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Objectives Retained As Is From Healthy People 2010
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MICH HP2020–6:
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Reduce cesarean births among low-risk (full-term, singleton, vertex presentation) women.
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a. Women giving birth for the first time
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Status: Retained Healthy People 2010 objective 16-9.
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View Objective Comments
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The American College of Nurse Midwives strongly supports the retention of this objective, as well as the WHO supported targets of 15% for women giving birth for the first time and 63% for women with a prior cesarean birth.
The US cesarean section rate has increased for 11 consecutive years, rising to the highest ever national rate of 31.8% in 2007. The rate of vaginal birth after cesarean has declined 73% from 1997 to a rate of 9.7% in 2006. (National Center for Health Statistics,, National Vital Statistics Reports, Childbirth Connection December 2009: United States Maternity Care Facts and Figures).
Despite these increases, the US has not made substantial improvement and is actually moving further away from objectives set for Healthy People 2010. Rates of preterm birth and low birth weight have increased. Maternal mortality appears to have increased, although changes in the reporting system may account for some of the rise. (http://www.healthypeople.gov/data/2010prog).
Increases in the cesarean delivery rate were not related to shifts in maternal risk profiles. (Declercq et al. 2006. American Journal of Public Health. 96:867-872.)
A higher rate of cesarean deliveries does not correspond with better perinatal outcomes. The currently high cesarean rate in the United States could be safely lowered without an increase in infant mortality. (Li et al, Obstetrics and Gynecology 2004; 101: 1204-1212).
Although C-sections have been effective in saving lives, they also can increase the risk of illness and death.” (http://www.healthypeople.gov/data/micourse/html/focusareas/FA16ProgressHP.htm.healthy people 2010)
Reducing the cesarean delivery rate has particular importance for efforts to address racial disparities in US health outcomes. Since 1995, Black non-Hispanic women have had higher cesarean delivery rates than any other group. (National Center for Health Statistics; Eugene Declercq, personal communication).
In 2004, the non-Hispanic Black maternal mortality rate, at 36.1 per 100,000, was 3-4 times the rate for Hispanic, for non-Hispanic White, and for Asian/Pacific Islander mothers. (http://www.healthypeople.gov/data/2010prog).
Failure to achieve HP2010 goals to reduce cesarean births among women giving birth for the first time and among women with a prior cesarean birth makes imperative stronger efforts to increase the numbers of women who give birth vaginally.
Further study of provider practices that are associated with higher and lower cesarean section rates must be supported, as should funding of initiatives for the promotion of strategies known to promote normal birth, such as intermittent auscultation of the fetal heart, alternatives to epidural anesthesia for labor pain, and continuous emotional and physical support in labor.
ACNM is proposing a new objective for Healthy People 2020 to increase physiologic birth to 70% among women with a full-term, singleton and vertex presentation infant.
Adoption of the objective will help to reduce the cesarean delivery rate.
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Objective Text:
all women deserve access to the midwifery model of care, birth center or home birth.
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This is an excellent goal. The goal should specify that children should have access not just to pharmacological treatment, but to evidence-based, effective, and safe treatments, including psychotherapy. For young children, there has been a substantial increase in rates of prescribing strong psychopharmacological agents, with rates close to 1 rx per 100 children under 5, with higher rates in higher risk populations. Only one class of medications has been tested in rigorous randomized controlled trials (stimulants) and the outcomes were not nearly as positive as in older children. In the last few years, rates of atypical antipsychotic agents, which are associated with substantial adverse medical morbidity, have increased substantially (more than doubled) in preschoolers. Psychotherapy is much more difficulty to access than medications- probably because of limited dissemination of these treatments, few trained providers outside of academic settings, 3rd payer limitations, perceived need for quick fix (including perceived pressure by child care providers and schools), and direct to consumer advertising. Evidence based psychotherapies have been demonstrated to cause sustained effects over years. In older children, psychotherapy is similarly less easy to access and has strong evidence.
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Objective Clarification, Objective Text:
Rewrite Objective: Reduce cesarean births among low-risk (full-term, singleton, vertex presentation) women.
a. Women giving birth for the first time
b. Non-medically indicated cesarean sections
Rationale: We do not yet have enough research to fully compare the risks and benefits of an elective cesarean section with a vaginal delivery. However, there are inherent risks associated with an invasive surgical procedure.
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The March of Dimes Foundation strongly supports retaining this objective in Healthy People 2020.
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Objective Clarification:
The objective should be to reduce primary cesarean, as all women of childbearing age could face a cesarean.
Increase the number of VBACs and you will decrease the number of cesarean births.
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Objective Clarification:
Why is the indicator "women giving birth for the first time" rather than "primary cesarean's" which is the data most organizations gather. What about the woman who has a NSVD this first time, but a primary c-section the 2nd birth; would she not be counted?
Kathryn Schrag CNM
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Objective Clarification:
Should decrease rates of elective induction of labor, as this increases risk of cesarean.
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Objective Clarification:
Increasing access to midwifery care, both CNM's and CPM's, as have decrease rates of all interventions, including lower cesarean rates. VBAC's should be supported. As the previous comments stated, VBACs should be financially encouraged (are less expensive than cesareans,with fewer complications).
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Objective Clarification:
a) Increasing access to midwifery care, both in- and out-of hospital is an important way to decrease the cesarean rate. CNMs have lower c-section rates than physicians.
b) Decrease mandated cesareans by requiring that rural hospitals and all federal facilities allow VBAC and giving financial support when necessary to allow adequate staffing for this.
This objective can improve outcomes in subsequent, as well as current, pregnancies.
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Objective Clarification:
I would have to disagree with the previous comments. I think this is a great objective. Sure lots of hospitals are refusing VBACs now when they would be perfectly safe and there are too many interventions, but that's why the objective is there. If there were not too many interventions and VBACs were allowed for healthy 2nd pregnancies, then you wouldn't need the objective to encourage change.
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There are so many C-sections done for "preservation of perineal integrity" I hope that this can change. VBACs on the other hand because of our society makes people sometimes too concerned about being sued to even consider them.
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Objective Clarification:
The fact that few people are doing instrument deliveries, breech deliveries or multifetal gestation deliveries vaginally or VBACs because of medical legal concerns makes this objective unrealistic
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Objective Clarification:
Again, what percentage over what amount of time?
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Objective Clarification:
There are too many hospitals that refuse to even consider doing a VBAC.
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