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Donna Strobino, PhD
Bloomberg School of Public Health

Trends in . . .
Š Low birth weight rates
Š Multiple birth rates
Š Artificial reproductive technology
Š Cesarean delivery rates
Š Live births vs. fetal deaths
Š Racial disparities in content of care
Š Early discharge postpartum
3

Trends in Low Birth Weight and Reasons for the Rise in Multiple Births

Š United States
Š Some Western European countries
– England and Wales
– France
– Norway
5

Š Rising percentage of multiple births
Š Rising percentage of LBW among multiple births
6

Live Births by Multiplicity and Birth Weight:
England and Wales, 1983, 1995–1997
1983
1995–1997
1983
1995–1997
1983
1995–1997
1983
1995–1997
<1500
0.7
0.9
7.7
9.1
27.8
35.1
0.8
1.2
Birth Weight (grams) (%)
1500-2499
Singletons
5.1
5.1
Twins
42.7
43.8
Triplets and More
66.4
60.8
All Births
5.9
6.1
<2500
5.8
6.0
50.4
52.9
94.2
95.9
6.7
7.3
7

Live Births by Multiplicity and Birth Weight
United States, 1981–1983, 1995–1997
1981–1983
1995–1997
1981–1983
1995–1997
1981–1983
1995–1997
1981–1983
1995–1997
<1500
1.1
1.2
10.7
10.5
37.0
37.5
1.3
1.5
Birth Weight (grams) (%)
1500-2499
Singletons
4.9
5.0
Twins
40.2
43.1
Triplets and More
52.3
55.7
All Births
5.6
6.0
<2500
6.0
6.2
50.9
53.6
89.3
93.2
6.9
7.5
8

Š Increase in twin births in Western Europe and U.S. since the 1970s
Š Precipitous increase in triplets or greater births since the 1970s
9

Increase in the Number of Twins and Triplets in France and in the United States,
1998 Compared to Mid-1970s
France
741,765
United States
3,941,553
1998 Data
Number of Births
Twins
% Increase
Number
Excess Number
Triplets
% Increase
Number
Excess Number
62%
21,106
8,000
310%
745
500
58%
110,670
40,500
696%
7,625
6,500
10

Percentage Increase in Triplets or Higher
Order Births, Lowest Point 1960-1975 to 1990
Germany
United Kingdom
Spain
France
Netherlands
Italy
Finland
Norway
Belgium
Sweden
Year of Lowest Rate
1960
1965
1960
1970
1965
1975
1960
1975
1960
1960
Percentage Increase in 1990
367
336
275
528
801
532
630
719
1158
695
11

Twin Deliveries
Š 1980—68,339
Š 1999—114,307
Š 2001—121,246
Š 2002—125,134
Triplet Deliveries
Š 1980—1,337
Š 1999—6,742
Š 2001—6,805
Š 2002—6,898
Š (7,401)
12

Quadruplets
Š 1989—269
Š 1994—336
Š 1996—641
Š 1998—641
Š 2002—434
13

Š Delayed childbearing
Š 25-33 % of the rise between 1975 and
1998 attributable to increase in maternal age
Š Data from England and Wales, France,
Sweden, and the U.S.
14

Š ART
– 10–24% of twin pregnancies
– 22–59% of triplet pregnancy
Š Ovulation stimulation alone
– At least 75% of triplet pregnancies in
France in 1993 and the U.S. in 1997
Š Ovulation stimulation in general
– 5.4% of twins and 69.8% of triplet pregnancies in Italy in 1993–1994
15

Š Variability among countries in a number of embryos transferred in ART procedures
Š Variability among countries in a number of multiple pregnancies
Š U.S. has higher success rates than Europe but greater numbers of embryos transferred and resulting multiple births
16

ART Cycles, Births, and Percentage of All
Births, 1999, All Clinics Reporting in Country
Iceland
Denmark
Finland
Sweden
Norway
France
Switzerland
Total
Number of Cycles
415
8793
7320
8660
4029
51868
4166
99629
% of All Births
2.6
1.8
1.4
0.7
1.6
3.6
3.2
2.7
ART Births (N)
(149)
(2119)
(1553)
(2293)
(1058)
(10167)
(548)
(17887)
17

Percentage Distribution of the Number of
Embryos Transferred after IVF and ICSI,
Western Europe Countries, 1999
Finland
Sweden
Switzerland
Belgium
France
Germany
Portugal
Italy
Greece
Ireland
Spain
11.1
12.8
11.3
10.0
8.2
8.6
One
20.8
11.2
12.9
10.6
13.8
37.3
30.1
31.1
20.0
22.0
16.3
Number of Embryos Transfer
Two Three Four Total N
73.9
84.3
5.3
4.5
0.0
0.0
4,052
6,247
57.1
46.7
42.3
28.1
34.0
37.2
1.9
8.6
6.7
2,415
8,015
30,459
51.6
40.9
40.9
32.2
67.3
45.6
0.0
16.9
16.9
37.8
2.5
29.4
41,490
10,198
10,198
5,209
972
8,355
18

Percentage Distribution of Singleton, Twin and Triplet or Greater Births after IVF and
ICSI, 1999, Western Europe Countries
Spain
Italy
Ireland
Germany
Portugal
Iceland
Switzerland
France
Finland
Greece
Norway
Sweden
Denmark
Total (Range)
Singleton
48.5
57.7
55.6
58.4
51.9
67.2
54.4
59.3
60.1
58.6
59.0
60.3
60.8
(42–79)
37.7
37.9
39.8
39.5
38.8
38.6
(19–44)
Twin
40.3
33.6
36.3
35.2
42.0
28.4
42.5
Triplet or Greater
11.2
8.7
8.1
6.3
5.1
4.5
3.1
3.1
1.6
1.6
1.4
0.6
0.6
(0.6–14.6)
9,230
1,670
1,670
1,058
2,087
1,965
36,135
Total N
2,547
2,775
259
9,112
362
134
391
19

Multiple Births by ART Transfer
Procedure, U.S. 2000
Number of
Multiple Birth
Deliveries
Percent of
Multiple Birth
Deliveries
Number of
Multiple
Birth/Infants
Percent of
Multiple
Birth/Infants
Patients eggs used
Freshly fertilized embryos
Thawed embryos
Donor eggs used
Freshly fertilized embryos
Thawed embryos
Total transfers
19,219
2.360
3,041
608
25,228
35.3
25.8
40.6
29.1
34.9
26,800
3,048
4,382
795
35,025
53.6
42.6
58.8
45.8
53.1
Source: Assisted Reproductive Technology Surveillance Systems, 2000
20

Assisted Reproductive Technologies
Š High cost of technology—who pays the bill?
Š Who is responsible for decisions about multiple pregnancies?
Š What is the cost of success?
21

Š Reduction in higher order transfers
Š Increase in transfer of two embryos
Š No change in transfer of one embryo
Š Less than 5% of transfers
22

Š UK—regulatory bodies determine number of transferred embryos
Š U.S.—American College of OB/GYN statement
– Limit the number of embryos transferred
– Withhold ovulation inducing drugs with many mature follicles
23

Š Transfer good quality embryos one at a time
Š Ovulation stimulation
– Performed only by specialists
– Network of providers of ART
24

Š Finland
– 50% reduction in triplet rate
– Better outcomes for IVF newborns
Š Norwegian IVF clinic:
– LBW percent declined from 47% to 14% after limiting number of embryos to three
25

Š Collect data about multiple births . . .
– Do not report them as success of infertility treatment
– Report them as complications of ART
26

Trends in Cesarean Deliveries and
Other Concerns

Š Across Western Europe—7% to 53% increase
Š Specific trends in the U.S.—3% decline, but increase to 2002
28

Cesarean Delivery Rates, 1990, 1994–
1996, 1996 for Selected Western European
Countries and the United States
United States
Italy
Portugal
Germany
France
Spain
Finland
Norway
United Kingdom
Sweden
Belgium
Netherlands
1990 1994 1995 1996 1999 % Change
22.7
21.2
20.8
20.7
22.0
20.8
24.8
26.1
26.4
31.1
18.6
23.9
24.2
24.6
27.5
15.7
17.1
17.2
17.6
19.8
-3
+49
+48
+26
13.9
15.1
15.0
15.4
15.7
14.2
17.8
18.8
19.3
--
14.2
15.2
15.5
15.5
15.5
12.8
12.6
12.6
12.7
13.7
12.4
15.5
15.8
16.0
17.0
10.8
11.7
12.0
11.8
14.4
10.4
12.9
13.4
13.7
15.9
7.4
9.2
9.6
10.1
11.3
+13
(+36)
+9
+7
+17
+33
+53
+53
Source: OECD Health Data, 2002, 4 th Edition 29

30

Š Consumer education
Š Clinical guidelines with feedback
– Individual physicians
– Maternity units
– Promote normal births in low risk settings
– Medical and review/education—little influence on practices
31

Š Rise in the smallest births
– Among live births
– Not comparable for stillbirths
32

Percentage of Very Low Birth Weight Births
Less than 500, 500-999, 1,000–1,499, and Less than 1500 Grams, 1974–1994, Alabama
Percentage of Births
Year of
Birth
1974
1977
1980
1984
1988
1990
1992
1994
60,228
62,707
64,128
60,964
61,374
64,110
62,885
61,421
Total Births
Less than
500 grams
0.20
0.21
0.33
0.37
0.46
0.46
0.45
0.51
500–999
Grams
0.72
0.72
0.81
0.85
0.92
0.92
0.98
0.90
1000–1499
Grams
Less than
1500 Grams
0.94
0.80
0.77
0.76
0.96
0.96
0.88
1.01
1.86
1.73
1.91
1.98
2.21
2.24
2.31
2.42
33

Percentage of Live Births of All Births (Live and
Stillbirths), Less than 500, 500-999, 1,000-1,499, and Less than 1500 Grams, 1974–1994, Alabama
100
90
80
70
60
50
40
30
20
10
0
1974 19
77
1980 198
4
19
88
1990 199
2
19
94
Year of Birth
Less than 500 grams grams 500-999 grams 1000-1499
Less than 1500 grams
34

Š Extending the limits of viability
– To as early as 23–24 weeks gestation
Š High mortality and subsequent morbidity
– Results in increase in VLBW births?
35

Š Extension of the limits of viability
– How does it affect obstetrical practice?
– How does it affect population statistics?
– What are the ultimate costs?
• To the family
• To society
36

Racial and Socioeconomic Disparities in Use of Prenatal Interventions
Š Lower rates among black, Latina, and poor women in the use of . . .
– Ultrasound
– Amniocentesis, CVS
Š Question whose preferences
37

Greater among Minorities and Low Income
Women on Sensitive Issues
Š HIV testing
Š Family violence
Š Family planning
Š Substance use
38

Š Early discharge
– SVD—12–24 hours
– CS—48-72 hours
Š Due to changes in the following:
– Medical practices
– Reimbursement
– Patient preferences
39

Š Guidelines for the Mother
– Minimal criteria for early discharge
– Mechanism for asking questions
– Follow-up telephone contact or home visit
– Little documentation
– Capacity in question?
40

Š AAP Suggested Guidelines
Š Medical and social evaluation before early discharge
Š Clinical follow-up within three days of discharge
– Type not specified
41

Š Effects—inconclusive
– No increase in neonatal mortality
– Rehospitalization—jaundice, dehydration, sepsis?
42

Š Inadequate time for detection of breastfeeding problems
Š Increase maternal-infant bonding at expense of maternal well-being
Š Reduction in time for in-hospital teaching and support
Š Completeness of newborn metabolic screening
43