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?
BirthByTheNumbers.org
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
Country
Rank
Country
Rank
Country
1
Andorra (1)
Greece
Cuba
Iceland
Ireland
Hungary
Japan
Italy
Israel
Luxembourg
Malta
Lithuania
San Marino
Monaco
Malaysia
Singapore
Norway
Netherlands
Belgium (2)
Portugal
New Zealand
Cyprus
Korea
Slovakia
Czech Republic
Slovenia
Switzerland
Denmark
Spain
United Kingdom
Estonia
Sweden
7
Finland
Rank
26
39
United States (4)
Australia (3)
Canada, Croatia
France
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
TWO PROBLEMS
Outcomes: Comparative(1)Neonatal
Rates
Comparisons Mortality
– Seven countries
Rank
Country
1
Iceland (1)
7
Rank
Rank Country
Country highlighted
had fewer combined births
Japan
than the state of Idaho
Greece
(2) Measurement Cuba
– Is neonatal mortality the
use?
Ireland best measure toHungary
Singapore
Italy
Israel
Andorra
Malta
Lithuania
San Marino
Monaco
Malaysia
Luxembourg
Norway
Netherlands
Belgium (2)
Portugal
New Zealand
Cyprus
Korea
Slovakia
Czech Republic
Slovenia
Switzerland
Denmark
Spain
United Kingdom
Estonia
Sweden
Finland
France
Germany
Source: World
Health Statistics 2011
26
39
United States (4)
Australia (3)
Canada, Croatia
Austria
Poland, Qatar
Brunei
Serbia, Un. Arab Emir.
http://www.who.int/healthinfo/statistics/mortality_neonatal/en/index.html
BirthByTheNumbers.org
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
Andorra
2009
Births
828
Iceland
5,027
Luxembourg
5,639
San Marino
Malta
Monaco
334
4,143
298
Brunei
7,280
TOTAL
23,549
BirthByTheNumbers.org
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 $1,500 in
US dollars.
BirthByTheNumbers.org
Defining a Set of Countries to Compare with the U.S.
16 Comparison
Countries
(OECD, Health Data 2010)
2010
Total Births
(000)
2009
Total exp. health –
PC, US$ PPP
2008
% Births by
Cesarean
Australia
296
3,445
30.8
Belgium
127
3,946
17.3
Canada
378
4,363
26.6
Czech Republic
117
2,108
20.5
France
829
3,809
19.9
Germany
681
4,218
29.4
Greece
118
2,679
NA
Italy
562
3,137
38.5
Japan
1,070
2,878
18.0
Korea
445
1,879
35.4
Netherlands
184
4,914
14.3
Portugal
101
2,508
32.7
Spain
480
3,067
24.6
Sweden
116
3,722
16.8
United Kingdom
779
3,487
23.4
4,248
7,960
United States
32.3
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), 2009,
Industrialized with 100,000+ Births
4.2
Uni ted States
Canada
3.8
3.4
U.S. Whi te
Uni ted Kingdom
3.2
3
Australia
2.8
Net herlands
France
2.6
2.5
2.5
2.4
2.3
2.3
Portugal
Bel gium
Kor ea
Italy
Ger many
Spai n
2.1
2
Greece
Sweden
1.6
1.6
Czech Republ ic
Japan
1.2
0
1
2
Source: OECD Health Data 2011 and NCHS, Deaths Final Data for 2007.
3
4
5
BirthByTheNumbers.org
Perinatal Mortality Rates (per 1,000 births), 2009,
Industrialized Countries with 100,000+ Births
13.9
France
7.6
Uni ted Kingdom
Uni ted States*
6.6
6.4
Canada#
6.0
5.6
Bel gium*
Net herlands
Ger many
5.3
5.2
Sweden
Portugal
4.6
Greece
4.6
4.4
Italy#
Spai n
3.6
Czech Republ ic
Australia*
3.6
3.6
*2005;
#2008
3.2
2.9
Kor ea#
Japan
0
5
10
15
Source: OECD Health Data 2011; MacDorman MF, Kirmeyer S. Fetal and perinatal mortality, United States, 2005.
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
12.7
United States#
12
Korea*
10.5
US WNH#
United Kingdom
8
France#
7.6
6.5
Canada
5.3
Germany
U.S. 2007:
Black non-Hispanic
White non-Hispanic
Hispanic
28.4
10.5
8.9
5
Japan
3.4
Spain
Italy^
2
Australia*
2
2
*2008; #2007;
^2006
Maternal Mortality Rate
Sources: OECD Health Data 2011; NCHS. 2009. Deaths, Final Data, 2007.
15
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?
BirthByTheNumbers.org
US Subgroups in Comparative Context
with other Industrialized Countries
US Subgroup
All
U.S. IMR
2007
6.8
Rank
(16 - 100K)
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.
US Subgroups in Comparative Context
with other Industrialized Countries
US Subgroup
U.S. IMR
2007
Rank
(16 - 100K)
All
6.8
16
White Non-Hispanic
5.6
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.
US Subgroups in Comparative Context
with other Industrialized Countries
US Subgroup
U.S. IMR
2007
Rank
(16- 100K)
All
6.8
16
White Non-Hispanic
5.6
16
White NH, Native Born
5.7
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.
US Subgroups in Comparative Context
with other Industrialized Countries
US Subgroup
U.S. IMR
2007
Rank
(16- 100K)
All
6.8
16
White Non-Hispanic
5.6
16
White NH, Native Born
5.7
16
White NH, Singleton Birth
4.9
15
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.
US Subgroups in Comparative Context
with other Industrialized Countries
US Subgroup
U.S. IMR
2007
Rank
(16- 100K)
All
6.8
16
White Non-Hispanic
5.6
16
White NH, Native Born
5.7
16
White NH, Singleton Birth
4.9
15
White NH, 30-34 yrs old
4.4
14
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.
Examining Trends over Time
U.S.
5
4
8% decrease
4.6 per 1,000
4.2 per 1,000
3
3.1 per 1,000
2
Industrialized
Countries
28% decrease
2.2 per 1,000
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
Rate per 1,000 live births
Neonatal Mortality Rate, 2000-2009, U.S.,
& Ave. for Industrialized Countries*
* Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany,
Greece, Italy, Japan, Netherlands, Portugal, Spain, Sweden, U.K.
Source: OECD Health Data, 2011
Rate per 1,000 live births
Neonatal Mortality Rate, 2000-2009, U.S.,
& Ave. for Industrialized Countries*
U.S.
5
4
8% decrease
4.6 per 1,000
4.2 per 1,000
3
3.1 per 1,000
2.2 per 1,000
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
2 neonatal mortality rate
If the U,S.
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.
Industrialized
Countries
28% decrease
* Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany,
Greece, Italy, Japan, Netherlands, Portugal, Spain, Sweden, U.K.
Source: OECD Health Data, 2011
Perinatal Mortality Rates, 2000-2008 ,
U.S., & Ave. for Industrialized Countries*
Rate per 1,000 live births
+ fetal deaths
7.5
7
U.S.
5.6 %
decrease
6.5
6
Industrialized
Countries
20.3% decrease
5.5
5
2000 2001 2002 2003 2004 2005 2006 2007 2008
* 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
Source: MacDormanM. Fetal and Perinatal Mortality, U.S., 2005. 2009.NCHS V. 57#8
and OECD Health Data 2011
Deaths per 100,000 live births
Maternal Mortality Ratios (per 100,000
births), 2000-2008, U.S. & Ave.
Industrialized Countries*
16
Case
Ascertainment??
U.S.
30%
Increase
12
Industrialized
Countries
15 % Decrease
8
4
2000 2001 2002 2003 2004 2005 2006 2007 2008
* 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.
Gestational Age, U.S. All Births, 1990, 2009
30%
1990
2009
25%
20%
15%
10%
5%
0%
<32
32-33 34-36
* Only births occurring at home.
Source: Vital Stats website
37
38
39
40
41
42+
What about process?
BirthByTheNumbers.org
US Cesarean Rates, 1989-2010
34
32
30
1,312,091
% 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
% Tot US 23 22.7 22.6 22.3 21.8 21.2 20.8 20.7 20.8 21.2 22.0 23 24 26 28 29 30 31 32 32 33 33
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.
Source: National Center for Health Statistics Annual Birth Reports
Cesarean Rates in Industrialized
Countries* with 100,000+ Births, 2009
Italy
Korea
Portugal
**Unit ed States
*Australia
Germany
*Canada
Spain
United Kingdom
Czech Republic
France
Japan
*Belgium
Sweden
*Nether lands
10%
38.4%
31.8%
33.0%
32.8%
30.8%
30.3%
26.6%
24.9%
23.7%
21.2%
20.0%
18.0%
17.3%
17.1%
14.3%
*2008;
**2010
* No data on cesarean rates in Greece
45%
Sources: OECD Health Data 2011; U.S. Natality Data; Japan – sample; Lancet 6736(09)61870-5.
Total cesarean rates by
race/ethnicity, U.S. 1989-2010
WNH
BNH
Hisp
Source: National Center for Health Statistics Annual Birth Reports
20
09
20
07
20
05
20
03
20
01
19
99
19
97
2010 BNH
+2.9 percentage
points
19
95
19
93
1989 WNH
+1.4percentage
points
19
91
19
89
36
34
32
30
28
26
24
22
20
18
Total Cesarean Rates (per 100 births) by Age
of Mother: United States, 1996 and 2009
Overall increase,
1996-2009: 58.5%
60
1996
50
2009
49.5
Percent
42.8
40
36.3
31.7
30
10
14.5
27.4
23.8
23.1
20
31.6
28.5
17.4
20.6
59%
64%
54%
53%
56%
57%
%
<20
20-24
25-29
30-34
35-39
40-54
0
Source: National vital statistics system, NCHS, CDC.
BirthByTheNumbers.org
VBAC Rates*, U.S.,1990-2009
30%
25%
20%
NOTE: Rates
for 2005-2009
are unofficial
15%
10%
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
5%
* Number of VBACs among women with prior cesarean
Source: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm
VBAC Rates, Selected Countries, 2004
U.S.
Latvia
Lithuania
Canada
Estonia
Malta
Slovenia
Spain-Valencia
Scotland
Belg-Flanders
France
Denmark
Czech Rep
Germany
Sweden
Finland
Norway
Netherlands
VBACs
8
9
19
20
24
25
25
25
27
32
35
39
41
41
0 from Peristats,
10
20 & Canadian
30 Data 40
Source: Adapted
US
45
51
51
55
50
60
Do High Rates of
Intervention Matter?
1. Outcomes (NMR & GA)
2. Costs
BirthByTheNumbers.org
Cesarean Rates and
Neonatal Mortality
Low Income
Medium Income
High Income
Source: Althabe F.Cesarean Section Rates and Maternal & Neonatal Mortality Birth.2006;33:270
Percent of singleton preterm (<37 weeks)
births by method of delivery, United States,
1991-2006
12
10
11.0%
9.7%
Cesarean no
induction
Percent
8
6
Cesarean after
induction
attempt
6.7%
5.7%
Induced
vaginal
4
Spontaneous
vaginal
2
0
1991
1996
2001
2006
Note: Births with method of delivery and induction of labor not stated are excluded.
Source: MacDorman et al. AJPH, 2011.
National Costs and
Hospitalizations
LEADING MAJOR DIAGNOSTIC CATEGORIES by
NUMBER OF HOSPITAL DISCHARGES, U.S., 2009
Diseases of The Circulatory System
5,801,081
Pregnancy, Childbirth
4,591.515
Newborns & Other Neonates
4,300,390
Respiratory System
3,964,889
Digestive System
3,429,592
Musculoskeletal System
3,370,140
Nervous System
2,210,056
Kidney & Urinary Tract
1,621,592
Mental Diseases & Disorders
1,490,050
,00
0
7,0
00
,00
0
6,0
00
,00
0
5,0
00
,00
0
4,0
00
,00
0
3,0
00
,00
0
2,0
00
,00
0
1,274,786
1,0
00
0
Endocrine, Nutritional & Metabolic
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
NOTE: Hospital charges; no physician costs
$18,000
Charge in 2009
$15,998
Increase in Charge in 2000-2009
$13,549
$7,272
Charge in 2000
$9,644
$6,130
$8,037
$4,614
$3,956
$7,419
$4,081
$8,726
$5,003
$0
Hospital Vaginal
no Complications
Hospital Vaginal Hospital Cesarean Hospital Cesarean
Complications No Complications Complications
Sources: AHRQ. 2010. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD:
AHRQ. http://hcupnet.ahrq.gov. Accessed 11/1/10;
Estimated Total Charges, Hospital
Birth, U.S., 1993-2009 (000,000)
Vag no Compl.
Vag w Compl.
Ces no Compl.
Ces w/ Compl.
60,000
50,000
40,000
$ 50,942
30,000
$ 14,039
20,000
10,000
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
0
Sources: AHRQ. 2009. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD:
AHRQ. http://hcupnet.ahrq.gov. Accessed 7/16/11.
Have maternal request
cesareans played a
major role in these
increases?
BirthByTheNumbers.org
Asking Mothers about
Maternal Request Cesareans
http://www.childbirthconnection.org
Two Components to Maternal
Request Primary Cesarean
1. Mother made request for planned
cesarean before labor
BirthByTheNumbers.org
Two Components to Maternal
Request Primary Cesarean
1. Mother made request for planned
cesarean before labor
2. Cesarean for no medical reason
BirthByTheNumbers.org
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
BirthByTheNumbers.org
Pressure to Accept Interventions by Method
of Delivery
Did you feel pressure from any health
professional to have a cesarean? % yes
Repeat
Cesarean
25%
Primary
Cesarean
26%
VBAC
35%
Vaginal
1%
0%
10%
20%
Source: Declercq et al. 2006. Listening to Mothers II.
30%
40%
Have maternal request
cesareans played a major
role in these increases?
NO!
So what is the reason for the
increasing cesarean rate?
BirthByTheNumbers.org
Have maternal request
cesareans played a major
role in these increases?
NO!
So what is the reason for the
increasing cesarean rate?
Practice Changes
BirthByTheNumbers.org
Cesarean Rates, Low Risk*, First-Time Mothers
for Medical Risk Factors & Labor Complications
Diabetes
Eclampsia
PregAss Hypertension
Chronic Hypertension
Prolonged Labor
Birthweight > 4000g
50
45
40
35
30
1991
*Singleton, Vertex, Full Gestation Births
1996
2009
US Cesarean Rates, 1989-2010
34
32
30
% 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
% Tot US 23 22.7 22.6 22.3 21.8 21.2 20.8 20.7 20.8 21.2 22.0 23 24 26 28 29 30 31 32 32 33 33
Source: National Center for Health Statistics Annual Birth Reports
Cesarean Rates, Low Risk*, First-Time Mothers
for Medical Risk Factors & Labor Complications
Diabetes
Eclampsia
PregAss Hypertension
Chronic Hypertension
Prolonged Labor
Birthweight > 4000g
50
45
40
35
30
1991
*Singleton, Vertex, Full Gestation Births
1996
2009
Cesarean Rates, Low Risk*, First-Time Mothers
for Medical Risk Factors & Labor Complications
Diabetes
Eclampsia
PregAss Hypertension
Chronic Hypertension
Birthweight > 4000g
50
45
40
35
30
1991
1996
Source: CDC Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm
*Singleton, Vertex, Full Gestation Births
2009
Women have not changed nearly
as much as practice patterns have
For more information and
additional resources regularly
check:
BirthByTheNumbers.org
The site is updated as additional
data becomes available.