1. Michelle J.K. Osterman, M.H.S. Joyce A. Martin, M.P.H. National Center for Health Statistics Extending Our Reach Through Partnerships June 2-6, 2013 Phoenix, Arizona

2. Why? Better outcomes with longer gestation 39 or more weeks Under 39 weeks Early term Late preterm 38 weeks 37 weeks 36 weeks 35 weeks 34 weeks

3. Outline Outcomes by gestational age Late preterm (34-36 weeks) 36 weeks Early term births (37-38 weeks) Labor and Delivery Management by gestational age Induction of Labor Cesarean delivery

4. Methods Birth certificate data 1990-2010 final 2011 preliminary Focus on births under 39 weeks Gestational age based on date of last menstrual period Singletons only

5. Methods Includes all births Medically-indicated Nonmedically-indicated Definitions Induction of labor = artificial initiation of labor prior to the onset of spontaneous labor Cesarean delivery = surgical extraction of the fetus, placenta, and membranes through abdominal incision

7. Births by gestational age: United States, 1990-2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 39 or more weeks Under 39 weeks

8. Births by gestational age: United States, 1990-2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 39 or more weeks Under 39 weeks 37%-11%

9. Gestational age groups Under 39 weeks Less than 34 weeks = Early preterm 34-36 weeks = Late preterm 37-38 weeks = Early term 39 or more weeks

10. Births by gestational age: United States, 1990 and 2006 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 1990 2006

11. Births by gestational age: United States, 1990, 2006 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 1990 20062011

12. Births by gestational age: United States, 2006 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System Early termLate preterm

13. Births by gestational age: United States, 2006 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System Early termLate preterm

14. Births by gestational age: United States, 2006 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System Early termLate preterm

15. Births by gestational age: United States, 2006 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System Early termLate preterm

16. Births under 39 weeks 2006-2011 decrease 36 weeks (late preterm) 37 weeks (early term) 38 weeks (early term) Combine weeks 36-38

17. Change in percentage of births occurring at 36-38 weeks: 2006 and 2011 MT WY ID WA OR UT CA ND SD NE CO TX OK KS AR MO MN IL KY TN AL GA FL SC VA WV OH DE CT MA NJ DE DC Decrease NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System AK HI AZ LA IN MI NY NC NE NM IA WI PA ME RI NH VT MD

18. Change in percentage of births occurring at 36-38 weeks: 2006 and 2011 Decrease MS No change NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System

20. Induction of labor: United States, 1990-2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System All gestational ages

21. Induction of labor by gestational age: United States, 1990-2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System Under 39 weeks 39 or more weeks

22. Induction of labor by gestational age: United States, 1990-2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System Under 39 weeks 39 or more weeks -7%

23. Induction of labor by gestational age: United States, 1990 and 2006 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 1990 2006

24. Induction of labor by gestational age: United States, 1990, 2006 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 1990 20062011

25. Births under 39 weeks 2006-2011 decrease 36 weeks (late preterm) 37 weeks (early term) 38 weeks (early term) Combine weeks 36-38

26. Change in induction of labor at 36-38 weeks: 2006 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System

27. Change in induction of labor at 36-38 weeks: 2006 and 2011 MT WY ID WA OR UT CA ND SD NE CO TX OK KS AR MO MN IL KY TN AL GA FL SC VA WV OH DE CT MA NJ DE DC Decrease NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System

28. Change in induction of labor at 36-38 weeks: 2006 and 2011 Decrease NE NM MS IA WI PA ME No change RI NH VT MD NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System

29. Change in induction of labor at 36-38 weeks: 2006 and 2011 AK HI AZ LA IN MI NY NC Decrease No change Increase NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System

31. Cesarean delivery: United States, 1990-2011 NOTES: Singletons only. 2011 data are preliminary. Source: CDC/NCHS, National Vital Statistics System All gestational ages

32. Cesarean delivery by gestational age: United States, 1990-2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 39 or more weeks Under 39 weeks

33. Cesarean delivery by gestational age: United States, 1990-2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 39 or more weeks Under 39 weeks -2%

34. Cesarean delivery by gestational age: United States, 1996 and 2009 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 1996 2009

35. Cesarean delivery by gestational age: United States, 1996, 2009 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System 1996 20092011

36. Change in cesarean delivery at 37 weeks: 2006 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System

37. Change in cesarean delivery at 37 weeks: 2006 and 2011 Decrease NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System DE CO TX MA

38. Change in cesarean delivery at 37 weeks: 2006 and 2011 Decrease NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System No change MT WY ID WA OR UT CA ND SD NE OK KS AR MO MN IL KY TN AL GA FL SC VA OH DE CT NJ RI AK AZ NE NM NH VT ME PA NY MI IN IA WI NC LA MS

39. Change in cesarean delivery at 37 weeks: 2006 and 2011 Decrease NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System No change Increase HI WV DC MD

40. Change in cesarean delivery at 38 weeks: 2006 and 2011 NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System

41. Change in cesarean delivery at 38 weeks: 2006 and 2011 Decrease NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System WA OR UT CA NE OK MO MN IL GA FL SC OH DE CT NJ MA AK AZ NE NH PA NY MI IN NC CO TX DE HI

42. Change in cesarean delivery at 38 weeks: 2006 and 2011 Decrease NOTES: Singletons only. Source: CDC/NCHS, National Vital Statistics System MT WY ID ND SD KS AR KY TN AL VA DE NM VT ME IA WI LA MS RI WV DC MD No change

44. Summary Overall rates Induction of labor increased from 1990-2006 Cesarean delivery increased from 1996-2009 Among births under 39 weeks 1990-2006 Percentage of births increased Most of increase occurred at late preterm and early term Rate of induction of labor increased Most of increase occurred at 36-38 weeks 1996-2009 Rate of cesarean delivery increased Most of increase occurred at 37-38 weeks

45. Summary Among births under 39 weeks 2006-2011 Percentage of births declined 11% Most of decline occurred at 36, 37, and 38 weeks Percent of 36-38-week births was down in 49 states and DC Induction of labor rate declined 7% All of decline at 36-38 weeks Rates at 36-38 weeks declined in 32 states and DC; increased in 8 states

46. Summary Among births under 39 weeks 2009-2011 Rate of cesarean delivery declined 2% Decline mainly occurred at 37 and 38 weeks Rates at 37 weeks declined in 4 states; increased in 2 states and DC Rates at 38 weeks declined in 29 states; unchanged in 21 states and DC

47. Limitations Induction of labor Gestational age No distinction for medical indication Medical items not comprehensive Current data quality concerns E.g., fetal intolerance of labor

48. Conclusions Induction of labor and cesarean delivery are declining for births under 39 weeks. Percentage of births under 39 weeks declining Decline in births under 39 weeks is more wide-spread than declines in induction of labor and cesarean delivery Pregnancies are getting longer!

49. Thank you!