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Perinatal mortality surveys in two small private hospitals in Cincinnati
Perinatal mortality
surveys in two
small private hosp itals in Cincinnati ARTHUR Cincinnuti,
G. KING.
M.D.
0hfo
are handicapped by the greatest value, absence of many of these elements. The staff is usually discouraged from undertaking such a project. Often there is marked apathy and sometimes downright hostility from influential but poorly oriented staff members. It is apparent that except for a few cases, no real study of perinatal mortality can be carried out without access to and careful review of the individual charts of the mothers and infants. In some hospitals permission to do this is obtained with and some doctors resent anyone difficulty, Icviewing their handling of a case. This can lx- overcome by an insistence on strict nnonymi t y when the case histories are studied by a committee. Only the chairman or secrrtary of the Perinatal Mortality Re\+w (:ommittc~c: should have access to the identifying data. Many administrators are Iukewarm, either because the record room personnel is bothered or because of a fear of possible malpractice suits if recorded data are re\,iewcd too carefully. On the other hand, a rcbvicw committee can protect both doctors and hospitals by insisting on the insertion of essential information, the omission of wlrich carries a suggestion of tic-gligencc. Finally. if the findings of the committee arc kept completely separate fr,om the clinical record after thr review, no critical animadversions can damage the lrospital or doc.lor. ‘I’ill recently anoth(:r grea.t difficulty has llcen the method of classifying the perinatal deaths bv causes. Many traditional but
T II E amazing decline in maternal mortality of the past 30 years has not been matched by the progress in fetal salvage, even though the same antibiotics, the same blood transfusions, the same laboratory facilities. and at least similar advances in knowledge and technique are as available to the infants as to their mothers. One reason may be that we are not applying these facilities and techniques on a large enough scale. The purpose of a perinatal mortality study is to find out in what conditions we are failing to USC our knowledge, and how best to act in order to reduce further the number of stillbirths and neonatal deaths. This discussion is limited to the practical aspects. the methods, and the difficulties of making such a study in a small private hospital and, hence? is pertinent to the problems facing every conscientious private practitioner of obstetrics. Difficulties
in collecting
data
Most reports of perinatal mortalitystudies come from the large teaching hospitals. where the entire staff is well trained, the staff discipline good, the charts complete, the house staff xkcpate and enthusiastic, the clerical help ample, and the funds for the study sufficient. The smaller hospitals, where these studies can hr of the From the Catherine the Jewish Hmpital
Booth Hospital of Cincinnati.
and
Presented at the Twenty-seventh Annuul Meetinp of the Central Association of Obstetr&i&s and Gynecologists, Chicogo, Illinois, Sept. 24-26, 1959.
876
Volume Number
79 5
Perinatal
imprecise diagnoses have been accepted by medical record rooms and boards of health, but they are valueless in arriving at a true cause of death. This has made impossible any sort of comparision of these basic causes in the published statistics. Again, the pathologists have not been very helpful by reporting “atelectasis” and “prematurity” as causes of death, which, of course, they are not, any more than “noncirculation of the blood” and “old age” are acceptable diagnoses. Finally, few of the doctors in the smaller hospitals will take the time or trouble to record on the chart itself, even though asked. clinical information, particularly of the antepartum period, often essential to assigning a cause of death or possible preventability. Procedures
adopted
in the
present
study
The study reported briefly here was begun by developing a classification of infant and fetal deaths which was simple, logical, clinical, and particularly easy for busy doctors to use. It has been modified in the last 5 years from time to time, but the form found most readily acceptable and satisfactory is shown in Fig. 2. In keeping with the principle of making it easy for the doctors to cooperate, a summary of essential information had to be obtained from them on a prepared form. It was felt that a form suitable for punch-card or I.B.M. machine use was too formidable to be practical. Although tabulation would be easier with such a form, it would be more time consuming for the individual doctor filling it out for each of his cases and might frighten him into ignoring all the questions. All the information requested from the doctor had to be on one page, preferably on the reverse of the sheet listing the cause of death. Fig 1 shows the form which, after many modifications, was found acceptable by the doctors and satisfactory to the committee. Even this simpIe form proved too much for some of the rugged individualists. The committee was able to get cooperation only after a hospital ruling was established that
mortality
surveys
877
any doctor failing to provide adequate information after a written request was required to attend the meetings of the review committee. This threat of “another meeting,” absence from which jeopardized the man’s obstetrical privileges, proved very helpful in having the forms filled out. On the other hand, many doctors with a interest in reducing genuine obstetrical wastage attended the meetings of the committee volunarily and with profit. Committee
analysis
of
data
There are three decisions which the Perinatal Mortality Study Committee has to make. The first is the most probable cause of death. As has been pointed out by others, this is very difficult and requires correlation of the antepartum history, the labor, the delivery, nursery records, the nurse’s notes, and the autopsy findings. Obviously, representatives of all these disciplines must be on the committee for proper correlation and interpretation. The second decision is whether the death was nonpreventable, possibly preventable, or definitely preventable. These three classifications were used, with “possibly preventable” being used in preference to “preventable” for several reasons: the committee did not wish to arrogate to itself a superior knowledge of either obstetrics or pediatrics; the pride of the individual doctor was not bruised, since many of them felt unhappy enough after losing a baby whose life might have been saved; and it was a further safeguard against legal complications. In this phase of committee work, there was a need for a firm philosophy and an uncompromising attitude. One of the more difficult problems in education was to explain to the staff the difference between “culpability” of the individual and “possible preventability” by world-wide professional improvement. For example, 20 years ago many congenital heart lesions resulted in death and at that time might justifiably have been listed as “nonpreventable.” Modern cardiac surgery has prevented many of the deaths. The same may be said for many other con-
878
King
PERINATAL The Attending Physician is requested to provide the following confidential information by filling in the appropriate spaces. Supply as much pertinent information as possible. SEE THE RE'7E3SESID3 Date of Delivery
Mother's age: as follow7
MORTALITY
STUDY City Hospital X&her's Unit 30. Child's Unit !io. Path Dept. No.
Stillbirth: macerated ( ) non-macerated < ) Neonatal Death: under 7 days of age ( ) over 7 days of’ ale ( ) Gestation: -Weight : -lbs.
_I_-
iqeeks since T,M.P. G.)
race Total number of previous pregnancies abort-under 20 weeks Stillbirths,20-28 weeks over 28 ueeks livebirths, 20-28 weeks over 28 weeks number of infants survivl=er 30 days of life
Total length of labor
hrS.
hours of delivery
Type an.l amount of premeditation
of ik?livery: Spontaneous( ),Low forceps( ),Midforceps( extration( ), Breech delivery( ), Aided breech delivery( frank breech to footling( ),Caesarian section ( ).
Condition of infant Comment:
ai Birth:
How soon after birth was infant How long did infant live?
Apgar rating
within
6
---_
~___-I
Anesthesia: None ( ), Local ( ), Spinal ( ), Caudal ( ), Intravenous If inhalation, kind and duration prior to delivery Type
oz. (
(
(
), Inhalation(
) -
),lrersion aIld ),Conversion of
) or Good ( ) Fair
(
seen by an attending pediatrician? Autopsy: yes ( ) noir7---
) Poor (
)
hrs.
Please give any significant details uf mother's past history, past pregnancies, present pregnancy and course of labor which might have had a bearing on this death, and abnormal findings in the placenta or amniotic fluid. Note any blood incompatibilities or abnormalities.
genital anomalies, such as tracheoesophageal fistulas and diaphragmatic hernias. In reviewing the cases, a death from congenital anomalies was listed as “possibly preventable” unless a prompt and competent consultation declared the situation hopeless. The third decision is the fixation of responsibility for the possibly preventable deaths. This is the most valuable part of the
study- as it points the way to makin,q changes which will save infant lives. 'The sim$o work sheet used by the committee had lines for ‘Causes of Death” (arrived at after study of all sources of information) ! “Comments,," and "Classification." The last was either “NP,” “PP,‘* or “P,” followed by a number which designated the responsible factors. These were: 1. Patient failure to
Volume 79 Number 5
Perinatal
For the sake applicable as amplification diseases, as
Death
Death
( (
) )
Standard Congenital anomaly (specify organ and type) Physiologic Inadequacy due to Prwturity Iiemolytic Disease (formerly Erytbroblastosis) Hypoprothrombinemia (formerly ksmorrh. Disease of Newborn) Birth Trauma (specify organ involved below, as “brain”) Anoxia, due to OPlacenta Previa ( ) tiemature Separation of the Placenta ( ) Fibrosis of the Placenta ( ) Infarction of the Placenta ( ) Strangulated Cord ( ) Cord Tight About Neck ( ) True Knot in Cord ( ) Cord Prolapse ( ) Prolo~lged or Tumultous Labor i j Mater& Circulatory CollapGe Respiratory Insufficiency, due to ( ) Maternal .Narcosis ( ) Hyaline Snd Formation ( ) Aspiration of Amniotic Fluid ( ) Bronchial dbstruction (substance developed within the body, such as mucus, vomitus, etc.) ( ) Aspiration bronchopneumonia (foreign substance from vithout the body: oil, milk, etc.) caused by conditions primary In tne mother ( ) Toxemia of Drewnw ( j Maternal Enbockne ksorder; specify below, such as diabetes, thyroid disease, etc. ( ) Maternal infections disease; specify below, such as rubella, mumps, syphilis, polio, etc. caused by disease acquired as an infant, not associated with the delivery process; specify below ( ) Acquired bronchopneumonia ( ) Other. Specify below Other causes of death. Specify below unknown
2. Form
for
indicating
judgment or technique. 3. Analgesia or anesthetic judgment or technique. 4. Pediatric care (delayed or inadequate). 5. Nursing judgment or technique. 6. Administrative deficiency (failure by the hospital to provide adequate nursing or resident coverage, supervision, equipment, or communication). 7. Inadequate community resources. Analgesia and anesthesia were linked together to pinpoint the field of error rather than the judgment of the individuals concerned. Because it is now recognized that or follow
advice.
surveys
879
of uniformity, please check one or Inore of the following diagnoses the cause of death in this case. Use the blank lines below for of the diagnoses, such as specific organs involved and specific well as for any conditions or causes of death not listed.
Fig.
seek
mortality
2. Obstetric
causes
of fetal
or neonatal
Nomenclature :011-076 (501-3991
< ; 1
(513-549
1
(93Y-050
1
(794-631 (794-900.5 (794-940
1 1 )
‘(;;;-:2 (799I638 (799-6L3 (799-631 (7x2-!% (MO-534
] 1 1 1 ) )
(010-370 (360~pro (362-438
1 1 )
(360-611.&
)
(361-496
1
(010-388
)
(010-382
)
(010-l..
)
1361-190 )1 (yoo-P
I
death.
a premature infant is placed in great jeopardy if the mother receives large amounts of narcotics, barbiturates, or inhalation anesthesia, the death of an infant, for example, born at 30 weeks’ gestation to a mother given more than minimal or any analgesia, was classed as “possibly preventable.” It was felt that many of the deaths of premature infants ascribed by the patholmight well have been ogist to “atelectasis” due to the impairment of the infant’s respiratory control as a result of the inju-
880
King
Table I. Comparison
of 1958 statistics from two contrasting hospitals (A.M.A. Prrinatal Mortality Period 1: A’0 of
fetrrsr~
Kate
Hospital A (private i .I)4 I 19.8/lWJl) Seneral hospital) Hospital B (13 bt=ci. no x-ray, laboratory. or facilities for cc’sarem 19.? ~100l1 section) 6”5* -. ‘Includin,~ all 1rmttwrs and idants transfemd dicious use of analgesia-producin,g the mother. Contrasted
results
in
two
agc,nts in
hospitals
To those who question thr value of these time-consuming studies, analysis of the data. dramatically shows where corrective action can be taken. Two hospitals were involved in this review. Hospital A had 3,640 infants born alive or dead in 1958: Hospital R had only 625. The latter is a small maternity hospital of 13 beds with no laboratory, no x-ray, and no facilities for c-csarean section. Almost all of the deliveries are by general practitioners or a I,esident. 7’11~ figurc:.r reported for Hospital B includr~ nzotfwrs und hahirs transferred to oth ho.spitals. Table I shows the data for 1958. It is based on the A.M.A. Prrinatal Mortality Period I, which excludes fetuses or infants weighing less than 1,000 grams or those dying after the schventh da); of life. There are two possible interpretations of these data. One is that a laboratory, x-ray department, facilities for cesarean section. and highly trained obstetricians are unnecessary for achieving a good perinatal mortality rate. The other interpretation is that therr arc differences in the operation of the two obstetrical departmenls which compensate for the great deficiencies existing in Hospital IS. Analysis of the two hospitals shows the latter to be the cas(‘. The patients in Hospital R were very definitely from a much lower economic grnup. Although about one third of them were under constant supervision in the attached Home for the last several months of gestation, many
Analgesia and ;inrslh&~ are kt*pt IO :i tninimum. ‘The\- iirt: rlsed in almost all GIWS. IrLfl in flows that fit11 far below [llr Ltvcragcb doses given in Hospital ,4. Prolongrd anesthesis with rther to “hold” the lvoman until the attendin,? ph\G:ian arri\-rs is absolutely forhiddcri. al’e rared fO1 [Iv 3 Finall?,, tilt ilifmtS c:arcfiillv sclrc tc*d l)anCl of Hoard-cjllalified ptdiatricians \tllo havc~ a Illo~.e-than-avel.aee intchrcst in the \vclfarc of th? little patients XI rhis particular llospital and who are willing to set’ at ai+’ time an)’ baby who need;; ptdiatric help. ‘l‘llty gratuitously make daily r01mds \vith ;I rcmarkabiv conscientious lllot~oll~llrlt~~?;.
Analysis
of
possibly
preventable
deaths
The possibly preventable deaths consti tulc the most interesting part of the survey. In Hospital A thy 3.640 ietustxs were delivered h!. 10 Board-qualitied obstetricians. :i \\-llo limited their practice to obstetrics. and II-i cren(*ral practitioncrk Of thf* 72 corrf~cttd zeaths. 28. or nearly 41) per cvnt, wta1.e considercsd possibly preventable. The distrihtitiorr is shown in Tablr IT. Refore any comparison can be made betwcrn the possibly preventable rates of the two hospitals ii. must hc rrmembered that there, were two different survey committees in\~olvt~d~ and tlic, designation of “possibly pwvtmtahle” is ;i matter of interpretation. Within Hospital .2 the ,gcneral practitioners had mow Imsil~l~. ~mwmtable deaths than thr Hoard-c~ualift:tI obstc~tricians, but thr qc~neral prac~itiorwrs at. Hospital H had
Volume Number
79 5
Perinatal
proportionately fewer possibly preventable deaths than even the Board-qualified obstetricians at Hospital A. Causes
of possibly
preventable
of factors deaths
deaths
in possibly
In Hospital A, studies of perinatal mortality had been done in 1948, 1954, and 1956, with use of, however, a different investigative technique. In 1948 the rate was 21.5, and among the deaths that were probably preventable were 3 from traumatic ga-
Table II. Relation
of obstetrical
training
to possibly
preventable
rate
Table III.
factors
Major
per
1,000
total
in possibly
cases
preventable
deaths
Limited practice
Boardqualified Number of operators Total cases Total mortality Possibly preventable Possibl; &-eventable
surveys
10 1,843 51 13 (7.0)
General practice
3 499 10 4
34 1,296 36 11 (8.5)
(8.0)
Ho.ypital B 625 19 4 (6.4)
deaths*
__Boardqualified No. possibly preventable Pediatric care Analgesia/anesthesia Obstetric judgment/technique *In
some
of the
deaths
(13) 6 5 2 there
were
multiple
factors.
881
vage. A prompt change in the rules in the nursery eliminated this cause of death for all subsequent years; little attention was paid to other recommendations which were made, however. In 1954 the rate was 21.0 and when the causes of the deaths were presented to the general staff, there was great indignation. However, changes were made in the staff organization and function which could eliminate or reduce some of these causes. These included a closer collaboration between the pediatricians and the obstetricians and a system of free obstetrical consultation for general practitioners. But such things as 3 out of 17 Rh-affected babies dying without the attending physician ever recording that the mother was Rh negative, or the pregnancy of a known diabetic mother being allowed to go to 42 weeks’ gestation with the infant weighing 11 pounds, required the slow process of education of the individual doctor for correction. In 1956 the rate went up to 21.7, and the analysis of deaths revealed that the individual doctors were neither taking advantage of the mechanisms available for raising the standards of obstetrical practice nor modifying to any extent their own philosophies and techniques. It was at this point, in 1957, that the current form of study of perinatal mortality was introduced. It met some opposition and a great deal of apathy.
On the other hand, the causes of death and responsibility assigned pointed the way to improvement of results in Hospital A, confirmed by the findings in Hospital B. Of the major factors assigned, the distribution is shown in Table III. The infants’ care in Hospital B, it will be remembered, was in the hands of a dedicated group of trained pediatricians, whereas in Hospital A many babies were cared for by the obstetricians or general practitioners. Again, the amount of anesthesia and analgesia used in Hospital B was far less than in Hospital A. As for errors in obstetrical judglnent, it must be remembered that the hospital had little control over the antepartum care given to the patients by many of the general practitioners. Correction preventable
mortality
Limited practice (4) 1 4 1
General practice (9) 8 9 3
Hospital B $1 0 4
882
King
However, the knowledge that each case was being studied individually by a committee which would determine tllr possible preventability of any death has led to a closer adherence to the hospital rules. The anesthetists have taken a greater interest in how much premeditation the Roman rccri\x:s. Less analgesia is being used, since the amount given has to be stated on the perinatal mortality forms; pediatricians are being called in much earlier than formerly, and their notes have become more voluminous and specific. The 19.58 rate of 19.8 represents some improvement, bttt the rate is no better than that of Hospital 13 despite the advantages in equipment and facilities. Perhaps the answer lies in staff discipline which can be stimulated I>); perinatal mortality studies. Summary
The difficulties in making a perinatal mortality survey in a small private hospital stem largely from the apathy of the medical staff, and the unnecessary fears of condemnation or exposure. Cooperation from doctors can be obtained if simple reporting forms are rrsed, such as those described, and judicious analyses are made and discussed by a devoted survey committee, supported by the hospital administration. Stillbirths and neonatal deaths of babies weighing over 1,000 grams are classified as nonpreventable, possibly preventable: and preventable, and, for the latter two groups, which number almost 40 per cent of the total, the responsible factors arc identified so that corrective action can be taken. Similar studies wore made in 1958 in two contrasted hosl)itals. One was an excellent pri\-ate general hospital with 3,640
births, with ‘in Ateeric staff of 10 Boardqualified obstetricans, 3 men ~vho limited their practice to obstetrics, and 33 general 1nactitioncrs. ‘l’hr other was a nonaccredited ! 3 bed maternity hospital with no labora10r)‘. no s-ray equipment, and no facilities for wsarcm section, in which 625 births tCJdi ~Jh’f2. ‘f’il(’ poorer hospital had thl, sli
‘I‘he purpose of a perinatal mortality sur\ev in any hospital is to determine the number and causes of possibly preventable deaths. Only when the responsible factors are determined can the medical staff intelligently modify its organization, rules, and procedures to pm\ ent these deaths. Even a poorly equipped. nonaccredited hospital can show an excellent fetal salvage rate if rt has good staff discipline in regard to obstetrical consultation, analgesia, and anesthvsia. and prompt. expert pediatric care. 199 William Howard Cincinnati 19, Ohio
Taft
Rd.
Discussion* DAVID BICKEL, South Bend, Indiana. It is significant that we discuss this subject here in Chicago, since this is the birthplace of perinatal DR.
and
*Joint paper
discussion by Dr.
of paper l&s.
by
Drs.
Berry
and
Toshacb
mortality studies. Even the term “perinatal mortality” was coined here in Chicago by Drs. Potter and Davis. PerinataI mortality is properly an obstetrical consideration, since 80 per cent of the mortality is accountable to obstetrics. The studies presented
Perinatal
today are comprehensive, and the technique of conducting a private hospital. They also studies can be made only at Perinatal mortality studies
are
effort.
DR. HAROLD S. MORGAN, Lincoln, Nebraska. These two studies have demonstrated the fact that there is no hospital staff that cannot, and should not take the time to organize a perinatal study committee. Several references have been made to the AMA Perinatal Period I and Perinatal Period II. For those of you who are not familiar with this
mittee on Maternal and Child Care of the American Medical Association. 3. Lack of autopsies. Without postmortem examination, the cause of death very frequently cannot be determined. Dr. Potter showed that very clearly. 4. Lack of direction and cooperation by public health agencies and local medical societies. One example of the benefits which accrue from peri-
terminology, may I tell you it is explained and the methods for inducting perinatal conferences are given in the AMA “Guide for the Study of Perinatal Mortality.” I have just been informed that copies of these Guides are to be sent to every hospital in the United States of 50 beds or over through the cooperation of the American Hospital Association and American Medical Association Committee on Maternal and Child
natal and
studies is the its associated
thirds
of the deaths.
ing
Care. It would seem to me that members of the Central Association who are leaders of obstetrical thought in their particular communities and their particular hospitals should be the ones who would carry the torch for perinatal mortality studies. It will be through you that your hospital administrator will be stimulated to lend his support. It will be through you that your pathologist will develop an interest in the postmortem
and it has been shown that 1 per cent of all infants delivered by elective section do not survive because of prematurity. 3. The proper management of diabetic mothers frequently permits prolonged gestation and delivery at the optimal time. 4. With conservative management of maternal hemorrhagic complications, pregnancy can frequently be prolonged. 5. Pregnancy can frequently be safely carried to the stage of viability in toxemic patients by the use of vasodepressor and saluretic agents. 6. Measures to surgically correct the incom-
examinations of these tiny babies whom they tend to discount at the present time. Also, it might be wise if the Central Association in its wisdom were to suggest to the Commission on Accreditation of Hospitals that full autopsy credit be given for the performance of autopsies on immature fetuses. I think that might stimulate the pathologist just a little bit, because the pathologist gets a little discouraged in doing these autopsies when he knows that he is not going to be given credit for the postmortem results. We constantly talk about preventable disease. There, we are treading on rather thin ice.. The Perinatal Mortality Guide suggests that one should be cautious of the term “preventable deaths,” since every death has preventable factors. In that way, if we consider that there are several factors operating in each case, I think we will be on a little bit safer ground when we discuss these matters.
prematurity is due to the following: 1. Improvement in socioeconomic conditions. Nearly all studies reveal that as the economic and educational situations improve, the premature births decrease. 2. Careful judgment in the eIectric induction of labor and the timing of elective section. Our own studies reveal that as the incidence of induction increased, premature births increased;
during
pregnancy
hospitals encounter many difficulties. In the main they are as follows: 1. Lack of staff interest-that is, lack of enthusiastic individuals such as Dr. Toshach, Dr. Berry, and Dr. King to spark the movement. 2. Lack of adequate and accurate records to show what is going on. Such forms as shown here by Dr. King are very important. A uniform summary sheet is in preparation by the Com-
We have accepted the situation that most instances of premature birth occur without any readily discernible cause, but we now recognize that there are preventable factors involved in prematurity. In some areas preventability involv-
or
883
petent
that prematurity account for two
before
surveys
they clearly show such a program in show that the basic the hospital level. in private general
recognition conditions
cervix
mortality
effective in preventing premature labor. 7. Essential knowledge of perinatal mortality can be gleaned only from such meticulous studies as these, which require a great deal of time and
DR. C. E. GALLOWAY, Evanston, Illinois. As I review this subject and hear \vhat. is being said, I believe the answer is not in the labor in the hospital. Thr answer is in the conduct of the mothrr. The prc,vcntion of thcxcl dtbaths will occur when WC cxdtlcate ~vv1n1~11 frown high school on up as to their responsibility when thcv IJCcome pregnant. Animals that are cared for properly are grstting 94 live babies for every 100 pqnanrirs. The human being is trlrning out from 75 to 80. You can‘t confine our women to the pasturr’ and the barn very well, and WC ~.ot 11p on ot,r hind legs about a million years ago, which pointed the birth canal toward the floor; hut that is all the more reason jvhy our women should conduct themselves properly when thq arc’ prcgmmt. Anothrr factor that enttars into this marltar is fatigllc. You can‘t go out t:\xsry Satllrday night and go from one party to aiicrther and cxlx’ct to br ablr: to makr up for iL the nc’xt c,nriplc of days. Our wo~nm tlot (only ha\,<, their i);tbi(~s t,ut they ha\:C to mist, thcxm. and ~tkilc t11c.yart’ raising them they have to hnvc other babies. That brings on fatigue and pr%rhaps au irritable uterus: which may product% miscarriage and fetal death. Another possible factor is sexual intercour~r~ during pregnancy. Other animals do not have this prohlcm when thq al-~’ pregnant. Liquor. ci~arrttcs. and diet rrprrxsnt an additional sprcinl prohlcm. You say yo11 arc goinK ttr improve things I)y gi\kq the, Lvoinari 2 ccrt;tin dirt. Tf you cv(‘r gave a woman a diet and rcaall\ thought she, would follo!v it, you cc~rtninly :lr(’ diffcrpnt from rnc’. I nt~v~ saw any woman \vhcJ would follo\v instructions if she. didn’t \vaut 10. And so the thing to do is to try III c~duc.atc~ thtx bvomen. it is their responsibility to h,~vl* children and to raise their babic~s and carry th(sir pregnancirs. If the woman dots not carry hcl baby fo full term---w:cll, I think CXICof the* larq~st factors is her oivn c,onduc-t. Whilr we arc> talkin,g :khollt prpvcnting perinatal deaths WC art: constantly increasing diahetrs through brcedin,q Evq diabetic M’OIIKII~ wants to become pr~gna~lt. and \VC help ht*r so shr can have another prcmatllrc. balmy and so add 10 this mortality rat<*. If WV nm~lcl breed some CIC these dkicnci~s ntlt, \CC \vnltld makes a lot more* progrrss. One of the main things in this situation is education of our women that thr! are responsil)lt> for carrying their babies.
Volume 79 Number 5
I thought you might be interested in knowing something that w-as accomplished in the state of South Dakota in the past year. The lack of cooperation from physicians in part has been due to the fear of records of study committees such as these being available for subpoena in court actions. We were able to get through our Legislature this past year a law which exempts perinatal studies, mortality studies, and hospital tissue committee reports in South Dakota from subpoena for legal purposes. DR. BERRY (Closing). I can appreciate the clifficultics that Dr. King has encountered in studying perinatal mortality studies in his hosl)itnls. We have gone through the same thing at Saginaw. In reviewing our statistics it surprised me to find that there were 30 stillbirths caused by toxemia of pregnancy, the majority of which were only a mild or very moderately severe toxemia of pregnancy. This rather clouded my impression of what eclampsia or pre-eclampsia could do to infants. I expected to find deaths from eclampsia, but not from mild toxemia of pregnancy. Another thing of interest was that 317 of the ii20 perinatal deaths were in mothers who had +xpcrienced no previous obstetrical loss. An additional 73 mothers had had only one abortion prior to this obstetrical loss. I would like to comment also concerning the voting. Each death is considered individually. In our voting we aimed at an academic ideal in order to eliminate personal feelings influencing this voting. Yo
Perinatal
mortality
surveys
885
whom the cause of death was virtually unexplained. These, according to our classifications, fall into the group of postnatal asphyxia, atelectasis, ill-defined or unspecified causes of death, maceration, and so on. These are wastebasket terms and don’t mean anything. This merely means that we haven’t explained the cause of death. As was pointed out, an increase in the number of autopsies and placental examinations should materially reduce this number. DR. KING (Closing). I would like to stress once again the point Dr. Morgan made about using the term, “possibly preventable,” rather than “preventable.” He has two very good arguments. First, you do not antagonize the doctor whose obstetrics leaves a little to be desired when you allow him a loophole that possibly nature might have caused the death. Second, you prevent the possibility of lawsuits, in my opinion. The discussants and Dr. Berry’s paper brought out that prematurity was the single largest cause of death. I dislike that term, because prematurity in itself is not a cause of death. Drs. Berry and Toshach are to be congratulated on their 90 per cent salvage of these premature infants. I am sure it was due to the prompt pediatric care. So, there is confirmation of our finding that the promptness with which the pediatrician (and a skilled pediatrician) gets on the case may make the difference. I am still hoping that someone will agree with me in the conclusion I drew from the comparison of the two hospitals, where one of the striking differences was the amount of analgesia and anesthesia used. I am certain (although I cannot prove it) that many of these ill-defined deaths that the pathologist says are caused by atelectasis or just prematurity are due to the impairment of the respiratory function of the baby right after he is born, as a result of the narcotizing influence of drugs and inhalation anesthesia that we give the mothers to relieve their pain.
surveys in two
small private hosp itals in Cincinnati ARTHUR Cincinnuti,
G. KING.
M.D.
0hfo
are handicapped by the greatest value, absence of many of these elements. The staff is usually discouraged from undertaking such a project. Often there is marked apathy and sometimes downright hostility from influential but poorly oriented staff members. It is apparent that except for a few cases, no real study of perinatal mortality can be carried out without access to and careful review of the individual charts of the mothers and infants. In some hospitals permission to do this is obtained with and some doctors resent anyone difficulty, Icviewing their handling of a case. This can lx- overcome by an insistence on strict nnonymi t y when the case histories are studied by a committee. Only the chairman or secrrtary of the Perinatal Mortality Re\+w (:ommittc~c: should have access to the identifying data. Many administrators are Iukewarm, either because the record room personnel is bothered or because of a fear of possible malpractice suits if recorded data are re\,iewcd too carefully. On the other hand, a rcbvicw committee can protect both doctors and hospitals by insisting on the insertion of essential information, the omission of wlrich carries a suggestion of tic-gligencc. Finally. if the findings of the committee arc kept completely separate fr,om the clinical record after thr review, no critical animadversions can damage the lrospital or doc.lor. ‘I’ill recently anoth(:r grea.t difficulty has llcen the method of classifying the perinatal deaths bv causes. Many traditional but
T II E amazing decline in maternal mortality of the past 30 years has not been matched by the progress in fetal salvage, even though the same antibiotics, the same blood transfusions, the same laboratory facilities. and at least similar advances in knowledge and technique are as available to the infants as to their mothers. One reason may be that we are not applying these facilities and techniques on a large enough scale. The purpose of a perinatal mortality study is to find out in what conditions we are failing to USC our knowledge, and how best to act in order to reduce further the number of stillbirths and neonatal deaths. This discussion is limited to the practical aspects. the methods, and the difficulties of making such a study in a small private hospital and, hence? is pertinent to the problems facing every conscientious private practitioner of obstetrics. Difficulties
in collecting
data
Most reports of perinatal mortalitystudies come from the large teaching hospitals. where the entire staff is well trained, the staff discipline good, the charts complete, the house staff xkcpate and enthusiastic, the clerical help ample, and the funds for the study sufficient. The smaller hospitals, where these studies can hr of the From the Catherine the Jewish Hmpital
Booth Hospital of Cincinnati.
and
Presented at the Twenty-seventh Annuul Meetinp of the Central Association of Obstetr&i&s and Gynecologists, Chicogo, Illinois, Sept. 24-26, 1959.
876
Volume Number
79 5
Perinatal
imprecise diagnoses have been accepted by medical record rooms and boards of health, but they are valueless in arriving at a true cause of death. This has made impossible any sort of comparision of these basic causes in the published statistics. Again, the pathologists have not been very helpful by reporting “atelectasis” and “prematurity” as causes of death, which, of course, they are not, any more than “noncirculation of the blood” and “old age” are acceptable diagnoses. Finally, few of the doctors in the smaller hospitals will take the time or trouble to record on the chart itself, even though asked. clinical information, particularly of the antepartum period, often essential to assigning a cause of death or possible preventability. Procedures
adopted
in the
present
study
The study reported briefly here was begun by developing a classification of infant and fetal deaths which was simple, logical, clinical, and particularly easy for busy doctors to use. It has been modified in the last 5 years from time to time, but the form found most readily acceptable and satisfactory is shown in Fig. 2. In keeping with the principle of making it easy for the doctors to cooperate, a summary of essential information had to be obtained from them on a prepared form. It was felt that a form suitable for punch-card or I.B.M. machine use was too formidable to be practical. Although tabulation would be easier with such a form, it would be more time consuming for the individual doctor filling it out for each of his cases and might frighten him into ignoring all the questions. All the information requested from the doctor had to be on one page, preferably on the reverse of the sheet listing the cause of death. Fig 1 shows the form which, after many modifications, was found acceptable by the doctors and satisfactory to the committee. Even this simpIe form proved too much for some of the rugged individualists. The committee was able to get cooperation only after a hospital ruling was established that
mortality
surveys
877
any doctor failing to provide adequate information after a written request was required to attend the meetings of the review committee. This threat of “another meeting,” absence from which jeopardized the man’s obstetrical privileges, proved very helpful in having the forms filled out. On the other hand, many doctors with a interest in reducing genuine obstetrical wastage attended the meetings of the committee volunarily and with profit. Committee
analysis
of
data
There are three decisions which the Perinatal Mortality Study Committee has to make. The first is the most probable cause of death. As has been pointed out by others, this is very difficult and requires correlation of the antepartum history, the labor, the delivery, nursery records, the nurse’s notes, and the autopsy findings. Obviously, representatives of all these disciplines must be on the committee for proper correlation and interpretation. The second decision is whether the death was nonpreventable, possibly preventable, or definitely preventable. These three classifications were used, with “possibly preventable” being used in preference to “preventable” for several reasons: the committee did not wish to arrogate to itself a superior knowledge of either obstetrics or pediatrics; the pride of the individual doctor was not bruised, since many of them felt unhappy enough after losing a baby whose life might have been saved; and it was a further safeguard against legal complications. In this phase of committee work, there was a need for a firm philosophy and an uncompromising attitude. One of the more difficult problems in education was to explain to the staff the difference between “culpability” of the individual and “possible preventability” by world-wide professional improvement. For example, 20 years ago many congenital heart lesions resulted in death and at that time might justifiably have been listed as “nonpreventable.” Modern cardiac surgery has prevented many of the deaths. The same may be said for many other con-
878
King
PERINATAL The Attending Physician is requested to provide the following confidential information by filling in the appropriate spaces. Supply as much pertinent information as possible. SEE THE RE'7E3SESID3 Date of Delivery
Mother's age: as follow7
MORTALITY
STUDY City Hospital X&her's Unit 30. Child's Unit !io. Path Dept. No.
Stillbirth: macerated ( ) non-macerated < ) Neonatal Death: under 7 days of age ( ) over 7 days of’ ale ( ) Gestation: -Weight : -lbs.
_I_-
iqeeks since T,M.P. G.)
race Total number of previous pregnancies abort-under 20 weeks Stillbirths,20-28 weeks over 28 ueeks livebirths, 20-28 weeks over 28 weeks number of infants survivl=er 30 days of life
Total length of labor
hrS.
hours of delivery
Type an.l amount of premeditation
of ik?livery: Spontaneous( ),Low forceps( ),Midforceps( extration( ), Breech delivery( ), Aided breech delivery( frank breech to footling( ),Caesarian section ( ).
Condition of infant Comment:
ai Birth:
How soon after birth was infant How long did infant live?
Apgar rating
within
6
---_
~___-I
Anesthesia: None ( ), Local ( ), Spinal ( ), Caudal ( ), Intravenous If inhalation, kind and duration prior to delivery Type
oz. (
(
(
), Inhalation(
) -
),lrersion aIld ),Conversion of
) or Good ( ) Fair
(
seen by an attending pediatrician? Autopsy: yes ( ) noir7---
) Poor (
)
hrs.
Please give any significant details uf mother's past history, past pregnancies, present pregnancy and course of labor which might have had a bearing on this death, and abnormal findings in the placenta or amniotic fluid. Note any blood incompatibilities or abnormalities.
genital anomalies, such as tracheoesophageal fistulas and diaphragmatic hernias. In reviewing the cases, a death from congenital anomalies was listed as “possibly preventable” unless a prompt and competent consultation declared the situation hopeless. The third decision is the fixation of responsibility for the possibly preventable deaths. This is the most valuable part of the
study- as it points the way to makin,q changes which will save infant lives. 'The sim$o work sheet used by the committee had lines for ‘Causes of Death” (arrived at after study of all sources of information) ! “Comments,," and "Classification." The last was either “NP,” “PP,‘* or “P,” followed by a number which designated the responsible factors. These were: 1. Patient failure to
Volume 79 Number 5
Perinatal
For the sake applicable as amplification diseases, as
Death
Death
( (
) )
Standard Congenital anomaly (specify organ and type) Physiologic Inadequacy due to Prwturity Iiemolytic Disease (formerly Erytbroblastosis) Hypoprothrombinemia (formerly ksmorrh. Disease of Newborn) Birth Trauma (specify organ involved below, as “brain”) Anoxia, due to OPlacenta Previa ( ) tiemature Separation of the Placenta ( ) Fibrosis of the Placenta ( ) Infarction of the Placenta ( ) Strangulated Cord ( ) Cord Tight About Neck ( ) True Knot in Cord ( ) Cord Prolapse ( ) Prolo~lged or Tumultous Labor i j Mater& Circulatory CollapGe Respiratory Insufficiency, due to ( ) Maternal .Narcosis ( ) Hyaline Snd Formation ( ) Aspiration of Amniotic Fluid ( ) Bronchial dbstruction (substance developed within the body, such as mucus, vomitus, etc.) ( ) Aspiration bronchopneumonia (foreign substance from vithout the body: oil, milk, etc.) caused by conditions primary In tne mother ( ) Toxemia of Drewnw ( j Maternal Enbockne ksorder; specify below, such as diabetes, thyroid disease, etc. ( ) Maternal infections disease; specify below, such as rubella, mumps, syphilis, polio, etc. caused by disease acquired as an infant, not associated with the delivery process; specify below ( ) Acquired bronchopneumonia ( ) Other. Specify below Other causes of death. Specify below unknown
2. Form
for
indicating
judgment or technique. 3. Analgesia or anesthetic judgment or technique. 4. Pediatric care (delayed or inadequate). 5. Nursing judgment or technique. 6. Administrative deficiency (failure by the hospital to provide adequate nursing or resident coverage, supervision, equipment, or communication). 7. Inadequate community resources. Analgesia and anesthesia were linked together to pinpoint the field of error rather than the judgment of the individuals concerned. Because it is now recognized that or follow
advice.
surveys
879
of uniformity, please check one or Inore of the following diagnoses the cause of death in this case. Use the blank lines below for of the diagnoses, such as specific organs involved and specific well as for any conditions or causes of death not listed.
Fig.
seek
mortality
2. Obstetric
causes
of fetal
or neonatal
Nomenclature :011-076 (501-3991
< ; 1
(513-549
1
(93Y-050
1
(794-631 (794-900.5 (794-940
1 1 )
‘(;;;-:2 (799I638 (799-6L3 (799-631 (7x2-!% (MO-534
] 1 1 1 ) )
(010-370 (360~pro (362-438
1 1 )
(360-611.&
)
(361-496
1
(010-388
)
(010-382
)
(010-l..
)
1361-190 )1 (yoo-P
I
death.
a premature infant is placed in great jeopardy if the mother receives large amounts of narcotics, barbiturates, or inhalation anesthesia, the death of an infant, for example, born at 30 weeks’ gestation to a mother given more than minimal or any analgesia, was classed as “possibly preventable.” It was felt that many of the deaths of premature infants ascribed by the patholmight well have been ogist to “atelectasis” due to the impairment of the infant’s respiratory control as a result of the inju-
880
King
Table I. Comparison
of 1958 statistics from two contrasting hospitals (A.M.A. Prrinatal Mortality Period 1: A’0 of
fetrrsr~
Kate
Hospital A (private i .I)4 I 19.8/lWJl) Seneral hospital) Hospital B (13 bt=ci. no x-ray, laboratory. or facilities for cc’sarem 19.? ~100l1 section) 6”5* -. ‘Includin,~ all 1rmttwrs and idants transfemd dicious use of analgesia-producin,g the mother. Contrasted
results
in
two
agc,nts in
hospitals
To those who question thr value of these time-consuming studies, analysis of the data. dramatically shows where corrective action can be taken. Two hospitals were involved in this review. Hospital A had 3,640 infants born alive or dead in 1958: Hospital R had only 625. The latter is a small maternity hospital of 13 beds with no laboratory, no x-ray, and no facilities for c-csarean section. Almost all of the deliveries are by general practitioners or a I,esident. 7’11~ figurc:.r reported for Hospital B includr~ nzotfwrs und hahirs transferred to oth ho.spitals. Table I shows the data for 1958. It is based on the A.M.A. Prrinatal Mortality Period I, which excludes fetuses or infants weighing less than 1,000 grams or those dying after the schventh da); of life. There are two possible interpretations of these data. One is that a laboratory, x-ray department, facilities for cesarean section. and highly trained obstetricians are unnecessary for achieving a good perinatal mortality rate. The other interpretation is that therr arc differences in the operation of the two obstetrical departmenls which compensate for the great deficiencies existing in Hospital IS. Analysis of the two hospitals shows the latter to be the cas(‘. The patients in Hospital R were very definitely from a much lower economic grnup. Although about one third of them were under constant supervision in the attached Home for the last several months of gestation, many
Analgesia and ;inrslh&~ are kt*pt IO :i tninimum. ‘The\- iirt: rlsed in almost all GIWS. IrLfl in flows that fit11 far below [llr Ltvcragcb doses given in Hospital ,4. Prolongrd anesthesis with rther to “hold” the lvoman until the attendin,? ph\G:ian arri\-rs is absolutely forhiddcri. al’e rared fO1 [Iv 3 Finall?,, tilt ilifmtS c:arcfiillv sclrc tc*d l)anCl of Hoard-cjllalified ptdiatricians \tllo havc~ a Illo~.e-than-avel.aee intchrcst in the \vclfarc of th? little patients XI rhis particular llospital and who are willing to set’ at ai+’ time an)’ baby who need;; ptdiatric help. ‘l‘llty gratuitously make daily r01mds \vith ;I rcmarkabiv conscientious lllot~oll~llrlt~~?;.
Analysis
of
possibly
preventable
deaths
The possibly preventable deaths consti tulc the most interesting part of the survey. In Hospital A thy 3.640 ietustxs were delivered h!. 10 Board-qualitied obstetricians. :i \\-llo limited their practice to obstetrics. and II-i cren(*ral practitioncrk Of thf* 72 corrf~cttd zeaths. 28. or nearly 41) per cvnt, wta1.e considercsd possibly preventable. The distrihtitiorr is shown in Tablr IT. Refore any comparison can be made betwcrn the possibly preventable rates of the two hospitals ii. must hc rrmembered that there, were two different survey committees in\~olvt~d~ and tlic, designation of “possibly pwvtmtahle” is ;i matter of interpretation. Within Hospital .2 the ,gcneral practitioners had mow Imsil~l~. ~mwmtable deaths than thr Hoard-c~ualift:tI obstc~tricians, but thr qc~neral prac~itiorwrs at. Hospital H had
Volume Number
79 5
Perinatal
proportionately fewer possibly preventable deaths than even the Board-qualified obstetricians at Hospital A. Causes
of possibly
preventable
of factors deaths
deaths
in possibly
In Hospital A, studies of perinatal mortality had been done in 1948, 1954, and 1956, with use of, however, a different investigative technique. In 1948 the rate was 21.5, and among the deaths that were probably preventable were 3 from traumatic ga-
Table II. Relation
of obstetrical
training
to possibly
preventable
rate
Table III.
factors
Major
per
1,000
total
in possibly
cases
preventable
deaths
Limited practice
Boardqualified Number of operators Total cases Total mortality Possibly preventable Possibl; &-eventable
surveys
10 1,843 51 13 (7.0)
General practice
3 499 10 4
34 1,296 36 11 (8.5)
(8.0)
Ho.ypital B 625 19 4 (6.4)
deaths*
__Boardqualified No. possibly preventable Pediatric care Analgesia/anesthesia Obstetric judgment/technique *In
some
of the
deaths
(13) 6 5 2 there
were
multiple
factors.
881
vage. A prompt change in the rules in the nursery eliminated this cause of death for all subsequent years; little attention was paid to other recommendations which were made, however. In 1954 the rate was 21.0 and when the causes of the deaths were presented to the general staff, there was great indignation. However, changes were made in the staff organization and function which could eliminate or reduce some of these causes. These included a closer collaboration between the pediatricians and the obstetricians and a system of free obstetrical consultation for general practitioners. But such things as 3 out of 17 Rh-affected babies dying without the attending physician ever recording that the mother was Rh negative, or the pregnancy of a known diabetic mother being allowed to go to 42 weeks’ gestation with the infant weighing 11 pounds, required the slow process of education of the individual doctor for correction. In 1956 the rate went up to 21.7, and the analysis of deaths revealed that the individual doctors were neither taking advantage of the mechanisms available for raising the standards of obstetrical practice nor modifying to any extent their own philosophies and techniques. It was at this point, in 1957, that the current form of study of perinatal mortality was introduced. It met some opposition and a great deal of apathy.
On the other hand, the causes of death and responsibility assigned pointed the way to improvement of results in Hospital A, confirmed by the findings in Hospital B. Of the major factors assigned, the distribution is shown in Table III. The infants’ care in Hospital B, it will be remembered, was in the hands of a dedicated group of trained pediatricians, whereas in Hospital A many babies were cared for by the obstetricians or general practitioners. Again, the amount of anesthesia and analgesia used in Hospital B was far less than in Hospital A. As for errors in obstetrical judglnent, it must be remembered that the hospital had little control over the antepartum care given to the patients by many of the general practitioners. Correction preventable
mortality
Limited practice (4) 1 4 1
General practice (9) 8 9 3
Hospital B $1 0 4
882
King
However, the knowledge that each case was being studied individually by a committee which would determine tllr possible preventability of any death has led to a closer adherence to the hospital rules. The anesthetists have taken a greater interest in how much premeditation the Roman rccri\x:s. Less analgesia is being used, since the amount given has to be stated on the perinatal mortality forms; pediatricians are being called in much earlier than formerly, and their notes have become more voluminous and specific. The 19.58 rate of 19.8 represents some improvement, bttt the rate is no better than that of Hospital 13 despite the advantages in equipment and facilities. Perhaps the answer lies in staff discipline which can be stimulated I>); perinatal mortality studies. Summary
The difficulties in making a perinatal mortality survey in a small private hospital stem largely from the apathy of the medical staff, and the unnecessary fears of condemnation or exposure. Cooperation from doctors can be obtained if simple reporting forms are rrsed, such as those described, and judicious analyses are made and discussed by a devoted survey committee, supported by the hospital administration. Stillbirths and neonatal deaths of babies weighing over 1,000 grams are classified as nonpreventable, possibly preventable: and preventable, and, for the latter two groups, which number almost 40 per cent of the total, the responsible factors arc identified so that corrective action can be taken. Similar studies wore made in 1958 in two contrasted hosl)itals. One was an excellent pri\-ate general hospital with 3,640
births, with ‘in Ateeric staff of 10 Boardqualified obstetricans, 3 men ~vho limited their practice to obstetrics, and 33 general 1nactitioncrs. ‘l’hr other was a nonaccredited ! 3 bed maternity hospital with no labora10r)‘. no s-ray equipment, and no facilities for wsarcm section, in which 625 births tCJdi ~Jh’f2. ‘f’il(’ poorer hospital had thl, sli
‘I‘he purpose of a perinatal mortality sur\ev in any hospital is to determine the number and causes of possibly preventable deaths. Only when the responsible factors are determined can the medical staff intelligently modify its organization, rules, and procedures to pm\ ent these deaths. Even a poorly equipped. nonaccredited hospital can show an excellent fetal salvage rate if rt has good staff discipline in regard to obstetrical consultation, analgesia, and anesthvsia. and prompt. expert pediatric care. 199 William Howard Cincinnati 19, Ohio
Taft
Rd.
Discussion* DAVID BICKEL, South Bend, Indiana. It is significant that we discuss this subject here in Chicago, since this is the birthplace of perinatal DR.
and
*Joint paper
discussion by Dr.
of paper l&s.
by
Drs.
Berry
and
Toshacb
mortality studies. Even the term “perinatal mortality” was coined here in Chicago by Drs. Potter and Davis. PerinataI mortality is properly an obstetrical consideration, since 80 per cent of the mortality is accountable to obstetrics. The studies presented
Perinatal
today are comprehensive, and the technique of conducting a private hospital. They also studies can be made only at Perinatal mortality studies
are
effort.
DR. HAROLD S. MORGAN, Lincoln, Nebraska. These two studies have demonstrated the fact that there is no hospital staff that cannot, and should not take the time to organize a perinatal study committee. Several references have been made to the AMA Perinatal Period I and Perinatal Period II. For those of you who are not familiar with this
mittee on Maternal and Child Care of the American Medical Association. 3. Lack of autopsies. Without postmortem examination, the cause of death very frequently cannot be determined. Dr. Potter showed that very clearly. 4. Lack of direction and cooperation by public health agencies and local medical societies. One example of the benefits which accrue from peri-
terminology, may I tell you it is explained and the methods for inducting perinatal conferences are given in the AMA “Guide for the Study of Perinatal Mortality.” I have just been informed that copies of these Guides are to be sent to every hospital in the United States of 50 beds or over through the cooperation of the American Hospital Association and American Medical Association Committee on Maternal and Child
natal and
studies is the its associated
thirds
of the deaths.
ing
Care. It would seem to me that members of the Central Association who are leaders of obstetrical thought in their particular communities and their particular hospitals should be the ones who would carry the torch for perinatal mortality studies. It will be through you that your hospital administrator will be stimulated to lend his support. It will be through you that your pathologist will develop an interest in the postmortem
and it has been shown that 1 per cent of all infants delivered by elective section do not survive because of prematurity. 3. The proper management of diabetic mothers frequently permits prolonged gestation and delivery at the optimal time. 4. With conservative management of maternal hemorrhagic complications, pregnancy can frequently be prolonged. 5. Pregnancy can frequently be safely carried to the stage of viability in toxemic patients by the use of vasodepressor and saluretic agents. 6. Measures to surgically correct the incom-
examinations of these tiny babies whom they tend to discount at the present time. Also, it might be wise if the Central Association in its wisdom were to suggest to the Commission on Accreditation of Hospitals that full autopsy credit be given for the performance of autopsies on immature fetuses. I think that might stimulate the pathologist just a little bit, because the pathologist gets a little discouraged in doing these autopsies when he knows that he is not going to be given credit for the postmortem results. We constantly talk about preventable disease. There, we are treading on rather thin ice.. The Perinatal Mortality Guide suggests that one should be cautious of the term “preventable deaths,” since every death has preventable factors. In that way, if we consider that there are several factors operating in each case, I think we will be on a little bit safer ground when we discuss these matters.
prematurity is due to the following: 1. Improvement in socioeconomic conditions. Nearly all studies reveal that as the economic and educational situations improve, the premature births decrease. 2. Careful judgment in the eIectric induction of labor and the timing of elective section. Our own studies reveal that as the incidence of induction increased, premature births increased;
during
pregnancy
hospitals encounter many difficulties. In the main they are as follows: 1. Lack of staff interest-that is, lack of enthusiastic individuals such as Dr. Toshach, Dr. Berry, and Dr. King to spark the movement. 2. Lack of adequate and accurate records to show what is going on. Such forms as shown here by Dr. King are very important. A uniform summary sheet is in preparation by the Com-
We have accepted the situation that most instances of premature birth occur without any readily discernible cause, but we now recognize that there are preventable factors involved in prematurity. In some areas preventability involv-
or
883
petent
that prematurity account for two
before
surveys
they clearly show such a program in show that the basic the hospital level. in private general
recognition conditions
cervix
mortality
effective in preventing premature labor. 7. Essential knowledge of perinatal mortality can be gleaned only from such meticulous studies as these, which require a great deal of time and
DR. C. E. GALLOWAY, Evanston, Illinois. As I review this subject and hear \vhat. is being said, I believe the answer is not in the labor in the hospital. Thr answer is in the conduct of the mothrr. The prc,vcntion of thcxcl dtbaths will occur when WC cxdtlcate ~vv1n1~11 frown high school on up as to their responsibility when thcv IJCcome pregnant. Animals that are cared for properly are grstting 94 live babies for every 100 pqnanrirs. The human being is trlrning out from 75 to 80. You can‘t confine our women to the pasturr’ and the barn very well, and WC ~.ot 11p on ot,r hind legs about a million years ago, which pointed the birth canal toward the floor; hut that is all the more reason jvhy our women should conduct themselves properly when thq arc’ prcgmmt. Anothrr factor that enttars into this marltar is fatigllc. You can‘t go out t:\xsry Satllrday night and go from one party to aiicrther and cxlx’ct to br ablr: to makr up for iL the nc’xt c,nriplc of days. Our wo~nm tlot (only ha\,<, their i);tbi(~s t,ut they ha\:C to mist, thcxm. and ~tkilc t11c.yart’ raising them they have to hnvc other babies. That brings on fatigue and pr%rhaps au irritable uterus: which may product% miscarriage and fetal death. Another possible factor is sexual intercour~r~ during pregnancy. Other animals do not have this prohlcm when thq al-~’ pregnant. Liquor. ci~arrttcs. and diet rrprrxsnt an additional sprcinl prohlcm. You say yo11 arc goinK ttr improve things I)y gi\kq the, Lvoinari 2 ccrt;tin dirt. Tf you cv(‘r gave a woman a diet and rcaall\ thought she, would follo!v it, you cc~rtninly :lr(’ diffcrpnt from rnc’. I nt~v~ saw any woman \vhcJ would follo\v instructions if she. didn’t \vaut 10. And so the thing to do is to try III c~duc.atc~ thtx bvomen. it is their responsibility to h,~vl* children and to raise their babic~s and carry th(sir pregnancirs. If the woman dots not carry hcl baby fo full term---w:cll, I think CXICof the* larq~st factors is her oivn c,onduc-t. Whilr we arc> talkin,g :khollt prpvcnting perinatal deaths WC art: constantly increasing diahetrs through brcedin,q Evq diabetic M’OIIKII~ wants to become pr~gna~lt. and \VC help ht*r so shr can have another prcmatllrc. balmy and so add 10 this mortality rat<*. If WV nm~lcl breed some CIC these dkicnci~s ntlt, \CC \vnltld makes a lot more* progrrss. One of the main things in this situation is education of our women that thr! are responsil)lt> for carrying their babies.
Volume 79 Number 5
I thought you might be interested in knowing something that w-as accomplished in the state of South Dakota in the past year. The lack of cooperation from physicians in part has been due to the fear of records of study committees such as these being available for subpoena in court actions. We were able to get through our Legislature this past year a law which exempts perinatal studies, mortality studies, and hospital tissue committee reports in South Dakota from subpoena for legal purposes. DR. BERRY (Closing). I can appreciate the clifficultics that Dr. King has encountered in studying perinatal mortality studies in his hosl)itnls. We have gone through the same thing at Saginaw. In reviewing our statistics it surprised me to find that there were 30 stillbirths caused by toxemia of pregnancy, the majority of which were only a mild or very moderately severe toxemia of pregnancy. This rather clouded my impression of what eclampsia or pre-eclampsia could do to infants. I expected to find deaths from eclampsia, but not from mild toxemia of pregnancy. Another thing of interest was that 317 of the ii20 perinatal deaths were in mothers who had +xpcrienced no previous obstetrical loss. An additional 73 mothers had had only one abortion prior to this obstetrical loss. I would like to comment also concerning the voting. Each death is considered individually. In our voting we aimed at an academic ideal in order to eliminate personal feelings influencing this voting. Yo
Perinatal
mortality
surveys
885
whom the cause of death was virtually unexplained. These, according to our classifications, fall into the group of postnatal asphyxia, atelectasis, ill-defined or unspecified causes of death, maceration, and so on. These are wastebasket terms and don’t mean anything. This merely means that we haven’t explained the cause of death. As was pointed out, an increase in the number of autopsies and placental examinations should materially reduce this number. DR. KING (Closing). I would like to stress once again the point Dr. Morgan made about using the term, “possibly preventable,” rather than “preventable.” He has two very good arguments. First, you do not antagonize the doctor whose obstetrics leaves a little to be desired when you allow him a loophole that possibly nature might have caused the death. Second, you prevent the possibility of lawsuits, in my opinion. The discussants and Dr. Berry’s paper brought out that prematurity was the single largest cause of death. I dislike that term, because prematurity in itself is not a cause of death. Drs. Berry and Toshach are to be congratulated on their 90 per cent salvage of these premature infants. I am sure it was due to the prompt pediatric care. So, there is confirmation of our finding that the promptness with which the pediatrician (and a skilled pediatrician) gets on the case may make the difference. I am still hoping that someone will agree with me in the conclusion I drew from the comparison of the two hospitals, where one of the striking differences was the amount of analgesia and anesthesia used. I am certain (although I cannot prove it) that many of these ill-defined deaths that the pathologist says are caused by atelectasis or just prematurity are due to the impairment of the respiratory function of the baby right after he is born, as a result of the narcotizing influence of drugs and inhalation anesthesia that we give the mothers to relieve their pain.