Birth By the Numbers 2014
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, 1990-2013
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
358,656 or 8.3%
3,957,577
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
3,800,000
Source: Adapted from CDC VitalSTATS. http://www.cdc.gov/nchs/VitalStats.htm
BirthByTheNumbers.org
U.S. Fertility Rates (per 1,000) by
Race/Ethnicity, 1989-2012
All
WNH
BNH
Hisp
110
100
90
80
70
60
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.
SOURCE: adapted from NCHS Annual Birth Reports.
Prematurity and Low Birthweight,
U.S., 1981-2012
13
12
Prematurity
9.8%
Decrease
2006-12
11
10
%
9
Low Birthweight
8
7
6
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011
Year
BirthByTheNumbers.org
Percent of all births at home, or in a birthing
center, United States, 1990-2012
43% Increase
2004-2012
1.4
1.2
1
46,956
(1.13%)
Total home &
birth center
0.8
50,761
(1.28%)
35,587
(0.87%)
35,184
Home
0.6
15,577
0.4
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
7
Country
Andorra (1/1,000)
Rank
14
Country
Germany
Rank
27
Country
Belarus
Iceland
Ireland
Netherlands
Japan
Israel
Greece
Luxembourg
Italy
Cuba
San Marino
Lithuania
Lithuania
Singapore
Monaco
New Zealand
Austria (2/1,000)
Norway
United Kingdom
Belgium
Portugal
Cyprus
Rep. of Korea
Switzerland
Croatia
Czech Republic
Slovenia
Estonia
24
Finland
13
Source: State of the World’s Children2014.
United States (4/1,000)
Sweden
Bahrain,Bosnia,Brunei
Australia (3/1,000)
Canada, Hungary, Qatar,
26
France
37
Belarus
Montenegro, Serbia,
Slovenia, Uruguay
BirthByTheNumbers.org
Outcomes
Total Births in the five
countries in red
background in 2012
were 11,429 or fewer
than the 12,104 in South
Dakota in 2012
Country
Andorra
2012
Births
757
Iceland
4,146
Luxembourg
6,034
San Marino
285
Monaco
207
TOTAL
11,429
BirthByTheNumbers.org
What’s a Fair Comparison with
the US?
In the most recent year available (2011):
• Countries with at least 100,000 births
• Countries with a total per capita annual
expenditure on health of at least $1,500
annually in US dollars.
BirthByTheNumbers.org
Defining a Set of Countries to Compare with the U.S.
17 Comparison Countries
(SOURCE: OECD, Health Data 2012
& State of World’s Children)
2011
Total Births
(000)
2011
Total exp. health –
PC, US$ PPP
Australia
302
Belgium
*129
4,061
*19.7
Canada
377
4,521
*26.1
Czech Republic
109
1,966
23.3
France
792
4,118
20.2
*678
4,495
31.4
Greece
106
2,361
NA
Israel
166
2,239
19.9
*557
3,012
37.7
Japan
1,051
*3,213
18.0
Korea
471
2,198
34.6
*184
5,099
*15.6
97
2,619
33.3
Spain
471
3,072
24.9
Sweden
112
3,925
16.2
United Kingdom
808
3,406
24.1
3,954
8,508
32.8
Germany
Italy
Netherlands
Portugal
United States
* 2010
*3,800
2011
% Births by
Cesarean
*31.2
BirthByTheNumbers.org
IOM chose 16 peer
countries. 13 are same
as the one’s we’ve used.
They use 3 countries
(Denmark, Finland,
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), 2011,
Industrialized Countries with 100,000+ Births
4.04
Uni ted States
Canada*
3.7
3
Uni ted Kingdom
Australia
2.7
2.7
Net herlands
Portugal
2.4
2.4
2.3
2.2
2.2
2.2
2.2
2.1
Ger many
France
Bel gium*
Italy*
Israel
Greece
Spai n
1.7
1.7
Kor ea
Czech Republ ic
Sweden
*2010 rate
1.4
1.1
Japan
0
1
Neonatal Mortality Rate
2
3
Source: OECD Health Data 2014 and NCHS, Deaths Preliminary Data for 2011.
4
5
BirthByTheNumbers.org
Neonatal Mortality Rates (per 1,000 births), 2011,
Industrialized Countries with 100,000+ Births
3.7
Canada*
3.45
U.S. WNH
Uni ted Kingdom
3
2.7
2.7
Australia
Net herlands
Portugal
2.4
2.4
2.3
2.2
2.2
2.2
2.2
2.1
Ger many
France
Bel gium*
Italy*
Israel
Greece
Spai n
1.7
1.7
Kor ea
Czech Republ ic
Sweden
*2010 rate
1.4
1.1
Japan
0
1
Neonatal Mortality Rate
2
Source: OECD Health Data 2014 and NCHS, Deaths Preliminary Data for 2011.
3
4
BirthByTheNumbers.org
Perinatal Mortality Rates (per 1,000 births),
2011, Industrialized Countries 100,000+ Births
France
Australia
United Kingdom
United States*
Belgium#
Canada#
Netherlands
Germany
Sweden
Greece
Israel
Italy#
Czech Republic
Portugal
Spain
Korea
Japan
12.1
8.4
7.5
6.5
6.5
6.1
5.5
5.5
4.7
4.6
4.5
4.3
3.9
3.8
3.7
*2006;
#2010
3.1
2.8
0
2
4
6
8
10
12
14
Perinatal Mortality Rate
Source: OECD Health Data 2014
BirthByTheNumbers.org
Perinatal Mortality Rates (per 1,000 births),
2011, Industrialized Countries 100,000+ Births
France
Australia
United Kingdom
Belgium#
Canada#
Netherlands
Germany
United States* WNH
Sweden
Greece
Israel
Italy#
Czech Republic
Portugal
Spain
Korea
Japan
12.1
8.4
7.5
6.5
6.1
5.5
5.5
5.3
4.7
4.6
4.5
4.3
3.9
3.8
3.7
3.1
2.8
0
Source: OECD Health Data 2014
2
4
6
*2006;
#2010
8
10
12
14
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), 2011,
Industrialized Countries with 300,000+ births
17.2
Korea
16.8
United States^
8.9
France*
7.6
Canada#
6.6
United Kingdom
4.7
Germany
4.1
Japan
Australia*
3.4
Spain
3.0
Italy*
2.9
2.0
U.S. 2007:
Black non-Hispanic
White non-Hispanic
Hispanic
28.4
10.5
8.9
*2010; #2009;
^CMQCC Estimate
Maternal Mortality Ratio
Sources: OECD Health Data 2014; ^California Maternal Quality Care
Collaborative (CMQCC) 2014; NCHS. 2009. Deaths, Final Data, 2007.
18.0
BirthByTheNumbers.org
Maternal Mortality Rates, (per 100,000 births), 2011,
Industrialized Countries with 300,000+ births
17.2
Korea
10.5
United States^
8.9
France*
7.6
Canada#
6.6
United Kingdom
4.7
Germany
28.4
10.5
8.9
4.1
Japan
Australia*
U.S. 2007:
Black non-Hispanic
White non-Hispanic
Hispanic
3.4
Spain
3.0
Italy*
2.9
*2010; #2009;
^2007
Maternal Mortality Ratio
2.0
Sources: OECD Health Data 2014; NCHS. 2009. Deaths, Final Data, 2007.
18.0
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
4.6
U.S.
13% decrease
4.0
4.0
Industrialized
Countries
23% decrease
3.0
3.1
2.0
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2.3
2011
5.0
2000
Rate per 1,000 live births
Neonatal Mortality Rate (per 1,000 births), 20002011, U.S., & Ave. for Industrialized Countries*
* Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany,
Greece, Israel, Italy, Japan, Netherlands, Portugal, 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.
4.6
U.S.
4.0
2011
2.3
2010
2009
2008
2007
2006
2001
2.0
2005
3.1
2004
3.0
2003
If the U.S. neonatal mortality rate
equaled the current average rate
of the other countries in 2011,
that would mean about 6,972
fewer deaths to babies 28 days
or younger annually.
4.0
2002
5.0
2000
Rate per 1,000 live births
Neonatal Mortality Rate (per 1,000 births), 20002011, U.S., & Ave. for Industrialized Countries*
* Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany,
Greece, Israel, Italy, Japan, Netherlands, Portugal, 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.
Capacity – 68,756
Perinatal Mortality Rates, 2000-2011 ,
U.S., & Ave. for Industrialized Countries*
7
U.S.
6%
decrease
6.5
6
5.5
Industrialized
Countries
14% decrease
5
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
* Countries with 100,000+ births (2011): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Israel, Italy,
Japan, Netherlands, Portugal, S. Korea, Spain, Sweden, United Kingdom
Sources: OECD Health Data 2014; NCHS. 2012. Fetal & Perinatal Mortality, 2006.
BirthByTheNumbers.org
Maternal Mortality Ratios (per 100K births),
2000-2011, U.S. & Comparable Countries *
Deaths per 100,000 live births
20
Case Ascertainment?
U.S.
71%
Increase
16
12
Industrialized
Countries
5 % Decrease
8
4
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
* Countries with 300,000+ births (2011): Australia, Canada, France, Germany, Italy, Japan, S. Korea, Spain, United Kingdom
Sources: OECD Health Data 2014; ^California Maternal Quality Care
Collaborative (CMQCC) 2014; NCHS. 2009. Deaths, Final Data, 2007.
NOTE: 2008-2010 US
rates unofficial^
What about process?
BirthByTheNumbers.org
US Cesarean Rates, 1989-2013
34
32
30
1,294,128
% 28
% 26
24
22
20
'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
% 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
If the 2013 cesarean rate was the same as in 1996, there
would have been 475,000 fewer cesareans in the U.S. in ’13.
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
Italy
Korea
*Portugal
United States
Germany
*Australia
*Canada
Spain
United Kingdom
Czech Republic
France
*Belgium
Israel
Japan
Sweden
*Nether lands
10%
37.7%
34.6%
33.4%
32.8%
31.4%
30.8%
26.1%
24.9%
24.1%
23.3%
20.2%
19.90%
19.8%
18.0%
16.2%
15.6%
*2010
* No data on cesarean rates in Greece
45%
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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