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Trends in Preterm Birth, Cesarean Delivery, and Induction of Labor in
IndianaStatistics from Live Birth
Data 1990-2006
Trends in Preterm Birth, Cesarean Delivery, and Induction
of Labor in Indiana, 1990-2006
• Changes in gestational age distribution,• Preterm rates by method delivery by
gestational age, race/ethnicity,• Cesarean rate by total, primary and repeat,• Rate of vaginal births after cesarean,• Induction rate stratified by maternal
race /ethnicity, age and plurality,• Index of occurrence by day of week and
time of day stratified by vaginal births, inductions, primary and repeat cesareans.
Definitions
• Term: 39 weeks and 0 days through 42 complete weeks of gestation.
• Near Term: 37 to 38 weeks gestation.
• “Late Preterm”: 34 to 36 6/7 weeks gestation
• Preterm: <37 completed weeks gestation
The Prematurity Problem
• Serious health crisis that costs the United States more than $26 billion annually.
• Key risk factor for infant death. • High risk of serious and sometimes lifelong
health problems. • Late preterm babies (34-36 weeks
gestation) have higher rates of death and disability than full-term babies.
• Near term infants (born at 37-38 weeks) have increased risk for problems compared to infants born at 39 weeks.
Percent Preterm BirthsIndiana and U.S, 1996-2006
In 2006, the preterm birth rate in Indiana was 13.4 percent compared to 12.8 percent for the U.S.
Close to 12,000 babies were born preterm.
More than 70 percent were late preterm births
Percent Distribution of Live Births by Gestational Age:
Indiana, 2006•Nationally we are seeing a shift in the distribution of gestational age from 40 weeks towards an earlier gestation of 39 weeks.
•In Indiana the highest number of births occur at 37-38 weeks gestation (near term) not 40 weeks.
Percent Change by Gestational Age
in Weeks: Indiana 1990-2006
Looking at the change in distribution of gestational age, between 1990-2006, we see a sharp increase in late preterm and near term births with a noticeable decline in births at 40 weeks or more.
+63%
+38%
-54%-46%-20%
Percent Preterm Births by Gestational Age
<37 weeks
Early preterm births have remained fairly consistent over time with a slight increase among both 32-33 weeks and < 32 weeks gestation.
The preterm rate in Indiana increased by 31 percent from 10.2 in 1990 to 13.4 in 2006
Percent of Preterm Births by Race and Hispanic Origin of
MotherPreterm rates remain persistently higher among non-Hispanic blacks compared to
non-Hispanic whites and Hispanics.
A 40% increase in the white preterm rate has shortened the disparity gap not because of less black babies being born preterm but because more white babies are being born preterm.
Percent Late Preterm Births (34-36 wks) by Race and Hispanic
Origin of Mother
Late preterm births increased sharply (by 48%) for non-Hispanic whites and moderately (16%) for Hispanics while there was actually a decrease among non-Hispanic blacks since 2005.
Percent Distribution of Preterm Births by Plurality
15% of preterm births occur among multiples a 33% increase since 1990
85% of preterm births occur among Singleton
births. a 26% increase
The remainder of this report will report data among singleton births only.
Very Preterm: Indiana, 2003-2006 Average
© March of Dimes Foundation, April 2009Very preterm is less than 32 completed weeks gestation. ** Indicates less than five events or missing data. Not able to calculate a reliable rate.Source: National Center for Health Statistics, final natality data. Retrieved October 26, 2009, from www.marchofdimes.com/peristats.
Total Cesarean Rate
In 2006, 29.3 percent of Indiana births were delivered by cesarean, a 48% increase from 19.8 percent in 1997.
Percent Preterm Births By Method Of Delivery Among
Singletons
This slide clearly shows the relationship of the increase in cesarean births to an increase in preterm births in Indiana.
Percent Preterm Births By Gestational Age And Method Delivery Among Singletons
there has been a 41% increase in late preterm births by cesarean section compared to a 27% increase in late preterm births among vaginal deliveries
Total and Primary Cesarean Rate and Vaginal Birth After
Cesarean Rate
The rate of VBAC in Indiana increased from 16.5 percent in 1990 to an all time high or 27.6 percent in 1997, followed by a dramatic decline to 5.8 percent.
Primary Cesarean Rate by Age of Mother
The 2006 rate for women 35 years of age and older (40.1%) was double the rate for mothers under 20 years of age (22.7%).
But
The largest increase (66%) in primary cesarean sections occurred in the <20 year old, dooming these young women to a lifetime of repeat cesareans and increase risk of
complications.
Primary Cesarean Deliveries: Indiana, 2003-2006 Average
© March of Dimes Foundation, April 2009
Elkhart
Newton
Jasper
Noble
Allen Whitley
Adams Wells
Huntington Wabash
Fulton
Miami
Cass
Pulaski
White
Benton
Warren
Tippecanoe
Carroll
Howard
Grant
Jay
Randolph
Delaware Madison Tipton
Hamilton
Henry
Hancock Marion
Boone
Clinton
Fountain Montgomery
Putnam Hendricks
Parke
Vigo
Sullivan
Clay
Greene
Owen
Morgan Johnson
Shelby
Monroe Brown Bartholomew
Lawrence Jackson
Orange
Washington
Posey
Gibson
Pike
Knox
Warrick
Dubois
Daviess Martin
Spencer
Perry
Crawford
Harrison
Floyd
Clark
Jennings
Jefferson
Decatur
Ripley
Dearborn
Wayne
Union Fayette
Switzerland
Rush
Franklin
Steuben
De Kalb
Lake Porter
La Porte St. Joseph
Marshall Kosciusko
La Grange
Vanderburg
Scott
Starke
Ver
mill
ion
Bla
ckf
or
d
Ohio
Over 20.0 (31)
16.9-20.0 (32)
Under 16.9 (29)
Total Cesarean Deliveries: Indiana, 2003-2006 Average
© March of Dimes Foundation, April 2009
Elkhart
Newton
Jasper
Noble
Allen Whitley
Adams Wells
Huntington Wabash
Fulton
Miami
Cass
Pulaski
White
Benton
Warren
Tippecanoe
Carroll
Howard
Grant
Jay
Randolph
Delaware Madison Tipton
Hamilton
Henry
Hancock Marion
Boone
Clinton
Fountain Montgomery
Putnam Hendricks
Parke
Vigo
Sullivan
Clay
Greene
Owen
Morgan Johnson
Shelby
Monroe Brown Bartholomew
Lawrence Jackson
Orange
Washington
Posey
Gibson
Pike
Knox
Warrick
Dubois
Daviess Martin
Spencer
Perry
Crawford
Harrison
Floyd
Clark
Jennings
Jefferson
Decatur
Ripley
Dearborn
Wayne
Union Fayette
Switzerland
Rush
Franklin
Steuben
De Kalb
Lake Porter
La Porte St. Joseph
Marshall Kosciusko
La Grange
Vanderburg
Scott
Starke
Ver
mill
ion
Bla
ckf
or
d
Ohio
Over 30.3 (30)
26.1-30.3 (35)
Under 26.1 (27)
Percent of live births
Level III OB Hospital
Only 7 counties in Indiana have a Level III OB Hospital. The majority of cesarean deliveries are not occurring in these counties.
It is imperative that we look more at this and begin to develop a perinatal system in Indiana.
49.4 48.3 47.844.0 43.8 43.4
39.7 39.5 39.4 38.5
29.8
0
10
20
30
40
50
60
2006
1 2 3 4 5 6 7 8 9 10 IN
Top Ten Hospitals with the Highest Cesarean Rate in 2006 Compared to
Indiana State Rate
l/l l/l l/l lll/lll l/l l/l ll/ll l/l ll/ll l/l
1/1 = Hospital Level of Care
ACOG Guidelines on the Induction of Labor
“The new criteria for confirming a term pregnancy provides clear and clinically relevant parameters to accurately document when inductions might be considered and cautions against inductions before 39 weeks in the absence of a medical indication,”
• The guidelines make clear that even mature lung development is not a reason to induce delivery for logistical reasons if the fetus is not at least 39 weeks old, unless it is medically necessary.
• Risk of having a cesarean section doubles if labor is induced and their cervix is not ready.
Comparison of Induced Labor Ending In Vaginal Delivery And Cesarean Delivery by
Day and Time
0
10
20
30
40
50
Mid-6am 6am-noon noon-6pm 6pm-mid
Inductions by Day and Time
Sun Mon Tue Wed Thu Fri Sat
0
10
20
30
40
50
Mid-6am 6am-noon noon-6pm 6pm-mid
Inductions Ending in Cesarean by Day and Time
Inductions in vaginal delivery show a different pattern than inductions resulting in cesarean delivery. Inductions with vaginal deliveries occur most often between noon-6PM on Mondays and Thursdays during the week
Inductions with subsequent cesarean occur most often during 6PM – midnight and more often on Mondays and Thursdays.