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Understanding Contemporary US Birth and the Role of Midwives Eugene Declercq, PhD Boston University School of Public Health Grantmakers in Health Annual Meeting Atlanta, Georgia March 6, 2014 BirthByTheNumbers.org
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Three Trends of Interest
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Total U.S. Births, 1990-2012 Source: Adapted from CDC VitalSTATS. http://www.cdc.gov/nchs/VitalStats.htm
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Prematurity and Low Birthweight, U.S., 1981-2012
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Percent of all births occurring outside a hospital, at home, or in a birthing center, United States, 1990-2012 Total out of hospital Home Birthing center 46,956 (1.13%) 35,587 (0.87%) 50,761 (1.28%) 43% Increase 2004-2013
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BirthByTheNumbers.org Key Question Is the U.S. really doing as badly as it seems in international comparisons? BirthByTheNumbers.org
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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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Outcomes: Comparative Neonatal Mortality Rates Rank Country Rank Country Rank Country 1 San Marino (1) 14 Israel 27 Belarus AndorraMonacoNetherlands IcelandRepublic of KoreaGreece JapanIrelandCuba SingaporeBelgiumLithuania CyprusCzech RepublicNew Zealand 7 Luxembourg (2)FranceUnited Kingdom SloveniaGermanySwitzerland SwedenItalyCroatia FinlandDenmarkMalaysia Estonia 24 Austria (3) 37 United States (4) NorwaySpain Canada, Hungary, U.A.E. 13 Portugal 26 Australia Poland, Qatar, Serbia Source: State of the World’s Children2013. http://www.unicef.org/sowc2013/statistics.html BirthByTheNumbers.org
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Outcomes Five countries in red background share a particular characteristic – almost no one actually lives there. Total Births in these countries in 2012 were 11,429 or fewer than the 11,450 in Alaska in 2011 Country2012 Births Andorra757 Iceland4,146 Luxembourg6,034 San Marino285 Monaco207 TOTAL11,429 BirthByTheNumbers.org
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What’s a Fair Comparison with the US? In the most recent year available (2010): Countries with at least 100,000 births Countries with a total per capita annual expenditure on health of at least $1,500 in US dollars.
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Defining a Set of Countries to Compare with the U.S. 17 Comparison Countries (SOURCE: OECD, Health Data 2012 & State of World’s Children) 2011 Total Births (000) 2011 Total exp. health – PC, US$ PPP 2011 % Births by Cesarean Australia302 *3,800*31.2 Belgium*1294,061*19.7 Canada3774,521*26.1 Czech Republic1091,96623.3 France7924,11820.2 Germany*6784,49531.4 Greece 1062,361 NA Israel1662,23919.9 Italy*5573,01237.7 Japan 1,051*3,213 18.0 Korea4712,19834.6 Netherlands*1845,099*15.6 Portugal972,61933.3 Spain4713,07224.9 Sweden1123,92516.2 United Kingdom8083,40624.1 United States3,9548,50832.8 BirthByTheNumbers.org * 2010
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BirthByTheNumbers.org IOM chose 16 peer countries. 13 are same as the one’s we’ve used. They use 3 countries (Denmark, Finland, Switzerland) that have 100,000 births. We include Belgium, Czech Republic, Greece and Hungary
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Neonatal Mortality Rates (per 1,000 births), 2010, Industrialized Countries with 100,000+ Births Source: OECD Health Data 2013 and NCHS, Deaths Final Data for 2007. BirthByTheNumbers.org
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Neonatal Mortality Rates (per 1,000 births), 2010, Industrialized Countries with 100,000+ Births Source: OECD Health Data 2013 and NCHS, Deaths Final Data for 2007. BirthByTheNumbers.org
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Maternal Mortality Ratios Maternal Mortality Ratio Maternal Deaths all causes X 100,000 _______________ Live births
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Maternal Mortality Rates, (per 100,000 births), 2010, Industrialized Countries with 300,000+ births Sources: OECD Health Data 2013; NCHS. 2009. Deaths, Final Data, 2007. U.S. 2007: Black non-Hispanic 28.4 White non-Hispanic 10.5 Hispanic 8.9 Maternal Mortality Rate *2009; #2008; **2007; ^Estimate
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BirthByTheNumbers.org Other countries do better because the U.S. is different: -- more diversity, -- weaker social support system, -- inequality in our health care system. What if we compared subgroups in the U.S. to other countries?
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US Subgroups in Comparative Context with other Industrialized Countries US SubgroupU.S. IMR 2010 Rank (17- 100K) All6.117 Source: U.S. subgroups: Mathews & M. MacDorman. 1/24/13. Infant mortality statistics from the 2009 period linked birth/infant death data set. NVSR v. 61 (8).Hyattsville, MD: NCHS, Table 2. *Other IMRs from OECD Health Data 2013.
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US Subgroups in Comparative Context with other Industrialized Countries US SubgroupU.S. IMR 2010 Rank (17- 100K) All6.117 White Non-Hispanic5.217 Source: U.S. subgroups: Mathews & M. MacDorman. 1/24/13. Infant mortality statistics from the 2009 period linked birth/infant death data set. NVSR v. 61 (8).Hyattsville, MD: NCHS, Table 2. *Other IMRs from OECD Health Data 2013.
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US Subgroups in Comparative Context with other Industrialized Countries US SubgroupU.S. IMR 2010 Rank (17- 100K) All6.117 White Non-Hispanic5.217 White NH, Native Born5.417 Source: U.S. subgroups: Mathews & M. MacDorman. 1/24/13. Infant mortality statistics from the 2009 period linked birth/infant death data set. NVSR v. 61 (8).Hyattsville, MD: NCHS, Table 2. *Other IMRs from OECD Health Data 2013.
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US Subgroups in Comparative Context with other Industrialized Countries US SubgroupU.S. IMR 2010 Rank (17- 100K) All6.117 White Non-Hispanic5.217 White NH, Native Born5.417 White NH, Singleton Birth4.616 Source: U.S. subgroups: Mathews & M. MacDorman. 1/24/13. Infant mortality statistics from the 2009 period linked birth/infant death data set. NVSR v. 61 (8).Hyattsville, MD: NCHS, Table 2. *Other IMRs from OECD Health Data 2013.
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US Subgroups in Comparative Context with other Industrialized Countries US SubgroupU.S. IMR 2010 Rank (17- 100K) All6.117 White Non-Hispanic5.217 White NH, Native Born5.417 White NH, Singleton Birth4.616 White NH, 30-34 yrs old4.115 Source: U.S. subgroups: Mathews & M. MacDorman. 1/24/13. Infant mortality statistics from the 2009 period linked birth/infant death data set. NVSR v. 61 (8).Hyattsville, MD: NCHS, Table 2. *Other IMRs from OECD Health Data 2013.
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US Subgroups in Comparative Context with other Industrialized Countries US SubgroupU.S. IMR 2010 Rank (17- 100K) All6.117 White Non-Hispanic5.217 White NH, Native Born5.417 White NH, Singleton Birth4.616 White NH, 30-34 yrs old4.115 White NH, 39-41 weeks1.81 Source: U.S. subgroups: Mathews & M. MacDorman. 1/24/13. Infant mortality statistics from the 2009 period linked birth/infant death data set. NVSR v. 61 (8).Hyattsville, MD: NCHS, Table 2. *Other IMRs from OECD Health Data 2013.
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Examining Trends over Time
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Neonatal Mortality Rate (per 1,000 births), 2000- 2011, U.S., & Ave. for Industrialized Countries* Source: OECD Health Data, 2014 & MacDorman MF, et al. Recent declines in infant mortality in the United States, 2005–2011. NCHS data brief, no 120. Hyattsville, MD: NCHS. 2013. U.S. * Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Israel, Italy, Japan, Netherlands, Portugal, Spain, S. Korea, Sweden, U.K. 2.3 4.0 4.6 3.1 Industrialized Countries 23% decrease 13% decrease
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Neonatal Mortality Rate (per 1,000 births), 2000- 2011, U.S., & Ave. for Industrialized Countries* Source: OECD Health Data, 2014 & MacDorman MF, et al. Recent declines in infant mortality in the United States, 2005–2011. NCHS data brief, no 120. Hyattsville, MD: NCHS. 2013. U.S. * Countries with 100,000+ births (2009): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Israel, Italy, Japan, Netherlands, Portugal, Spain, S. Korea, Sweden, U.K. 2.3 4.0 4.6 3.1 If the U,S. neonatal mortality rate equaled the current average rate of the other countries in 2011, that would mean almost 6,955 fewer deaths to babies 28 days or younger annually.
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Maternal Mortality Ratios (per 100,000 births), 2000-2011, U.S. & Ave. Industrialized Countries* Industrialized Countries 3 % Increase U.S. 71% Increase Sources: OECD Health Data 2014; NCHS. 2010. Deaths, Final Data, 2007. * Countries with 300,000+ births (2011): Australia, Canada, France, Germany, Italy, Japan, S. Korea, Spain, United Kingdom NOTE: 2008-2010 US rates unofficial
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BirthByTheNumbers.org But Gene, you’ve only looked at outcomes What about process?
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US Cesarean Rates, 1989-2012 Source: National Center for Health Statistics Annual Birth Reports % 1,296,070 If the 2012 cesarean rate was the same as in 1996, there would have been 478,000 fewer cesareans in the U.S. in ’12.
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BirthByTheNumbers.org
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Do High Rates of Intervention Matter? 1. Outcomes 2. Costs
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Gestational Age, U.S. All Births, 1990 * Only births occurring at home. Source: Martin JA, Hamilton BE, Osterman MJK, Curtin S and Mathews TJ. Births: Final data for 2012. National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2014.
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Gestational Age, U.S. All Births, 1990, 2012 * Only births occurring at home. Source: Martin JA, Hamilton BE, Osterman MJK, Curtin S and Mathews TJ. Births: Final data for 2012. National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2014.
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Gestational Age, U.S. All Births, 1990, 2012 * Only births occurring at home. Source: Martin JA, Hamilton BE, Osterman MJK, Curtin S and Mathews TJ. Births: Final data for 2012. National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2014.
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Source: Althabe F.Cesarean Section Rates and Maternal & Neonatal Mortality Birth.2006;33:270 Cesarean Rates and Neonatal Mortality Low Income Medium Income High Income
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But Gene, while our foundation focuses on health, we’ve never prioritized birth. Why should we start now? Economics of Childbirth in the U.S.
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LEADING MAJOR DIAGNOSTIC CATEGORIES by NUMBER OF HOSPITAL DISCHARGES, U.S., 2011 AHRQ. 2014. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1/2014. 5,258,172 4,237,975 3,941,545
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MEDIAN FACILITY LABOR & BIRTH CHARGES BY MODE OF BIRTH, U.S., 2011 Sources: AHRQ. 2011. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1/14;http://hcupnet.ahrq.gov NOTE: Hospital charges; no physician costs 72%
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Estimated Total Charges, Hospital Birth, U.S., 1993-2011 (000,000) Sources: AHRQ. 2009. HCUPnet, Healthcare Cost & Utilization Project. Rockville, MD: AHRQ. http://hcupnet.ahrq.gov. Accessed 3/1614.http://hcupnet.ahrq.gov $ 52,734 $ 14,039
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Can Midwives Make a Difference?
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BirthByTheNumbers.org Benefits of midwifery Midwife-led continuity of care was associated with several benefits for mothers and babies, and had no identified adverse effects compared with models of medical-led care and shared care. Reduction in epidurals, episiotomies & instrumental births Increase in spontaneous vaginal births Less preterm birth Less miscarriage No difference in cesareans or stillbirths December, 2013
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BirthByTheNumbers.org CNMs per births & Cesarean Rate in State 2011 CNM per 1,000 births in state Cesarean Rate LA UT FL NJ VT NH ID TX MI CA NY GA MA NM AL CO WA AZ
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BirthByTheNumbers.org Proportion of all U.S. Births Attended by Midwives, 1989-2012
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OBGYN per 100K, 2011 SOURCE: Area Resource File 1,459 (46%) U.S. Counties with no OB 3,142 U.S. Counties
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CNMs per 100K, 2011 SOURCE: Area Resource File 3,142 U.S. Counties 1,758 (56%) U.S. Counties with no CNM
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SOURCE: Area Resource File CNMs & OBs per 100K, 2011 3,142 U.S. Counties 1,263 (40%) U.S. Counties with no OB or CNM
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Childbirth Advocacy Led by Mothers www.birthbythenumbers.org www.childbirthconnection.org
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BirthByTheNumbers.org Extra Slides
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Percent of singleton preterm (<37 weeks) births by method of delivery, United States, 1991-2012 Source: Adapted from MacDorman et al. AJPH, 2011. 9.7% 5.7% 6.7% 11.1% 10.0% 4.8% 3.6% 3.9% 2.3% Spontaneous Vaginal Cesarean Cesarean post induction Induced Vaginal
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Sources: OECD Health Data 2013; U.S. Natality Data; Japan – sample; Lancet 6736(09)61870-5. Cesarean Rates in Industrialized Countries* with 100,000+ Births, 2011 *2010 * No data on cesarean rates in Greece
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BirthByTheNumbers.org Are mothers & babies the cause of these changes?
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BirthByTheNumbers.org Is it Older Mothers? Total Cesarean Rates (per 100 births) by Age of Mother: United States, 1996 and 2012 Source: National vital statistics system, NCHS, CDC. Percent Overall increase, 1996-2012: 58.5%
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Are Babies Getting Bigger? % Singleton Babies by Birthweight, U. S., 1991-2012 41% 39% 36% BirthByTheNumbers.org
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Prepregnancy Obesity, U.S. 2003, 2006, 2009 Source: S. Fisher. Is obesity still increasing among pregnant women? Preventive Medicine 2013; 56: 372-378.
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Induction No 53% Epidural No 39% Epidural Yes 61% Induction Yes 47% Epidural No 22% Epidural Yes 78% First-time mothers who experienced labor Cesarean Yes 20% Cesarean Yes 5% Cesarean Yes 31% Cesarean Yes 19% Cascade of intervention in first-time mothers who experienced labor Base: first-time mothers with full term births who experienced labor n=821 Note: in this group, which included 93% of first-time mothers, the overall epidural rate was 71% and overall cesarean rate was 19% BirthByTheNumbers.org
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Perinatal Mortality Rates, 2000-2011, U.S., & Ave. for Industrialized Countries* * Countries with 100,000+ births (2011): Australia, Belgium, Canada, Czech Republic, France, Germany, Greece, Israel, Italy, Japan, Netherlands, Portugal, S. Korea, Spain, Sweden, United Kingdom
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Total cesarean rates by race/ethnicity, U.S. 1989-2012 Source: National Center for Health Statistics Annual Birth Reports 1989 WNH +1.4percentage points 2011 BNH +3.5 percentage points
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VBAC Rates, Selected Countries, 2004 Source: Adapted from Peristats, US & Canadian Data
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BirthByTheNumbers.org Have maternal request cesareans played a major role in these increases?
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BirthByTheNumbers.org Two Components to Maternal Request Primary Cesarean 1. Mother made request for planned cesarean before labor
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BirthByTheNumbers.org Two Components to Maternal Request Primary Cesarean 1. Mother made request for planned cesarean before labor 2. Cesarean for no medical reason
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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 and Canada confirm very low rates of maternal request cesareans
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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
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Inductions in Vaginal Births, U.S., 1990-2012 Source: Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. http://www.cdc.gov/nchs/vitalstats.htm. http://www.cdc.gov/nchs/vitalstats.htm BirthByTheNumbers.org
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U.S. Fertility Rates (per 1,000) by Race/Ethnicity, 1989-2012 Fertility rates computed by relating total births, regardless of age of mother, to women 15-44 years. BirthByTheNumbers.org
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Proportion of Births to Older Mothers, U.S. 1990-2012 NOTE: Since 2003 Cesarean Rate Increased by 20% > 35 >30 BirthByTheNumbers.org
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Are Babies Getting Bigger? % Singleton Babies by Birthweight, U. S., 1991-2011 41% 39% 36% BirthByTheNumbers.org
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Rates of Multiple Births (proportion of all babies in multiple births), U.S., 1980-2012 BirthByTheNumbers.org
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Primary Cesarean and VBAC Rates, U.S., 1989-2011 r = -.95 Source: NCHS. Annual Birth Reports & Vital Stats Note: 2005-2011 unofficial
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VBAC Rates*, U.S.,1990-2011 Source: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm * Number of VBACs among women with prior cesarean NOTE: Rates for 2005-2011 are unofficial
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BirthByTheNumbers.org Perinatal Mortality Rates (per 1,000 births), 2010, Industrialized Countries 100,000+ Births
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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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