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Archive for October, 2008

Infant Mortality: U.S. Ranks 29th

U.S. Ties Slovakia, Poland for 29th Place in Infant Deaths
By Daniel J. DeNoon
WebMD Health News
Reviewed by Louise Chang, MD

Oct. 15, 2008 — The U.S. ranks 29th worldwide in infant mortality, tying Slovakia and Poland but lagging behind Cuba, the CDC reports.

The CDC’s latest estimates for international rankings are based on 2004 data. But as of 2005, the numbers haven’t changed much since 2000.

Nearly seven U.S. babies die out of every 1,000 live births. More than 28,000 American babies die before their first birthday.

In Japan, ranked in third place behind Singapore and Hong Kong, the infant mortality rate is 2.8 per thousand live births — less than half the U.S. rate.

In one way, the U.S. has improved since 1960. Back then, 26 in 1,000 infants died. That was good enough to land the U.S. in 12th place.

We’ve advanced since then, but not as fast as many other nations. By 1990, the U.S. had fallen to 23rd place.

“The U.S. infant mortality rate is higher than rates in most other developed countries,” note CDC researchers Marian F. MacDorman, PhD, and T.J. Mathews. “The relative position of the United States in comparison to countries with the lowest infant mortality rates appears to be worsening.”

What’s going on? Racial and ethnic disparities clearly play a role. In 2005, for every 1,000 live births, the infant mortality rate was:

  • 13.63 among non-Hispanic black Americans
  • 5.76 among non-Hispanic white Americans

Premature birth is a factor in more than two-thirds of infant deaths. From 2000 to 2005, the U.S. preterm birth rate went up from 11.6% to 12.7%.

MacDorman and Mathews report the data in the CDC’s October 2008 National Center for Health Statistics data brief, “Recent Trends in Infant Mortality in the United States.”

Infant Mortality Rates by Country

Here is the complete list of infant mortality rates per 1,000 live births for 2004:

1. Singapore 2.0

2. Hong Kong 2.5

3. Japan 2.8

4. Sweden 3.1

5. Norway 3.2

6. Finland 3.3

7. Spain 3.5

8. Czech Republic 3.7

9. France 3.9

10. Portugal 4.0

11. Germany 4.1

11. Greece 4.1

11. Italy 4.1

11. Netherlands 4.1

15. Switzerland 4.2

16. Belgium 4.3

17. Denmark 4.4

18. Austria 4.5

18. Israel 4.5

20. Australia 4.7

21. Ireland 4.9

21. Scotland 4.9

23. England and Wales 5.0

24. Canada 5.3

25. Northern Ireland 5.5

26. New Zealand 5.7

27. Cuba 5.8

28. Hungary 6.6

29. Poland 6.9

29. Slovakia 6.9

29. United States 6.9

32. Puerto Rico 8.1

33. Chile 8.4

34. Costa Rica 9.0

35. Russian Federation 11.5

36. Bulgaria 11.7

37. Romania 16.8

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Suspect Diagnoses Come with Biophysical Profiling

by Gloria Lemay

[Editor’s note: This article first appeared in Midwifery Today Issue 69, Spring 2004.]

Many North American women are being told at the very end of their pregnancies to go to an ultrasound clinic and have a biophysical profile done. Most are impressed by the thoroughness of their practitioner and have no idea what this test involves or what sort of harm could follow from consenting to this diagnostic procedure. They will probably not be told that there is no scientific basis for having faith in the test results and that no improvement in health has been proved from large numbers of fetuses being “profiled.” Certainly, no one will mention that the only benefits of the procedure are: 1) the ultrasound clinic will earn $275; and 2) the medical practitioner will be able to cover themselves legally in the very rare instance that a baby might die in utero.

Until recently, physicians and midwives would tell women who were carrying their babies beyond 41 weeks gestational age to do “kick counts.” If the baby has 10 distinct movements between the hours of 9 a.m. and 3 p.m., it is widely accepted that the baby is thriving under the mother’s heart. In a culture that loves technology and with the push to expand the commercial use of ultrasound, it was inevitable that someone would come up with a more complex strategy to provide reassurance of the baby’s wellbeing in late pregnancy. Thus the biophysical profile (BPP) was born. Here is the content of the testing, as it appears on the Family Practice Notebook Web site (www.fpnotebook.com/OB44.htm):

  1. Cost: $275
  2. Criteria (2 points for each)
    1. Fetal Breathing
      1. Thirty seconds sustained breathing in 30 minutes
    2. Fetal Tone
      1. Episode extremity extension and flexion
    3. Body Movement
      1. Three episodes body movement over 30 minutes
    4. Amniotic Fluid Volume
      1. More than 1 pocket amniotic fluid 2 cm in depth
    5. Non-Stress Test
      1. Reactive
  3. Scoring
    1. Give 2 points for each positive above
  4. Interpretation
    1. Biophysical Profile: 8-10
      1. Low risk or Normal result
      2. Repeat Biophysical Profile weekly
      3. Indications to repeat Biophysical Profile biweekly
        1. Gestational Diabetes
        2. Gestational age 42 weeks
    2. Biophysical Profile: 8
      1. Delivery Indications: Oligohydramnios
    3. Biophysical Profile: 6
      1. Suspect asphyxia
      2. Repeat Biophysical Profile in 24 hours
      3. Delivery Indications
        1. Repeat Biophysical Profile less than or equal to 6
    4. Biophysical Profile: 4
      1. Suspect asphyxia
      2. Delivery Indications
        1. Gestational age 36 weeks
        2. Lung Maturity Tests positive (L/S Ratio 2)
    5. Biophysical Profile: 0-2
      1. Likely asphyxia
      2. Continue monitoring for 2 hours
      3. Delivery Indications
        1. Biophysical Profile ‹ 4

“Breathing” above refers to movements in the lungs that show activity of the lungs in preparation for life outside the womb. The baby’s oxygen supply in utero comes via the placenta and umbilical cord while in the mother’s womb.

In the past year, I have had a number of letters and phone calls from doulas, midwives and childbirth educators about a flaw in this testing method. An unusually large number of diagnoses seem to be made that “there is not enough amniotic fluid.” This seems to be the factor in this outline that is most often used as an excuse for induction. It is important for parents to know that this is likely an inaccurate assessment. What the ultrasound technician is doing could be compared to viewing an adult in a see-through plexiglass bathtub from below the tub. In such a scenario, it would be difficult to assess how much water is in the tub above the body that is resting on the bottom of the tub. You might be able to get an idea of the water volume by measuring how much water was showing below the elbows and around the knees, but if the elbows were down at the bottom of the tub, too, you might think there was very little water. This is what the technician is trying to do in late pregnancy—find pockets of amniotic fluid in little spaces around the relatively large body of an 8 lb. baby who is stuffed tightly into an organ that is about the size of a watermelon (the uterus). If most of the amniotic fluid is near the side of the uterus closest to the woman’s spine, it can not be seen or measured. This diagnosis of low amniotic fluid frightens the parents-to-be into acquiescing to an induction of labour. Even though the official BPP guidelines do not require immediate induction for a finding of low amniotic fluid, in practise, the parents are pressured to induce. Stories abound of mothers who are induced for this indication and then report having abundant fluid when the membranes released in the birth process. The risks of induction, which can be catastrophic, and the resulting increase in the need for pain relief medication and cesarean section are usually not discussed with the parents prior to embarking on induction of the birth. Be warned that this latest suspect diagnosis using ultrasound is increasing in frequency and causing increased harm to mothers and unborn babies through aggressive use of induction.

Gloria Lemay has been attending births in Vancouver, B.C., for 25 years. She is an advisory board member of the International Cesarean Awareness Network (ICAN), as well as a contributing editor for Midwifery Today and contributing expert for the Birthlove Web site. Visit her Web site at www.glorialemay.com.


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October 12th, 2008 by Judith Lothian

The Milbank Report, Evidence-Based Maternity Care: What It Is and What It Can Achieve, was released on October 8. This report should shake the world of maternity care to its very core!

The authors of Evidence-Based Maternity Care, Carol Sakala and Maureen Corry, have a  long involvement with evidence-based maternity care including planning and leading Childbirth Connection’s national program to promote such care over the past decade.

Childbirth Connection, the Reforming States Group and the Milbank Memorial Fund collaborated in planning, developing and issuing the report, including formulating policy recommendations.

The Millbank Memorial Fund is a foundation that works to improve health by helping decision makers in the public and private sectors acquire and use best available evidence to inform health policy. The Reforming States Group, organized in 1992, is a voluntary association of leaders in health policy from all 50 states, Canada, England, Scotland and Australia. Childbirth Connection (formerly the Maternity Center Association), founded in 1918, is a national not for profit organization that works to improve the quality of maternity care through research, education, advocacy and policy.

Many national policy, quality and maternity care leaders provided detailed feedback on report drafts and further strengthened the report.

In a nutshell, the report finds that despite the good intentions of health care providers and huge  expenditures (by Medicaid, private insurers and women themselves) the quality of US maternity care is poor. Evidence-based care practices are underused and poor quality practices, like procedures, tests, and medications that are not needed, are overused. The report highlights best evidence that, if widely implemented, would have a positive impact on many mothers and babies and would improve value for payers.

USA Today quotes University of Wisconsin’s Douglas Laube, a former president of the American College of Obstetricians and Gynecologists, who blames “very significant external forces” for the overuse of expensive technologies in maternity care.

“I don’t like to admit it, but there are economic incentives” for doctors and hospitals to use the procedures, says Laube, who reviewed the new report before its release. Dr. Laube goes on to say that some doctors might get bonuses for performing more labor inductions, which adds costs and increases the risk of C-sections, which, in turn, increase hospital profits because they require longer stays. Some doctors order unnecessary tests because of fear of litigation.

Consumer Reports had this to say: “When it’s time to bring a new baby into the world, there’s a lot to be said for letting nature take the lead. The normal, hormone-driven changes in the body that naturally occur during delivery can optimize infant health and encourage the easy establishment and continuation of breastfeeding and mother-baby attachment. Childbirth without technical intervention can succeed in leading to a good outcome for mother and child, according to a new study.” We couldn’t agree more!

The full report plus ongoing press coverage can be found at Childbirth Connection. Every women in America needs to read this report. Every insurance provider needs to read this report. Every health care provider and hospital needs to read this report. Making the changes necessary to improve outcomes and make birth safer for mothers and babies is a collaborative responsibility. Evidence-Based Maternity Care is a call to action, for all of us.

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