Q&A: Driving factors for US birth outcomes ‘complex and layered’

Key takeaways:

• U.S. teenage birth rates declined by 3% from 2021 to 2022.
• It is important to improve preterm birth, maternal mortality, maternal morbidity, data collection and surveillance.

Despite the decreases noted in a recently released CDC report for teenage and preterm birth rates and cesarean section rates, experts highlight the need for continued work in improving maternal and infant health outcomes.

The CDC report Births: Provisional Data for 2022 collected data through the National Vital Statistics System; findings are based on all birth records received and processed by the National Center for Health Statistics for 2022. Researchers found that provisional teenage birth rates in the U.S. have hit a historic low with 5.5 births per 1,000 women aged 15 to 19 years and 25.6 births per 1,000 women aged 18 to 19 years, which represents a 2% and 4% decline from 2021, respectively. Data are consistent with previous years as teenage birth rates from 2007 to 2021 declined by 9% per year among women aged 15 to 17 years and 7% per year among those aged 18 to 19 years.

The report also noted racial disparities in maternal health, including the finding that Black and American Indian/Alaska Native women have higher preterm birth rates compared with women of other races and ethnicities and that cesarean delivery rates have increased from 2021 to 2022.

Healio spoke with Juviza Rodriguez, MS, senior director of consumer health at March of Dimes, about the reported 2022 data on U.S. births and future steps to improving these outcomes. March of Dimes is a nonprofit organization whose mission is to address preventable maternal and infant health risks and mortality, including preterm births.

Healio: Why might the number of births decline among some racial/ethnic groups but not others?

Rodriguez: The decline could be caused by several factors, so it’s difficult to say what could be driving this change. American Indian/Alaska Native and white women experienced the largest decline in number of births at 3%; for Black women, the decline was just 1%. These are small shifts, but it brings up a lot of questions about what may be the driving factors.

Women of color, specifically American Indian/Alaska Native and Black women, are most impacted by the maternal health crisis in the U.S. There are maternity care deserts across the country, and these two groups experience adverse birth outcomes at a greater rate. When you’re facing poor access to quality maternity care it can impact your decision to have a baby. Some other factors influencing this trend could be a change in priorities — maybe women are waiting to start their families for professional or personal reasons.

Healio: What caused the decreased overall birth rate and general fertility rate in 2022, and are there implications from the total fertility rate remaining below replacement since 2007?

Rodriguez: [The lower overall birth and general fertility rates] could be attributed to the rise of women in the workforce, greater access to higher education, more awareness and access to contraception and family planning and even waiting longer between pregnancies. If we look back 30 years ago, it was very much the norm for women to have children in their early 20s. Today, many women are waiting to have children at a later stage in their life and are now OK with that. There is also the very real issue of cost. Unfortunately, some people are limited financially because of the type of work they do, and from an economic standpoint, childcare can be very expensive. But also, we don’t have very good paid parental leave policies in this country.

If you work for an organization or company that does not accommodate or prioritize the health and well-being of people, especially new moms, this can all play a major role when deciding on the best time to start a family. Ultimately, if you don’t have the right support to have a baby, that will impact your decision about when, or if, you decide to start a family. These are two key factors that we cannot disregard and probably contribute to these slight decreases. It speaks volumes on the improvements that need to be made to ensure that we’re providing people the ability to make these decisions for themselves at a time that makes sense for them.

As for what implications a decrease in overall birth rate and general fertility can have, right now I wouldn’t say it’s especially alarming or concerning. The rate is very small. But, over time it can certainly affect population rates, and these trends could have domino effects — especially on the workforce and economy. In an ideal world the trends remain steady and consistent.

Healio: Why might the 2022 birth rates have increased from 2021 for women of certain age groups, but not others?

Rodriguez: The age groups that experienced greater increases in birth rates were women ages 35 to 39 and 40 to 44 years, which makes sense since by this age many women might be at a different stage, economically and professionally, in life than their younger counterparts. Priorities change for people, and I suspect that younger age groups, especially those in their early 20s, are waiting to have babies a little while longer.

Healio: Why might cesarean delivery rates have increased for Asian, Hispanic and white women from 2021, but not change for Black and Native Hawaiian or Pacific Islander women?

Rodriguez: Overall, the cesarean delivery rate increased a little bit in 2021. It’s the third increase in a row after a general decline. Even though there may not have been any significant increases among different racial and ethnic groups, the reality is that among Black women the cesarean delivery rate is higher than it is for all women. There are cases where there’s an unnecessary need for a cesarean delivery, and it’s something we highlight and are paying close attention to, especially given today’s maternal health landscape. It’s worrisome because of the short- and long-term risks that are associated with a procedure like this. In 2022, more than 1,200 women died because of maternal causes, and about 50,000 women experienced severe maternal morbidity. Essentially these are near misses or events that could lead to short-term and long-term consequences, and sometimes procedures like cesarean delivery are linked to these outcomes.

Healio: The CDC data noted declines in both early and late preterm births in 2022 compared with a rise of 4% in 2021. What could be causing this decrease in preterm births?

Rodriguez: These decreases are slight and certainly not as significant or not as large as we would hope. The early preterm rate declined, and the late preterm rate declined by about 1%. These decreases are great. Anytime we have a decline, it is certainly something to celebrate, but we can’t forget that preterm birth is a chronic problem, and we certainly can’t forget about the disparities that exist.

A lot of factors may have driven this small, but meaningful decline. It could be greater awareness or greater empowerment among people giving birth in the country in the last 2 years. We’ve seen greater focus on raising awareness of maternal health outcomes, especially the impact had on women of color and particularly Black women. If you Google “maternal health in the United States,” you’re going to find several articles talking about the issue and what must be done, etc. So, I’m inclined to believe that, hopefully, there’s a greater awareness among the general audience and among people who desire to have a baby and expand their family.

With greater awareness comes, ideally, greater empowerment.

However, even though there’s this positive change, we still have these terrible disparities. The rate of preterm birth among Black women is higher than the rate of preterm birth among white or Hispanic women. And overall, Black, American Indian/Alaska Native and Hispanic women have worse rates than white women. Women who are Native Hawaiian and other Pacific Islander also have high rates of preterm birth — not enough people are talking about this. So, many things can increase the risk of preterm birth, and as a nation we need to do better to ensure that we make greater strides in helping achieve a bigger decline. Again, it’s certainly something to celebrate when we see a decline or no movement or real change between groups, but so much more needs to continue to be done.

Healio: How might the COVID-19 pandemic in 2020 have affected 2020-2022 birth trends?

Rodriguez: The distress from the pandemic certainly had negative effects on our well-being, and higher stress can lead to other health complications. Not everyone was afforded the opportunity to stay home or have a steady income, but those who did certainly saw benefits from this. Some folks were home and it afforded them the opportunity to reduce certain stressors, especially unspoken chronic stressors that I think a lot of times people forget. If you’re somebody who is at high risk for preterm birth or any other complication that leads to preterm birth, being able to drastically reduce the stress of your daily hustle can certainly help.

At the same time, the pandemic exacerbated things. Understand that, despite the small declines — they’re great, and we must celebrate — at the same time, we can’t forget that grave disparities existed during the pandemic and we still feel those effects today. Those disparities between groups don’t go away. They are still evident. The pandemic led to greater stress reduction or access to telehealth services. But, for every great thing happening, there’s another group of people that are being left behind. What about the people that don’t have access to telehealth? What about essential workers that couldn’t stay home? It’s complex and layered, and not really a straightforward answer, but it’s important to compile all these little factors that may be contributing to birth trends today, and in the future.

Healio: What do these data mean for the future of U.S. pregnancy outcomes?

Rodriguez: To one extent, these data create greater awareness and put pressure on policy makers and the medical community to think of what measures will strengthen our public health system. Data helps build support for continued research and education that will improve the health and well-being of families. To implement the strategies that will help prevent things like maternal death or preterm birth, we need to understand all the ways moms are being impacted.

Again, everything has a domino effect. These data can help shape the way we invest in vital federal public health programs that will benefit moms and babies directly. It can help pave the road for a more robust public health infrastructure that will help us identify the contributors to poor health outcomes. These data also can shape policy. I’m hopefully that these data can be the spark that helps leaders — U.S. federal, state and local policymakers, health officials, health care providers, hospitals and community-based organizations — all work together to support efforts to improve maternal and infant health. Cross-sectoral collaboration is so critical here.

I think these data also provide an opportunity to advance our understanding of maternal health and severe maternal morbidity. If you’re a woman that experienced a complication in your first birth, and you don’t have access to the right care or the right support, the likelihood of experiencing complications in your next pregnancy is much higher. It’s so complex and it’s so layered. There’s no one direct thing that we can do to resolve everything. But data is a very powerful tool that we can lean on to keep building strategies and implementing feasible solutions.

Healio: Is there anything else you would like to add?

Rodriguez: The work must continue. At March of Dimes, we know that not having adequate prenatal and obstetric care leads to unfavorable outcomes. Maternity care deserts are on the rise, and the United States remains among the most dangerous developed countries to give birth in. According to the March of Dimes Report Card, the U.S. ranked a D+ grade for preterm birth. It’s one of the worst grades March of Dimes has ever recorded. Implicit bias and discrimination are a real problem and fuel the maternal health crisis.

We need to do better — there is a great importance that needs to be placed on inclusive quality care. All birthing people, regardless of what they look like or where they live, should have access to quality care before, during and after pregnancy.

At March of Dimes, we are placing great efforts on education, advocacy and research. Our website has a robust library of bilingual health information and articles for women and their families at every stage of the pregnancy journey. I very much believe that when people are well informed, they feel more empowered. And when they are empowered, they advocate for themselves and for the care that they need and deserve, in order to have a healthy and safe pregnancy.

Reference:

• Births: Provisional Data for 2022. www.cdc.gov/nchs/data/vsrr/vsrr028.pdf. Published June 1, 2023. Accessed June 1, 2023.