AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000358486.53560.15
AJN Reports

Born in the USA

Nelson, Roxanne BSN, RN

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New trends in childbirth and maternity care.

About 4.3 million infants were born in the United States in 2006, the most recent year for which complete birth data are available. This is the largest number of births in one year in more than 40 years—since the end of the baby boom. Unprecedented increases have also occurred in the rates of cesarean sections, midwife-attended births, and births to single and teen mothers. What accounts for these increases is unclear, but with childbirth the leading reason for hospitalization in this country—23% of all hospital discharges are either newborns or new mothers—it's certain that they will have an unmistakable effect on nurses, staffing, and the skills nurses need.

Figure. Rates of ces...
Figure. Rates of ces...
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The most significant trend, and one with pronounced implications for maternal and child health and for the health care system, is the precipitous rise in the number of cesarean sections performed. Final Centers for Disease Control and Prevention (CDC) data for 2006 births indicate that the rate of cesarean sections has reached an all-time high of 31.1% (see http://bit.ly/An36C for the report).

In some geographic regions, the rate of cesarean sections is climbing even faster. Florida state records, for example, show that in the most populous county, Miami-Dade, for the first time more infants were born by cesarean section than were born vaginally. According to an article in the May 8 Miami Herald, from July 2007 through June 2008, the rate of cesarean sections in Miami-Dade County was 51.2%, and in neighboring Broward County it was 43.7%. Several Florida hospitals also had rates of cesarean sections that were well over 50% of all births. At Kendall Regional Medical Center, 70% of infants were born by cesarean section; South Miami Hospital had a rate just shy of 60%, and Mercy Hospital was close behind at 58%.

"This increase in cesarean sections affects both nursing care and hospital operations," says Kathleen R. Simpson, a perinatal clinical nurse specialist at St. John's Mercy Medical Center in St. Louis. For one thing, patients who've had cesareans require a longer hospital stay than those who deliver vaginally, Simpson points out, and more vigilance is generally required for their care. These factors will affect both patient acuity and the type of staffing required.

Lori Armstrong, president of the National Association of Neonatal Nurses, agrees, saying that the rising rate of cesarean sections "absolutely" affects nurses at the unit level and hospitals at the systems level. "If the cesarean section rate keeps rising, then occupancy will keep rising, and eventually hospitals will have occupancy issues," she says. "Many obstetrics departments are already dealing with space constraints. And at the nursing level, hospitals need to provide more nurses to care for an increasing number of higher-acuity patients."

From 1989 to 1996 the cesarean section rate in the United States dropped by 9%, while the rate of vaginal births after a previous cesarean jumped by 50%. These trends reversed after 1996. As the rate of cesarean sections steadily rose from 2000 to 2006, it set a new record high each year. The 2006 rate of 31.1% represents a 50% increase from the rate of 20.7% 10 years earlier.

The decline in the rate of vaginal births after a previous cesarean was probably due to emerging data on the risks of the practice and was accompanied by an increase in repeat cesareans. However, the rate of first cesarean sections also increased, says Armstrong.

Elective cesarean sections. First cesarean sections that are not medically indicated are still on the rise. But the extent of patient demand for elective cesarean sections remains unclear. According to a survey conducted by the not-for-profit Childbirth Connection, an organization "dedicated to improving the quality of maternity care" ( http://bit.ly/LGv5X), only one of 252 respondents who had a first cesarean section reported undergoing the procedure at her own request and for nonmedical reasons. However, 9% of respondents reported being pressured by their provider to have a cesarean. Because there's "a fear of litigation" among physicians, says Armstrong, "if there are any suspected problems" physicians may pressure patients to have the procedure. Other reasons include medical indications, the physician's preference, and hospital policy, although there are no firm statistics on which factors are the strongest.

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Another trend identified by the CDC's 2006 birth statistics is the growing rate of induced labors, which occurred in 22.5% of births in 2006—more than double the rate (9.5%) in 1990.

However, according to Simpson, "the induction rate is underreported." She also points out that many elective inductions end up as cesarean sections, especially if it's a first baby. The data don't "tease out if the inductions are medically indicated or elective," she says, "but approximately 75% of inductions are elective."

An increase in induced labors requires an increase in high-acuity nursing care. With a spontaneous delivery, a woman may labor at home and then come to the hospital shortly before giving birth, explains Simpson. "But with an induction, a woman may be laboring for a much longer period and then end up with a cesarean section. Induced labor requires much more care as well as increased vigilance on the part of the nurse."

The bottom line is that a patient who's on a "high-alert" (among the most dangerous) medication because labor is being induced and who'll be in the hospital longer is at a higher risk for a cesare an section. "This creates a need for more robust RN staffing," Simpson says.

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At the opposite end of the spectrum, the number of women seeking a more natural approach to childbirth has also been growing dramatically. In 2006 the American College of Nurse–Midwives (ACNM) reported that certified midwives and certified nurse midwives attended a record number of births—317,168 in total (http://bit.ly/vPYVu). This number represents 7.4% of all births and 10.8% of all vaginal births and may be a low estimate if midwife-attended deliveries are underreported.

"This is the best of times and the worst of times," says Eileen Beard, senior practice advisor at the ACNM. "Although we have wonderful technology that can save the lives of moms and babies, we use this technology on healthy women who don't need it." For these women, midwives offer a natural alternative and are increasingly present in hospitals, where statistics show most midwife-attended births (97%) occur, with only 1% taking place at home and 2% in birth centers.

The demand for midwife-attended births has grown steadily, and so has the number of midwives practicing in the United States. "This trend is really important," says Beard. "There aren't enough primary care physicians, and many obstetricians are giving up their practice because they fear malpractice litigation. Midwives and NPs can fill an important role by providing care throughout a woman's life."

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In 2006 a CDC National Center for Health Statistics' "data brief" (http://bit.ly/gK0vC) reported that 38.5% of all births were to single mothers, and in 2007 that proportion rose to nearly 40%, the highest it's ever been. Although historically most births to single women have been to teenagers, the demographics have changed. In 2007, 60% of births to single women were to women between the ages of 20 and 24.

Although some of these births are to cohabiting couples in long-term relationships, many are to young women lacking a strong support system or an involved partner, says Simpson. "Nurses need to carefully assess the woman's support system and make social service referrals as needed."

Data show that births to single women carry a higher risk of poorer outcomes, including preterm birth, low birth weight, and infant death. In addition, social and financial resources may be more limited for these women.

From 2005 to 2006 the teen birth rate increased by 3%, ending a 14-year period of decline that began in 1991. Teenage birth rates significantly increased in 26 states, representing almost all regions in the United States.

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When it comes to maternity care, far from meeting targets set by the national Healthy People 2010 initiative, the United States is moving in the opposite direction. For example, World Health Organization data show that compared with the United States, 29 countries have lower estimated maternal mortality rates, 33 have lower neonatal mortality rates, and 35 have lower early neonatal mortality rates. Moreover, between 1981 and 2006, preterm birth rates in the United States increased by 36% and the proportion of low-birth-weight infants increased by 22%. So, although U.S. health care spending exceeds that of any other nation, it's not reflected in performance. A 2008 report from the Childbirth Connection in collaboration with the Reforming States Group and the Milbank Memorial Fund (http://bit.ly/xzNEG) refers to this trend of doing more but accomplishing less as the "perinatal paradox."

Childbirth trends in the United States have come and gone over the past several decades, with statistics for various measures in constant flux. With the Obama administration's proposed health care reforms and cost-cutting measures looming, childbirth trends will undoubtedly be affected—and will continue to affect nurses at the bedside as well. If the rates of cesarean sections, births to single mothers, and midwife-attended births continue to increase, so will RN staffing needs and the need for higher staffing ratios overall.

Roxanne Nelson, BSN, RN

© 2009 Lippincott Williams & Wilkins, Inc.


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