Hospitals & Asylums
Natality in the United States HA-15-6-08
By Tony Sanders
El Baby Boomito
In 2006 there were 4,265,996 births out of nearly 6.6 million pregnancies, a 3 percent increase from the year before, the largest single-year increase since 1989 and the highest total number of births since 1961, near the end of the baby boom. For the first time in 35 years, the U.S. fertility rate has climbed high enough to sustain a stable population, solidifying the nation's unique status among industrialized countries as a growth state. The 2006 fertility rate of 2.1 children is the highest level since 1971. The overall fertility rate increased 2 percent between 2005 and 2006, nudging the average number of babies being born to each woman to 2.1. That marks the first time since 1971 that the rate has reached a crucial benchmark of population growth: the ability of each generation to replace itself. The nation's total fertility rate hit a high of nearly 3.8 in the United States in 1957 during the postwar Baby Boom. But it fell sharply through the 1960s and 1970s with the introduction of the birth control pill, legalization of abortion and other trends, including women delaying childbearing to attend college and pursue a career. The rate dipped below replacement level in 1972 and hit a low of 1.7 in 1976, but it started rising again in the late 1970s, climbed steadily through the 1980s, hovering close to but never hitting the replacement rate throughout the '90s although the population grew to over 300 million in 2006 (Stobbe 2008). The total U.S. population crossed the 100 million mark around 1915, the 200 million mark in 1967, and the 300 million mark in 2006. The U.S. population more than tripled during the 20th century, a growth rate of about 1.3 percent a year. 45% of American children under the age of 5 are minorities. In 2006, the nation’s minority population reached 100.7 million. In 2007 the total population growth rate was estimated at exactly 1percent - the birth rate was 14.2, net migration 3.05 and death rate 8.3 per thousand. The infant mortality rate was 6. 4 death per 1,000 live births.
The reasons for the unusual U.S. fertility rate are the focus of intense interest. Some of the increase is explained by immigration. Hispanics have the highest fertility rate -- about 2.9 -- followed by blacks (2.1), Asians (1.9) and whites (1.86). But Hispanics do not represent enough of the population to fully explain the trend, and the fertility rate of U.S. whites is still higher than that of other developed countries. Experts can only speculate, but they cite a complex mix of factors, including lower levels of birth control use than in other developed countries, widely held religious values that encourage childbearing, social conditions that make it easier for women to work and have families, and a growing Hispanic population whose children are automatically US citizens improving their chances at citizenship. To be sure, the fertility rate among Hispanics — 3 children per woman — has been a major contributor. That’s the highest rate for any group. In 2006, for the first time, Hispanics accounted for more than 1 million births. The high rate probably reflects cultural attitudes toward childbirth developed in other countries, experts said. Fertility rates average 2.7 in Central America and 2.4 in South America. Fertility rates often rise among immigrants who leave their homelands for a better life. For example, the rate among Mexican-born women in the U.S. is 3.2, but the overall rate for Mexico is just 2.4 (Stein 2007). The young people seem to be grappling with the looming retirement of the baby boomers by having a small baby boom of their own. A low birthrate results in an old society. It will be hard to support social systems when you have so few people relative to older people. With the propaganda regarding the insolvency of the social security trust funds for the retirement of the baby boomers and the economic slowdown it makes economic sense for women of all ages to have more children.
Are higher birthrates a trend or a one-year phenomenon? I would hypothesize from the surge in pregnancies amongst my friends and family that does not seem to be slowing down, that the answer is that we are indeed witnessing a higher birth rate trend. Teen pregnancies were way up in 2006. While the birth rate among 10-to-14-year-old girls continued to fall, the rate for those ages 15 to 19 increased from 40.5 per 1,000 girls to 41.9 births per 1,000 in 2006. The birth rate rose by 3 percent between 2005 and 2006 among 15-to-19-year-old girls, the same as for all women, after plummeting 34 percent between 1991 and 2005. The increase was greatest among black teens, whose birth rate rose 5 percent between 2005 and 2006, reaching 63.7 per 1,000 teens. That was particularly disappointing because black teens had previously made the greatest reductions, with the rate among 15-to-17-year-olds dropping by more than half. The rate rose 2 percent, to 83 births per 1,000, for Hispanic teens, and 3 percent, to 26.6 per 1,000, for white teens (Stein 2007). Older women, in their forties, are also having more children, up to 7 from 4 per 1,000, however the vast majority of the child birth is done by women in their twenties and thirties. Women ages 20-29 have more than 200 births per 1,000. Teens 18-19 have 90 births per 1,000. In the 1990s women 35-39 overtook teens 15-17 years for the first time since 1967 with 39 versus 31 births per 1,000. Women of all ages but those younger than 17 are giving birth to more children than during the seventies and eighties but not as frequently as the Baby Boomers before 1970 (Ventura, Mosher, Curtin, Abma & Henshaw 2001)
Both single and married women are increasingly keeping their children however single women are much more likely, 35 percent, to get an abortion, while only 6 percent of married women get abortions. Nearly half (45 percent) of the 6.4 million pregnancies in 2004 occurred among unmarried women. Pregnancy totals among unmarried women increased from over 2.7 million in 1990 to over 2.8 million in 2004, whereas pregnancy totals among married women declined from 4.1 million in 1990 to 3.5 million in 2004. The average U.S. woman is expected to have 3.2 pregnancies in her lifetime at current pregnancy rates; black and Hispanic women are expected to have 4.2 pregnancies each, compared with 2.7 for non-Hispanic white women. Three out of four pregnancies among married women (75 percent) ended in a live birth in 2004, while 19 percent ended in fetal loss, and 6 percent ended in abortion. For unmarried women, slightly over half of pregnancies (51 percent) ended in live birth, an increase from 43 percent in 1990. Thirty-five percent of these pregnancies ended in abortion and 13 percent ended in fetal loss (CDC 2008). Improved counseling regarding the value of bearing children seems to be paying off and more single women are delivering their babies. The constitutional principles regarding the right to an abortion are articulated by the Supreme Court in Roe v. Wade (1973), and in keeping with the science and values of medicine, the AMA recommends that abortions not be performed in the third trimester except in cases of serious fetal anomalies incompatible with life.
The United States’ under-5 mortality rate (8 per 1,000 live births) is twice that of Belgium, Czech Republic, Finland, France, Italy, Japan and Norway (4 per 1,000 live births) and more than twice that of Iceland and Sweden (3 per 1,000 live births). In the United States, America-Indian and Alaska-Native infants are 1.5 to 2 times more likely to die than white infants and African-American infants are 2.4 times more likely to die than white infants. Although the United States spends more money on health care per capita than nearly any other country in the world the US has the highest rates of child poverty and the lowest levels of child health and safety of the rich countries. As a result, infant and child mortality rates in the United States are higher than in any other industrialized country. Despite substantial reductions in U.S. infant mortality during the past several decades, the black-white infant survival gap has widened. From 1980-2000, even as overall infant mortality rates declined, the black-white ratio of infant mortality increased 25 percent. From the mid-1960s through 1980, the poor in the United States made health gains and their infant death rates declined as the survival gap shrank. Since 1980, however, disparities between rich and poor in the U.S. have widened and infant death rates among the poor remain higher than among the rich. One recent study found that if – between 1965 and 2002 – all families in the U.S. had enjoyed the same improvement in infant mortality rates as the highest income quintile, 20 percent of all infant deaths could have been averted and an estimated 460,000 people might still be alive. And if all infants had experienced the same yearly infant death rates as the richest white infants, 20 percent of all white infant deaths and 25 percent of deaths among infants of color could have been prevented in 2000 alone.
In the United States, 21 percent of children under age 5 live below the poverty line – that is 1 child in 5. Poverty rates are highest among children of color. Forty percent of all African-American children, 39 percent of American- Indian/Alaska-Native children, 30 percent of Hispanic children and 16 percent of white children live in poverty. Approximately 11 percent of American children under age 6 do not have health insurance. Hispanic children are over 3 times more likely to be uninsured than their white peers – 20 percent of Hispanic children have no health insurance coverage. More than 40 percent of uninsured Hispanic children do not receive any medical care. Roughly 9 percent of African-American children are uninsured, of which 15 percent do not receive medical care. Among white children, 6 percent are uninsured. White children see physicians at twice the rate of minority children. The poorest children in the United States are 20 percent more likely to go without preventive care. More than 30 percent of children living below the poverty line do not receive even one preventive medical (or “well-child”) visit per year. Immunization rates show similar disparities. Black children and American-Indian/Alaska-Native children have the lowest vaccination rates, while whites have the highest rates. Even greater coverage gaps are seen between rich and poor. Nearly one-quarter of poor children are not fully immunized, compared to 13 percent of children from high income families. Maternal mortality rates in the United States outstrip those of all other developed countries largely due to the mortality rates among women of color. The maternal mortality rate among black women (36.1 per 100,000 live births) is about 4 times the rate among white women (9.8 per 100,000 live births). This gap has widened since 2000. Women of color in the United States, especially low-income women, are less likely to receive prenatal care that is vital to healthy birth. Early prenatal care among minority groups has increased by at least 20 percent since 1990, but disparities still exist. Hispanic and black women are more than twice as likely as white women to receive no prenatal care or late prenatal care. American-Indian/Alaska-Native mothers are more than 3 times as likely as white mothers to receive inadequate prenatal care. All in all the United States slipped in its ranking for maternal health from 26th in 2007 to 27th in 2008 (Save the Children 2008).
Fertilization and Fetal Development
Pregnancy is divided into trimesters which last about 12 - 14 weeks each. Generally, the first trimester is week 1 through the end of week 13. The second trimester usually ends around the 26th week and consists of the 4th, 5th and 6th completed months. The third trimester can end anywhere between the 38th - 42nd week and is the 7th, 8th and 9th completed months of pregnancy. To calculate the due date, count ahead 40 weeks from the start of last period. This system of calculating a due date is obviously imprecise and in practice only 5% of births occur on the date predicted. The “due date” is actually a window of about two weeks before or after the date predicted The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum. The uterus is the symbol of fertility. It is in the uterus that the human embryo and fetus develop into a human baby. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth. During pregnancy, a woman's body goes through a series of physical changes. At six months: the uterus has enlarged - and now extends above the level of the navel - to accommodate the growing fetus; the enlargement of the uterus displaces the abdominal organs upward. At nine months: the abdominal organs continue to be pushed upward by the expanding uterus, and the fetus drops lower into the pelvis.
When sperm is deposited in the vagina, it travels through the cervix and into the Fallopian tubes. The goal of fertilization is the union of a sperm nucleus with the female pronucleus within the activated oocyte (Asch, Simerly, Ord, Ord & Schatten 1995). To create conditions where this is possible a woman ovulates monthly in a menstrual cycle that releases ova , from millions stored in the ovaries from birth, into the fallopian tubes where they can be fertilized by male sperm cells. Every month these proto nucleuses are swept out in a bloody discharge known as menstruation. Women are not fertile during menstruation or the period shortly after menstruation. In the act of fertilization a single sperm penetrates the mother's egg cell, and the resulting cell is called a zygote. The zygote contains all of the genetic information (DNA) necessary to become a child. The zygote has 46 chromosomes — 23 from the male and 23 from the female. These chromosomes contain genetic material that will determine the baby's sex and traits such as eye color, hair color, height, facial features and — at least to some extent — intelligence and personality. After the second week the sperm and egg unite in one of the fallopian tubes to form a one-celled entity called a zygote. If more than one egg is released and fertilized, there may be multiple zygotes that develop into multiple babies. Soon after fertilization, the zygote travels down the fallopian tube toward the uterus. At the same time, it will begin dividing rapidly to form a cluster of cells resembling a tiny raspberry. The inner group of cells will become the embryo. The outer group of cells will become the membranes that nourish and protect it. By the third week, the zygote — by this time made up of about 500 cells — is now known as a blastocyst. When it reaches the uterus, the blastocyst will burrow into the uterine wall for nourishment. The placenta, which will nourish your baby throughout the pregnancy, also begins to form. By the end of this third week, a pregnancy test will be positive.
In the blastocyst stage the embryo consists of three layers, the inner group of cells will become the embryo, while the outer group of cells will become the membranes that nourish and protect it. The blastocyst reaches the womb (uterus) around the third week and implants itself into the uterine wall the next day. At this point in the mother's menstrual cycle, the lining of the uterus has grown and is ready to support a fetus. The blastocyst sticks tightly to the lining, where it receives nourishment via the mother's bloodstream. The cells of the embryo now multiply and begin to take on specific functions. This process is called differentiation. It leads to the various cell types that make up a human being (such as blood cells, kidney cells, and nerve cells). There is rapid growth, and the baby's main external features begin to take form. The fourth week marks the beginning of the embryonic period, when the baby's brain, spinal cord, heart and other organs begin to form. The baby is 1/25 of an inch long. The embryo is made of three layers. The top layer — the ectoderm — will give rise to a groove along the midline of your baby's body. This will become the neural tube, where your baby's brain, spinal cord, spinal nerves and backbone will develop. Your baby's heart and a primitive circulatory system will form in the middle layer of cells — the mesoderm. This layer of cells will also serve as the foundation for your baby's bones, muscles, kidneys and much of the reproductive system. The inner layer of cells — the endoderm — will become a simple tube lined with mucous membranes. Your baby's lungs, intestines and bladder will develop here. At week five, the baby is 1/17 of an inch long — about the size of the tip of a pen. This week, the baby's heart and circulatory system are taking shape. Your baby's blood vessels will complete a circuit, and his or her heart will begin to beat. Although you won't be able to hear it yet, the motion of your baby's beating heart may be detected with an ultrasound exam. With these changes, blood circulation begins — making the circulatory system the first functioning organ system.
The following list describes specific changes that occur in the womb:
The end of the eighth week marks the end of the "embryonic period" and the beginning of the "fetal period". A fetus is surrounded by a complex life support system in the form of the uterus and of course the mother. A fetus has the potential to become an independent entity with the prospect of a full life.
Pre-natal care, offered by obstetricians, is basically a screening program. Pregnant women are usually expected to see the obstetrician each month during the first two trimesters and, twice a month for the seventh and eighth months and weekly for the last month. The visits typically take 10 to 15 minutes or less, in which the woman is weighed, her blood pressure taken, and her urine tested. Blood is drawn for yet more screening and testing. She lies on an examining table and the fetal heart rate is noted as is the position of the baby. If she has symptoms to present, these are noted and remedies may be prescribed. Pre-natal care offered by midwives tends to stress the psychological aspects of motherhood and the visits last 30 minutes. The prevailing medical belief is that pregnant women should aim for a weight gain of 15 to 20 pounds above their ideal weight. That is a woman 10 pounds overweight would be allowed a weight gain of 5 to 10 pounds in the course of her pregnancy while a woman who is 30 pounds overweight would be asked to lose 10 to 15 pounds. Excessive weight gain can impair health. A correlation exists with high blood pressure complications such as toxemia or eclampsia. However it depends on the mother and no objective measure can be set. Midwifes tend not to count the pounds but focus instead on nutrition as the single most important aspect of pregnancy care (Rothman 2007). Counsel on pre-natal care is typically to maintain a healthful diet and exercise plan. Do not use tobacco, alcohol, or any illegal drugs. Use educational resources to learn as much as possible about the process of pregnancy, labor, and the methods of delivery. Get plenty of rest as the due date approaches, labor and delivery may be lengthy and tiring (Torpy, Lynm & Glass 2005).
The medical literature defines childbirth as a three-stage process. In the first stage the cervix, the opening of the uterus into the vagina, dilates from being nearly closed to its fullest dimension of approximately 10 centimeters, almost 4 inches. This is referred to as “labor” and the contractions of the uterus that pull on the cervix is known as “labor pains”. The difference between “false labor” and “true labor” is that true labor pains produce a demonstrable thinning of the cervix while the effect of false labor pains on the cervix is minimal. The length of labor is not fixed, for some women it can be 4 hours and for others 36, the length has been greatly shortened as the result of modern active and induced labor management from 13 hours in 1948 to 5 hours in 1980. In the second stage, the baby is pushed through the opened cervix and through the vagina, or birth canal, out of the mother’s body. This is the “delivery”. This stage takes around fifty minutes for a first birth or 20 minutes for every subsequent birth. The third stage is the expulsion of the placenta or “afterbirth”. This stage takes almost no time and if any placenta has not separated spontaneously by the time of the delivery of the infant after five minutes the placenta is manually removed (Rothman 2007). When a woman is upright, each contraction presses the baby down against her cervix, opening up the birth passage. When she is lying down, the weight of the baby presses on her spine, accomplishing nothing but increase her discomfort. Doctors prefer women lying on their back because it gives them complete access, women on the hand feel like beeched whales and the baby must often be manipulated to get it out of the birth canal without the help of gravity. Even under optimal conditions labor is painful but it is not necessarily the defining experience of giving birth. Pain is managed either with chemical pharmacological tecniques or with physical contact and comfort. Usually medicine is prescribed after the worst pain has passed. Most women report late labor “transition” as the most painful part and the “delivery” actually pushing the baby our, as not a painful and often quite pleasant or exciting (Rothman 2007).
There are four types of births. First, spontaneous vaginal birth—the baby is born through the vagina, usually with only guidance and assistance by the doctor or midwife. Second, vacuum-assisted vaginal birth—a suction (vacuum) device is placed on the baby’s head to help the baby’s body transit the birth canal. Third, forceps-assisted vaginal birth—instruments called forceps are placed around the
presenting part (usually the baby’s head), allowing the doctor to complete a difficult delivery. Fourth, cesarean birth (abdominal delivery)—a major surgical procedure requiring anesthesia and a recovery period. The cesarean section rate increased from slightly over 5% in 1970 to 29.1% in 2004 (Rothman 2007). The cesarean rate in other parts of the world varies greatly (Torpy, Lynm & Glass 2005). Alternatively, there are two types of births, home births and hospital births, or the midwifery model and medical model. The difference between the models of pregnancy developed by obstetrics and the home birth movement and midwifery are based upon their underlying ideologies and self interest. Medicine has to emphasize the disease-like nature of pregnancy, its riskiness in order to justify medical
management. Midwifery, in contrast, has to emphasize the normal nature of pregnancy in order to justify non-medical control in a society in which medicine has a monopoly on illness management (Rothman 2007). Laws specifically prohibit direct-entry midwifery, without a nursing license, in ten states, but licensure or some other form of state registration or certification is available to midwives in only 23 states. Midwives can receive Medicaid reimbursement for home birth in only ten of these states. Generally midwives do the delivery and the doctor is for any complications (Simond 2007).
99% of American births take place in the hospital and 92% of births are attended by a medical doctor. More than 70 % of US women receive epidural anesthesia for pain relief during labor (Norman & Rothman 2007). Women who give birth during the day are much more likely to have obstetric interventions than those who give birth during the “off peak” hours of 2 am to 8 am. Women who gave birth during peak hospital hours were 43% more likely to have forceps or vacuum extraction, 86% more likely to have drug induced labors and 10% more likely to have an episiotomy. Epitiotomies is done to prevent tearing of the perineum by cutting it surgically, although still the most widely performed surgical procedure on women, every few years new studies show that they cause rather than prevent such gynecological conditions as prolapsed uteri, tears in the vaginal wall (Rothman 2001). Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision. Although obstetricians often watch the clock it is not part of the midwifery approach. Physicians control birth in hospitals because it is done in their territory under their expertise. As the senior professionals around they control all the other workers and the patients (Rothman 2007). The presence of a doula, birth attendant, tends to reduce the overall cesarean rate by roughly 45%, length of labor by 25%, oxytocin use by 50%, pain medication by 31%, the need for forceps by 34%, and requests for epidurals by 10-60% (Norman & Rothman 2007).
A premature baby, or preemie, is born before the 37th week of pregnancy. Premature birth occurs in between 8 percent to 10 percent of all pregnancies in the United States. Babies born weighing less than 5 pounds, 8 ounces (2,500 grams) are considered low birth-weight. Low birth-weight babies are at increased risk of serious health problems as newborns, lasting disabilities and even death. When a baby is first born they should receive the colostrums and then milk to receive the immunity conferred by these products of the mother’s breast. Breastfeeding is more highly recommended these days. It is however much easier to gauge the sufficiency of a baby’s food intake in a bottle than a breast. When a baby is fist born it is recommended to let them suckle for five minutes on each breast about every four hours. That time is later extended to ten minutes on each breast. When an infant ceases to suckle on woman’s breast milk production quickly dries up. While some women use powder formulas from the beginning others suckle their children for years.
The United States lags dramatically behind all high-income countries, as well as many middle- and low-incomecountries when it comes to public policies designed to guarantee adequate working conditions for families. One hundred sixty-three countries around the world guarantee paid leave to women after childbirth; the United States does not. Forty-five countries ensure that fathers either receives paid paternity leave or paid parental leave; the United States does not. Seventy-six countries protect workingwomen’s right to breastfeed at work; the United States offers no such protection. Ninety-six countries offer paid annual leave; the United States does not require employers to provide any paid annual leave. One hundred thirty-nine countries provide paid leave for short or long-term illnesses; the United States has no national policy regarding sick leave. The list of working conditions relevant to families where the United States lags behind goes on and includes, among others, maximum hour legislation, legislation guaranteeing minimum days of rest, and leave for major family events. Where this comprehensive global data are available, the United States also appears to lag significantly behind in services available to children in working families. The United States ranks 39 in available data on early childhood education enrollment and 91 in student-to-staff ratios. The school year in the United States is shorter than that of 54 other countries around the world. While the United States has high rates of 0- to 3-year-olds in childcare, this is mainly due to families paying privately for care that is necessary in the absence of paid parental leave, not to either publicly-provided care or to parents choosing infant and toddler care when parental leave is available.
The only other industrialized country, which does not have paid maternity or parental leave for women, Australia, guarantees a full year of unpaid leave to all women in the country. In contrast, the Family and Medical Leave Act of February 5, 1993 (PL-303-3) in the U.S. provides only 12 weeks of unpaid leave to approximately half of mothers in the U.S. and nothing for the remainder. 45 countries ensure that fathers either receive paid paternity leave or have a right to paid parental leave. The United States guarantees fathers neither paid paternity nor paid parental leave. At least 76 countries protect working women’s right to breastfeed; the U.S. does not, in spite of the fact that breastfeeding has been shown to reduce infant mortality several-fold. In fact, nearly two-thirds of these countries protect breastfeeding for 15 months or longer. Nearly nine out of ten protect this right for at least a year. At least 96 countries around the world in all geographic regions and at all economic levels mandate paid annual leave. The U.S. does not require employers to provide paid annual leave. At least 37 countries have policies guaranteeing parents some type of paid leave specifically for when their children are ill. Of these countries, two-thirds guarantee more than a week of paid leave, and more than one-third guarantee 11 or more days. 139 countries provide paid leave for short- or long-term illnesses, with 117 providing a week or more annually. The U.S. provides up to 12 weeks of unpaid leave for serious illnesses through the FMLA (Heyman et al 2004). Pregnant women are expected to pay the doctor for an estimated twenty pre-natal care visits plus expensive hospital births. This is very expensive and many poor women do without leading to great disparities in health outcomes between races and the rich and poor. However women in every state can get help to pay for medical care during their pregnancies, that is a Medicaid covered expense for people regardless of their income. This prenatal care can help to have a healthy baby. Every state in the United States has a program to help. Programs give medical care, information, advice and other services important for a healthy pregnancy. To find out about the state program call 1-800-311-BABY (1-800-311-2229)
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