General Considerations

As of 2007, the average birth rate for the world is 20.3 live births per year per 1000 total population, which for a world population of 6.6 billion amounts to 134 million babies born per year. In 2007, in the United States, the birth rate was 14.16 per 1000 total population. The lower birth rate in the United States reflects primarily the current smaller proportion of women of childbearing age as baby boomers age and Americans are living longer.

The lowest birth rates worldwide, less than 8.5 per 1000, were recorded in Japan, Germany, Singapore, Hong Kong and Macao. The highest birth rates, 49.0 or more per 1000, were recorded in Niger, Liberia, Guinea-Bissau, and Democratic Republic of the Congo.

Childbearing among teenagers has been on a long-term decline in the United States since the late 1950s, except for a brief, but steep, upward climb in the late 1980s through 1991. The 2004 birth rate (41.2 births per 1000 teenagers from 15 to 19 years of age) is 1% lower than in 2002 and 33% lower than the most recent peak in 1991.

The birth rate for African-American teenagers in 2004 was down 46% to 62.9 per 1000 teenagers from a high of 115.5 in 1991. The birth rate for Hispanic teenagers in 2004 was down 23% to 82.6 per 1000 teenagers from a high of 106.8 in 1993. More than 25% of all children were delivered by cesarean section;the total cesarean delivery rate was 26.1%, the highest ever reported in the United States.

The average age of mothers at first birth has increased steadily since the mid-1970s, to 25.1 years in 2002, an all-time high for the nation. In 2002, by state, the average age of mothers at first birth ranged from 23 years to 28 years. Mothers living in northeastern states were the oldest at first birth;mothers living in Arkansas, Louisiana, Mississippi, New Mexico, Oklahoma, and Wyoming were the youngest.

Slightly more than 1 per 10 women smoked during pregnancy in 2002, a decline of 42% since these data were first collected in 1989.

The risk of death from complications of pregnancy has decreased approximately 99% during the 20th century. However, since 1982, there has been no further decrease in the maternal mortality rate. Racial disparity in pregnancy-related mortality persists: The mortality rate among African-American mothers is at least three to four times higher than that among white mothers. In a 2003 study, the Centers for Disease Control and Prevention reviewed the pregnancy-related mortality rate in the United States from 1991 to 1999. During this period, there were 4200 deaths from pregnancy-related conditions. The overall pregnancy-related mortality rate was 11.8 deaths per 100,000 live births for the 9-year surveillance period. In comparison with pregnancy-related mortality rates among white women, excess risk for African-American women increased significantly with age and was most evident at ages older than 39 years. The most frequent pregnancy outcome associated with a pregnancy-related death was live birth (60%), followed by undelivered pregnancy (10%) and stillbirth (7%). The leading causes of pregnancy-related death were embolism (19.6%), hemorrhage (17.2%), pregnancy-induced hypertension (15.7%), infection (12.6%), cardiomyopathy (8.3%), stroke (5.0%), and anesthesia (1.6%).

Any woman in the reproductive age group who is sexually active and misses her menstrual period should be considered pregnant until proven otherwise. Even if she presents with symptoms not directly related to the abdomen, she should be evaluated for pregnancy. A sexually active woman in the reproductive age group may have a history of 2 years of amenorrhea (loss of menstrual periods) but can be pregnant nonetheless. Whatever the cause of the amenorrhea was 2 years ago, it may be different now. ''Think pregnancy'' should be your motto in the evaluation of such patients. This is extremely important because the diagnosis or treatment of a woman's medical or surgical problem may be deleterious to the developing fetus if she is pregnant. As discussed later in this chapter, many of the symptoms of pregnancy are nonspecific and can be interpreted erroneously if the pregnancy is not recognized. For example, the urinary frequency that is common in early pregnancy might easily be mistaken for cystitis. The patient might then receive an antibacterial agent such as a sulfonamide or a quinolone, which is potentially toxic to the developing fetus. When the urinary symptoms fail to respond to the medication, the patient might then be referred for intravenous pyelography, which adds the risk of radiation to an early pregnancy.

Pregnancy And Childbirth

Pregnancy And Childbirth

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