[PPT] - Birth By the Numbers Fall, 2020 Is there a problem with U.S. PowerPoint Presentation

SLIDE 1

Birth By the Numbers Fall, 2020

Is there a problem with U.S. maternity care outcomes?

Gene Declercq, PhD www.birthbythenumbers.org

With initial support from: The Transforming Birth Fund

BirthByTheNumbers.org

SLIDE 2

Total U.S. Births, 1990-2019*

3,600,000 3,800,000 4,000,000 4,200,000 4,400,000 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

3,745,540 4,316,233 Net Decrease 2007-2019 570,693 or 13.2%

Source: Annual NCHS Reports on Births *2019 data is preliminary BirthByTheNumbers.org

SLIDE 3

U.S. Fertility Rates (per 1,000) by Race/Ethnicity, 1989-2018

50 60 70 80 90 100 110

1 9 8 9 1 9 9 1 1 9 9 3 1 9 9 5 1 9 9 7 1 9 9 9 2 1 2 3 2 5 2 7 2 9 2 1 1 2 1 3 2 1 5 2 1 7 All WNH BNH Hisp Fertility rates computed by relating total births, regardless of age of mother, to women 15-44 years. www.BirthByTheNumbers.org

SLIDE 4

Fears of a “Majority/Minority” of births are unfounded…for now

Proportion of all U.S. Births, 1989-2019*

10% 20% 30% 40% 50% 60% 70%

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Non-Hispanic White Hispanic Non-Hispanic Black

Source: Adapted from NCHS Annual Birth Reports *2019 data is preliminary www.BirthByTheNumbers.org

SLIDE 5

Prematurity(<37 weeks) and Low Birthweight (<2500 grams), U.S., 1981-2018 & 2019

6 7 8 9 10 11 12 13

1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019

Prematurity (LMP) Low Birthweight

%

Prematurity (OE)

Year BirthByTheNumbers.org LMP – based on last menstrual period OE – based on obstetric estimate

SLIDE 6

Percent of all births at home, or in a birthing center, United States, 1990-2018

0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1990 1995 2000 2005 2010 2015 2016 2017 2018

Total home & birth center Home Birthing center

46,956 (1.13%) 35,587 (0.87%)

59,596 (1.57%)

80% Increase 2004-2018

38,555 1.01% 21,041 0.55% BirthByTheNumbers.org Source: NCHS Annual Birth Reports

%

SLIDE 7

BirthByTheNumbers.org

Is the U.S. really doing as badly as it seems in international comparisons?

SLIDE 8

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

SLIDE 9

Outcomes: Comparative Neonatal Mortality Rates

Rank Country Country Country

1

Andorra

17

Cuba

33

Bahrain

2

Belarus

18

Czechia

34

Canada

3

Cyprus

19

Germany

35

Croatia

4

Estonia

20

Hungary

36

Denmark

5

Finland

21

Ireland

37

France

6

Iceland

22

Israel

38

Greece

7

Japan

23

Italy

39

New Zealand

8

Luxembourg

24

Latvia

40

Poland

9

Norway

25

Lithuania

41

Romania

10

Republic of Korea

26

Monaco

42

Russian Federation

11

San Marino

27

Montenegro

43

Serbia

12

Singapore

28

Netherlands

44

Slovakia

13

Slovenia

29

Portugal

45

Switzerland

14

Australia

30

Spain

46

United Kingdom

15

Austria

31

Sweden

47 United States

16

Belgium

32

Antigua and Barbuda

Source: WHO. World Health Statistics 2020

SLIDE 10

Outcomes: Comparative Neonatal Mortality Rates

Rank Country Country Country

1

Andorra

17

Cuba

33

Bahrain

2

Belarus

18

Czechia

34

Canada

3

Cyprus

19

Germany

35

Croatia

4

Estonia

20

Hungary

36

Denmark

5

Finland

21

Ireland

37

France

6

Iceland

22

Israel

38

Greece

7

Japan

23

Italy

39

New Zealand

8

Luxembourg

24

Latvia

40

Poland

9

Norway

25

Lithuania

41

Romania

10

Republic of Korea

26

Monaco

42

Russian Federation

11

San Marino

27

Montenegro

43

Serbia

12

Singapore

28

Netherlands

44

Slovakia

13

Slovenia

29

Portugal

45

Switzerland

14

Australia

30

Spain

46

United Kingdom

15

Austria

31

Sweden

47 United States

16

Belgium

32

Antigua and Barbuda

Source: WHO. World Health Statistics 2020

SLIDE 11

Outcomes

Total Births in the six countries in red background in 2018-9* were 12,957 or thousands fewer than the 16,787 in Hawaii in 2019

Country 2018-19* Births Andorra 539 Antigua & Barbuda 1,015 Iceland 4,452 Luxembourg 6,230 San Marino 232 Monaco 489 TOTAL 12,957

BirthByTheNumbers.org * Country data represents the most recent single year available ranging from 2018-2019.

SLIDE 12

BirthByTheNumbers.org

What’s a Fair Comparison with the US?

In the most recent year available (2019):

Countries with at least 100,000 births
Countries with a total per capita GDP of at least $40,000

annually in US dollars.

SLIDE 13

Defining a Set of Countries to Compare with the U.S.

15 Comparison Countries

(SOURCE: OECD, Health Data 2020)

2018 Total Births (000) 2019 GDP per capita U.S. $ 2018 % Births by Cesarean Australia 309 54,765 *33.9 Belgium 118 53,746 21.1 Canada 376 50,967 *27.7 Czech Republic 114 42,242 23.1 France 759 47,868 19.5 Germany 788 55,795 29.6 Israel 184 40,261 14.9 Italy 440 43,901 33.2 Japan 918 42,477 18.5 Korea 358 43,445 45.1 Netherlands 169 59,636 *15.7 Spain 371 41,903 24.5 Sweden 116 55,095 17.0 United Kingdom 731 48,226 28.5 United States 3,746 65,281 32.0 BirthByTheNumbers.org

*2017

SLIDE 14

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, and Israel

SLIDE 15

How is the U.S. doing relative to comparison countries?

Neonatal Mortality Rate

Infant Deaths in First 27 days X 1,000 _____________ Live Births

Perinatal Mortality Rate

Fetal deaths + deaths in the first week X 1,000 _______________ Live births + fetal deaths

BirthByTheNumbers.org

SLIDE 16

Neonatal Mortality Rates (per 1,000 births), 2018, Industrialized Countries with 100,000+ Births

0.9 1.3 1.6 1.6 1.9 2 2 2.2 2.3 2.4 2.5 2.7 2.8 3.5 3.8

0.5 1 1.5 2 2.5 3 3.5 4

Japan Sweden Korea Czech Republic Spain Italy* Israel Belgium# Germany Australia Netherlands France United Kingdom Canada United States

Source: OECD Health Data 2019 and NCHS, Deaths Final Data for 2017.

BirthByTheNumbers.org *2017 #2016 Neonatal Mortality Rate

SLIDE 17

Neonatal Mortality Rates (per 1,000 births), 2018, Industrialized Countries with 100,000+ Births

0.9 1.3 1.6 1.6 1.9 2 2 2.2 2.3 2.4 2.5 2.7 2.8 3.1 3.5 3.8

0.5 1 1.5 2 2.5 3 3.5 4

Japan Sweden Korea Czech Republic Spain Italy* Israel Belgium# Germany Australia Netherlands France United Kingdom US White* Canada United States*

Source: OECD Health Data 2019 and NCHS, Deaths Final Data for 2017.

BirthByTheNumbers.org *2017 #2016 Neonatal Mortality Rate

SLIDE 18

BirthByTheNumbers.org

Perinatal Mortality Rates (per 1,000 births), 2018, Industrialized Countries 100,000+ Births

2.2 2.8 3.4 4.1 4.4 4.7 4.9 5.2 5.6 5.8 5.9 6.0 6.2 7.6 10.6

2 4 6 8 10 12

Japan* Korea Czech Republic Italy# Spain# Sweden Netherlands Israel Germany Canada United States Belgium* United Kingdom Australia France#

#2017; *2016

Source: OECD Health Data 2020

SLIDE 19

BirthByTheNumbers.org

Perinatal Mortality Rates (per 1,000 births), 2018, Industrialized Countries 100,000+ Births

2.2 2.8 3.4 4.1 4.4 4.7 4.9 5.0 5.2 5.6 5.8 5.9 6.0 6.2 7.6 10.6

2 4 6 8 10 12

Japan* Korea Czech Republic Italy# Spain# Sweden Netherlands U.S. White* Israel Germany Canada United States Belgium* United Kingdom Australia France#

#2017; *2016

Source: OECD Health Data 2020

SLIDE 20

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

SLIDE 21

Maternal Mortality Ratios (per 100,000 births), 2017-18

2 4 6 8 10 12 14 16 18

United States Iran Albania Bahrain Chile Hungary Kuwait Serbia South Korea Bosnia and Herzegovina Bulgar ia Canada Kazakhstan Estonia New Zealand Qatar Croatia France Portugal Singapore Germany Macedonia Slovenia Turkmenistan United Kingdom Australia Cyprus Malta Montenegro Austria Belgium Ireland Japan Lithuania Luxembourg Netherlands Slovakia Switzerland Denmar k Iceland Spain Sweden Czech Republic Finland Greece Israel United Arab Emirates Belarus Italy Norway Poland

Countries in green have fewer than 100,000 births. Let’s do a more reasonable comparison

Source: WHO. Trends In Maternal Mortality, 2000-2017. (Geneva, 2019)

www.birthbythenumbers.org

SLIDE 22

U.S. MMR (per 100,000 births ) Compared to Countries with 300,000+ births, 2018

17.4 11.3 8.6 8 6.5 4.8 3.6 3.5 3.2 1.9 2 4 6 8 10 12 14 16 18 20

U.S. Korea Canada France# U.K.* Australia Japan Italy* Germany Spain

Source: OECD Database 2020. # France from WHO. Trends In Maternal Mortality, 2000-2017 & U.S. U.S. Hoyert DL etal. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: NCHS. 1/30/2020. www.birthbythenumbers.org * 2017

SLIDE 23

U.S. Maternal Mortality Ratio (per 100,000 births ) Compared to Industrialized Countries with 300,000+ births, 2017-18

17.4 14.7 11 10 8 7 7 6 5 4 2 2 4 6 8 10 12 14 16 18 20

U.S. U.S. White Korea Canada France Germany U.K. Australia Japan Spain Italy

Source: WHO. Trends In Maternal Mortality, 2000-2017 & U.S. Hoyert DL etal. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: NCHS. 1/30/2020.

www.birthbythenumbers.org

SLIDE 24

Are things Getting Better or Worse?

SLIDE 25

Are things Getting Better or Worse? Yes

SLIDE 26

Are things Getting Better or Worse? Yes

Things are getting better in the U.S., but at a slower pace than comparable countries

SLIDE 27

Examining Trends

ver Time

SLIDE 28

Neonatal Mortality Rate (per 1,000 births), 2000- 2018, U.S., & Ave. for Industrialized Countries*

2.0 3.0 4.0 5.0

2 2 2 2 4 2 6 2 8 2 1 2 1 2 2 1 4 2 1 6 2 1 8

Rate per 1,000 live births

Source: OECD Health Data, 2019 & Ely DM, Driscoll AK. Infant mortality in the United States, 2017: Data from the period linked birth/infant death file. National Vital Statistics Reports, vol 68 no 10. Hyattsville, MD: National Center for Health Statistics. 2019. .

U.S.

* Countries with 100,000+ births (2017): Australia, Belgium, Canada, Czech Republic, France, Germany, Israel, Italy, Japan, Netherlands, Spain, S. Korea, Sweden, U.K.

2.1 3.8 4.6 3.2

Industrialized Countries 34% decrease

17% decrease

SLIDE 29

Neonatal Mortality Rate (per 1,000 births), 2000- 2018, U.S., & Ave. for Industrialized Countries*

2.0 3.0 4.0 5.0

2 2 2 2 4 2 6 2 8 2 1 2 1 2 2 1 4 2 1 6 2 1 8

Rate per 1,000 live births

Source: OECD Health Data, 2019 & Ely DM, Driscoll AK. Infant mortality in the United States, 2017: Data from the period linked birth/infant death file. National Vital Statistics Reports, vol 68 no 10. Hyattsville, MD: National Center for Health Statistics. 2019. .

U.S.

* Countries with 100,000+ births (2017): Australia, Belgium, Canada, Czech Republic, France, Germany, Israel, Italy, Japan, Netherlands, Spain, S. Korea, Sweden, U.K.

2.1 3.8 4.6 3.2

Industrialized Countries 34% decrease

17% decrease

If the U.S. neonatal mortality rate equaled the current average rate of the

ther countries in 2017, that would mean

about 6,478 fewer deaths to babies 28 days or younger annually.

SLIDE 30

Capacity – 92,524

>128,000 fewer neonatal deaths 2000-2018

SLIDE 31

BirthByTheNumbers.org

Perinatal Mortality Rates, 2000-2017 , U.S., & Ave. for Industrialized Countries*

5.0 5.5 6.0 6.5 7.0

2 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 2 1 2 1 1 2 1 2 2 1 3 2 1 4 2 1 5 2 1 6 2 1 7

U.S. 16 % decrease

Industrialized Countries 9% decrease * Countries with 100,000+ births (2017): Australia, Belgium, Canada, Czech Republic, France, Germany, Israel, Italy, Japan, Netherlands, S. Korea, Spain, Sweden, United Kingdom

Sources: OECD Health Data 2019;

U.S.

SLIDE 32

Maternal Mortality Ratios (per 100K births), 2000-2018, U.S. & Comparable Countries *

4.0 8.0 12.0 16.0 20.0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Deaths per 100,000 live births

OECD 15% Decrease

U.S. 38% Increase

* Countries with 300,000+ births (2018): Australia, Canada, France, Germany, Italy, Japan, S. Korea, Spain, United Kingdom

Sources: OECD Health Data 2020; For U.S., HoyertD. 2018 & PetersenE.

Case Ascertainment?

SLIDE 33

BirthByTheNumbers.org

What about process?

SLIDE 34

US Cesarean Rates, 1989-2019

'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 15 16 17 18 19 % 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 32 32 32 32 32

20 22 24 26 28 30 32 34

Source: National Center for Health Statistics Annual Birth Reports

%

1,187,336

If the 2019 cesarean rate was the same as in 1996, there would have been 412,000 fewer cesareans in the U.S. in ’19.

BirthByTheNumbers.org

SLIDE 35

BirthByTheNumbers.org

Primary Cesarean and VBAC Rates, U.S., 1989-2018

5% 10% 15% 20% 25% 30%

1 9 8 9 1 9 9 1 9 9 1 1 9 9 2 1 9 9 3 1 9 9 4 1 9 9 5 1 9 9 6 1 9 9 7 1 9 9 8 1 9 9 9 2 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 2 1 2 1 1 2 1 2 2 1 3 2 1 4 2 1 5 2 1 6 2 1 7 2 1 8

Chart Title

Primary Cesarean Rate VBAC Rate

Note: 2005-2015* unofficial

r = -.94 21.7% 13.3%

SLIDE 36

Cesarean Rates (%) in Industrialized Countries* with 100,000+ Births, 2018

14.9 15.7 17.1 19.5 21.1 23.1 24.5 28.6 28.8 29.6 31.7 33.2 33.9 45.2

5 10 15 20 25 30 35 40 45 50 Israel Netherlands* Sweden France Belgium Czech Republic Spain United Kingdom Canada Germany United States Italy Australia* Korea*

*2017

Source: OECD data, 2020. * No comparative data on cesarean rates in Japan

SLIDE 37

Trends in Overall Cesarean Rate (per 1,000) 1990 – 2018, Countries with Current Highest & Lowest Rates

50 100 150 200 250 300 350 400 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Australia Finland Israel Italy Netherlands Norway Portugal Slovak Republic Sweden Switzerland United States

Sources: OECD data 2020; WHO Europe Health for All Database.

SLIDE 38

VBAC Rates Industrialized Countries, 2015

55 48 42 38 38 35 33 32 29 27 25 24 22 22 21 16

12

12 11 5 10 20 30 40 50 60

Finland Norway France Estonia Netherlands Iceland Denmark Belgium Germany England Czech Republic Lithuania Luxembourg Malta Slovenia Scotland U.S. Latvia Italy Cyprus

Source: Euro-Peristat Project. European Perinatal Health Report. Core indicators of the health and care of pregnant women and babies in Europe in 2015. November 2018.

SLIDE 39

BirthByTheNumbers.org

Do High Rates of Intervention Matter?

1. Outcomes
2. Costs

SLIDE 40

Gestational Age, U.S. All Births, 1990

3% 7% 20% 22% 23% 14% 11%

0% 5% 10% 15% 20% 25% 30% 35% <34 34-36 37-38 39 40 41 42+

SLIDE 41

Gestational Age, U.S. All Births, 2018

3% 8% 26% 31% 19% 8% 5%

0% 5% 10% 15% 20% 25% 30% 35% <34 34-36 37-38 39 40 41 42+

SLIDE 42

Gestational Age, U.S. All Births, 1990, 2018

3% 7% 20% 22% 23% 14% 11% 3% 8% 26% 31% 19% 8% 5%

0% 5% 10% 15% 20% 25% 30% 35% <34 34-36 37-38 39 40 41 42+

SLIDE 43

Gestational Age, U.S. Hospital Births & Planned Home Births that Occur at Home, 2018

3% 8% 26% 31% 19% 8% 5% 0% 2% 13% 24% 31% 19% 10%

0% 5% 10% 15% 20% 25% 30% 35% <34 34-36 37-38 39 40 41 42+ Hospital Home

Weeks

SLIDE 44

Economics of Childbirth in the U.S.

SLIDE 45

BirthByTheNumbers.org

LEADING MAJOR DIAGNOSTIC CATEGORIES by NUMBER OF HOSPITAL DISCHARGES, U.S., 2016

1,655,989 2,169,444 2,249,114 2,933,033 3,207,261 3,545,520 3,923,116 4,101,991 4,337,872

1,000,000 2,000,000 3,000,000 4,000,000 5,000,000

Diseases & Disorders Of The Kidney & Urinary Tract Infectious & Parasitic Diseases Diseases & Disorders Of The Nervous System Diseases & Disorders Of The Digestive System Diseases & Disorders Of The Respiratory System Diseases & Disorders Of The Musculoskeletal Syst Newborns & Other Neonates Pregnancy, Childbirth & The Puerperium Diseases & Disorders Of The Circulatory System

AHRQ. 2020. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/2/20.

SLIDE 46

BirthByTheNumbers.org

Total Payments for Maternity Care, U.S. 2008 & 2015

$29,518 $24,317 $39,702 $29,314 $23,148 $43,774

$0 $10,000 $20,000 $30,000 $40,000 $50,000

Total Pay.-- All Total Vaginal Total Cesarean

2008 2015

Total maternity care—defined as health care services used during the twelve months before delivery, during the delivery hospitalization, and up to three months after delivery. Includes all health care services used in the period before and after delivery. Standardized costs reflect allowed payments for services, not the amount charged for a service or the amount an insurer actually paid for a service.

Source: MonizM. Health Affairs 2020;39:18-23

1%

+10%

5%

SLIDE 47

Is it hopeless? What can be done

SLIDE 48

BirthByTheNumbers.org

Evidence – keep an open

mind and ask different questions.

Advocacy – work for the

change you want.

SLIDE 49

BirthByTheNumbers.org

www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Preventio n_of_the_Primary_Cesarean_Delivery

Safe Prevention of Primary Cesarean Delivery

Rethinking the Evidence

SLIDE 50

http://www.choicesinchildbirth.org/ Childbirth Advocacy Led by Mothers

SLIDE 51

https://www.childbirthconnection.org/

Childbirth Advocacy Led by Mothers

SLIDE 52

www.ourbodiesourselves.org/

SLIDE 53

Virtual Gathering May 4, 2020

www.birthbythenumbers.org