NEWS
A dramatic decline in the number of unintended pregnancies between 1987 and 1994 in the United States is largely the result of greater use of contraceptives, according to a recent study by the Alan Guttmacher Institute (Fam Planning Perspectives Jan/Feb 1998). During the study period, the proportion of women having unintended pregnancies dropped 16 percent, from 54 to 45 pregnancies per 1000 women; the abortion rate declined 11 percent, from 27 to 24 abortions per 1000 women; and the rate of unintended births dropped 22 percent, from 27 to 21 births per 1000 women. Other factors contributing to the decline include the aging of the baby-boom generation, with more women entering their less fertile years, changing attitudes toward abortion, and restricted access to abortion services in some areas. Preliminary data for 1995 showed that 20 legal, induced abortions occurred per 1000 women. The Guttmacher research suggests that abortions are fewer not because more women are giving birth, but because more are not getting pregnant in the first place. The researchers noted, however, that unplanned pregnancy continues to be much higher in the United States than in most comparable developed countries.
A revised and strong policy statement on breastfeeding and the use of human milk has been issued by the American Academy of Pediatrics (Pediatrics 1997;100(6):1035–1039). In addition to summarizing the benefits of breastfeeding to the infant, mother, and nation, it sets forth principles to guide pediatricians and other health caregivers in the initiation and maintenance of breastfeeding. Recommended breastfeeding practices include the following (full text, pp 1036–1037):
1. Human milk is the preferred feeding for all infants, including premature and sick newborns.
2. Breastfeeding should begin as soon as possible after birth, usually within the first hour. Except under special circumstances, the newborn infant should remain with the mother throughout the recovery period.
3. Newborns should be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing, or rooting. Crying is a late indicator of hunger. Newborns should be nursed approximately 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes on each breast.
4. No supplements (water, glucose water, formula, and so forth) should be given to breastfeeding newborns unless a medical indication exists.
5. When discharged less than 48 hours after delivery, all breastfeeding mothers and their newborns should be seen by a pediatrician or other knowledgeable health care practitioner when the newborn is 2 to 4 days of age.
6. Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth. It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired.
7. In the first 6 months, water, juice, and other foods are generally unnecessary for breastfed infants.
8. Should hospitalization of the breastfeeding mother or infant be necessary, every effort should be made to maintain breastfeeding, preferably directly, or by pumping the breasts and feeding expressed breastmilk, if necessary.
The Academy of Pediatrics “firmly adheres to the position that breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant.”
The 1996 Survey of Professional Liability by The American College of Obstetricians and Gynecologists addresses the impact that professional liability is having on the practice of obstetrics and gynecology. It is the sixth such survey conducted by the College. Of the 1800 respondents, 70.7 percent were men, the average age was 46 years, and the average length of time in practice was 14.2 years. Of those who had formerly practiced obstetrics, the average age at which they stopped practicing obstetrics was 46.6 years, compared with the 1992 average age of 48.9 years. Professional liability insurance has increased between 1992 and 1995. In 1995, respondents reported paying an average of $40,660 (in New York $91,841, in California $29,854); in 1992, the average was $33,798 (in New York $63,016, in California $27,223). At least one malpractice claim was filed against 73 percent of respondents (79.4% in 1992), and the average number of claims filed against all respondents during their careers was 2.31. Of all claims filed between 1992 and 1995, 61.5 percent involved obstetrical care and 38.2 percent gynecological care. Neurologically impaired infant claims were the most common primary allegation of an obstetrical claim (29.8%). Compared with the national average, New York obstetrician-gynecologists had more claims filed against them (3.13), and were more likely to have a neurologically impaired infant claim (43%). The average payment for an obstetrical claim was $328,614, and for a neurologically impaired infant claim was $609,117. Because of the risk of malpractice, 8.9 percent of survey respondents stopped practicing, 18.7 percent decreased the level of high-risk obstetrical care, and 6.3 percent decreased the number of deliveries.
Advances toward uncovering the mechanisms of labor and preterm birth were among the new developments reported from the basic science fields at an international conference on the prevention of preterm birth (Prenatal Neonatal Med Feb 1998). The conference was held in October 1997 by the Department of Maternal and Child Health of the University of Alabama at Birmingham, and more than 40 of the invited presentations are published in the conference proceedings. Researchers noted that growing evidence shows that many previously recommended interventions have had little measurable benefit on the reduction of preterm birth rates. New proposals for alternate etiologic pathways with the separate identification of antecedents, mediators, and markers to explain scientific causes of preterm birth are generating optimism for finding effective ways to reduce it. Major progress has been made toward revealing the role of infections on preterm birth, and understanding is increasing about the pathways by which stress and socioeconomic deprivation may influence the problem. Greater research interest needs to be stimulated in the economic issues related to preterm birth and its prevention. Researchers suggested that present activities toward the goal of lowering preterm birth rates include improving the coordination of preconception, prenatal, delivery, and postnatal care by the health care system; encouraging the improvement of patient-provider communication; supporting policies aimed at reducing smoking and sexually transmitted diseases; and promoting earlier provision of general health and reproductive health education to the entire population.
An announcement that the terbutaline infusion pump is potentially dangerous and has been shown not to work when used by pregnant women to prevent premature birth (also known as tocolytic therapy) has been made by the U.S. Food and Drug Administration (FDA) (Network News Nov/Dec 1997). In late November 1997, the FDA sent letters to practitioners, home health agencies, and insurers across the United States warning them about absence of data establishing the device's effectiveness and safety and its potential health risks. The FDA is also investigating the promotional activities of companies that provide tocolytic therapy services, and encourages health care professionals to report adverse events associated with use of the device. The FDA action followed a three-year investigation by the National Women's Health Network on the safety of the pump and their recommendation to the FDA to stop Matria Healthcare (formerly Tokos Medical Corporation) from continuing to distribute it. It was reported in an earlier issue (Birth 1997;24(4):266) that Matria sued the Network for “interfering with business relations and conspiring to commit deceptive trade practices.” After the FDA action to alert the health practitioners and agencies, Matria withdrew its lawsuit against the Network. The Network recently proclaimed its victory (Network News Jan/Feb 1998) with the statement, “With the FDA decision and the end of the suit, we accomplished our main goal—protecting women from potential harm associated with using an unproven treatment. We're proud of successfully defending ourselves against a multimillion dollar corporation that tried to frighten us. We refused to be silenced and we were vindicated.”
Fertility clinics are successful about 20 percent of the time in the United States, according to a recent report released by the Centers for Disease Control and Prevention, the American Society for Reproductive Medicine, the Society for Assisted Reproductive Technology, and RESOLVE, a patient advocacy group (Rochester Democrat & Chronicle 19 Dec 1997). The findings were from 1995 data, the most recent available. In that year almost 60,000 “cycles” (attempts) of assisted reproduction occurred, resulting in 11,315 live births. In vitro fertilization, in which a woman's eggs are retrieved from her ovaries, mixed with sperm, and returned to her uterus, accounted for 70 percent of the procedures. In cases involving a woman's own eggs, the live birth rate was 19.6 percent. The success rate for women aged 21 to 43 years was about 25 percent. It slowly decreased with age to 0 percent for women 47 years and older. Women aged 36 years had more success using donor eggs rather than their own. Thirty-seven percent of all the live births were multiple births, compared with 2 percent in the general population.
A quiet but fast-emerging assisted reproduction technique has been described as a “supermarket approach to embryos,” by Lori B. Andrews, professor of law at Chicago-Kent College of Law and expert on legal issues of reproduction (Rochester Democrat & Chronicle 23 Nov 1997). At some leading infertility clinics, human eggs and sperm are mixed to make a variety of embryos with different pedigrees. These are then frozen. Prospective parents may select “premade human embryos,” whose parents resemble them physically or have the same ethnic background and are well educated. The cost at Columbia-Presbyterian Medical Center in New York City, for example, is $2750. The technique has resulted in an unknown number of births. Some embryos are custom made by physicians, whereas others have been made for infertile couples, and then not used. These couples paid for their egg and sperm donors, but ended up with more embryos than they needed. These extra embryos are offered up for “adoption” to people who cannot afford the more than $16,000 it would cost them for a single attempt at pregnancy with sperm and egg donors they select themselves. The few centers using the technique have waiting lists of couples who want the premade embryos. Such embryos seem to inhabit ambiguous legal territory, said Andrews. Laws governing sperm and egg donors vary from state to state, and many states have no laws. The law has also not addressed questions such as the status of embryos formed in the laboratory.
International News
More than 15 percent of deliveries were by cesarean section in England in 1994–1995, according to a recent national report on maternity statistics issued by the Department of Health, London, in December 1997 (Statistical Bulletin 1997/98). About 20 percent of labors were induced, 10 percent were instrumental deliveries, and epidural or spinal anesthesia was used in 25 percent of all deliveries. The bulletin fills a long-standing gap in maternity care data, and is expected to become a regular and annual series. The bulletin also contains information about duration of stay, complications of labor and delivery, use of episiotomy, day of the week for delivery, and analysis of how intervention rates are associated with the mother's age and parity and the number of babies she is expecting.
For the midwives of British Columbia, January 1, 1998, was a historic day. At 12:33 am, Vancouver's first baby of the year was born with the assistance of a registered midwife on the first day that midwives were registered in British Columbia. The first home birth, also with a registered midwife, occurred in Vancouver 24 hours later. After many years of intense effort and debate over the legislation and regulation of the practice of midwifery, British Columbia joined the province of Ontario to allow deliveries to be conducted by midwives. Alberta and Quebec are expected to follow suit soon. On December 19, 1997, the Minister of Health announced that midwifery would be publicly funded, fueling outspoken disagreement. Dr. Michael Klein noted in an editorial, however (Vancouver Sun 30 Dec 1997), that “financial distractions” have taken away from what really matters to both midwives and physicians, namely, good quality care for the women and children they serve. The families of British Columbia worked long and hard to legalize midwifery, and the addition of registered midwives will give families in the province a wider choice in caregivers for pregnancy, birth, and after birth. The College of Midwives has developed a regulatory framework of standards and policies to ensure that a safe, collaborative, and community-based model of care will be available, in which physicians and midwives will develop new collegial relationships and work together in the best interests of mothers and babies.
