Birth By the Numbers Fall, 2019 Is there a problem with U.S. - - PowerPoint PPT Presentation

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Birth By the Numbers Fall, 2019 Is there a problem with U.S. - - PowerPoint PPT Presentation

Jan 04, 2024 226 likes •896 views

Updating the Original Birth By the Numbers Fall, 2019 Is there a problem with U.S. maternity care outcomes? Gene Declercq, PhD www.birthbythenumbers.org BirthByTheNumbers.org With initial support from: The Transforming Birth Fund Total U.S.

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SLIDE 1

Updating the Original Birth By the Numbers Fall, 2019

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

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SLIDE 2

Total U.S. Births, 1990-2018

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

3,788,235 4,316,233 Net Decrease 2007-2018 527,998 or 12.2%

Source: Annual NCHS Reports on Births BirthByTheNumbers.org

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SLIDE 3

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

50 60 70 80 90 100 110

All WNH BNH Hisp Fertility rates computed by relating total births, regardless of age of mother, to women 15-44 years. www.BirthByTheNumbers.org

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SLIDE 4

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

Proportion of all U.S. Births, 1989-2018*

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

Non-Hispanic White Hispanic Non-Hispanic Black

Source: Adapted from NCHS Annual Birth Reports *2018 data is preliminary www.BirthByTheNumbers.org

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SLIDE 5

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

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

Prematurity (LMP) Low Birthweight

%

Prematurity (OE)

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

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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

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

%

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SLIDE 7

Percentage of out-of-hospital births by race/ethnicity, U. S., 2004-18

0.00 0.50 1.00 1.50 2.00 2.50 3.00 2004 2006 2008 2010 2012 2014 2016 2018

Non-Hispanic white Hon-Hispanic black Hispanic Native American API

API= Asian or Pacific Islander. Source: Birth certificate data from the National Center for Health Statistics.

%

www.BirthByTheNumbers.org

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SLIDE 8

BirthByTheNumbers.org

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

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SLIDE 9

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

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SLIDE 10

Outcomes: Comparative Neonatal Mortality Rates

Rank Country Country Country 1 Andorra (1 per 1,000) 16 France 31 Spain 2 Estonia 17 Germany 32 Sweden 3 Iceland 18 Hungary 33 Bahrain (3 per 1,000) 4 Japan 19 Ireland 34 Croatia 5 San Marino 20 Israel 35 Denmark 6 Singapore 21 Italy 36 Greece 7 Slovenia 22 Latvia 37 New Zealand 8 Australia (2 per 1,000) 23 Lithuania 38 Poland 9 Austria 24 Luxembourg 39 Russian Federation 10 Belarus 25 Monaco 40 Slovakia 11 Belgium 26 Montenegro 41 Switzerland 12 Cuba 27 Netherlands 42 United Kingdom 13 Cyprus 28 Norway

43 United States of America (4 per 1,000)

14 Czechia 29 Portugal 44 Bahamas 15 Finland 30 Republic of Korea Source: WHO. World Health Statistics 2019

BirthByTheNumbers.org

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SLIDE 11

Outcomes: Comparative Neonatal Mortality Rates

Rank Country Country Country 1 Andorra (1 per 1,000) 16 France 31 Spain 2 Estonia 17 Germany 32 Sweden 3 Iceland 18 Hungary 33 Bahrain (3 per 1,000) 4 Japan 19 Ireland 34 Croatia 5 San Marino 20 Israel 35 Denmark 6 Singapore 21 Italy 36 Greece 7 Slovenia 22 Latvia 37 New Zealand 8 Australia (2 per 1,000) 23 Lithuania 38 Poland 9 Austria 24 Luxembourg 39 Russian Federation 10 Belarus 25 Monaco 40 Slovakia 11 Belgium 26 Montenegro 41 Switzerland 12 Cuba 27 Netherlands 42 United Kingdom 13 Cyprus 28 Norway

43 United States of America (4 per 1,000)

14 Czechia 29 Portugal 44 Bahamas 15 Finland 30 Republic of Korea Source: WHO. World Health Statistics 2019

BirthByTheNumbers.org

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SLIDE 12

Outcomes

Total Births in the five countries in red background in 2016-18* were 11,769 or fewer than the 11,893 in South Dakota in 2018

Country 2016-18* Births Andorra 543 Iceland 4,228 Luxembourg 6,274 San Marino 235 Monaco 489 TOTAL 11,769

BirthByTheNumbers.org * Country data represents the most recent single year available ranging from 2016-2018.

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SLIDE 13

BirthByTheNumbers.org

What’s a Fair Comparison with the US?

In the most recent year available (2018):

  • Countries with at least 100,000 births
  • Countries with a total per capita GDP of at least $35,000

annually in US dollars.

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SLIDE 14

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

15 Comparison Countries

(SOURCE: OECD, Health Data 2019)

2017 Total Births (000) 2018 GDP per capita U.S. $ 2017 % Births by Cesarean

Australia 311 54,095 *33.7 Belgium 120 50.470 20.9 Canada 376 48.262 *27.7 Czech Republic 114 39,620 *23.8 France 770 45,384 19.7 Germany 785 53,823 30.1 Israel 184 39,871 14.8 Italy 458 41,594 33.8 Japan 946 42,913 18.0 Korea 358 40,112 45.1 Netherlands 170 56,444 *16.6 Spain 391 39,971 24.4 Sweden 115 53,053 16.6 United Kingdom 755 45,637 27.3 United States 3,856 62,503 32.0

BirthByTheNumbers.org

* 2016

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SLIDE 15

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

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SLIDE 16

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

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SLIDE 17

Neonatal Mortality Rates (per 1,000 births), 2017, Industrialized Countries with 100,000+ Births

0.9 1.5 1.6 1.8 1.9 2 2 2.2 2.3 2.4 2.7 2.8 2.8 3.5 3.9

0.5 1 1.5 2 2.5 3 3.5 4

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

BirthByTheNumbers.org *2016 Neonatal Mortality Rate

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SLIDE 18

Neonatal Mortality Rates (per 1,000 births), 2017, Industrialized Countries with 100,000+ Births

0.9 1.5 1.6 1.8 1.9 2 2 2.2 2.3 2.4 2.7 2.8 2.8 3.1 3.5 3.9

0.5 1 1.5 2 2.5 3 3.5 4

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

BirthByTheNumbers.org *2016 Neonatal Mortality Rate

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SLIDE 19

BirthByTheNumbers.org

Perinatal Mortality Rates (per 1,000 births), 2017, Industrialized Countries 100,000+ Births

2.4 2.7 3.8 4.0 4.4 4.8 4.5 4.6 5.6 5.8 5.9 6.0 6.3 8.1 10.8

2 4 6 8 10 12

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

#2012; *2016

Source: OECD Health Data 2019

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SLIDE 20

BirthByTheNumbers.org

Perinatal Mortality Rates (per 1,000 births), 2017, Industrialized Countries 100,000+ Births

2.4 2.7 3.8 4.0 4.4 4.8 4.5 4.6 5.0 5.6 5.8 5.9 6.0 6.3 8.1 10.8

2 4 6 8 10 12

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

#2012; *2016

Source: OECD Health Data 2019; US NHW -- NCHS (2018) Lack of Change in Perinatal Mortality in the U.S., 2014–2016

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SLIDE 21

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

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SLIDE 22

U.S. MMR* Compared to Countries with 300,000+ births, 2014-15

4 5 5 6 6 7 8 9 11 15.9

2 4 6 8 10 12 14 16 18

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

#

* Maternal Mortality per 100,000 births; # 2015 Estimated U.S. average

Source: Maternal Mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group & UN Population Division. Geneva: 2015; Petersen E. MMWR .vol.68. May 7, 2019. 1-7.

BirthByTheNumbers.org

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SLIDE 23

U.S. MMR* Compared to Countries with 300,000+ births, 2014-15

4 5 5 6 6 7 8 9 11 12.8 15.9

2 4 6 8 10 12 14 16 18

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

* Maternal Mortality per 100,000 births; # 2015 Estimated U.S. average

Source: Maternal Mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group & UN Population Division. Geneva: 2015; Petersen E. MMWR .vol.68. May 7, 2019. 1-7.

#

BirthByTheNumbers.org

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SLIDE 24

Infant Mortality

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SLIDE 25

BirthByTheNumbers.org

Infant Mortality Rates (per 1,000 births), 2017, Industrialized Countries 100,000+ Births

2.0 2.4 2.7 2.7 2.7 2.8 3.1 3.3 3.3 3.6 3.6 3.9 3.9 4.5 5.8

1 2 3 4 5 6

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

Source: OECD Health Data 2019; 2019. Infant Mortality in the United States, 2017: Data From the Period Linked Birth/Infant Death File;

BirthByTheNumbers.org

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SLIDE 26

US Subgroups in Comparative Context with other Industrialized Countries

US Subgroup U.S. IMR 2017 Rank

(15 - 100K)

All 5.8 15

Source: OECD Health Data 2019; 2019. Infant Mortality in the United States, 2017: Data From the Period Linked Birth/Infant Death File;

BirthByTheNumbers.org

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SLIDE 27

US Subgroups in Comparative Context with other Industrialized Countries

US Subgroup U.S. IMR 2017 Rank

(15 - 100K)

All 5.8 15 White Non-Hispanic 4.7 15

Source: OECD Health Data 2019; 2019. Infant Mortality in the United States, 2017: Data From the Period Linked Birth/Infant Death File;

BirthByTheNumbers.org

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SLIDE 28

US Subgroups in Comparative Context with other Industrialized Countries

US Subgroup U.S. IMR 2017 Rank

(15 - 100K)

All 5.8 15 White Non-Hispanic 4.7 15 White NH, Native Born 4.8 15

Source: OECD Health Data 2019; 2019. Infant Mortality in the United States, 2017: Data From the Period Linked Birth/Infant Death File;

BirthByTheNumbers.org

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SLIDE 29

US Subgroups in Comparative Context with other Industrialized Countries

US Subgroup U.S. IMR 2017 Rank

(15 - 100K)

All 5.8 15 White Non-Hispanic 4.7 15 White NH, Native Born 4.8 15 White NH, Singleton Birth 4.2 14

Source: OECD Health Data 2019; 2019. Infant Mortality in the United States, 2017: Data From the Period Linked Birth/Infant Death File;

BirthByTheNumbers.org

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SLIDE 30

US Subgroups in Comparative Context with other Industrialized Countries

US Subgroup U.S. IMR 2017 Rank

(15 - 100K)

All 5.8 15 White Non-Hispanic 4.7 15 White NH, Native Born 4.8 15 White NH, Singleton Birth 4.2 14 White NH, 30-34 yrs old 3.8 12

Source: OECD Health Data 2019; 2019. Infant Mortality in the United States, 2017: Data From the Period Linked Birth/Infant Death File;

BirthByTheNumbers.org

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SLIDE 31

US Subgroups in Comparative Context with other Industrialized Countries

US Subgroup U.S. IMR 2017 Rank

(15 - 100K)

All 5.8 15 White Non-Hispanic 4.7 15 White NH, Native Born 4.8 15 White NH, Singleton Birth 4.2 14 White NH, 30-34 yrs old 3.8 12 White NH, 39-40 weeks 1.6 1

Source: OECD Health Data 2019; 2019. Infant Mortality in the United States, 2017: Data From the Period Linked Birth/Infant Death File;

BirthByTheNumbers.org

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SLIDE 32

Are things Getting Better or Worse?

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SLIDE 33

Are things Getting Better or Worse? Yes

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SLIDE 34

Are things Getting Better or Worse? Yes

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

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SLIDE 35

Examining Trends

  • ver Time
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SLIDE 36

Neonatal Mortality Rate (per 1,000 births), 2000- 2017, U.S., & Ave. for Industrialized Countries*

2.0 3.0 4.0 5.0 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.

2.2 3.9 4.6 3.2

Industrialized Countries 31% decrease

15% decrease

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SLIDE 37

Neonatal Mortality Rate (per 1,000 births), 2000- 2017, U.S., & Ave. for Industrialized Countries*

2.0 3.0 4.0 5.0 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.

2.2 3.9 4.6 3.2

Industrialized Countries 31% decrease

15% 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.

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SLIDE 38

Capacity – 92,524

>116,000 fewer neonatal deaths 2000-2017

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SLIDE 39

BirthByTheNumbers.org

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

5.0 5.5 6.0 6.5 7.0 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.

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SLIDE 40

Maternal Mortality Ratios (per 100K births), 2000-2017, U.S. & Comparable Countries *

4.0 8.0 12.0 16.0 20.0

Deaths per 100,000 live births

OECD 22% Decrease

U.S. 21% Increase

* Countries with 300,000+ births (2017): Australia, Canada, France, Germany, Italy, Japan, S. Korea, Spain, United Kingdom

NOTE: 2008-2015 US rates unofficial^

Sources: OECD Health Data 2019; Petersen E. MMWR .vol.68. May 7,

  • 2019. 1-7.

Case Ascertainment?

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SLIDE 41

BirthByTheNumbers.org

What about process?

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SLIDE 42

US Cesarean Rates, 1989-2018

'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 % 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

20 22 24 26 28 30 32 34

Source: National Center for Health Statistics Annual Birth Reports

%

1,208,447

If the 2018 cesarean rate was the same as in 1996, there would have been 424,000 fewer cesareans in the U.S. in ’18.

BirthByTheNumbers.org

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SLIDE 43

BirthByTheNumbers.org

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

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

Chart Title

Primary Cesarean Rate VBAC Rate

Note: 2005-2015* unofficial

r = -.94 21.7% 13.3%

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SLIDE 44

Cesarean Rates (%) in Industrialized Countries* with 100,000+ Births, 2017

14.8 16.6 16.6 19.7 20.9 23.8 24.4 27.3 27.7 30.0 32.0 33.7 33.8 45.1

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

#2015; *2016

Source: OECD data, 2019. * No comparative data on cesarean rates in Japan

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SLIDE 45

Trends in Overall Cesarean Rate (per 1,000) 1990 – 2017, Countries with Current Highest & Lowest Rates

50 100 150 200 250 300 350 400 Australia Finland Israel Italy Netherlands Norway Portugal Slovak Republic Sweden Switzerland United States

Sources: OECD data 2019; WHO Europe Health for All Database.

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SLIDE 46

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.

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SLIDE 47

BirthByTheNumbers.org

Do High Rates of Intervention Matter?

  • 1. Outcomes
  • 2. Costs
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SLIDE 48

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+ Completed Weeks of Pregnancy

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SLIDE 49

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+ Completed Weeks of Pregnancy

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SLIDE 50

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+ Completed Weeks of Pregnancy

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SLIDE 51

Gestational Age, U.S. Home Births, 2003 & 2018

3% 5% 17% 22% 28% 16% 10% 2% 3% 16% 24% 29% 17% 9%

0% 5% 10% 15% 20% 25% 30% 35% <34 34-36 37-38 39 40 41 42+ 2003 2018

Completed Weeks of Pregnancy

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SLIDE 52

Economics of Childbirth in the U.S.

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SLIDE 53

BirthByTheNumbers.org

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

1,449,148 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

500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000

Mental Diseases & Disorders D&D Kidney Infectious & Parasitic Dis. D&D Nervous System D&D Digestive System D&D Respiratory System D&D Musculoskeletal System Neonates Pregnancy & Childbirth D&D Circulatory System

D&D – Diseases and Disorders

  • AHRQ. 2019. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 8/10/19.
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SLIDE 54

MEDIAN FACILITY LABOR & BIRTH CHARGES BY MODE OF BIRTH, U.S., 2014

$10,580 $18,570 $13,010 $21,704

$0 $22,000

Vaginal no Complications Cesarean No Complications Vaginal Complications Cesarean Complications

Sources: AHRQ. 2017. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD:

  • AHRQ. http://hcupnet.ahrq.gov . Accessed 2/18/17;

NOTE: Hospital charges; no physician costs

76%

Birthbythenumbers.org

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SLIDE 55

Estimated Total Charges, Hospital Birth, U.S., 1993-2014 (000,000)

10,000 20,000 30,000 40,000 50,000 60,000 70,000

Vag no Compl. Vag w Compl. Ces no Compl. Ces w/ Compl.

Sources: AHRQ. 2017. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD:

  • AHRQ. http://hcupnet.ahrq.gov. Accessed 2/17/17.

$ 62,689

$ 14,039

Birthbythenumbers.org

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SLIDE 56

Is it hopeless? What can be done

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SLIDE 57

BirthByTheNumbers.org

  • Evidence – keep an
  • pen mind and ask

different questions.

  • Advocacy – work for

change.

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SLIDE 58

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

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SLIDE 59

https://www.childbirthconnection.org/

Childbirth Advocacy Led by Mothers

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SLIDE 60

www.ourbodiesourselves.org/

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SLIDE 61

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

slide-62
SLIDE 62

BirthByTheNumbers.org

www.thebusinessofbeingborn.com/

Childbirth Advocacy Led by Mothers

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SLIDE 63

Summary

  • The U.S. generally ranks last in maternal and infant health in

comparisons with other wealthy, large countries.

  • Even looking at lower risk subgroups, the U.S. doesn’t fare

any better than comparable countries.

  • Examining trends over time, the U.S. was well behind

comparison countries in 2000 and falling further behind.

  • The U.S. maintains one of the highest cesarean rates among

comparisons countries & among the lowest VBAC rates.

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SLIDE 64

Summary

  • The U.S. has shifted its average gestational age back a

full week (40 tom39 weeks) since 1990.

  • The maternity care system in the US. In highly costly and

the reliance on medical intervention adds to those costs.

  • Active consumer-led efforts are underway to reduce

medical interventions and improve outcomes in U.S. birth.

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SLIDE 65

www.birthbythenumbers.org

Facebook: www.facebook.com/BirthByTheNumbers Twitter: @BirthNumbers Email: birthbynumbers@gmail.com

Jordy Staige Lucy Corey Allison Sarah Christina Veronica Brittany Jessica Kali Gene Katie Sheridan Ebere Lee Maya Kylia Ruby