A Review of 1,000 Maternal Deaths in a Rural State*

A REVIEW OF 1,000 MATERNAL DEATHS IN A RURAL STATE* RoBERT A. Ross, M.D., CHAPEL HILL, N. C. (From the Department of Obstetrics and Gyuecology, University of North Carolina School of Medicine)

A

MARKED reduction in morbidity and mortality is seldom spontaneous and is seldom due to a single factor or circumstance. Such phenomena occur when there is a combination of sociologically conscious populace, friendly and devout legislators, financial aid, and, if fortunate, improved remedial aids. Maternal mortality rates in North Carolina have shown a steady decline: 71.1 per 10,000 live births 1932-36 33.0 per 10,000 live births 1941-45 11.8 per 10,000 live births 1949 1951-Figures indicate further decrease in total maternal deaths with relative increase in nonobstetric causes.

North Carolina has been anxious for improved facilities for over a half century but the greatest impetus came in 1925 with the establishment of the Duke Endowment. This assured financial aid for indigent patients, help in hospital construction, and the beginning of an independent four-year medical ;.;chool and teaching hospital. The enactment of the Hill-Burton Bill by Congress was the next enabling factor. This is clearly demonstrated by the fact that 60 per cent of the hospitals built with Hill-Burton funds are in rural areas, and North Carolina is the largest rural state in the Union. Another pertinent fact is that these hospitals must provide for both white and nonwhite sick; and this in a state that has the second largest Negro birth rate and fourth largest Indian population. In 1924 there were 2,186 hospital beds in the State, in 1947 there were 9,635, and at present there are 13,700. In 1945 a statewide "Good Health" program was authorized by the Legislature and supported by the State Medical Society and a large group of interested laymen. At that time the State was forty-fifth in doctor-population ratio, forty-second in hospital bed population percentage, and forty-first in n1aternal mortality.

and the hospitals and health centers have increased 71 and 35 per cent, respectively. All of these new units have accommodations for maternity patients and the maternal mortality position has improved to thirty-fifth in the list of states. HOSPITALS AND CENTERS

1924 1947 1952

71 115 248

BEDS

BLOOD BANKS

2,186 9,636 13,700

0 9 52

•Presented at the Seventy-sixth Annual Meeting of the American flyne0ological Society. Lake Placid, N.Y., June 15 to 17, 1953. II 1:'.

Am. j. O!H & {;y~l{'< November. 1tJ ~ ~

111-l:

The present :\laternal Mortality Collunittee wa~ established in HJ46. It ltas no legal authority nnd has no paid '· ,,·orkers." Its dnty is to analyze dna t ], t'f'Cords, assem hlf' a II possihl<' in formation, and attempt to re<·OJtl11H'Ild possihh• remedial measures. 11 recognized thf' valnabl0 eontribution such 1-('l'OUps .lwd made in rechwing maternal mortality in other areas. The <·l·itcria it 'let wen' more stringent than those in use hy the Federal agencies; herwc onr figures a r·e higher. It was felt that the greatest goo<1 could come from rigid rnles. This has prnalizcd the doctors, hut has given sc.rupnlons information. I11eidentally, tit<' SJJeeialists in tlte crnters have heen gin'ti more minnie inspection and TtiOJ'(' pointed letters than the general physicians workiug umler less favorable cit·cumsiances. J\Iauzy' has g-iven an analysis of this (·ommittee 's report on the firs1 1,000 (leaths that were reviewed. TAHJ.E

J.

::\L\TE!t:-.!AJ, lVIORTALI'l'Y IN NoRTH CAK
],000

Hemorrhage Embolism Infection Cardiac disea~e Anesthesia Other obstetrie Non obstetric Insufficient informatiou

MATERNAL DEATHS

:l5H

~5.!)

'i± 73

7.4 7.3 6.4 2.5 lO.:l 11.2 2.6 100.0

fi4

25 }()::

112

26 1,000

-- ·-·-. - -

-·--~-----

---

The plan as outlined by the committee is: The Bureau of Vital Statistics will look up a birth certificate which was filed six months or less befor(~ the death of the mother. Because of the alertness and efficiency of this Bureau, the committee's figures on North Carolina's maternal mortality are somewhat higher than those compiled by the Federal Government. A standard questionnaire is mailed to the physician signing the death or birth certificate (or both) iu every case of a. maternal death. ucca.:s.iona.lly no reply is received from the physician, and the questionnaire must be sent to the public health officer, a near-by member of the committee, or the lo<'al medical society. Generally speaking, this questionnaire supplies all the information necessary for the analysis of a case. Occasionally it is necessary to send questionnaires to various consultants. The question of preyentahility is often discussed. 'rhe committee has followed this rule: As a part of the analysis of every case,. the committee decides whether or not they feel that the death was preventable. It should be emphasized that this decision is made on the basis of the ''ideal'' situation. In other words, a maternal death is considered preventable if it "probably" could have been avoided by the application of ideal standards of medical care. In those cases which are eonsidered preventable, the responsible factor in preventability is sought. One such factor is assigned to each case-physician, patient and/or family, midwife, or facilities. If the responsible factor lies with the physician,

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it is further subdivided into the four factors of diagnosis, judgment, technique, and management. In caseR where multiple factors were involved, the committee selecte
l'UYSICIAN

Hemorrhage Toxemia Infection Anesthesia Embolism Cardiac Other obstetric causes Total

184 of 259 127 of 264 34 of 73 25 of 25 25 of 74 19 of 64 51 of 103 465 of 862

Sometimes there is confusion and correspondence with doctors regarding ''terms.'' The committee has this definition of terms: A maternal death is defined as any death, regardless of cause, occurring during pregnancy, or within six months after the termination of pregnancy. This includes any death due to homicide, suicide, accident, or disease not even remotely connected with pregnancy. All maternal deaths are divided into "obstetric" and "nonobstetric" deaths. A "nonobstetric" death is one in which the major cause of death is in no way related to the pregnancy. A death is considered "obstetric" if the major cause of death falls into any one of the following three general groups: 1. Direct obstetric complications, such as abortion, ectopic pregnancy, hyperemesis, postpartum hemorrhage, toxemia, pulmonary embolism, and anesthesia. 2. Diseases which are aggravated by the physiologic changes in the demands of pregnancy, such as renal or hepatic disease, tuberculosis, and pneumonia. :3. Diseases which lead to obstetric complications or necessitate obstetric intervention, for example, acute peritonitis following appendicitis leading to abortion or premature labor. OTHER OBSTETRIC DEATHS

Tuberculosis Acute yellow atrophy Peumonia Puerperal accident Shock due to exhaustion Appendicitis Intestinal obstruction Peritonitis Transfusion reaction Pyelonephritis Amniotic embolism Poisoning due to abortifacient Diabetes Chorionepithelioma Sagittal sinus thrombosis Influenza Ruptured hemorrhoidal varix Drug sensitivity Pyelophlebitis Total

26 14 9 8 7 7 6 4 3 3 3 3 3 2 1 1 1 1 1 103

Each of these deaths was scrupulously analyzed and "''e believe corrertl.'· classified. Donnelly 2 has studied these figures from many approaches and a tragic fact has been the associated fetal wastage. One of the biologic functions of the mar-

t\m . .f. Obst. & Gynec. Novemher, 195'

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1116

ried women is that of reproduction, yet this analysis reveals 844 obstetri<· deaths and associated with this maternal loss is a fetal salvage of m1ly ..J-9 1~<'1' <'t'llt not. including neonatal deaths. 'l'hus the loss is romponndcd. ----~-···------.

TABLE -----

II.

_L__ ~'B'l'AI'__I-()_SS 1

CAUSE OF DEAT_H_________

Toxemia Hemorrhage Embolism Infection Cardiac Anesthesia Other obstetric causes Total

882 PA'l'IEN'l'S -------------------·---- --·- ·---------- · - - - - - - - - - - - - FETAL SALVAGE FETAL SALVAGE PERCENTAGE

FE'l'AL NA!.VAGE,

-----~·---·------------·

] "'' 142 53 172 87 33 37 47 60 71 2 3 25 39 61 15 60 10 50 53 51 477_-----------;3c-;;8c;;5--- ---:4·9 ----------------------

There were 259 deaths from hemorrhage. The usual background of placenta previa, abruptio placentae, ruptured uterus, interference, and abortion follows orthodox figures but analysis of 33 deaths from ectopic pregnancy is revealing. Twenty-three patients were not operated upon and only one patient had any type of accessory examination for diagnosis and this was a curettage. Only 81 patients in this hemorrhage group had any blood at all. This omission is better understood when it is shown that all but 9 of the 52 blood banks in this state were started after 1947; yet the first blood bank in America was established at Salisbury, N. C. The 264 deaths (26.4 per cent) from the toxemias and renal diseases simply confirm what has been written over the years regarding this miserable preventable complication which is rampant in this area. Equally significant, the toxemias were thought to be a contributing factor in 93 cases in which the primary cause of death was listed in some other category. The 73 deaths from ''puerperal infection'' also reflect the influence of poverty, malnutrition, anemia, and the inability of the "medically inarticulate" to avail themselves of even obvious and ready aid. '!'hey also point to the increasing abortion rate in the nonwhite. During the years 1946 through 1950 there were 532,310 live births. The midwife delivered 2.7 per cent of white and 35.9 per cent of nonwhite mothers in North Carolina. Though we know of the large numbers of mothers cared for by these people, there is a certainty that we have not helped them and used them in a thoroughly intelligent manner. They are sensitive. They have unbounded confidence in their own ability and any criticism or suggestion of criticism is likely to lead to sullenness, anonymity, or even chicanery. Our best approach is through the County Health Department. Millen 3 has made this observation: It has been my experience that when there is an inferior method working in the same area where a superior method exists, the inferior one is much worse than the method in some areas where there is no better method. In other words, I think that the midwifery Kosmak speaks about for the remote parts of our country where there are no doctors is one thing, but midwifery in counties where there are good doctors usually means that both the midwife and the people who use them are really having the shrouds pulled in over their heads because it is only the worse kind of midwife who would tend to play second

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J!ddle. I was rather struck, when I was abroad this summer visiting in some hospitals, by finding that the gynecological aspect of English medicine is remarkably good but the delivery by a midwife was below what we would accept here. TABLE III.

MORTALITY RATES AND PLACE OF DELIVERY IN REPRESENTATJVE STATES FOR 1949 (MAUZY~-1949)

STATE North Carolma Mississippi Distric.t of Columbia Illinois Pennsvlvania New "tork California

PER· CENTAGE NONWHITE 32.9 56.2 41.3 10.0 7.5 8.8 8.3

TOTAL DELIVERIES 35,555 37,318 8,190 18,917 16,861 26,504 20,414

MORTALITY (PER 10,000 LIVE BIRTHS) 21.7 30.8 8.5 12.1 16.0 20.8 13.7

DELIVERY (PERCENTAGE) M.D. AT HOME MIDWIFE HOSPITAL 35.0 30.0 35.0 21.0 62.0 17.0 3.0 97.0 0.0 21.0 1.0 78.0 91.0 9.0 0.0 96.0 3.0 1.0 9.0 3.0 1.0

I

I

Mauzy 1 collected data from diverse geographic areas in the United States on nonwhite maternal deaths. The totals were sufficient to be statistically sound and the division into home, hospital, physician, and midwife deliveries gives interesting and helpful information. In North Carolina during the year's study there were 35,555 nonwhite deliveries, only 35 per cent of which UTA-ro in ' ' ..._,.._ V .L.L.I..

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state there were 26,504 such deliveries, 96 per cent of which were in hospitals and the mortality was 20.8 per cent. New England, the northwest, and west central areas are not included because of the very low nonwhite population, as is shown in the following tabulation. PERCENTAGE OF NONWHITE POPULATION IN THE UNITED STATES AND EACH GEOGRAPHIC DIVISION, 1950 (Population enumerated as of April 1) UNITED STATES 11.0 New England 2.0 Middle Atlantic 7.0 East North Central 6.5 West North Central 3.5 South Atlantic 24.0 East South Central 23.0 West South Central 16.5 Mountain 5.0 Pacific 6.0

If one transposed the United States maternity mortality statistics to this tabulation it would become immediately evident that the highest maternal mortality is in the highest nonwhite areas. Is this a simple coincidence~ Do pellagra and toxemia simply parallel each othed Do the placenta, the pituitary, and the ovary in the female in New England differ from that of the female in Alabama 7 Temperature, weather, rain fall, humidity, and other regional and seasonal variables have been duly recorded without conclusive evidence. Are vitamins an exogenous hormone? If not, can the bodily economy maintain an adequate hormone level without penalizing the female llvmg on a ··G-oldberg diet'' "I We have seen and recorded the paradox of maternal mortality, especially the toxemia deaths, in relation to the economic fluctuations. In the "lean years" when cotton and tobacco are not profitable

1118

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& Gy11c•. Novemher, )0~ ~

the rural dwellers and '·share croppers'' do have a vegetable gar,ien, <'0\\·. and chickens. 'rhey are on "relif'f" and aJ'I:' eating more wist>ly. The dPa1b rate is lowl:'r. In the "years of vleuty" all hours and interest are devoted 1o the "cash crop." 'l'he county store o1· commissary substitutes for thP ganle1; and salt pork ("fat back"), molasses, and corn meal are the stomach-satisfying articles of diet and the energy-producing factors. Rancid fat is not cnusidered a vitamin-negating substance, nor soft sweet carbonated drinks a n·markable substitute for citrus drinks. The triad of "ill huuse
Inrligent-l'ri'l:ate Patient Rat-io.'roxemia Hemorrhage Infection 3: 1 P1·ivate 'Paticnt-Ind(qent Ratio.-Emholism 48:26 Anesthesia 15:10

We were interested in the major cause of death in the so-called '' indigent" and "private" groups. Some of the data are of such small totals that. statistically, they are nonconclusive. Toxemias, hemorrhage, and infection do stand out in the indigent group. Heart disease, to a lesser degree, comes in this category. The relative number of deaths from embolism and anesthesia is small but the majority do fall in the private group. It is difficult to disassociate embolism from infection and it is extremely difficult definitely to certify this cause of death. However, we did find a relative proved increase in the ''private'' group. 'l'he anesthesia deaths were carefully scrutinized. At present our State group of anesthetists is undertaking a survey of all anPsthesia deaths in detailed fashion. Kine of the patients had surgical doses of spinal anesthesia and the uniform remark was that the obstetrician had to give the spinal anesthesia because an anesthetist was not availahle. None had ehloroform. Since the detailed analysis, including I.B.lVI. punch card recording, of the first 1,000 deaths was completed in 1950-1951, the committee had an additional 400 charts which have been reviewed hut not finally classified. It is gratifying to note an indication that the matrrnal death-live birth ratio has further decreased and the nonobstetric causes are more evident. It is a soun·e of enormous satisfaction to know that the general physicians, hospitals, agencies, and specialists are cooperative and apparently feel no animosity toward a eommittee that has been motivated medically by altruistic objectivity. t'nder such circumstances the committee can label a death "physician responsibility"

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if there is a single factor that might have altered the patient's downward course after she was first seen by a physician. We now consider secondary highways, all-weather rural roads, improved farming methods, communications of all sorts of equal importance as Board certification and Federal grants. Most reports agree that once a patient reaches a hospital she will receive good treatment. We have missed the grandparents, but we do have the grandchild.

References Tr. Fifth Am. Congress on Obst. & Gynec. (Supp. vol. AM. J. OBST. & GYNEC.) 64A: 214, 1952. 2. Donnelly, J. F.: North Carolina M. J. 14: 127, 1953; personal communication, 1953. 3. Millen, R. S.: Personal communications, 1953. 1. Mauzy, C. H.:

Discussion DR. S. LEON ISRAEL, Philadelphia, Pa. (by invitation).-It is a privilege to open the discussion upon Dr. Ross's frank, illuminating analysis of 1,000 maternal deaths in a rural state. He has highlighted, quite boldly, the apparent fact that maternal mortality bears a direct relation to the socioeconomic. standards of a eommunity. His critical sifting emphasizes once again that the three horsemen who carry death to parturients-toxemia, hemorrhage, and infection-ride twice as frequently among the indigent. Happily, however, Dr. Ross's report also has a brighter side. North Carolina, keeping pace with its sister states, has harvested a sharp drop in maternal mortality during the last two decade~. PHILADELPHIA:

MATERNAL MORTALITY,

1920 - 1951

40 MATERNAL

DEATHS

30 -

PER

10,000

20 -

LIVE BIRTHS

10 -

1920

1950

Fig. 1.

'l'he factors responsible for the eountrywide betterment include improvement training of medical and nursing personnel, the ready availability of blood transfusion, anesthesiology, the use of antibiotics, better obstetric technique, clearer evaluation of the nutritional aspects of pregnancy, and the smooth functioning of local maternal mortality committees. The last mentioned ia deservedly credited in the North Carolina report. The provocative statement by Dr. Ross anent the shift of nonwhite population from rural to metropolitan areas stimulated me to compare the maternal mortality in North

ROSI-'

11~0

.\m.

J. Obst.

& Gyr1e1.

November. f9t; ~

l'arolina wnn rnat of Philadelphia, a mgn1y industrialized eity which also boasts ,,f "" tlfficient maternal mortality committee. lt iR most agrpeable to learn that Philadelphia·, t•xperience supports the contention of ]Jr. Ross that the northward shift of nonwhit<· population is counterbalanced by adequate hospital faciiities and a !Jeter dietary. A,, shown in Fig. l, the maternal mortality in Philadelphia has also declined sharply. It is of equal interest to study the most recently computed annual rate, that for the year 1951 . which is summarized in Table I. Quite apparent therein are two items of interest, namely. that the ratio of white to nonwhite births approximates that of North Carolina and tha 1 hospital deliveries are the rule. The similar percentage of nonwhite parturients makt'' it possible to contrast the maternal mortality of Philadelphia and that of North Carolina, The lower mortality in Philadelphia, in spite of the eomparaiJ]!, ~ts expressed in Table II. 30 per cent ratio of nonwhite deliveries, must he attributed to the high incidence of ho~­ pitalization, the excellence of which is owed-at least in part-to the forceful leadership of the maternal mortality committee during the past 30 years. 'l'his brings me, finally, to agree with the inescapble conclusion of Dr. Ross that l> .. tter roads, improved planting schedules, and more hospitals will lower further tl1p maternal mortality of any rural area. TABLE

I.

PH!LADF;LPHIA1

1951

38,917 ] 1,401 (30%) PLACE OF DELIVERY

NONWHJ1'~~

WHITE

5% 95%

Home Hospital TABLE

PLACE

North Carolina Philadelphia

II.

NONWHITE DELIVERIES, NORTH CAROLINA AND PHILADELPHIA PERCENTAGE NONWHITE

TOTAL DELIVERIES

PERCENTAGE HOSPITAl,

35.0 35,555 32.9 ___30.0 -~~-----1_1,401__ ~----·-9_5_.0_

I10,000

MORTALITY PER LIVE BIRTHS

21.7

8.0