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Nineteen-year survey of maternal mortality at the Cook County Hospital
Y (3F 1~ATE~~A~ .MOBTALITH CBUMTY MOSPITAL~Z
NINETEEN-YEAR 3.
(Pwm
E.
:~‘ITZ:~EMAI,D,
the Depnrtwcjlt md
&r.n.,
.\SI)
~~T,?GCSTd
of Obstetrics, Cook County Gynecology, Xorthwestern
\TTEBSTER,
Hospital, University
&r.n.,
&ICAGO,
IJ,L.
ctrtd the Department Medical School)
of Obsiel,~~ics
HIS report, concerns the maternal mortality in the obstetrical wards of the Cook Coa~ty Hospital for the past nineteen years. These wards OCCUPY a peculiar position in the large free hospitals of the United States. TO them is sent every pregnant woman regardless of what pathologic condition is present. Thus, we are responsible for pregnant women with gunshot wounds of the abdomen, gastrointestinal carcinoma, acute leukemia, brain t,umor; and many other conditions entirely unrelated to pregnancy. All patients in this series whose deaths were due to pregnancy per se have been so designat.ed by the Subcommittee on Naternal Morta.lity of the City of Chicago. Everyone knows the story of maternal mortality in the United States for the past twenty-five years. No one is quite able to explain completely the marked For this reason, we thought a review of decrease in death due to pregnancy. our fatalities over a period of years might be of interest. During the period studied we had 104,123 live births in the hospital. dpproximately one-fifth of the mothers had prenatal care in the hospital clinic. Three-fifths had prenatal care by outside agencies without hospital facilities or were referred by private doctors. One-fifth had no prenatal care. Fig. 1 gives a general picture of all deaths which occurred in the wards for the nineteen-year period. Total number of deaths is indicated by the figures on the left, total number of live births by the figures on the rjght. The top line of the.graph shows the total number of ward deaths. This Includes a number of patients who were not pregnant, but were sent to the wards with diagnoses of pregnancy with associated pathology. The next line shows the yearly number of deaths in pregnant women. The third line shows the mortality in patients whose deaths were due to pregnancy. The last line shows the maternal deaths due to pregnancy less those due to abortion. This last line, we believe, requires some explanation. We have no idea that deaths from abortion are not obstetrieal deaths. Nevertheless, we believe that our admission rate for abortions is far above that of the average hospital. This is particularly true when one remembers that most abort,ing patients enter the Cook County Hospital bleeding The patients mhom we dangerously or infected to the point of incapacitation. serve seldom seek hospitalization without more than sufficient reason. If we stady the causes of mortality in more detail, we find the following facts : Infection (Fig. 2) .Infection always has been one of the three leading causes of materIla1 mar. tality, and until recently accounted for more deaths than any other single cause. and
LPieseilted (:yaecologists,
at
tl:e Twentieth Memphis, Tan.,
Annual Oct.
Meeting
30 to Nov.
of the Central 1, 1952.
Association
of
Obstetricians
Volumr Kumber
65 3
MATERNAL
MORTALITY
AT
COOK
COUNTY
HOSPITAL
In the last twenty years marked decrease of maternal death due to sepsis been noted all over the nation, in fact, all over the world. Blood banks blood readily available and in quantity have been invaluable. Our bank started in March, 1937. We had some sulfanilamide, beginning in 1938, penjcillin was available to the wards in 1945 in limited amounts. ~9x5 34 35 36
37 38 39
40 41
42 43
44 45 46
48 49
539
has with was and
50 51
70 65
10000
60
9000
55
8500 8000 7500 7000
40 2 .P 35 s a 3o 25
6500
20 15 10 5
Fig.
22 20Ft;‘~,Sep!si!3 I
1.
I
I - 10.000 I I II
1
16
10 6,000
a 6
'5,000
40
42 Fig.
46
Q
2.
Nevertheless, we believe that there is an X factor which may be as important as blood banks or sulfonamides or antibiotics in the decreased mortality due to sepsis. Fulminating, fatal postpartum peritonitis following completely
530
FITZGERALD
AN-D WEB8TER
normal delivery after easy normal labors was an all-too-frequent occurrence in our wards twenty-five years ago. It is so rare now that very few residents see a single case during their training period. This is not because the disease is controlled by modern methods. The diseasedoes not occur. Severe puerperal mastitis, breast abscesses,and drainage thereof have likewise disappeared. Twenty-five years ago, with a relatively small service, a dozen or more draining abscesseswere routine on our wards. Now, they are almost completely nonexistent. This is not due to decrease in breast feeding, because all of our patients breast feed if possible, and the majority of them are able to do so. Nor is it because they do not return to the hospital if breasts become infected, because the patients have nowhere else to go.
2000 1900
1600 1700
1600 15cO 1400 1300
Fig. 3. During the period of this report, ward and operating room techniques have changed but little. Better prenatal care may be partly responsible, but there is still an undetermined factor which has a great deal to do with the absence of puerperal sepsis. This situation exists outside the obstetrical field. Archibald Hoynel reports that in Chicago the incidence of scarlet fever at Municipal Contagious Hospital dropped from 4,705 in the two years of 1939 and 1940 (about normal for the time) to 451 for the two years of 1947 and 1948. For the sameyears, erysipelas2 at the Cook County Hospital, which accepts all of the cases, dropped from 343 to 96. Hoyne insists that neither immunization nor sulfonamides had any influence on the incidence of these diseases. He believes that the decline in such infections is attributable to increased resistance by the patient, diminished virulence of the streptococci, and advances in sanitation. Perhaps this X factor explains the safety of the extraperitoneal cesarean section, or the fact that in our wards we do ordinary transperitoneal sections
Volume Number
65 3
MATERNAL
MORTALITY
AT
COOK
COUNTY
HOSPITAL
531
on patients in such condition that twenty years ago the operation would have been considered foolhardy, if not criminal. At any rate, mortality from puerperal sepsis is rapidly reaching the vanishing point in our wards. Practically every death from sepsis we have had in recen.t years occurred in patients who came to the hospital with such advanced lesions that treatment was useless. They were not patients delivered in the wards. Abortions (Fig. 3) .IDeaths from abortion result mostly from hemorrhage and sepsis. Although the sharp decline in deaths due to abortion began about 1937, the most dramatic changes happened about 1945-1946 when, in spite of a sharp rise in admissions, the tlotal number of deaths decreased markedly and the decrease persists.
9,000
18
16 8,000 14
“,““”
6
6 5.000 4
Fig.
4.
Active treatment of abo,rtion has been liberalized in the past few years3 because of need for beds due to increased patient load. For many years we did not curette patients until they had been temperature free for five days, unless hemorrhage threatened life. Lately we have been curetting every patient We a0 with incomplete abortion except in the presence of active infection. not believe that this change in procedure has any bearing on the lowered mortality. 19;emorrhage (Fig. 4) .-Next to sepsis, hemorrhage, including ectopie pregnancy, accounted for the lalrgest. number of deaths in our series. Fig. 4 shows the deaths from hemorrhage. There were 49 deaths, including 19 cases of abruptio placentae, 11 cases of ruptured uterus, 7 of postpartum hemorrhage, and 5 of placenta previa. Of this group of 49 patients, 29 were admitted to the ward in severe shock due to excessive hemorrhage. If the term is not acceptable, the fact remains that 60 per cent of the deaths occurred in patients who were in marked jeopardy Twenty-four, approximately 50 per cent, lived when they entered the hospital. less than eight hours after they entered the hospital. Twenty-seven died before the blood bank was established.
Ectopic Breynarq (Fig. 5) .-Eight hundred three ectopic pregnancies vwx operaLed upon from the During the same period a large numwards during the nineteen-year period. ber were operated upon from the general surgery and from the gynecology 10,000
9,000
8,000
7,000
6,000
5,000
4.m 1934
36
30
40
42 Fig.
44
46
40
50
52
3.500
5. 10.000
22 20
9,000
10 16
0,000 14 $7. i0 '6,000
a b-
5,000 42r-l-
4,000 1954
36
3b
42
44
Fig.
6.
4’6
S’e
56
.zclno 52-‘---
departments. These are not included in this report. The gross mortality was 1.73 per cent-one out of twenty, which is much too high, of coxlrse. Our series resulted in 38 deaths. Twenty-eight of these patients lived less than twelve
Volume Number
65 3
MATERNAL
MORTALITY
AT
COOK
COUNTY
HOSPITAL
533
hours; after hospitalization and of these, 11 died in 6 hours or less. This, we believe, is indicative of the condition in which patients are admitted to the wards. Death from ectopic pregnancy can be prevented only by: earlzj hospitalization, enrly diagnosis, .ea.rly blood replacement, e&r& operation. Patients admitted with irreversible changes due to hemorrhage will be little helped by blood replacement, or control of hemorrhage. Toxemia (Fig. 6) .Deaths from toxemia diminish as prenatal care increases. Nevertheless, toxemia accounts for a high percentage of maternal deaths. In our series there were 415 patients with eclampsia. Fifty-three of these died. The gross mortality, therefore, is 13 per cent. It is evident that deaths from eclampsia can be prevented only by preventing eclampsia itself. In our 53 fatal cases, 29 patients had no prenatal care, 7 had completely inadequate care and were referred to the hospital at the time of their first visit to the clinic, and 3 refused hospitalization.
1934
36
38
40
42 Fig.
44
46
48
50
52
7.
Twenty-eight of the 53, more than half, had convulsions before admission to the hospital. Fourteen died within twelve hours after hospitalization. Included in the series there were 17 deaths from hypertensive disease not due t,o toxemia. These are only questionably maternal deaths. Ten of these women were pregnant six months or less and of these 4 not more than three months. Only 2 of the 17 had any prenatal care. Organic Heart Disease.-Gross organic heart lesions were present in 33 of all the patients who died. Twenty had no prenatal care. In only 22 of these cases was pregnancy considered the factor responsible for death. Of the 22 patients whose deaths were due to pregnancy, 9 had full-term deliveries, 5 delivered prematurely, 4 died undelivered (5 to 7 months), 3 died after hysterotomy, and 1 died 4 weeks post partum.
FITZGERALD
534
aND WEBSTER
Other OiSsCetirdc Games.-There were 44 deaths in the series as a result which are listed as follows: 1’9 Pyelonephritis
of other
obstetric
causes
13 Anesthesia
5 Hyperemesis gravidarum 4 Chorionepithelioms 3 Transfusion
reaction
1 Acute yellow atrophy I Pituitrin
reaction
Causes (Fig. 7) .Nonobstetric causesaccounted for 97 of 590 deaths : Nonobstetric
25 Pneumonia 20 Tuberculosis 11 Organic heart disease in which pregnancywas not a factor
8 Malignancy 3 Sickle-cell
anemia
5 Rupturedappendix 20 Miscellaneous
The nonobstetric group does not show the steady decrease in mortalit> noted in other groups, and this is easiIy understandable. The great gain has been made in deaths due to pneumonia. Practically aZZof the deaths from pneumonia occurred before either sulfonamides or antibiotics were available, and only one death from pneumonia occurred in the last seven years.
Review of the Deaths of the Past Two Years A short review of the ward deaths for the past two years will give a fairpicture of the problems to be met. In 1950, 8.,394 live babies were delivered. There were 14 adult deaths. Of these, 2 patrents were not pregnant. The causesof death in the 12 pregnant women were : 1. 3. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Adenocarcinoma of the pancreas with metastases. Acute mono&c leukemia. Thrombosis of cerebellar artery. Ruptured appendix. Hypertensive heart disease with hemorrhage into the fourtth ventricle (patient in the hospital 4 hours and 10 minutes). Advanced tuberculosis with eclampsia (patient in the hospital 30 minutes). Sepsis after criminal abortion (patient in the hospital 2% days). Advanced puerperal sepsis. (Patient sent in 10 days after delivery, moribund. Admission temperature 105.4” F.) Unattended delivery with infanticide. Lower nephron nephrosis following 3,500 e.e. transfusion for treatment of postpartum hemorrhage in abruptio placentae. Ruptured uterus. Massive pulmonary embolus in a patient who had been operated upon for ectopic pregnancy. Intra-abdominal hemorrhage in a patient with undiagnosed ectopie pregnancy. This was a definitely preventable death.
In 1951 there were 10,121 live births. The causesof death included : 1. Diabetes with brain 2. Miliary tuberculosis. 3. Status asthmaticus.
atrophy.
There were fifteen adult deaths.
Valume Number
65 3
MATERNAL
MORTALITY
AT
COOK
COUNTY
HOSPITAL
535
4. 5. 6. 7. 8. 9. lo. 11. .12.
Frontal lobe abscess at G months’ gestation. Tuberculous meningitis. Sepsis following criminal abortion. Miliary tuberculosis with sickle-cell anemia. Cerebral hemorrhage in :a patient with chronic hypertension at 24 weeks’ gestation. Rheumatic heart disease (patient 30 weeks pregnant, not in labor). Postpartum suicide. Massive pontine hemorrh.age in an eclamptic patient. Ruptured ectopic pregna.ncy in a patient who died 20 minutes after reaching the ward. 13. Ruptured ectopic pregnancy three hours postoperatively. 114. Pulmonary embolus following repeat cesarean section. 15. Severe pre-eclampsia (death 24 hours after cesarean section; uric acid 25.2 mg. per cent).
No comment is made on these cases. They are detailed in order to show the l,arge percentage of patients who arrive in the wards too late for helpful treat:ment.
Summary Il. Maternal deaths following delivery of 104,123 live babies in nineteen years at the Cook County Hospital are reviewed. 2. In spite of inadequate facilities and limited nursing personnel, the maternal mortality has dropped from 150 per 10,000 live births in 1934 to 7.9 in 19151(Fig. 8). 160 150 140 130 120 110 100
90 80 70 60 50 40 30 20 10 0
1934
36
Death
30
40
Rates
42
44
46
per 10.000 Live Fig.
40
50
Births
8.
:3. Reasons for the increased safety of motherhood are discussed. These include the sulfonamides, blood banks, the antibiotics, better prenatal care, incre.ased awareness on the part of both physician and patient as to the necessity of prompt investigation of abnormal signs and symptoms.
1. The greatest hope for further lowering of maternal mortality lies II: the complete elimination of deaths due to tosemia. Proper prenatal care, ~111s convincing physicians that mortality from toxemia is practically zero if conwlsions are prevented, could accomplish this. TV~ wish to express our appreciation of the valuable assistance of Miss Sidonia. Spiaka. B.S.,
M.T.,
in the preparation
of this
article.
References 1. Hoyne, Archibald 2. Hoyne, Archibald 0. Webster, Augusta:
L.: Texas State E., Wolf, A. Alvin, AM.
J.
OBST.
J. Med. 45: 474, 1949. and Prim, Leona: J. A. M. A. 113: & GYP;EC.
62:
1327,
2279,
1939.
1951.
Discussion DR. LEO J. HARTNETT, St. Louis, MO.-A study of this type represents consider:ll+ The conclusions are sauntl from every effort and application on the part of the essayists. standpoint, and while we are inclined to view the improvement in maternal death rate in this country at large much as a pleasant change in the weather, analysis brings out the tremendous effort in the accumulation and application of knowledge which was necessary. The authors have not mentioned that a great part in this improvement has been played by those teachers who have thoroughly trained their pupils during the past 19 years. I can take issue only with the last statment in their conclusions. It is interesting to note that the authors have metltioned that out of 104,000 deliveries there were only 13 deaths from anesthesia, and the authors have informed me privately that 3 have occurred during the past five years. In the light of this information I am presenting Table I, analyzing the number of deaths in five of the better institutions in St. Louis during the pasl five years. This shows the number of births, the number of maternal deaths, and the cause, a.s was determined by the record analysis and person.al information. You will see that anesthesia was responsible for 40 per cent of the deaths. Table II shows the cause of death as recorded in the hospital files, tha,t should have been listed as anesthetic deaths. This brings to my mind a question: If 73 per cent of the anesthetie deaths are hidden in such a manner in our hospital files, why would it not likely he the case elsewhere? It must be understood that, in my opinion, this is not a deliberate attempt by anyone to mislead, hut, rather, it is a weakness in record-filing systems. TABLE I. INFOX~IATION FROX ST. LOUIS MATERNITY HOSPITAL, ST. LOUIS CITY HOSPITAL, AND ST. Lot-IS COUKTY HOSPITAL
--
ST. MAXY?S HOSPITAL Gwur, DURIXG LAST FIVE Ymu,s
Total number of deliveries (no abortions Or ectopic pregnancies) Sumber of maternal deaths Number of anesthetic deaths Number listed as anesthetic deaths Number listed as somet,hing else “TWO due to crossed feed lines. TABLE
1. 2. 3. 4. 5. 6. 7. 8.
II.
Xow
EIGHT
ANESTZETIC
49,054 25 11 *;
DE~TKS
Bronchopneumonia, aspiration Aspiration of foreign hod?(under Congestion, edema, and atelectasis Vasomotor collapse Drug idiosyncrasy, procaine Edema of larynx, due to poisoning Pulmonary edema, congestive heart Pulmonarv edema due to aspiration
\VRRIZ
(0.05%) (44%) ;p,’ I
FIISD
gas~oxpgen-ether)
(anesthetic) failure
We have antibiotics to combat and prevent sepsis, blood banks and better trained medical talent to combat hemorrhage and shock, prenatal care to combat the toxemias, but there is no protection against the improper application of anesthesia in the delivery room.
Volulne 6i Number
3
The exception, delivery room Cook
County
AMATERNAL
MORTALITY
of course, is in those is under the supervision Hospital
has such
AT
COOK
hospitals where of competent
competent
COUNTY
HOSPITAL
537
the administration of anesthesia anesthetists. I presume, therefore,
in
the that
ones.
It has been my experience that obstetrical anesthesia has been avoided by the trained anesthetist, and tolerated, for the most part, by the obstetrician. It may be that the obstetrician has been trained somewhat in this field, and he feels confident that he can direct the administration under ordinary circumstances. The patient scheduled for the operating room is carefully prepared for anesthesia and the administration is exacting under the supervision of trained personnel. The obstetrical patient for the most part reaches the delivery table ill prepared for anesthesia, and with little thought as to its proper choice or administration. Such circumstances should require even more expert supervision than in the case of the operating room patient, and certainly should not be entrusted to the unskilled medical student, intern, or nurse. What can be done to improve this troublesome situation9 This can be done only when Then, and only then, can we know how anesthetic deaths are assigned to the proper causes. big the problem really is. We should have a better training program for the patient, wherein she can be taught to face parturition with less fear and apprehension in order that the benefits of local anesthesia and analgesia can be enhanced. Then if she remembers something There will, of course. always about her delivery she will not think she has been mistreated. The department head must insist that the be a certain percentage of unstable people. hospital administrator procure the necessary personnel trained in anesthesia. Many of the administrators apparently refuse to recognize the existence of this problem, in the hope that if they ignore it long enough it will go away. 1-t is apparent that training programs for obstetrical anesthesia for the most part are lagging. It is likewise obvious that a career as an obstetrical anesthetist or anesthesiologist is not highly desirable, and therefore hospital administrators must realize that there must be some compensation for this. As the maternal death is likely to become the major measures to overcome it.
rate from one, unless
other causes is reduced, the problem we can recognize it as a problem and
HR. C. R. MAYS, Shreveport, La.-We at Shreveport Charity Hospital, a general those Iof Cook County Hospital. 28,915
The period admissions
of study was from 1941 and 27,746 live births.
have hospital to
recently caring
1951,
reviewed our for patients
inclusive,
during
of anesthesia take effective
maternal similar which
in
time
mortality type to we
had
For the purpose of e0mparin.g our changing death rates and the distribut.ion of causes In period one (1941.1945) there were 9,164 of death, we divided our study into two periods. live births and 36 deaths, giving the death rate of 39 per 10,000 live births. In period two (1946.1951) there were 18,600 live births and 27 deaths, giving a gross death rate of 14 per 101,000 live births. When these deaths were corrected to exclude abortions, ectopic prega miscellaneous group of medical diseases including two nancies under 20 weeks’ gestation, burns, one sickle-cell anemia crisis, one adenoma carcinoma of the colon, one nephrosclerosis, two cases of myelogenous leukemia and one case of typhoid fever, the corrected mortality was 28 per 10,000 live births for period one and 11 per 10,000 live births for period two. The over-all picture of the distribution of causes of death in the two periods was one of increasing relative importance of hemorrhage and coincidental medical complications as a cause of death in period two, along with a nearly stationary position of toxemia of pregnancy There was a sharp drop in the frequency of deaths from sepsis in period as a lethal factor. two. Forty-four per cent of the deaths from sepsis occurred among 4,185 patients admitted Among the last 21,328 admissions since 1944 we would have had only one in 1941 and 1942. genital-tract death from sepsis had we not experieneed a foreign body accident at a hysterectomy for ruptured uterus.
538
PITZGER&D
AND
WEBSTER
kn. J.
Obsr.
L Gy;ynrc.
March, 1953
It is of interest that the patients who died from hemorrhages in period one received an average af 1,520 C.C. of blood, while for those who died from hemorrhage in period two, the average volume of blood and plasma transfused before death was 4,376 cc. Four of 13 deaths from hemorrhage in period two were from sequelae of shock in the form of lower nephron nephrosis, bilateral cortical necrosis, and pituitary necrosis. In the second period of our analysis there has been a percentagewise rate of decrease of 62 per cent in over-al1 mortality, 57 per cent decrease in corrected mortality, a 34 per cent decrease in mortality from hemorrhage, an 89 per cent decrease in mortality from postpartum sepsis, a 63 per cent decrease in mortality from toxemia of pregnancy, and a 67 per cent decrease in mortality from accidents of pregnancy. We delivered these patients, in period one, with a staff of one visiting man, one resident in training, and two interns. In period two we have had an adequate resident and visiting staff. These women were delivered from only forty-five beds. Next year we will move into a new physical facility with the romantic and very sectional title of “Confederate Memorial Hospital. ’’ The organization of a good resident training program has yielded us a very gratifying, though not yet satisfying, maternal mortality rate. DR. RUDOLPH W. HOLMES, Charlottesville, Virginia.-1 have had an abiding interest in the work of the County Hospital since I was a member of the medical staff all of forty years and more ago. The County Hospital has held a unique position in the medical world ever since its origin nearly one hundred years ago, and that is peculiarly true of the obstetric service. “The County” was about the first hospital in Chicago to have a provision for confinements. To be comparable, figures must be reduced to a common denominator; every endeavor to contrast the activities and mortality rates of diverse hospitals is surely going to give invidious answers unless the background of the various units is fully appreciated. Chicago almost from its origin was a cosmopolitan city; especially in its early years its population increments resulted from immigrations of peoples of the world. They brought with them their national tongues, their customs, their traditions, their habits of isolationism, so the city seemed to be sectioned off into alien communities; in their obstetric habits they quite commonly were all unified in that they employed midwives to the extent of fetishism. In the dawn of this century about 60 per cent of all confinements were in the hands of these women, largely untrained, ignorant, and inspired by vicious superstitions. (In a recent census report there were only 128 deliveries conducted by midwives.) The rnidzoife peril became an acute agony in the late eighteen nineties; the hospitals had not awakened to the necessity of providing an obstetric service within their walls. To be sure, a certain few hospitals did provide a few beds for obstetrics but the facilities were so inadequate, so crude, that their value was negligible. It was essentiahy true that the County Hospital was the only institution which provided an isolated division for infected patients, a ward with some twenty or more beds, usually fully occupied. Parenthetically, a deputy coroner, and a deputy coroner ‘s physician had definite quarters within the hospital, holding inquests on patients who died from violence (accidents, murders, suicides, criminal abortions, etc.). The conditions of the times being what they were, The County had to receive the great mass of mismanaged, neglected, and abused patients afllicted with lethal complications for which midwives were responsible. If the quoted puerperal mortality rate were 2 per cent, it was not startlingly high considering the character of the flotsam brought to the hospital doors; rather, the fact that 98 per cent of the clientele recovered was an accolade to the staff. In late years the County Hospital has developed a highly efficient materna1 welfare service which a large proportion of prospective inmates accept gratefully; nevertheless, a goodly Proportion of the patients neglect to avail themselves of the service. I would stress the fact that the County must accept all comers; the County continues to receive mismanaged, neglected patients, seriously compromised. Neither the type of patients, nor the high incidence rates of complications are comparable to those of many maternity services where the class of patients is selected so that their patients rarely die. With these facts before you, YOU will appreciate that the data accumulated by Drs. Fitzgerald and Webster reveal efficient and successful maternity service.
NINETEEN-YEAR 3.
(Pwm
E.
:~‘ITZ:~EMAI,D,
the Depnrtwcjlt md
&r.n.,
.\SI)
~~T,?GCSTd
of Obstetrics, Cook County Gynecology, Xorthwestern
\TTEBSTER,
Hospital, University
&r.n.,
&ICAGO,
IJ,L.
ctrtd the Department Medical School)
of Obsiel,~~ics
HIS report, concerns the maternal mortality in the obstetrical wards of the Cook Coa~ty Hospital for the past nineteen years. These wards OCCUPY a peculiar position in the large free hospitals of the United States. TO them is sent every pregnant woman regardless of what pathologic condition is present. Thus, we are responsible for pregnant women with gunshot wounds of the abdomen, gastrointestinal carcinoma, acute leukemia, brain t,umor; and many other conditions entirely unrelated to pregnancy. All patients in this series whose deaths were due to pregnancy per se have been so designat.ed by the Subcommittee on Naternal Morta.lity of the City of Chicago. Everyone knows the story of maternal mortality in the United States for the past twenty-five years. No one is quite able to explain completely the marked For this reason, we thought a review of decrease in death due to pregnancy. our fatalities over a period of years might be of interest. During the period studied we had 104,123 live births in the hospital. dpproximately one-fifth of the mothers had prenatal care in the hospital clinic. Three-fifths had prenatal care by outside agencies without hospital facilities or were referred by private doctors. One-fifth had no prenatal care. Fig. 1 gives a general picture of all deaths which occurred in the wards for the nineteen-year period. Total number of deaths is indicated by the figures on the left, total number of live births by the figures on the rjght. The top line of the.graph shows the total number of ward deaths. This Includes a number of patients who were not pregnant, but were sent to the wards with diagnoses of pregnancy with associated pathology. The next line shows the yearly number of deaths in pregnant women. The third line shows the mortality in patients whose deaths were due to pregnancy. The last line shows the maternal deaths due to pregnancy less those due to abortion. This last line, we believe, requires some explanation. We have no idea that deaths from abortion are not obstetrieal deaths. Nevertheless, we believe that our admission rate for abortions is far above that of the average hospital. This is particularly true when one remembers that most abort,ing patients enter the Cook County Hospital bleeding The patients mhom we dangerously or infected to the point of incapacitation. serve seldom seek hospitalization without more than sufficient reason. If we stady the causes of mortality in more detail, we find the following facts : Infection (Fig. 2) .Infection always has been one of the three leading causes of materIla1 mar. tality, and until recently accounted for more deaths than any other single cause. and
LPieseilted (:yaecologists,
at
tl:e Twentieth Memphis, Tan.,
Annual Oct.
Meeting
30 to Nov.
of the Central 1, 1952.
Association
of
Obstetricians
Volumr Kumber
65 3
MATERNAL
MORTALITY
AT
COOK
COUNTY
HOSPITAL
In the last twenty years marked decrease of maternal death due to sepsis been noted all over the nation, in fact, all over the world. Blood banks blood readily available and in quantity have been invaluable. Our bank started in March, 1937. We had some sulfanilamide, beginning in 1938, penjcillin was available to the wards in 1945 in limited amounts. ~9x5 34 35 36
37 38 39
40 41
42 43
44 45 46
48 49
539
has with was and
50 51
70 65
10000
60
9000
55
8500 8000 7500 7000
40 2 .P 35 s a 3o 25
6500
20 15 10 5
Fig.
22 20Ft;‘~,Sep!si!3 I
1.
I
I - 10.000 I I II
1
16
10 6,000
a 6
'5,000
40
42 Fig.
46
Q
2.
Nevertheless, we believe that there is an X factor which may be as important as blood banks or sulfonamides or antibiotics in the decreased mortality due to sepsis. Fulminating, fatal postpartum peritonitis following completely
530
FITZGERALD
AN-D WEB8TER
normal delivery after easy normal labors was an all-too-frequent occurrence in our wards twenty-five years ago. It is so rare now that very few residents see a single case during their training period. This is not because the disease is controlled by modern methods. The diseasedoes not occur. Severe puerperal mastitis, breast abscesses,and drainage thereof have likewise disappeared. Twenty-five years ago, with a relatively small service, a dozen or more draining abscesseswere routine on our wards. Now, they are almost completely nonexistent. This is not due to decrease in breast feeding, because all of our patients breast feed if possible, and the majority of them are able to do so. Nor is it because they do not return to the hospital if breasts become infected, because the patients have nowhere else to go.
2000 1900
1600 1700
1600 15cO 1400 1300
Fig. 3. During the period of this report, ward and operating room techniques have changed but little. Better prenatal care may be partly responsible, but there is still an undetermined factor which has a great deal to do with the absence of puerperal sepsis. This situation exists outside the obstetrical field. Archibald Hoynel reports that in Chicago the incidence of scarlet fever at Municipal Contagious Hospital dropped from 4,705 in the two years of 1939 and 1940 (about normal for the time) to 451 for the two years of 1947 and 1948. For the sameyears, erysipelas2 at the Cook County Hospital, which accepts all of the cases, dropped from 343 to 96. Hoyne insists that neither immunization nor sulfonamides had any influence on the incidence of these diseases. He believes that the decline in such infections is attributable to increased resistance by the patient, diminished virulence of the streptococci, and advances in sanitation. Perhaps this X factor explains the safety of the extraperitoneal cesarean section, or the fact that in our wards we do ordinary transperitoneal sections
Volume Number
65 3
MATERNAL
MORTALITY
AT
COOK
COUNTY
HOSPITAL
531
on patients in such condition that twenty years ago the operation would have been considered foolhardy, if not criminal. At any rate, mortality from puerperal sepsis is rapidly reaching the vanishing point in our wards. Practically every death from sepsis we have had in recen.t years occurred in patients who came to the hospital with such advanced lesions that treatment was useless. They were not patients delivered in the wards. Abortions (Fig. 3) .IDeaths from abortion result mostly from hemorrhage and sepsis. Although the sharp decline in deaths due to abortion began about 1937, the most dramatic changes happened about 1945-1946 when, in spite of a sharp rise in admissions, the tlotal number of deaths decreased markedly and the decrease persists.
9,000
18
16 8,000 14
“,““”
6
6 5.000 4
Fig.
4.
Active treatment of abo,rtion has been liberalized in the past few years3 because of need for beds due to increased patient load. For many years we did not curette patients until they had been temperature free for five days, unless hemorrhage threatened life. Lately we have been curetting every patient We a0 with incomplete abortion except in the presence of active infection. not believe that this change in procedure has any bearing on the lowered mortality. 19;emorrhage (Fig. 4) .-Next to sepsis, hemorrhage, including ectopie pregnancy, accounted for the lalrgest. number of deaths in our series. Fig. 4 shows the deaths from hemorrhage. There were 49 deaths, including 19 cases of abruptio placentae, 11 cases of ruptured uterus, 7 of postpartum hemorrhage, and 5 of placenta previa. Of this group of 49 patients, 29 were admitted to the ward in severe shock due to excessive hemorrhage. If the term is not acceptable, the fact remains that 60 per cent of the deaths occurred in patients who were in marked jeopardy Twenty-four, approximately 50 per cent, lived when they entered the hospital. less than eight hours after they entered the hospital. Twenty-seven died before the blood bank was established.
Ectopic Breynarq (Fig. 5) .-Eight hundred three ectopic pregnancies vwx operaLed upon from the During the same period a large numwards during the nineteen-year period. ber were operated upon from the general surgery and from the gynecology 10,000
9,000
8,000
7,000
6,000
5,000
4.m 1934
36
30
40
42 Fig.
44
46
40
50
52
3.500
5. 10.000
22 20
9,000
10 16
0,000 14 $7. i0 '6,000
a b-
5,000 42r-l-
4,000 1954
36
3b
42
44
Fig.
6.
4’6
S’e
56
.zclno 52-‘---
departments. These are not included in this report. The gross mortality was 1.73 per cent-one out of twenty, which is much too high, of coxlrse. Our series resulted in 38 deaths. Twenty-eight of these patients lived less than twelve
Volume Number
65 3
MATERNAL
MORTALITY
AT
COOK
COUNTY
HOSPITAL
533
hours; after hospitalization and of these, 11 died in 6 hours or less. This, we believe, is indicative of the condition in which patients are admitted to the wards. Death from ectopic pregnancy can be prevented only by: earlzj hospitalization, enrly diagnosis, .ea.rly blood replacement, e&r& operation. Patients admitted with irreversible changes due to hemorrhage will be little helped by blood replacement, or control of hemorrhage. Toxemia (Fig. 6) .Deaths from toxemia diminish as prenatal care increases. Nevertheless, toxemia accounts for a high percentage of maternal deaths. In our series there were 415 patients with eclampsia. Fifty-three of these died. The gross mortality, therefore, is 13 per cent. It is evident that deaths from eclampsia can be prevented only by preventing eclampsia itself. In our 53 fatal cases, 29 patients had no prenatal care, 7 had completely inadequate care and were referred to the hospital at the time of their first visit to the clinic, and 3 refused hospitalization.
1934
36
38
40
42 Fig.
44
46
48
50
52
7.
Twenty-eight of the 53, more than half, had convulsions before admission to the hospital. Fourteen died within twelve hours after hospitalization. Included in the series there were 17 deaths from hypertensive disease not due t,o toxemia. These are only questionably maternal deaths. Ten of these women were pregnant six months or less and of these 4 not more than three months. Only 2 of the 17 had any prenatal care. Organic Heart Disease.-Gross organic heart lesions were present in 33 of all the patients who died. Twenty had no prenatal care. In only 22 of these cases was pregnancy considered the factor responsible for death. Of the 22 patients whose deaths were due to pregnancy, 9 had full-term deliveries, 5 delivered prematurely, 4 died undelivered (5 to 7 months), 3 died after hysterotomy, and 1 died 4 weeks post partum.
FITZGERALD
534
aND WEBSTER
Other OiSsCetirdc Games.-There were 44 deaths in the series as a result which are listed as follows: 1’9 Pyelonephritis
of other
obstetric
causes
13 Anesthesia
5 Hyperemesis gravidarum 4 Chorionepithelioms 3 Transfusion
reaction
1 Acute yellow atrophy I Pituitrin
reaction
Causes (Fig. 7) .Nonobstetric causesaccounted for 97 of 590 deaths : Nonobstetric
25 Pneumonia 20 Tuberculosis 11 Organic heart disease in which pregnancywas not a factor
8 Malignancy 3 Sickle-cell
anemia
5 Rupturedappendix 20 Miscellaneous
The nonobstetric group does not show the steady decrease in mortalit> noted in other groups, and this is easiIy understandable. The great gain has been made in deaths due to pneumonia. Practically aZZof the deaths from pneumonia occurred before either sulfonamides or antibiotics were available, and only one death from pneumonia occurred in the last seven years.
Review of the Deaths of the Past Two Years A short review of the ward deaths for the past two years will give a fairpicture of the problems to be met. In 1950, 8.,394 live babies were delivered. There were 14 adult deaths. Of these, 2 patrents were not pregnant. The causesof death in the 12 pregnant women were : 1. 3. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Adenocarcinoma of the pancreas with metastases. Acute mono&c leukemia. Thrombosis of cerebellar artery. Ruptured appendix. Hypertensive heart disease with hemorrhage into the fourtth ventricle (patient in the hospital 4 hours and 10 minutes). Advanced tuberculosis with eclampsia (patient in the hospital 30 minutes). Sepsis after criminal abortion (patient in the hospital 2% days). Advanced puerperal sepsis. (Patient sent in 10 days after delivery, moribund. Admission temperature 105.4” F.) Unattended delivery with infanticide. Lower nephron nephrosis following 3,500 e.e. transfusion for treatment of postpartum hemorrhage in abruptio placentae. Ruptured uterus. Massive pulmonary embolus in a patient who had been operated upon for ectopic pregnancy. Intra-abdominal hemorrhage in a patient with undiagnosed ectopie pregnancy. This was a definitely preventable death.
In 1951 there were 10,121 live births. The causesof death included : 1. Diabetes with brain 2. Miliary tuberculosis. 3. Status asthmaticus.
atrophy.
There were fifteen adult deaths.
Valume Number
65 3
MATERNAL
MORTALITY
AT
COOK
COUNTY
HOSPITAL
535
4. 5. 6. 7. 8. 9. lo. 11. .12.
Frontal lobe abscess at G months’ gestation. Tuberculous meningitis. Sepsis following criminal abortion. Miliary tuberculosis with sickle-cell anemia. Cerebral hemorrhage in :a patient with chronic hypertension at 24 weeks’ gestation. Rheumatic heart disease (patient 30 weeks pregnant, not in labor). Postpartum suicide. Massive pontine hemorrh.age in an eclamptic patient. Ruptured ectopic pregna.ncy in a patient who died 20 minutes after reaching the ward. 13. Ruptured ectopic pregnancy three hours postoperatively. 114. Pulmonary embolus following repeat cesarean section. 15. Severe pre-eclampsia (death 24 hours after cesarean section; uric acid 25.2 mg. per cent).
No comment is made on these cases. They are detailed in order to show the l,arge percentage of patients who arrive in the wards too late for helpful treat:ment.
Summary Il. Maternal deaths following delivery of 104,123 live babies in nineteen years at the Cook County Hospital are reviewed. 2. In spite of inadequate facilities and limited nursing personnel, the maternal mortality has dropped from 150 per 10,000 live births in 1934 to 7.9 in 19151(Fig. 8). 160 150 140 130 120 110 100
90 80 70 60 50 40 30 20 10 0
1934
36
Death
30
40
Rates
42
44
46
per 10.000 Live Fig.
40
50
Births
8.
:3. Reasons for the increased safety of motherhood are discussed. These include the sulfonamides, blood banks, the antibiotics, better prenatal care, incre.ased awareness on the part of both physician and patient as to the necessity of prompt investigation of abnormal signs and symptoms.
1. The greatest hope for further lowering of maternal mortality lies II: the complete elimination of deaths due to tosemia. Proper prenatal care, ~111s convincing physicians that mortality from toxemia is practically zero if conwlsions are prevented, could accomplish this. TV~ wish to express our appreciation of the valuable assistance of Miss Sidonia. Spiaka. B.S.,
M.T.,
in the preparation
of this
article.
References 1. Hoyne, Archibald 2. Hoyne, Archibald 0. Webster, Augusta:
L.: Texas State E., Wolf, A. Alvin, AM.
J.
OBST.
J. Med. 45: 474, 1949. and Prim, Leona: J. A. M. A. 113: & GYP;EC.
62:
1327,
2279,
1939.
1951.
Discussion DR. LEO J. HARTNETT, St. Louis, MO.-A study of this type represents consider:ll+ The conclusions are sauntl from every effort and application on the part of the essayists. standpoint, and while we are inclined to view the improvement in maternal death rate in this country at large much as a pleasant change in the weather, analysis brings out the tremendous effort in the accumulation and application of knowledge which was necessary. The authors have not mentioned that a great part in this improvement has been played by those teachers who have thoroughly trained their pupils during the past 19 years. I can take issue only with the last statment in their conclusions. It is interesting to note that the authors have metltioned that out of 104,000 deliveries there were only 13 deaths from anesthesia, and the authors have informed me privately that 3 have occurred during the past five years. In the light of this information I am presenting Table I, analyzing the number of deaths in five of the better institutions in St. Louis during the pasl five years. This shows the number of births, the number of maternal deaths, and the cause, a.s was determined by the record analysis and person.al information. You will see that anesthesia was responsible for 40 per cent of the deaths. Table II shows the cause of death as recorded in the hospital files, tha,t should have been listed as anesthetic deaths. This brings to my mind a question: If 73 per cent of the anesthetie deaths are hidden in such a manner in our hospital files, why would it not likely he the case elsewhere? It must be understood that, in my opinion, this is not a deliberate attempt by anyone to mislead, hut, rather, it is a weakness in record-filing systems. TABLE I. INFOX~IATION FROX ST. LOUIS MATERNITY HOSPITAL, ST. LOUIS CITY HOSPITAL, AND ST. Lot-IS COUKTY HOSPITAL
--
ST. MAXY?S HOSPITAL Gwur, DURIXG LAST FIVE Ymu,s
Total number of deliveries (no abortions Or ectopic pregnancies) Sumber of maternal deaths Number of anesthetic deaths Number listed as anesthetic deaths Number listed as somet,hing else “TWO due to crossed feed lines. TABLE
1. 2. 3. 4. 5. 6. 7. 8.
II.
Xow
EIGHT
ANESTZETIC
49,054 25 11 *;
DE~TKS
Bronchopneumonia, aspiration Aspiration of foreign hod?(under Congestion, edema, and atelectasis Vasomotor collapse Drug idiosyncrasy, procaine Edema of larynx, due to poisoning Pulmonary edema, congestive heart Pulmonarv edema due to aspiration
\VRRIZ
(0.05%) (44%) ;p,’ I
FIISD
gas~oxpgen-ether)
(anesthetic) failure
We have antibiotics to combat and prevent sepsis, blood banks and better trained medical talent to combat hemorrhage and shock, prenatal care to combat the toxemias, but there is no protection against the improper application of anesthesia in the delivery room.
Volulne 6i Number
3
The exception, delivery room Cook
County
AMATERNAL
MORTALITY
of course, is in those is under the supervision Hospital
has such
AT
COOK
hospitals where of competent
competent
COUNTY
HOSPITAL
537
the administration of anesthesia anesthetists. I presume, therefore,
in
the that
ones.
It has been my experience that obstetrical anesthesia has been avoided by the trained anesthetist, and tolerated, for the most part, by the obstetrician. It may be that the obstetrician has been trained somewhat in this field, and he feels confident that he can direct the administration under ordinary circumstances. The patient scheduled for the operating room is carefully prepared for anesthesia and the administration is exacting under the supervision of trained personnel. The obstetrical patient for the most part reaches the delivery table ill prepared for anesthesia, and with little thought as to its proper choice or administration. Such circumstances should require even more expert supervision than in the case of the operating room patient, and certainly should not be entrusted to the unskilled medical student, intern, or nurse. What can be done to improve this troublesome situation9 This can be done only when Then, and only then, can we know how anesthetic deaths are assigned to the proper causes. big the problem really is. We should have a better training program for the patient, wherein she can be taught to face parturition with less fear and apprehension in order that the benefits of local anesthesia and analgesia can be enhanced. Then if she remembers something There will, of course. always about her delivery she will not think she has been mistreated. The department head must insist that the be a certain percentage of unstable people. hospital administrator procure the necessary personnel trained in anesthesia. Many of the administrators apparently refuse to recognize the existence of this problem, in the hope that if they ignore it long enough it will go away. 1-t is apparent that training programs for obstetrical anesthesia for the most part are lagging. It is likewise obvious that a career as an obstetrical anesthetist or anesthesiologist is not highly desirable, and therefore hospital administrators must realize that there must be some compensation for this. As the maternal death is likely to become the major measures to overcome it.
rate from one, unless
other causes is reduced, the problem we can recognize it as a problem and
HR. C. R. MAYS, Shreveport, La.-We at Shreveport Charity Hospital, a general those Iof Cook County Hospital. 28,915
The period admissions
of study was from 1941 and 27,746 live births.
have hospital to
recently caring
1951,
reviewed our for patients
inclusive,
during
of anesthesia take effective
maternal similar which
in
time
mortality type to we
had
For the purpose of e0mparin.g our changing death rates and the distribut.ion of causes In period one (1941.1945) there were 9,164 of death, we divided our study into two periods. live births and 36 deaths, giving the death rate of 39 per 10,000 live births. In period two (1946.1951) there were 18,600 live births and 27 deaths, giving a gross death rate of 14 per 101,000 live births. When these deaths were corrected to exclude abortions, ectopic prega miscellaneous group of medical diseases including two nancies under 20 weeks’ gestation, burns, one sickle-cell anemia crisis, one adenoma carcinoma of the colon, one nephrosclerosis, two cases of myelogenous leukemia and one case of typhoid fever, the corrected mortality was 28 per 10,000 live births for period one and 11 per 10,000 live births for period two. The over-all picture of the distribution of causes of death in the two periods was one of increasing relative importance of hemorrhage and coincidental medical complications as a cause of death in period two, along with a nearly stationary position of toxemia of pregnancy There was a sharp drop in the frequency of deaths from sepsis in period as a lethal factor. two. Forty-four per cent of the deaths from sepsis occurred among 4,185 patients admitted Among the last 21,328 admissions since 1944 we would have had only one in 1941 and 1942. genital-tract death from sepsis had we not experieneed a foreign body accident at a hysterectomy for ruptured uterus.
538
PITZGER&D
AND
WEBSTER
kn. J.
Obsr.
L Gy;ynrc.
March, 1953
It is of interest that the patients who died from hemorrhages in period one received an average af 1,520 C.C. of blood, while for those who died from hemorrhage in period two, the average volume of blood and plasma transfused before death was 4,376 cc. Four of 13 deaths from hemorrhage in period two were from sequelae of shock in the form of lower nephron nephrosis, bilateral cortical necrosis, and pituitary necrosis. In the second period of our analysis there has been a percentagewise rate of decrease of 62 per cent in over-al1 mortality, 57 per cent decrease in corrected mortality, a 34 per cent decrease in mortality from hemorrhage, an 89 per cent decrease in mortality from postpartum sepsis, a 63 per cent decrease in mortality from toxemia of pregnancy, and a 67 per cent decrease in mortality from accidents of pregnancy. We delivered these patients, in period one, with a staff of one visiting man, one resident in training, and two interns. In period two we have had an adequate resident and visiting staff. These women were delivered from only forty-five beds. Next year we will move into a new physical facility with the romantic and very sectional title of “Confederate Memorial Hospital. ’’ The organization of a good resident training program has yielded us a very gratifying, though not yet satisfying, maternal mortality rate. DR. RUDOLPH W. HOLMES, Charlottesville, Virginia.-1 have had an abiding interest in the work of the County Hospital since I was a member of the medical staff all of forty years and more ago. The County Hospital has held a unique position in the medical world ever since its origin nearly one hundred years ago, and that is peculiarly true of the obstetric service. “The County” was about the first hospital in Chicago to have a provision for confinements. To be comparable, figures must be reduced to a common denominator; every endeavor to contrast the activities and mortality rates of diverse hospitals is surely going to give invidious answers unless the background of the various units is fully appreciated. Chicago almost from its origin was a cosmopolitan city; especially in its early years its population increments resulted from immigrations of peoples of the world. They brought with them their national tongues, their customs, their traditions, their habits of isolationism, so the city seemed to be sectioned off into alien communities; in their obstetric habits they quite commonly were all unified in that they employed midwives to the extent of fetishism. In the dawn of this century about 60 per cent of all confinements were in the hands of these women, largely untrained, ignorant, and inspired by vicious superstitions. (In a recent census report there were only 128 deliveries conducted by midwives.) The rnidzoife peril became an acute agony in the late eighteen nineties; the hospitals had not awakened to the necessity of providing an obstetric service within their walls. To be sure, a certain few hospitals did provide a few beds for obstetrics but the facilities were so inadequate, so crude, that their value was negligible. It was essentiahy true that the County Hospital was the only institution which provided an isolated division for infected patients, a ward with some twenty or more beds, usually fully occupied. Parenthetically, a deputy coroner, and a deputy coroner ‘s physician had definite quarters within the hospital, holding inquests on patients who died from violence (accidents, murders, suicides, criminal abortions, etc.). The conditions of the times being what they were, The County had to receive the great mass of mismanaged, neglected, and abused patients afllicted with lethal complications for which midwives were responsible. If the quoted puerperal mortality rate were 2 per cent, it was not startlingly high considering the character of the flotsam brought to the hospital doors; rather, the fact that 98 per cent of the clientele recovered was an accolade to the staff. In late years the County Hospital has developed a highly efficient materna1 welfare service which a large proportion of prospective inmates accept gratefully; nevertheless, a goodly Proportion of the patients neglect to avail themselves of the service. I would stress the fact that the County must accept all comers; the County continues to receive mismanaged, neglected patients, seriously compromised. Neither the type of patients, nor the high incidence rates of complications are comparable to those of many maternity services where the class of patients is selected so that their patients rarely die. With these facts before you, YOU will appreciate that the data accumulated by Drs. Fitzgerald and Webster reveal efficient and successful maternity service.