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A program of indigent obstetric care and planned parenthood in a rural North Carolina county
A program of indigent obstetric care and planned parenthood in a rural North Carolina county J.
EDWIN
Greenville,
CLEMENT, North
M.D.
Carolina
The results of a specifically planned maternal health program associated with a planned parenthood program in a rural North Carolina county have been reviewed. The numbers of patients attending postpartum clinics have increased since the introduction of specific methods of contraception, namely, the IUCD and the pill. The numbers of such indigent patients being cared for by the private practitioner in the rural community is phenomenal and poses a serious problem in health care as the new decade begins.
Material and methods Half of Pitt County’s population of approximately 75,000 lives in the county scat of Greenville. The entire county is ser\.ed by one county health clinic, and one hospital, where all deliveries take place. The prmata1 and postpartum clinics are held on OIK day per week in the health department, with on< morning and one afternoon clinic. Approximately 95 per cent of patients attendiqg these clinics are nonwhite, and all patients attending the clinics are of the same general socioeconomic status. All clinic p:iticnt care is rendered by the four local obstetricians, with help from some volunteer members of the county medical society in the planned parenthood program.
o u G H the state of North Carolina is becoming more and more urbanized, it has traditionally been rooted in rural society. The problems of rural family life in this state are deeply involved, particularly in the nonwhite population, in the failure of the family unit to plan its propagation and development. Thus, North Carolina has lagged far behind in maternal and fetal mortality rates, and has had prior to recent years an extremely high birth rate among indigents. Fairly typical of the rural North Carolina county is that of Pitt, where the population at the present time is approximately 75,000, 42 per cent of which is nonwhite. The purpose of this presentation is to review the results of specific planning toward better prenatal care in Pitt County, North Carolina, and to observe the effects of planned parenthood among the county’s indigent population. ALT
H
Obstetric
care
From 1960 through 1968, there was an increase in the number of indigent patients attending the prenatal clinic from 32 to 69 per cent of total nonwhite county ).Jatknts who were delivered of infants. The results of better prenatal care, however, are not glaringly apparent, since there was no irnprovement in county prematurity r&c>, fcltai mortality rate, or maternal mortalitv rate:
From the Department of Obstetrics and Gynecology, Pitt County Memorial Hospital. and Pitt County Department of Health. Presented at the Thirty-second Annual Meeting of the South Atlantic Associa?ioh of Obstetricians and Gynecologists, Tampa, Florida, Jan. 18-21, 1970. 63
64
Clement
Amer.
among this group of patients. However, the county nonwhite birth rate declined from 34 per 1,000 in 1957 to 19 per 1,000 in 1968, representing a decrease of almost 50 per cent in the past 11 years. Planned
parenthood
program
Attendance. Postpartum clinics have been available for many years in the county health department. The numbers of new patients attending these clinics has increased from 50 to 90 in 1957-1962, to 225 to 275 patients per year in 1966-1968. County health nurses visited each patient after delivery and have been largely responsible for the fact that 60 per cent of indigent patients who were delivered of infants attend this clinic. Contraceptives. Prior to 1963 only chemical agents and male prophylactics were available to patients. In 1963, intrauterine device insertion was begun. In 1965, oral contraceptives were made available for the first time. Patients were charged $1.00 for insertion of an IUCD and $1.00 per month for pills. As far as could be observed, this fee did not deter use of the agents. Through 1968, 592 patients had been fitted for IUCD’s, and 239 patients had been placed on oral contraceptives. Each year there has been an increase in the number of patients who accept each method. Follow-up of these patients is not part of the present study. Voluntary sterilization. In 1965, the North Carolina legislature passed a very inclusive voluntary sterilization law. Concurrent with the change in legal attitude in North Carolina, concerted effort was begun in the Pitt County health clinic to encourage voluntary sterilization in indigent multigravidas. Since 1965, 290 indigent county females have had elective sterilization, mostly post partum. Comment Planned parenthood for an indigent group of people in a rural area such as Pitt County, North Carolina, must involve not only rendering contraceptive advice but also furnishing the young pregnant clinic patient good prenatal care. In 1957 a local county physician became
September J. Obstet.
1: 1970 Gynec.
concerned over the extremely high rate of illegitimacy and poor fetal and maternal outcome among the county nonwhite patients, and he began to work through the schools and social groups to provide better insight into the problem locally. In reviewing statistics of the county, it was felt that 1957 would, therefore, be a good starting point. The illegitimacy rate is of particular note since it has changed very little in the ensuing years in spite of efforts of physicians in the health clinic as well as through the organizations mentioned above. As is fairly typical throughout the country, the percentage of illegitimacy among whites has increased since 1957 from approximately 2 to approximately 3vz per cent in both the state and the county. However, among the nonwhite in Pitt County, the rate has increased from 26.9 to 42.4 per cent from 1957 through 1968. The latter figure is considerably above the 1968 rate of 32.4 per cent in the state of North Carolina. Thus, it would appear that in spite of efforts to lower this rate, very little change has actually occurred. The problem of indigent obstetric care in a community in which such patients must be cared for by physicians in private practice can become phenomenal. As pointed out by Johnson before this Society in Hot Springs last year, upward of 30 per cent of obstetric patients in the rural-type setting in the South are indigent.l It behooves, therefore, every local medical group in this area to arrange the best method for care of these obstetric indigent patients and at the same time improve survival rates and lower birth rates wherever possible. Half the patients seen in a clinic such as described are welfare recipients and will now qualify for Title XIX Medicaid payments. Whether or not these patients are looked upon as undesirables who must be tolerated or as patients who will allow the physician a fair rate of return for services rendered, the fact remains that there will be in this county and in many other areas in the country too many patients for delivery by physicians doing obstetrics. It is largely for this reason that nurse midwives and obstetric physicians’ as-
Maternal
sistants are being evaluated in many areas, and may become a vital part of care rendered to obstetric patients in community hospitals such as ours with no house staff. The problem of poor results even in the face of a “planned attack” as administered in Pitt County, North Carolina, are discouraging at best. These problems will continue to require the best of physicians con-
health
program
65
cerned over the welfare of the poor x;oung citizens who must face life in the environment of a high chance of overpopulation and poor chance of the best medical results. It must continue to be our responsibility. duty, and challenge to assure these youngsters-newborn, teen-agers, and older gravidas--that our best will go into planning for their welfare.
REFERENCE
1. Johnson, Charles A.: AMER. 105: 73, 1969.
J. OBSTET.
GYNEC.
Discussion
T. V. FINCH, Sarasota,Florida. The problems of indigent obstetricsin Pitt County, North DR.
Carolina, are not unique. The increasing demand for obstetric care among the indigent in Sarasota County, Florida, has paralleled somewhat this North Carolina community. One of our main problems has been that of losing general practitioners from obstetric practice when the obligation to rotate on clinic services required that they do more indigent deliveries than private ones. The eventual result is that a number of our good general practitioners have given up obstetrics because of the clinic work load. Of 1,347 deliveries in 1969, 11 per cent were clinic. Th e problem has recently been relieved by conferring with our County Commissioners and pointing out to them a statute which puts the responsibility of indigent medical care on their shoulders and the suggestion that they employ a physician to do this work for them, as they might employ architectural, engineering, or legal services. When they added up the cost of such a physician, the obstetric staff was finally offered a fee of $175.00 for each delivery and the clinic coverage has been improved and no more resignations from the obstetric staff have occurred. As far as planned parenthood activities, our local effort is a four-way project involving the cooperation of ( 1) members of the County Medical Society; (2) county health department; (3) Sarasota Memorial Hospital; and (4) the Planned Parenthood Association of Sarasota County, Inc. In 1966 we began with one evening clinic a month, and we now operate five evening clinics: two at the hospital, two in a Negro community, and one in the south county. In addition
to these, there are two obstetric clinics each week with family planning advice and materials being dispensed in these clinics. Seven physicians have volunteered for working in the planned parenthood clinic, one of whom is the county health officer. The main problems, as I see them in our efforts in family planning activities are ( 1) reaching more of those who really need help and (2) dropouts. With increased expenditure of money and effort and better follow-up of postpartum
patients, we hope to reach a higher percentage of these individuals. Currently, we arc serving only 8 per cent of the 3,600 indigent women of childbearing age in our county. The dropout problem is a real one. Incentive
to return for suppliesappearsto wane 3s time from the delivery the large clinic at have been reported cal sterilization, on
increases. Dropout rams for Jackson Memorial in Miami as high as 38 per ccm. Surgithe other hand, has been the
one method essentiallyfree of the droIx)trt prohlem. I am pleased to read that Dr. Clrnient and his group have surgically sterilized an a\t:rage of 58 indigent patients per year the last 5 years. In Sarasota County, although we average (3 years) 74 tubal ligations yearly; only 23 per cent of these are on indigent patients. Certainly, the cost to the taxpayers of Pitt County, North Carolina, for those sterilization procedures has be,n minimal and most rewarding, especially when one estimates the cost of rearing an indigent child from birth to maturity to be from $8,000 to $40,000, depending upon how normal----physically and mentally-this child might be. Zntervnl female sterilization. There :ire many women who have difficulty in getting their hns-
66
Clement Amer.
bands to agree, or may not make up their minds by the time of the delivery; these women will get out of the hospital and home before they realize the benefits of surgical sterilization. I am convinced that these women make up a large segment of family planning patients and they should be allowed every consideration for this procedure, with a reasonable and liberal interpretation of factors such as age and parity. I realize that voluntary male sterilization is an easier, safer, and less expensive method as compared to female sterilization, but in the indigent individuals, especially among Negro males, this has not yet become a widely acceptable practice, and cries of “genocide” have inhibited Federal emphasis on this procedure. Transvaginal tubal ligation is a simple, safe, and very acceptable procedure. Though roughly four times as expensive as male sterilization, it can be accomplished by a well-trained vaginal surgeon and requires only 48 to 72 hours of hospitalization, as a rule. It requires no special equipment. In my opinion, many women, who are now being bombarded with television and magazine propaganda articles about the hazards of the “pill,” will soon be demanding other methods of contraception, and I would heartily recommend wider use of transvaginal tubal ligation, especially in the multiparous individual 30 years of age and older, married or single, among both the indigent and private sectors of our practice. DR. BOTHWELL TRAYLOR, Athens, Georgia. Dr. Clement has focused our attention on problems common to all communities and multiplied many times over when we think of the country as a whole. The problem of indigent obstetric care in the majority of cities and communities without teaching programs has been well documented by Dr. Clement. The burden entailed in delivering 125 extra obstetric patients per year, in addition to looking after a busy and overloaded practice, seems almost insurmountable. Dr. Clement suggested enlisting the aid of nurse-midwives, and while I have never had any experience working with them, from reports I have read about them their services are most satisfactory. There are only a few states having laws licensing nurse-midwives. Most southern states, however, license midwives. It would seem feasible to train obstetrically oriented nurses from our own delivery suites to be licensed as midwives. In addition to attending uncomplicated deliveries, they could help con-
September J. Obstet.
1, 1970 Gynec.
duct the antenatal, postnatal, and family planning clinics. Another source of help to be investigated would be the medical schools. Junior and senior students interested in obstetrics could be sent to approved communities for practical courses under the supervision of the local obstetricians. The Medical College of Georgia has promised us two students for the spring of 1970, and we shall do all we can to make their time with us worthwhile, with the hope of making the arrangement permanent. Dr. Clement and his colleagues have made an enviable record in the reduction of the birth rate in Pitt County, North Carolina. In Clarke County, Georgia, our birth rate is 23.4, as compared to 19.1 for the State of Georgia. Our birth rate is still over twice the national death rate of 9.4 per thousand, and thus the birth rate should be further reduced to maintain a stable population. At our present rate of growth, Georgia’s population will double in the next 33 years. Georgia’s population density now is one person for every ten acres, and when the population doubles, there will be one person for every 5 acres. If we consider Georgia as an ecologic unit, after density becomes greater than one person per 5 acres, the standard of living of the citizens will decline. In 1965 in Clarke County, Georgia, we assigned a high priority to a family planning clinic. The clinic now has 1,087 registered patients and meets 4 mornings per week. We are fortunate in having a director of public health who is vitally interested in this clinic and does much of the actual work himself. In the past 5 years we have had a decrease in our birth rate from 26.3 to 23.4. Our registered obstetric clinic patients have dropped from 357 in 1964 to 209 in 1969. Over the past 5 years our percentage of patients attending postpartum clinics has increased from 58 per cent (in 1964) to 84 per cent (in 1969). Since 1965 we have diagnosed 193 cases of gonorrhea1 salpingitis in our family planning clinic. Most of these patients were wearing the IUCD and came in complaining of pain from the device. We do not remove the device but treat the patient with penicillin. One bonus we have received from our clinic is the discovery of 13 cases of cervical cancer. Only 2 of these have been invasive. (In view of the recent discussion in Congress concerning oral contraceptives as a cause of cervical cancer, only
Voiume
108
Number
1
2 of these patients had ever had exposure to birth control pills.) We obtain Papanicolaou smears on all of our patients and encourage them to return once a year for repeat smears. The State of Georgia pays a local pathologist a token fee of $1.50 for each smear he reads. The state also furnishes all of our contraceptive materials without charge, and I wonder if this could be a factor in our high rate of postpartum visits. Georgia has a voluntary sterilization law similar to the one in North Carolina. In the past 4 years in our clinic we have performed only 16 postpartum tubal ligations. DR. G. C. MCDANIEL, Fort Lauderdale, Florida. Broward Medical Center in Fort Lauderdale, Florida, is a general hospital of 666 beds. In 1959, 52 tubal ligations were performed, 2.6 per cent of deliveries, or one tubal ligation for every 40 deliveries. Two of these tubal ligations were performed vaginally. During the years of 1967, 1968, and 1969 there were a total of 9,504 deliveries (55 per cent of these were private patients). A total of 1,437 tubal ligations (60 per cent of these were private patients) were performed during these years. For these three years this represents a tubal ligation percentage of 15.7 or aproximately one tubal ligation for every 7 deliveries. Vaginal :ubal ligation in these 3 years numbered: 1967 15: 1968 34; 1969 60. The highest percentage of tubal ligation reported in the literature was 18 per cent from Puerto Rico. A 1966 questionnaire among 133 United States hospitals revealed some hospitals with rates of 8 or 9 per cent. In 1967, review of California insurance reports showed that 5.4 per cent of women that were delivered of infants had postpartum sterilizations. The entire reproductive cycle of the female is moving ahead at a rate which many of us may not yet recognize. Sexual maturity in the female is said to
Maternal
health
program
67
be advancing as much as 6 months every two decades, and so it goes with initiation of sexual activity, the age of marriage, the age at birth of the first child, and the age at which family size is completed. The third and fourth child of our private patients-the so called middle class-constitute the bulk of the explosive population growth in the United States. We should greatly liberalize our criteria for voluntary sterilization in terms of parity and age. The conscientious and honest obstetrician in consultation with his patient is a far better judge of whether sterilization is reasonable than any hospital or national committee. Recently, we have been seing a “new syndrome” consisting of a family unit with three or four children. The wife, who may be 28 to 34 years of age, is not currently pregnant. A variety of contraceptive methods have been tried in the past with frequently the use of contrar~eptive tablets for 4 to 6 years. The tablets have been associated with moderate side effects, and considerable apprehension on the part of the patient concerning future use. Vaginal tubal ligation is our answer to this “syndrome.” It invcblves a relatively minor operation in comparison with vaginal hysterectomy and repair and is much more readily accepted by the patient. Whian contrasted with the alternative of ten or more years of contraception by constant use of hormonal agents or mechanical devices, vaginal tubal ligation offers a satisfactory solution to thii “syndrome.” We have had no deaths or tubal ligation failures after either postpartum or vaginal tubal ligation in our private practice that now f,xttmds over a period of 15 years. Tubal ligation requires clear explanation to the patient, but we have found it a wl’y satisfactory answer to many contraceptive prdtlems.
EDWIN
Greenville,
CLEMENT, North
M.D.
Carolina
The results of a specifically planned maternal health program associated with a planned parenthood program in a rural North Carolina county have been reviewed. The numbers of patients attending postpartum clinics have increased since the introduction of specific methods of contraception, namely, the IUCD and the pill. The numbers of such indigent patients being cared for by the private practitioner in the rural community is phenomenal and poses a serious problem in health care as the new decade begins.
Material and methods Half of Pitt County’s population of approximately 75,000 lives in the county scat of Greenville. The entire county is ser\.ed by one county health clinic, and one hospital, where all deliveries take place. The prmata1 and postpartum clinics are held on OIK day per week in the health department, with on< morning and one afternoon clinic. Approximately 95 per cent of patients attendiqg these clinics are nonwhite, and all patients attending the clinics are of the same general socioeconomic status. All clinic p:iticnt care is rendered by the four local obstetricians, with help from some volunteer members of the county medical society in the planned parenthood program.
o u G H the state of North Carolina is becoming more and more urbanized, it has traditionally been rooted in rural society. The problems of rural family life in this state are deeply involved, particularly in the nonwhite population, in the failure of the family unit to plan its propagation and development. Thus, North Carolina has lagged far behind in maternal and fetal mortality rates, and has had prior to recent years an extremely high birth rate among indigents. Fairly typical of the rural North Carolina county is that of Pitt, where the population at the present time is approximately 75,000, 42 per cent of which is nonwhite. The purpose of this presentation is to review the results of specific planning toward better prenatal care in Pitt County, North Carolina, and to observe the effects of planned parenthood among the county’s indigent population. ALT
H
Obstetric
care
From 1960 through 1968, there was an increase in the number of indigent patients attending the prenatal clinic from 32 to 69 per cent of total nonwhite county ).Jatknts who were delivered of infants. The results of better prenatal care, however, are not glaringly apparent, since there was no irnprovement in county prematurity r&c>, fcltai mortality rate, or maternal mortalitv rate:
From the Department of Obstetrics and Gynecology, Pitt County Memorial Hospital. and Pitt County Department of Health. Presented at the Thirty-second Annual Meeting of the South Atlantic Associa?ioh of Obstetricians and Gynecologists, Tampa, Florida, Jan. 18-21, 1970. 63
64
Clement
Amer.
among this group of patients. However, the county nonwhite birth rate declined from 34 per 1,000 in 1957 to 19 per 1,000 in 1968, representing a decrease of almost 50 per cent in the past 11 years. Planned
parenthood
program
Attendance. Postpartum clinics have been available for many years in the county health department. The numbers of new patients attending these clinics has increased from 50 to 90 in 1957-1962, to 225 to 275 patients per year in 1966-1968. County health nurses visited each patient after delivery and have been largely responsible for the fact that 60 per cent of indigent patients who were delivered of infants attend this clinic. Contraceptives. Prior to 1963 only chemical agents and male prophylactics were available to patients. In 1963, intrauterine device insertion was begun. In 1965, oral contraceptives were made available for the first time. Patients were charged $1.00 for insertion of an IUCD and $1.00 per month for pills. As far as could be observed, this fee did not deter use of the agents. Through 1968, 592 patients had been fitted for IUCD’s, and 239 patients had been placed on oral contraceptives. Each year there has been an increase in the number of patients who accept each method. Follow-up of these patients is not part of the present study. Voluntary sterilization. In 1965, the North Carolina legislature passed a very inclusive voluntary sterilization law. Concurrent with the change in legal attitude in North Carolina, concerted effort was begun in the Pitt County health clinic to encourage voluntary sterilization in indigent multigravidas. Since 1965, 290 indigent county females have had elective sterilization, mostly post partum. Comment Planned parenthood for an indigent group of people in a rural area such as Pitt County, North Carolina, must involve not only rendering contraceptive advice but also furnishing the young pregnant clinic patient good prenatal care. In 1957 a local county physician became
September J. Obstet.
1: 1970 Gynec.
concerned over the extremely high rate of illegitimacy and poor fetal and maternal outcome among the county nonwhite patients, and he began to work through the schools and social groups to provide better insight into the problem locally. In reviewing statistics of the county, it was felt that 1957 would, therefore, be a good starting point. The illegitimacy rate is of particular note since it has changed very little in the ensuing years in spite of efforts of physicians in the health clinic as well as through the organizations mentioned above. As is fairly typical throughout the country, the percentage of illegitimacy among whites has increased since 1957 from approximately 2 to approximately 3vz per cent in both the state and the county. However, among the nonwhite in Pitt County, the rate has increased from 26.9 to 42.4 per cent from 1957 through 1968. The latter figure is considerably above the 1968 rate of 32.4 per cent in the state of North Carolina. Thus, it would appear that in spite of efforts to lower this rate, very little change has actually occurred. The problem of indigent obstetric care in a community in which such patients must be cared for by physicians in private practice can become phenomenal. As pointed out by Johnson before this Society in Hot Springs last year, upward of 30 per cent of obstetric patients in the rural-type setting in the South are indigent.l It behooves, therefore, every local medical group in this area to arrange the best method for care of these obstetric indigent patients and at the same time improve survival rates and lower birth rates wherever possible. Half the patients seen in a clinic such as described are welfare recipients and will now qualify for Title XIX Medicaid payments. Whether or not these patients are looked upon as undesirables who must be tolerated or as patients who will allow the physician a fair rate of return for services rendered, the fact remains that there will be in this county and in many other areas in the country too many patients for delivery by physicians doing obstetrics. It is largely for this reason that nurse midwives and obstetric physicians’ as-
Maternal
sistants are being evaluated in many areas, and may become a vital part of care rendered to obstetric patients in community hospitals such as ours with no house staff. The problem of poor results even in the face of a “planned attack” as administered in Pitt County, North Carolina, are discouraging at best. These problems will continue to require the best of physicians con-
health
program
65
cerned over the welfare of the poor x;oung citizens who must face life in the environment of a high chance of overpopulation and poor chance of the best medical results. It must continue to be our responsibility. duty, and challenge to assure these youngsters-newborn, teen-agers, and older gravidas--that our best will go into planning for their welfare.
REFERENCE
1. Johnson, Charles A.: AMER. 105: 73, 1969.
J. OBSTET.
GYNEC.
Discussion
T. V. FINCH, Sarasota,Florida. The problems of indigent obstetricsin Pitt County, North DR.
Carolina, are not unique. The increasing demand for obstetric care among the indigent in Sarasota County, Florida, has paralleled somewhat this North Carolina community. One of our main problems has been that of losing general practitioners from obstetric practice when the obligation to rotate on clinic services required that they do more indigent deliveries than private ones. The eventual result is that a number of our good general practitioners have given up obstetrics because of the clinic work load. Of 1,347 deliveries in 1969, 11 per cent were clinic. Th e problem has recently been relieved by conferring with our County Commissioners and pointing out to them a statute which puts the responsibility of indigent medical care on their shoulders and the suggestion that they employ a physician to do this work for them, as they might employ architectural, engineering, or legal services. When they added up the cost of such a physician, the obstetric staff was finally offered a fee of $175.00 for each delivery and the clinic coverage has been improved and no more resignations from the obstetric staff have occurred. As far as planned parenthood activities, our local effort is a four-way project involving the cooperation of ( 1) members of the County Medical Society; (2) county health department; (3) Sarasota Memorial Hospital; and (4) the Planned Parenthood Association of Sarasota County, Inc. In 1966 we began with one evening clinic a month, and we now operate five evening clinics: two at the hospital, two in a Negro community, and one in the south county. In addition
to these, there are two obstetric clinics each week with family planning advice and materials being dispensed in these clinics. Seven physicians have volunteered for working in the planned parenthood clinic, one of whom is the county health officer. The main problems, as I see them in our efforts in family planning activities are ( 1) reaching more of those who really need help and (2) dropouts. With increased expenditure of money and effort and better follow-up of postpartum
patients, we hope to reach a higher percentage of these individuals. Currently, we arc serving only 8 per cent of the 3,600 indigent women of childbearing age in our county. The dropout problem is a real one. Incentive
to return for suppliesappearsto wane 3s time from the delivery the large clinic at have been reported cal sterilization, on
increases. Dropout rams for Jackson Memorial in Miami as high as 38 per ccm. Surgithe other hand, has been the
one method essentiallyfree of the droIx)trt prohlem. I am pleased to read that Dr. Clrnient and his group have surgically sterilized an a\t:rage of 58 indigent patients per year the last 5 years. In Sarasota County, although we average (3 years) 74 tubal ligations yearly; only 23 per cent of these are on indigent patients. Certainly, the cost to the taxpayers of Pitt County, North Carolina, for those sterilization procedures has be,n minimal and most rewarding, especially when one estimates the cost of rearing an indigent child from birth to maturity to be from $8,000 to $40,000, depending upon how normal----physically and mentally-this child might be. Zntervnl female sterilization. There :ire many women who have difficulty in getting their hns-
66
Clement Amer.
bands to agree, or may not make up their minds by the time of the delivery; these women will get out of the hospital and home before they realize the benefits of surgical sterilization. I am convinced that these women make up a large segment of family planning patients and they should be allowed every consideration for this procedure, with a reasonable and liberal interpretation of factors such as age and parity. I realize that voluntary male sterilization is an easier, safer, and less expensive method as compared to female sterilization, but in the indigent individuals, especially among Negro males, this has not yet become a widely acceptable practice, and cries of “genocide” have inhibited Federal emphasis on this procedure. Transvaginal tubal ligation is a simple, safe, and very acceptable procedure. Though roughly four times as expensive as male sterilization, it can be accomplished by a well-trained vaginal surgeon and requires only 48 to 72 hours of hospitalization, as a rule. It requires no special equipment. In my opinion, many women, who are now being bombarded with television and magazine propaganda articles about the hazards of the “pill,” will soon be demanding other methods of contraception, and I would heartily recommend wider use of transvaginal tubal ligation, especially in the multiparous individual 30 years of age and older, married or single, among both the indigent and private sectors of our practice. DR. BOTHWELL TRAYLOR, Athens, Georgia. Dr. Clement has focused our attention on problems common to all communities and multiplied many times over when we think of the country as a whole. The problem of indigent obstetric care in the majority of cities and communities without teaching programs has been well documented by Dr. Clement. The burden entailed in delivering 125 extra obstetric patients per year, in addition to looking after a busy and overloaded practice, seems almost insurmountable. Dr. Clement suggested enlisting the aid of nurse-midwives, and while I have never had any experience working with them, from reports I have read about them their services are most satisfactory. There are only a few states having laws licensing nurse-midwives. Most southern states, however, license midwives. It would seem feasible to train obstetrically oriented nurses from our own delivery suites to be licensed as midwives. In addition to attending uncomplicated deliveries, they could help con-
September J. Obstet.
1, 1970 Gynec.
duct the antenatal, postnatal, and family planning clinics. Another source of help to be investigated would be the medical schools. Junior and senior students interested in obstetrics could be sent to approved communities for practical courses under the supervision of the local obstetricians. The Medical College of Georgia has promised us two students for the spring of 1970, and we shall do all we can to make their time with us worthwhile, with the hope of making the arrangement permanent. Dr. Clement and his colleagues have made an enviable record in the reduction of the birth rate in Pitt County, North Carolina. In Clarke County, Georgia, our birth rate is 23.4, as compared to 19.1 for the State of Georgia. Our birth rate is still over twice the national death rate of 9.4 per thousand, and thus the birth rate should be further reduced to maintain a stable population. At our present rate of growth, Georgia’s population will double in the next 33 years. Georgia’s population density now is one person for every ten acres, and when the population doubles, there will be one person for every 5 acres. If we consider Georgia as an ecologic unit, after density becomes greater than one person per 5 acres, the standard of living of the citizens will decline. In 1965 in Clarke County, Georgia, we assigned a high priority to a family planning clinic. The clinic now has 1,087 registered patients and meets 4 mornings per week. We are fortunate in having a director of public health who is vitally interested in this clinic and does much of the actual work himself. In the past 5 years we have had a decrease in our birth rate from 26.3 to 23.4. Our registered obstetric clinic patients have dropped from 357 in 1964 to 209 in 1969. Over the past 5 years our percentage of patients attending postpartum clinics has increased from 58 per cent (in 1964) to 84 per cent (in 1969). Since 1965 we have diagnosed 193 cases of gonorrhea1 salpingitis in our family planning clinic. Most of these patients were wearing the IUCD and came in complaining of pain from the device. We do not remove the device but treat the patient with penicillin. One bonus we have received from our clinic is the discovery of 13 cases of cervical cancer. Only 2 of these have been invasive. (In view of the recent discussion in Congress concerning oral contraceptives as a cause of cervical cancer, only
Voiume
108
Number
1
2 of these patients had ever had exposure to birth control pills.) We obtain Papanicolaou smears on all of our patients and encourage them to return once a year for repeat smears. The State of Georgia pays a local pathologist a token fee of $1.50 for each smear he reads. The state also furnishes all of our contraceptive materials without charge, and I wonder if this could be a factor in our high rate of postpartum visits. Georgia has a voluntary sterilization law similar to the one in North Carolina. In the past 4 years in our clinic we have performed only 16 postpartum tubal ligations. DR. G. C. MCDANIEL, Fort Lauderdale, Florida. Broward Medical Center in Fort Lauderdale, Florida, is a general hospital of 666 beds. In 1959, 52 tubal ligations were performed, 2.6 per cent of deliveries, or one tubal ligation for every 40 deliveries. Two of these tubal ligations were performed vaginally. During the years of 1967, 1968, and 1969 there were a total of 9,504 deliveries (55 per cent of these were private patients). A total of 1,437 tubal ligations (60 per cent of these were private patients) were performed during these years. For these three years this represents a tubal ligation percentage of 15.7 or aproximately one tubal ligation for every 7 deliveries. Vaginal :ubal ligation in these 3 years numbered: 1967 15: 1968 34; 1969 60. The highest percentage of tubal ligation reported in the literature was 18 per cent from Puerto Rico. A 1966 questionnaire among 133 United States hospitals revealed some hospitals with rates of 8 or 9 per cent. In 1967, review of California insurance reports showed that 5.4 per cent of women that were delivered of infants had postpartum sterilizations. The entire reproductive cycle of the female is moving ahead at a rate which many of us may not yet recognize. Sexual maturity in the female is said to
Maternal
health
program
67
be advancing as much as 6 months every two decades, and so it goes with initiation of sexual activity, the age of marriage, the age at birth of the first child, and the age at which family size is completed. The third and fourth child of our private patients-the so called middle class-constitute the bulk of the explosive population growth in the United States. We should greatly liberalize our criteria for voluntary sterilization in terms of parity and age. The conscientious and honest obstetrician in consultation with his patient is a far better judge of whether sterilization is reasonable than any hospital or national committee. Recently, we have been seing a “new syndrome” consisting of a family unit with three or four children. The wife, who may be 28 to 34 years of age, is not currently pregnant. A variety of contraceptive methods have been tried in the past with frequently the use of contrar~eptive tablets for 4 to 6 years. The tablets have been associated with moderate side effects, and considerable apprehension on the part of the patient concerning future use. Vaginal tubal ligation is our answer to this “syndrome.” It invcblves a relatively minor operation in comparison with vaginal hysterectomy and repair and is much more readily accepted by the patient. Whian contrasted with the alternative of ten or more years of contraception by constant use of hormonal agents or mechanical devices, vaginal tubal ligation offers a satisfactory solution to thii “syndrome.” We have had no deaths or tubal ligation failures after either postpartum or vaginal tubal ligation in our private practice that now f,xttmds over a period of 15 years. Tubal ligation requires clear explanation to the patient, but we have found it a wl’y satisfactory answer to many contraceptive prdtlems.