.2
46,956
(1.13%)
Total home &
birth center
52,993
(1.35%)
35,587
(0.87%)
36,080
1
Home
0.8
0.6
0.4
16,913
Birthing center
0.2
0
Source: NCHS Annual Birth Reports
BirthByTheNumbers.org
Is the U.S. really doing as
badly as it seems in
international
comparisons?
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
BirthByTheNumbers.org
Outcomes: Comparative Neonatal Mortality Rates
Rank
1
8
Country
Andorra (1/1,000)
Rank
14
Country
Czech Republic
Rank
27
Country
Sweden
Finland
Denmark
Canada (3/1,000)
Iceland
Estonia
Croatia
Japan
France
Cuba
Luxembourg
Germany
Greece
San Marino
Ireland
Lithuania
Singapore
Israel
Netherlands
Australia (2/1,000)
Austria
Italy
Monaco
New Zealand
Poland
Bahrain
Norway
Spain
Belarus
Belgium
Portugal
Repub. of Korea
Switzerland
United Kingdom
13
26
Cyprus
Source: State of the World’s Children2015.
39
Slovenia
United States
(4/1,000)
BirthByTheNumbers.org
Outcomes
Total Births in the five
countries in red
background in 2012
were 11,685 or fewer
than the 12,278 in South
Dakota in 2014
Country
2012-14
Births
Andorra
737
Iceland
4,375
Luxembourg
6,070
San Marino
296
Monaco
207
TOTAL
11,685
BirthByTheNumbers.org
What’s a Fair Comparison with
the US?
In the most recent year available (2013):
• Countries with at least 100,000 births
• Countries with a total per capita annual
expenditure on health of at least $2,000
annually in US dollars.
BirthByTheNumbers.org
Defining a Set of Countries to Compare with the U.S.
16 Comparison Countries
(SOURCE: OECD, Health Data 2015
& State of World’s Children, 2015)
2013
Total Births
(000)
2013
Total exp. health –
PC, US$ PPP
2013
% Births by
Cesarean
*3,866
*31.2
Australia
308
Belgium
129
4,256
*19.7
Canada
396
#4,429
*26.1
Czech Republic
118
2,040
23.3
France
792
4,124
20.2
Germany
702
Greece
#
5,002
31.4
108
2,366
NA
Israel
157
2,428
19.9
Italy
560
#
37.7
Japan
1,062
#
18.0
Korea
472
#
34.6
Netherlands
179
#
5,217
*15.6
Spain
488
*2,928
24.9
Sweden
115
4,904
16.2
United Kingdom
770
3,235
24.1
3,954
8,713
32.8
United States
* 2012 #2014
3,126
3,768
2,440
BirthByTheNumbers.org
IOM chose 16 peer
countries. 13 are same as
the one’s we’ve used. They
use 4 countries (Denmark,
Finland, Portugal,
Switzerland) that have
<100,000 births. We include
Belgium, Czech Republic,
Greece and Israel
BirthByTheNumbers.org
How is the U.S. doing relative to
comparison countries?
Neonatal Mortality Perinatal Mortality
Rate
Rate
Infant Deaths in
First 27 days
X 1,000
_____________
Live
Births
Fetal deaths + deaths in
the first week
X 1,000
_______________
Live births + fetal
deaths
BirthByTheNumbers.org
Neonatal Mortality Rates (per 1,000 births), 2012,
Industrialized Countries with 100,000+ Births
4.1
Uni ted States
3.6
Uni ted Kingdom
Sweden
2.9
2.6
Spai n
2.4
2.4
Net herlands
Kor ea
2.3
2.2
2.2
Australia
Japan
Italy
2.1
Israel
2
1.9
Greece
Ger many
1.7
1.7
France
Czech Republ ic
Canada#
*2010; #2011 rate
1.6
1
Bel gium*
0
1
Neonatal Mortality Rate
2
Source: OECD Health Data 2015 and NCHS, Deaths Final Data for 2012.
3
4
5
BirthByTheNumbers.org
Neonatal Mortality Rates (per 1,000 births), 2012,
Industrialized Countries with 100,000+ Births
3.6
Uni ted Kingdom
U.S. NHWhite
3.45
2.9
Sweden
2.6
Spai n
2.4
2.4
Net herlands
Kor ea
2.3
2.2
2.2
Australia
Japan
Italy
2.1
Israel
2
1.9
Greece
Ger many
1.7
1.7
France
Czech Republ ic
Canada#
*2010; #2011 rate
1.6
1
Bel gium*
0
1
Neonatal Mortality Rate
Source: OECD Health Data 2015 and NCHS, Deaths Final Data, 2012.
2
3
4
BirthByTheNumbers.org
Perinatal Mortality Rates (per 1,000 births),
2012, Industrialized Countries 100,000+ Births
France
Australia
United Kingdom
Belgium*
United States
Canada#
Greece
Netherlands
Germany
Sweden
Israel
Italy
Spain
Czech Republic
Korea
Japan
11.9
8.2
7.0
6.7
6.2
6.0
5.6
5.3
5.3
5.1
4.7
*2010; #2011
4.0
3.7
3.7
3.1
2.7
0
2
4
6
8
10
12
14
Perinatal Mortality Rate
Source: OECD Health Data 2015
BirthByTheNumbers.org
Perinatal Mortality Rates (per 1,000 births),
2012, Industrialized Countries 100,000+ Births
France
Australia
United Kingdom
Belgium*
Canada#
Greece
Netherlands
Germany
U.S. NHWhite
Sweden
Israel
Italy
Spain
Czech Republic
Korea
Japan
11.9
8.2
7.0
6.7
6.0
5.6
5.3
5.3
5.2
5.1
4.7
*2010; #2011
4.0
3.7
3.7
3.1
2.7
0
2
4
6
8
10
12
14
Perinatal Mortality Rate
Source: OECD Health Data 2015
BirthByTheNumbers.org
Maternal Mortality Ratios
Maternal Mortality Ratio
Maternal Deaths* all causes
X 100,000
_______________
Live births
* Deaths in pregnancy and up to 42 days postpartum
BirthByTheNumbers.org
Maternal Mortality Rates, (per 100,000 births), 2012,
Industrialized Countries with 300,000+ births
12.7
United States^
10.5
U.S. NHWhite^
9.9
Korea
6.4
United Kingdom
6.1
France*
5.2
Australia
Canada*
4.8
Japan
4.8
4.6
Germany
Spain
2.2
Italy
2.1
U.S. 2007:
Black non-Hispanic
White non-Hispanic
Hispanic
28.4
10.5
8.9
*2011; ^2007
Maternal Mortality Ratio
1
Sources: OECD Health Data 2015; NCHS. 2009. Deaths, Final Data, 2007.
15
Are things Getting
Better or Worse?
Are things Getting
Better or Worse?
Yes
Are things Getting
Better or Worse?
Yes
Things are getting better in
the U.S., but at a slower
pace than comparable
countries
Examining Trends
over Time
5
U.S.
4.6
11% decrease
4.1
4
3
Industrialized
Countries
31% decrease
3.2
2.2
20
12
20
10
20
08
20
06
20
04
20
02
2
20
00
Rate per 1,000 live births
Neonatal Mortality Rate (per 1,000 births), 20002012, U.S., & Ave. for Industrialized Countries*
* Countries with 100,000+ births (2012): Australia, Belgium, Canada, Czech Republic, France, Germany,
Greece, Israel, Italy, Japan, Netherlands, Spain, S. Korea, Sweden, U.K.
Source: OECD Health Data, 2014 & MacDorman MF, et al. Recent declines in infant mortality in the
United States, 2005–2011. NCHS data brief, no 120. Hyattsville, MD: NCHS. 2013.
5
U.S.
4.6
4
3
3.2
11% decrease
4.1
If the U.S. neonatal mortality rate
equaled the current average rate
of the other countries in 2012,
Industrialized
that would mean about 7,345
Countries
fewer deaths to babies 28 days 31% decrease
2.2
or younger annually.
20
12
20
10
20
08
20
06
20
04
20
02
2
20
00
Rate per 1,000 live births
Neonatal Mortality Rate (per 1,000 births), 20002012, U.S., & Ave. for Industrialized Countries*
* Countries with 100,000+ births (2012): Australia, Belgium, Canada, Czech Republic, France, Germany,
Greece, Israel, Italy, Japan, Netherlands, Spain, S. Korea, Sweden, U.K.
Source: OECD Health Data, 2014 & MacDorman MF, et al. Recent declines in infant mortality in the
United States, 2005–2011. NCHS data brief, no 120. Hyattsville, MD: NCHS. 2013.
95,000 fewer neonatal deaths 2000-2012
Capacity – 92,524
Perinatal Mortality Rates, 2000-2012 ,
U.S., & Ave. for Industrialized Countries*
7.0
U.S.
11 %
decrease
6.5
6.0
5.5
Industrialized
Countries
14% decrease
5.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
* Countries with 100,000+ births (2012): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Israel, Italy,
Japan, Netherlands, S. Korea, Spain, Sweden, United Kingdom
Sources: OECD Health Data 2015; NCHS. 2012. Fetal & Perinatal Mortality, 2006.
BirthByTheNumbers.org
Maternal Mortality Ratios (per 100K births),
2000-2013, U.S. & Comparable Countries *
Deaths per 100,000 live births
24
20
Case Ascertainment?
16
U.S. 124%
Increase
12
8
OECD 19%
Decrease
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
4
* Countries with 300,000+ births (2012): Australia, Canada, France, Germany, Italy, Japan, S. Korea, Spain, United Kingdom
Sources: OECD Health Data 2015; ^California Maternal Quality Care
Collaborative (CMQCC) 2014; NCHS. 2009. Deaths, Final Data, 2007.
NOTE: 2008-2013 US
rates unofficial^
What about process?
BirthByTheNumbers.org
US Cesarean Rates, 1989-2014
34
32
30
28
%
% 26
24
22
20
1,283,467
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 '14
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33 32
If the 2014 cesarean rate was the same as in 1996, there
would have been 458,000 fewer cesareans in the U.S. in ’14.
Source: National Center for Health Statistics Annual Birth Reports
Primary Cesarean and VBAC Rates,
U.S., 1989-2011
30%
Prim Ces Rate
VBAC
25%
20%
15%
9.2%
Source: NCHS. Annual Birth Reports & Vital Stats
20
11
20
09
20
07
20
05
20
03
20
01
19
95
19
93
19
91
19
89
5%
19
99
Note: 2005-2011
unofficial
19
97
10%
r = -.95
Cesarean Rates in Industrialized
Countries* with 100,000+ Births, 2011
33.4%
Italy
32.8%
Korea
United States
Austr ali a
31.4%
30.8%
30.9
Germany
Canada
26.2
25.2
Spain
Czech Republic
United Kingdom
France
Belgium
Israel
Sweden
Netherlands
1000%
24.4
24.3
20.8
20.2
*2010
16.4
16.3
15.6
* No data on cesarean rates in Greece
4500%
Sources: OECD Health Data 2014; U.S. Natality Data; Japan – sample; Lancet 6736(09)61870-5.
Cesarean Rates (%) in Industrialized
Countries* with 100,000+ Births, 2012
36.8
36.0
Italy
Korea
32.2
32.1
30.9
United States^
Australia
Germany
26.2
25.2
24.4
24.3
Canada*
Spain
Czech Republic
United Kingdom
20.8
20.2
France
Belgium
#2010; *2011;
^2014
16.4
16.3
15.6
Israel
Sweden
Netherlands#
0
5
10
15
20
25
30
* No data on cesarean rates in Greece and Japan
35
40
Cesarean Rates in Industrialized
Countries* with 100,000+ Births, 2011
33.4%
Italy
32.8%
Korea
United States
Austr ali a
31.4%
30.8%
30.9
Germany
Canada
26.2
25.2
Spain
Czech Republic
United Kingdom
France
Belgium
Israel
Sweden
Netherlands
1000%
24.4
24.3
20.8
20.2
*2010
16.4
16.3
15.6
* No data on cesarean rates in Greece
4500%
Sources: OECD Health Data 2014; U.S. Natality Data; Japan – sample; Lancet 6736(09)61870-5.
VBAC Rates, Selected Countries, 2004
VBACs
8
U.S.
Latvia
Lithuania
Canada
Estonia
Malta
Slovenia
Spain-Valencia
Scotland
Belg-Flanders
France
Denmark
Czech Rep
Germany
Sweden
Finland
Norway
Netherlands
9
19
20
24
25
25
25
27
32
35
39
41
41
45
51
51
55
0
10
20
30
40
Source: Adapted from EuroPeristats, US & Canadian Data
50
60
Do High Rates of
Intervention Matter?
1. Outcomes
2. Costs
BirthByTheNumbers.org
Gestational Age, U.S. All Births, 1990
30%
25%
20%
20%
22%
23%
14%
15%
11%
10%
5%
7%
2%
1%
<32
32-33
0%
34-36
37-38
39
40
41
42+
* Only births occurring at home.
Source: Martin JA, Hamilton BE, Osterman MJK, Curtin S and Mathews TJ. Births: Final data for 2012.
National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2014.
Gestational Age, U.S. All Births, 2012
30%
30%
25%
25%
20%
20%
15%
9%
8%
10%
6%
5%
2%
1%
<32
32-33
0%
34-36
37-38
39
40
41
42+
* Only births occurring at home.
Source: Martin JA, Hamilton BE, Osterman MJK, Curtin S and Mathews TJ. Births: Final data for 2012.
National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2014.
Gestational Age, U.S. All Births, 1990 & 2012
30%
30%
1990
2012
25%
25%
22%
20%
20%
23%
20%
14%
15%
11%
10%
5%
7%
8%
9%
6%
2% 2% 1% 1%
0%
<32
32-33
34-36
37-38
39
40
41
42+
* Only births occurring at home.
Source: Martin JA, Hamilton BE, Osterman MJK, Curtin S and Mathews TJ. Births: Final data for 2012.
National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2014.
Gestational Age, U.S. All Births & Planned Home
Births*, 2012
35%
31%
30%
30%
All
Home
25%
25%
24%
20%
20%
19%
15%
15%
10%
5%
9%
8%
10%
6%
2%
0%
1%
0%
2%
<32
32-33
34-36
0%
37-38
39
40
41
42+
* Only births occurring at home.
Source: Martin JA, Hamilton BE, Osterman MJK, Curtin S and Mathews TJ. Births: Final data for 2012.
National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2014.
Economics of Childbirth
in the U.S.
LEADING MAJOR DIAGNOSTIC CATEGORIES by
NUMBER OF HOSPITAL DISCHARGES, U.S., 2012
Circulatory System
4,796,175
4,160,286
Pregnancy, Childbirth & The Puerperium
3,933,511
Newborns & Other Neonates
3,549,166
Respiratory System
Musculoskeletal System & Conn Tissue
3,251,134
Digestive System
3,242,725
2,192,941
Nervous System
,00
0
7,0
00
,00
0
6,0
00
,00
0
5,0
00
4,0
00
3,0
00
2,0
00
1,0
00
,00
0
1,428,045
,00
0
Infectious & Parasitic Diseases
,00
0
1,428,060
0
Mental Diseases & Disorders
,00
0
1,671,380
Kidney & Urinary Tract
AHRQ. 2014. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov.
Accessed 3/1/2014.
MEDIAN FACILITY LABOR & BIRTH CHARGES BY
MODE OF BIRTH, U.S., 2012
$20,000
NOTE: Hospital charges; no physician costs
$19,358
$16,465
70%
$11,539
$9,705
$0
Vaginal no
Complications
Cesarean No
Complications
Vaginal
Complications
Cesarean
Complications
Sources: AHRQ. 2011. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD:
AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1/14;
Estimated Total Charges, Hospital
Birth, U.S., 1993-2012 (000,000)
Vag no Compl.
Vag w Compl.
Ces no Compl.
Ces w/ Compl.
60,000
50,000
40,000
$ 55,771
30,000
$ 14,039
20,000
10,000
20
11
20
09
20
07
20
05
20
03
20
01
19
99
19
97
19
95
19
93
0
Sources: AHRQ. 2009. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD:
AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1614.
Is it hopeless?
What can be done
•Evidence – keep an
open mind and ask
different questions.
• Advocacy – work for
change.
BirthByTheNumbers.org
Rethinking the Evidence
Safe Prevention of Primary Cesarean Delivery
www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Preventio
n_of_the_Primary_Cesarean_Delivery
BirthByTheNumbers.org
Childbirth Advocacy Led by Mothers
http://www.choicesinchildbirth.org/
Childbirth Advocacy Led by Mothers
www.thebusinessofbeingborn.com/
BirthByTheNumbers.org
Childbirth Advocacy Led by Mothers
https://www.childbirthconnection.org/
Childbirth Advocacy Led by Mothers
http://orgasmicbirth.com/online-resources
www.ourbodiesourselves.org/
www.birthbythenumbers.org
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