birthbythenumbers.org myth and reality concerning cesarean section in the u.s. professor gene...
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BirthByTheNumbers.org
Myth and Reality Concerning Cesarean Section in the U.S.
Professor Gene Declercq, PhDBoston University School of Public Health
www.birthbythenumbers.org
With support from: The Transforming Birth Fund
Slides Updated through January 15,2015
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US Cesarean Rates, 1989-2013
20
22
24
26
28
30
32
34
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
%
Source: National Center for Health Statistics Annual Birth Reports
%
1,284,339cesareans
in 2013
If the 2013 cesarean rate was the same as in 1996, there would have been 475,000 fewer cesareans in the U.S. in ’13.
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US Cesarean Rates, 1989-2013
20
22
24
26
28
30
32
34
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
%
Source: National Center for Health Statistics Annual Birth Reports
%
BirthByTheNumbers.org
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US Cesarean Rates, 1989-2013
20
22
24
26
28
30
32
34
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
%
Source: National Center for Health Statistics Annual Birth Reports
%
BirthByTheNumbers.org
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US Cesarean Rates, 1989-2013
20
22
24
26
28
30
32
34
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
%
Source: National Center for Health Statistics Annual Birth Reports
%
BirthByTheNumbers.org
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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
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Older Mothers? % Births to Mothers 30 +, U.S. 1990-2013
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Between 2003 & 2010 CS Rate increased by 20%
> 35> 35
>30
BirthByTheNumbers.org
From 2010-2013, CS rate unchanged
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BirthByTheNumbers.org
Total Cesarean Rates (per 100 births) by Age of Mother: United States, 1996 and 2013
14.517.4
20.623.8
27.431.6
21.8
27.631.3
35.5
41.6
49.6
0
10
20
30
40
50
60
<20 20-24 25-29 30-34 35-39 40-54
1996 2013
50% 59% 52% 49% 52% 57%
Source: National vital statistics system, NCHS, CDC.
Per
cent
Overall increase, 1996-2013: 58.0%
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Multiple Births? Proportion of all babies in multiple births,
U.S., 1980-2013
19801982
19841986
19881990
19921994
19961998
20002002
20042006
20082010
20120.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
BirthByTheNumbers.orgSource: National Center for Health Statistics Annual Birth Reports
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Cesarean Rates for Multiple Births, U.S. 1990-2013
56% 56%
60%
74%76%
50%
55%
60%
65%
70%
75%
80%
1990 1995 2000 2006 2013
BirthByTheNumbers.org
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Are Babies Getting Bigger?% Singleton Babies by Birthweight, U. S., 1991-2013
11% 11% 10% 8% 8%
30% 30% 29%28% 28%
0%
10%
20%
30%
40%
50%
1991 1996 2001 2006 2013
3500-3999gms
4000+gms41% 41% 39%
36% 36%
BirthByTheNumbers.org
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% Cesareans in Singleton Births, U.S. by Birthweight, 1991-2013
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
1991 1996 2001 2006 2013
3500 - 3999gms
4000 - 4499gms
4500+gms53.6%
38.6%
31.3%
21.8%
27.8%
38.2%
BirthByTheNumbers.org
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BirthByTheNumbers.org
Mothers’ Health?Prepregnancy Obesity, U.S. 2003, 2006, 2009, 2011
2003 2006 2009 201110%
12%
14%
16%
18%
20%
22%
17.6%
19.5%
20.5% 20.3%
Sources: 2003-2009 -- S. Fisher. Is obesity still increasing among pregnant women?Preventive Medicine 2013; 56: 372-378; 2011 – CDC VitalStats.
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BirthByTheNumbers.org
Mothers’ Health?Cesarean Rate Singleton Births by Prepregnancy
Weight Range, U.S. 2013
Underwei
ght
Normal
Wei
ght
Ove
rwei
ght
Obes
e I
Obes
e II
Obes
e III
-10%
0%
10%
20%
30%
40%
50%
60%
22.3%27.1%
33.6%39.7%
45.4%
54.0%
Source: CDC VitalStats, 2013.
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BirthByTheNumbers.org
Mothers’ Health?Diabetes* & Hypertension*, 1992,2002,2013
1992 2002 20130%
1%
2%
3%
4%
5%
6%
7%
2.2%
3.2%
6.0%
3.4%
4.4%
6.4%Any Diabetes
Any Hypertension
* Either gestational or chronic condition
Source: CDC VitalStats, selected years.
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BirthByTheNumbers.org
Mothers’ Health?Cesarean Rates, Singleton Births, U.S.,
1990, 1996, 2004, 2013
1990 1996 2004 201330%
40%
50%
60%
70%
Prepregnancy DiabetesChronic Hypertension
Source: CDC VitalStats, selected years.
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BirthByTheNumbers.org
Mothers’ Health?Cesarean Rates, Singleton Births, U.S.,
1990, 1996, 2004, 2013
1990 1996 2004 201330%
40%
50%
60%
70%
Prepregnancy DiabetesChronic Hypertension
Source: CDC VitalStats, selected years.
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BirthByTheNumbers.org
Mothers asked for it
Have maternal request cesareans played a major
role in these increases?
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http://www.childbirthconnection.org
Asking Mothers about
Maternal Request Cesareans
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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, Canada and U.S. states
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
7%
28%
28%
22%
0% 5% 10% 15% 20% 25% 30%
Vaginal
VBAC
PrimaryCesarean
RepeatCesarean
Source: Declercq et al. 2013. Listening to Mothers III.BirthByTheNumbers.org
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BirthByTheNumbers.org
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
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BirthByTheNumbers.org
Commonly Used Explanations for the High Cesarean Rate
• Mothers are getting older – NO
• More multiples being born
• Babies are getting bigger
• Maternal health is worse: obesity,
diabetes & hypertension
• Mothers are asking for it
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BirthByTheNumbers.org
Commonly Used Explanations for the High Cesarean Rate
• Mothers are getting older – NO
• More multiples being born– NO
• Babies are getting bigger
• Maternal health is worse: obesity,
diabetes & hypertension
• Mothers are asking for it
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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
• Mothers are asking for it
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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
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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
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BirthByTheNumbers.org
If the usual explanations for the rising cesarean
rate don’t account for the changes what does?
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BirthByTheNumbers.org
If the usual explanations for the rising cesarean
rate don’t account for the changes what does?
Practice Changes
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BirthByTheNumbers.org
Leading Indications for Cesareans
34%
23%
17%
7%
5%
4%4%
3% 3%
Labor ArrestNonreassuring fetal trac-ingMalpresentationMultiple GestationMaternal-FetalMacrosomiaOther Obstet.PreeclampsiaMaternal Request
Source: ACOG & SMFM. Safe Prevention of Primary Cesarean Delivery. 3/2014.
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Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications
20
30
40
50
60
70
1990 1996 2011
Prolonged Labor
Nonreassuring FetalTracing
Macrosomia
Twins
*Singleton, Vertex, Full Gestation Births BirthByTheNumbers.org
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20
22
24
26
28
30
32
34
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
%
Source: National Center for Health Statistics Annual Birth Reports
%
Revisiting the trend in cesareans in the US for comparison
BirthByTheNumbers.org
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Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications
30
40
50
60
70
1990 1996 2011
Prolonged Labor
Nonreassuring Fetal Tracing
Macrosomia
Twins
*Singleton, Vertex, Full Gestation Births BirthByTheNumbers.org
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Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications
30
40
50
60
70
1990 1996 2011
Prolonged Labor
Nonreassrg Fetal Trace
Macrosomia
Twins
*Singleton, Vertex, Full Gestation Births BirthByTheNumbers.org
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Women have not changed nearly as much as practice patterns have
BirthByTheNumbers.org
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Any other evidence that this is about a culture of
practice?
BirthByTheNumbers.org
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Let’s look at variation.
If the practice of maternity care is evidence based, then differences in rates should be based primarily on different risk profiles of mothers.
BirthByTheNumbers.org
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MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VAWV
OH
MINY
PA
MDDE
NJ
CTRI
MA
ME
VTNH
AK
HI
31.6%+
22.6-31.5%
DC
Cesarean Delivery Rates1, 2012
1Percentage of all live births by cesarean delivery
Source: Martin J, et al. Births Final Data 2012. National Vital Statistics System, 2014. BirthByTheNumbers.org
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MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VAWV
OH
MI
NY
PA
MDDE
NJ
CTRI
MA
ME
VTNH
AK
HI
DC
1960 Electoral College Map
Nixon 219
Harry Byrd 15
Kennedy 303
BirthByTheNumbers.org
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BirthByTheNumbers.org
JFK 1960 Vote and 2012 Cesarean Rates
20% 25% 30% 35% 40% 45%35
40
45
50
55
60
65
r = +.28
2012 Cesarean Rate
JFK
% V
ote
Each dot represents a U.S. state
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Variation is not just at the state level but at the hospital level as well
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% Cesarean Deliveries by Hospital for ALL MA Births, 2004-2006
N = 49 Mean =31.2 σ2 =29.6
41.9
21.1
0
5
10
15
20
25
30
35
40
45
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Hospital Rank
%CSAll 49 Hospitals
Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact. PLOS One.2013; 8 (3): e57817
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All Hospitals
10.3
35.0
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Hospital Rank
%CS
% Cesarean Deliveries by Hospital for NTVS, Spontaneous Labor, BWT 2500-4000g Births
N = 49 Mean =21.1 σ2 =37.1
Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact. PLOS One.2013; 8 (3): e57817 BirthByTheNumbers.org
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How does a culture of intervention get manifested
in a hospital setting?
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How does a culture of intervention get manifested
in a hospital setting?
Consider the Cascade of Interventions
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InductionNo
53%
EpiduralNo
39%
EpiduralYes61%
InductionYes47%
EpiduralNo
22%
EpiduralYes78%
First-time mothers with term births (37-41 weeks’ gestation) who experienced labor
Cesarean Yes
20%
Cesarean Yes
5%
Cesarean Yes
31%
Cesarean Yes
19%In this group, which included 85% of first-time mothers, the overall epidural rate was 69% and overall cesarean rate was 21%.
Cascade of interventions in first-time mothers with term births who experienced labor
Base: first-time mothers with term births who experienced labor n=750
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What about Vaginal Birth After Cesarean
(VBAC) ?
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VBAC Rates*, U.S.,1990-2011
5%
10%
15%
20%
25%
30%
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
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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% VBAC Lower Risk* Mothers, U.S., Monthly Rates, 1990-2012
6%
9%
12%
15%
18%
21%
24%
27%
30%
33%
* Full-gestation(37+ weeks), vertex presentation, singleton births
Sachs, NEJM 1/99
ACOG New VBAC Guidelines 10/98 & 7/99
Lydon-Rochelle & Greene 7/01
LandonNEJM 12/04Flamm
Studies1988,’90, ‘94
McMahon NEJM 9/96
ACOG guidelines encourage VBAC, 1/82 10/88 Reaffirmed 1991
Revised ACOG Guide-
lines 8/10
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VBAC Rates Industrialized Countries, 2010
MaltaIcelandFinland
NetherlandsNorway
GermanyFrance
BelgiumDenmark
EnglandEstonia
LuxembourgCzech Republic
SloveniaScotland
LithuaniaItalyU.S.
LatviaCyprus
0 10 20 30 40 50 60 70 8074
5252
4746
363534
333029
2828
2121
1110
97
6
Source: Adapted from Peristats & US Data
VBAC % = VBACS Women w/ Prior CS
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August, 2010
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Mother had cesarean in the past, and did not have the option of a VBAC for recent birth.
LTMI 2000-02
LTMII 2005
LTMIII2011-12
Did not have the option because caregiver was unwilling to do a VBAC
36% 45% 24%
Did not have the option because hospital was unwilling to allow a VBAC
12% 23% 15%
Medical reason unrelated to prior cesarean 38% 20% 45%
U.S. Mothers Report of Experience Seeking a VBAC, 2000, 2005, 2012
Source: Listening to Mothers 3. New VBAC Guidelines
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So is a rising cesarean rate inevitable?
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So is a rising cesarean rate inevitable?
ABSOLUTELY NOT
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US Cesarean Rates, 1989-2012
20
22
24
26
28
30
32
34
% Tot US 23 22.722.622.321.821.220.820.720.821.222.0 23 24 26 28 29 30 31 32 32 33 33 33 33
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12
%
Source: National Center for Health Statistics Annual Birth Reports
%
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Trends in Cesarean Rates (per 1000 births), Comparison Countries, 1990-2011
50
100
150
200
250
300
350
400
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
Sources: OECD Health Data 2013; WHO Health for All Database, 2014. BirthByTheNumbers.org
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Trends in Caesarean Rates (per 1000 births), Comparison Countries, 1990-2011
50
100
150
200
250
300
350
400
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
Sources: OECD Health Data 2013; WHO Health for All Database, 2014. BirthByTheNumbers.org
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www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery
Safe Prevention of Primary Cesarean Delivery
Questioning the Rising Cesarean Rate
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Evidence Based Advocacy
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Prematurity and Low Birthweight, U.S., 1990-2012
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
6
7
8
9
10
11
12
13
Prematurity
Low Birthweight
9.8%Decrease 2006-12
%
YearBirthByTheNumbers.org
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http://www.choicesinchildbirth.org/
Evidence Based Advocacy
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https://www.childbirthconnection.org/
Evidence Based Advocacy
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