1. BirthByTheNumbers.org Midwives as the Linchpin in Evidence Based Care Maternity Care: The Case of Unnecessary Cesarean Sections Professor Gene Declercq, PhD Boston University School of Public Health www.birthbythenumbers.org

2. BirthByTheNumbers.org Outline of the presentation Premise of the talk – making midwives central to women’s health care in the community and the facility Debates over rising cesarean rates Midwives critical role

3. Premise: Framework for quality maternal & newborn care Renfrew et al. The Lancet - 23 June 2014. DOI: 10.1016/S0140-6736(14)60789-3

4. Framework for quality maternal and newborn care Renfrew et al The Lancet - 23 June 2014. DOI: 10.1016/S0140-6736(14)60789-3 This is where Cesareans can be life saving

5. So how frequent should cesarean section be? Source Publication Yr CountriesData Years Recomm/ Finding WHO1985?? 10-15% Althabe et al. 2006119~2000- 2001 15% ish Ye et al.201419 industrialized ~1980 -- ~2010 10%-15% Molina et al. 2015194 WHO Cntries 2012 (2005-2012) 19% WHO. Lancet. 1985 Aug 24;2(8452):436-7. Althabe. Birth.2006.33:270-277. Ye. Birth. 2014. 41:237-44. Molina. JAMA. 2015;314(21):2263-2270.

6. Trends in Cesarean Rates (per 1000 births), Industrialized Countries, 1990-2007 Sources: OECD Health Data 2016; WHO Health for All Database, 2016. BirthByTheNumbers.org

7. “….China and Brazil account almost for 50% of the total number of unnecessary Cesarean Sections. Using 20% as the threshold rate to define the overuse of CS, 4 million CS are in excess in 46 countries.” Worldwide, CS that are possibly medically unnecessary appear to command a disproportionate share of global economic resources. CS arguably function as a barrier to universal coverage with necessary health services. 'Excess' CS can therefore have important negative implications for health equity both within and across countries. It’s not just industrialized countries Based on 2008 data

8. BirthByTheNumbers.org India’s Cesarean rate (%) by Subgroup, 1992-2006 Source: DHS Stat Compiler

9. US Cesarean Rates, 1989-2014 Source: National Center for Health Statistics Annual Birth Reports % 1,283,467 If the 2014 cesarean rate was the same as in 1996, there would have been 458,000 fewer cesareans in the U.S. in ’14. So why the major increase?

10. BirthByTheNumbers.org Commonly Used Explanations for the High Cesarean Rate Mothers are getting older More multiples being born Maternal obesity increasing Babies are getting bigger Mothers are generally less healthy Mothers are asking for it What do these explanations have in common?

11. Older Mothers? % Births to Mothers 30 +, U.S. 1990-2014 Between 2003 & 2010 CS Rate increased by 20% > 35 >30 BirthByTheNumbers.org From 2010- 2014, CS rate unchanged

12. BirthByTheNumbers.org Total Cesarean Rates (per 100 births) by Age of Mother: United States, 1996 and 2014 Source: National vital statistics system, NCHS, CDC. Percent

13. Multiple Births? Proportion of all babies in multiple births, U.S., 1980-2014 BirthByTheNumbers.org Source: National Center for Health Statistics Annual Birth Reports

14. Cesarean Rates for Multiple Births, U.S. 1990-2014 BirthByTheNumbers.org

15. Are U.S. Babies Getting Bigger?...NO! % Singleton, Full Term Babies by Birthweight, U. S., 1990-2014 41% 44% 39% 38% www.BirthByTheNumbers.org 39% Source: Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. http://www.cdc.gov/nchs/vitalstats.htm. (Access 12/23/15)http://www.cdc.gov/nchs/vitalstats.htm

16. % Cesareans in Singleton Births, U.S. by Birthweight, 1991-2014 52.9% 37.9% 30.7% 21.8% 27.8% 38.2% BirthByTheNumbers.org

17. Mothers’ Health? Prepregnancy Obesity, U.S. 2003, 2006, 2009, 2011 Sources: 2003-2009 -- S. Fisher. Is obesity still increasing among pregnant women? Preventive Medicine 2013; 56: 372-378; 2011 – CDC VitalStats.

18. BirthByTheNumbers.org Mothers’ Health? Cesarean Rate Singleton Births by Prepregnancy Weight Range, U.S. 2014 Source: CDC VitalStats, 2014.

19. ~ Adjusted for maternal age, race/ethnicity, education, trimester prenatal care began, nativity (US or foreign-born), method of payment for the delivery, and pre-pregnancy and gestational diabetes and hypertension. ^ “Normal weight” (BMI 18.5-24.9) was the reference group; Error Bars represent 95% Confidence Intervals. *Singleton, vertex, 37-41 weeks of gestational age. LBO = live birth order Source: Declercq et al. Birth. 2015.42(4):309-18

20. BirthByTheNumbers.org Mothers’ Health? Diabetes* & Hypertension*, 1992,2002,2014 * Either gestational or chronic condition. Measurement changed in 2014. Source: CDC VitalStats, selected years.

21. BirthByTheNumbers.org Mothers’ Health? Cesarean Rates, Singleton Births, U.S., 1990, 1996, 2004, 2014* Source: CDC VitalStats, selected years. * Measures of chronic diabetes & hypertension changed in 2014.

22. BirthByTheNumbers.org Mothers’ Health? Cesarean Rates, Singleton Births, U.S., 1990, 1996, 2004, 2014 Source: CDC VitalStats, selected years.

23. BirthByTheNumbers.org Mothers asked for it Have maternal request cesareans played a major role in these increases?

24. http://www.childbirthconnection.org Asking Mothers about Maternal Request Cesareans

25. BirthByTheNumbers.org Two Components to Maternal Request Primary Cesarean 1. Mother made request for planned cesarean before labor

26. BirthByTheNumbers.org Two Components to Maternal Request Primary Cesarean 1. Mother made request for planned cesarean before labor 2. Cesarean for no medical reason

27. BirthByTheNumbers.org Patient Choice Primary Cesareans Combining reason for cesarean and timing of decision found only about 1% of respondents had a planned primary cesarean for no medical reason. “ “I think that [cesarean] is… the best way … to give birth. It is a planned way, no hassle, no pain, the baby doesn’t struggle to come out, the baby is not pressed to come out …I think that … everybody should have the baby by cesarean section.” (quote from LtM2) Studies from England, Canada and U.S. states confirm very low rates of maternal request primary cesareans

28. Pressure to Accept Interventions by Method of Delivery Did you feel pressure from any health professional to have a cesarean? % yes Source: Declercq et al. 2013. Listening to Mothers III. BirthByTheNumbers.org

29. Commonly Used Explanations for the High Cesarean Rate Mothers are getting older More multiples being born Babies are getting bigger Maternal health is worse: obesity, diabetes & hypertension Mothers are asking for it

30. BirthByTheNumbers.org Commonly Used Explanations for the High Cesarean Rate Mothers are getting older– NO More multiples being born – NO Babies are getting bigger – NO !! Maternal health is worse: obesity, diabetes & hypertension – Some Mothers are asking for it – NO

31. So is a rising cesarean rate inevitable? ABSOLUTELY NOT BirthByTheNumbers.org

32. Trends in Cesarean Rates (per 1000 births), Industrialized Countries, 1990-2007 Sources: OECD Health Data 2016; WHO Health for All Database, 2016. BirthByTheNumbers.org

33. Trends in Cesarean Rates (per 1000 births), Comparison Countries, 1990-2013 Sources: OECD Health Data 2016; WHO Health for All Database, 2016. BirthByTheNumbers.org

34. So where do midwives come in?

35. Framework for quality maternal and newborn care The scope of midwifery – panel 2 and appendix Renfrew et al The Lancet - 23 June 2014. DOI: 10.1016/S0140-6736(14)60789-3 This is where midwives come in

36. BirthByTheNumbers.org Cesarean Rates & % CNM Births, U.S. States, 2014 CS Rate % CNM

37. BirthByTheNumbers.org Practice Categories

38. BirthByTheNumbers.org

40. Midwives as the linchpin Ideally suited to apply these principles in the community where prevention must begin. With respectful care midwifery in the community builds the trust that’s necessary to: A.Convince women of the value and safety of facility births when necessary in developing countries; and B. Provide women in industrialized countries with the support and care that can minimize unnecessary cesareans

41. BirthByTheNumbers.org Why midwives can’t wait until pregnancy – the case for community level women’s health care.

42. Adjusted*OR for Neonatal Mortality by Prepregnancy BMI Category, 38 states and D.C., 2012-13 * Adjusted for maternal age, race/ethnicity, education, parity, prenatal care, payer source, chronic diabetes, chronic hypertension, gestational age, birthweight small for gestational age. Waiting for pregnancy is too late. Source: Declercq et al. Obstetrics and Gynecology. 2016.127(2):279-87

43. The problem isn’t cesareans – it’s the need for systems of care with midwives in a central role in women’s health care in both communities and facilities Renfrew et al. The Lancet - 23 June 2014. DOI: 10.1016/S0140-6736(14)60789-3

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