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The Arizona high-risk maternal transport system: An initial view
The Arizona high-risk maternal transport system: An initial view HARLAN JERRY WM.
C. D. Tucson
R. GILES, ISAMAN,
J.
MOORE,
M.D. M.A.
M.D.
CHRISTIAN, and Phoenix,
M.D. Arizona
There are two Level III Maternity Centers in Arizona at the present time. A statewide system of maternal transport to these two centers exists as part of the Arizona Perlnatal Program, and the characteristics of the first 357 maternal transports to one of these centers (Arizona Medical Center, Tucson) are reported herein. The manner in which the Prcgram was developed is described. It is our hope that this overview of our initial experience will be of interest to those persons developing a graded-care program for high&k maternal patients. (AM. J. OBSTET. GYNECOL. 128: 400, 1977.)
FROM THE TIME of the 1971 American Medical Association House of Delegates statement,* which states the position that community (regional) systems of graded care for the parturient patient and her offspring would further reduce maternal and infant mortality rates and morbidity, to the present, there have been many papers and position statements reiterating the gradedcare concept. One of the first states to take a positive position was California. The California Medical Association adopted the concept of centralized community care, and recently this view has been expanded into a publication2 The California Criteria for Levels I, II. and III (or rural, urban, and regional or primary, secondary, and tertiary-no one system of terminology is satisfactory to everyone) centers are those that have been adopted in general by most states or regions considering regionahzation of the graded-care concept for mothers and infants.
The recent publication by the National Foundation-March of Dimes, Toward Im@kng the @itcome oj Pregnancy, ’ is one of the more complete statements of the how and why of graded obstetric care. The report of the Ross Conference” and the statement of the American College of Obstetricians and Gynecologists are also recommended for further background reading.
Arizona presents some geographic and population distribution features that are unique to certain western and midwestern states. Sixth in land size, Arizona had an estimated population of 2,245,OOO persons in 1975, and ranked thirty-second among states in population. The majority of the population resides in two of the 14 counties. Maricopa County (Phoenix) contains 54.8 per cent and Pima County (Tucson) 20.1 per cent of the population of the state. AIthough the over-all popuiation density is some 19 persons per square mile, the density outside of the two metropolitan counties is only six persons per square mile. Likewise, the considerable majority of physicians of the state reside in these two counties. Of the 142 trained obstetricians-gynecologists of the state who are currently engaged in the practice of obstetrics, 90 are in the Phoenix area and 41 are in the Tucson area. Similar percentage figures exist for pediatricians in the state, and it was from the earlier neonatal and infant transport data that the establishment of a structured maternal transport system seemed to make such
From the Department of Obstetrics and Gynecology, University of Arizona College of Medicine, and the University Hospital Arizona Medical Center, the Arizona Perinatal Program. The maternal transports Were supported by a grant from the Robert Wood Johnson Foundation to thp University oj Arizona and the State of Arizona. The prenatal diagnostic laboratory was supported in part by a Medical Services Grant from the National Foundation-March of Dimes. Presented by invitation at the Forty-third Annual of the Pacific Coast Obstetrical and,Gynecological Kona, Hawaii, November 7-13, 1976.
Meeting Society,
Reprint requests: Dr. C. D. Christian, Department of Obstetrics and Gynecology, Arizona Medical Center, Tucson, Arizona 85724. 400
Volume 128
Arizona high-risk maternal transport
401
Number4
imminent good sense. In 1960, the statewide infant mortality rate ranked forty-fifth of the 50 states, and 43 per cent of the inpatients hospitalized for custodial care of severe retardation in the Arizona Children’s Colony became retarded during the perinatal period. A group of concerned physicians and nurses, among other citizens, created the Advisory Committee on the Premature to the Arizona State Division of Maternal and Child Health.3 In 1967, the State Health Department initiated a demonstration project to transport sick newborn infants from rural hospitals to one of two hospital centers in Phoenix. The experience was so salutary that, in 1970, The Arizona State Department of Health Services began funding neonatal transport services and a third hospital center was added in Tucson. Arizona improved in the national state ranking by infant mortality rate from forty-fifth to forty-third during the period from 1959 to 1966 and from forty-third to the eleventh during the five years from 1967 to 1972. The advantages of having the ready and willing cooperation of the neonatologists and their considerable and excellent experience and the opportunity to open a new 300 bed hospital center (University Hospital, University of Arizona, Tucson) fully equipped to meet all criteria of Level III care for obstetrics made maternal transport an obvious and desired end. From the opening in the fall of 197 1 until the beginning of 1973, however, transport took place in the usual ad hoc unstructured fashion. When the perinatologist (H. R. G.) joined the staff, transport was begun in a structured manner. Nurses and physicians were instructed in the vagaries of transporting high-risk maternity patients by ambulance, helicopter, and fixed-wing aircraft. The physicians of the state were notified that consultative services by phone are available around the clock and that transportation services exist. However, there was no funding for transportation, and each individual transport had to be managed in whatever manner available. The State Department of Public Safety was always cooperative and provided an airplane or helicopter whenever such was available. The Neonatal Transport System was also maximally cooperative and allowed some of the funding from the State Division of Maternal Child Health to be used for maternal transport. Funding of such a system poses a unique problem in Arizona. Arizona is the only state that does not have Medicaid. It has a relatively low tax base because only 17.5 per cent of land ownership is private (43.5 per cent is federally owned, 12.2 per cent is state owned, and 26.7 per cent comprises Indian reservations). The uniqueness of any funding situation is, of course, rel-
ative and exists for any state or area. However, funding is of absolute necessity, for such a program, and for this reason The Robert Wood Johnson Grant for regionalization of high-risk maternal services made our current structured transport system possible. At the present time, infants are transported to one of two hospital centers in Phoenix (St. Joseph’s Hospital or Good Samaritan Hospital) or to either of two hospitals in Tucson (Arizona Medical Center or Tucson Medical Center) under the auspices of the Arizona Infant Transport Program. The Infant Transport System is divided into two regions, with those transports from northern Arizona going primarily to Phoenix and those from the Southern portion generally going to Tucson. Maternal transports are made to St. Joseph’s Hospital in Phoenix or the Arizona Medical Center in Tucson. Transports to these hospital centers are not made along regional lines and a physician may transport a parturient patient to either center. Maternal transports are made under the auspices of the Arizona Perinatal Program (APP), which was developed on receipt of The Robert Wood Johnson Grant in September of 1975. The Grant is unusual in that it was made jointly to the University of Arizona and the State of Arizona through the offices of the Arizona Medical Association Foundation. Therefore, this is a privatesector specialized health-care program designed to the end of providing care to women during high-risk pregnancies. The APP provides the following services: (1) maternal care (a fixed but limited amount is paid to tertiarycare centers for each inpatient day for program beneficiaries); (2) maternal transport; (3) consultation services; (4) communication and data systems; (5) transportation for nonroutine laboratory specimens; (6) education (physician, patient, and public).
Material and methods Medical records of the University Hospital, Arizona Medical Center, have been reviewed, and the initial 357 consecutive maternal transport patients were identified. For purposes of the study, a maternal transport patient was defined as a high-risk parturient patient who was specifically referred for the purpose of specialized care. Criteria for inclusion in the study group included: (1) referral of the patient by a physician, nurse, or appropriate ancillary medical personnel, (2) physical transportation of the patient from another health service facility, and (3) certification of the appropriateness of the transfer by the perinatal coordinator. Outpatient referrals to the high-risk clinic and self-referred or walk-in patients to Arizona Medical Center were specifically excluded.
402
Giles et al.
June 15, 1977 Am. J. Obstet. Gynecol.
Table I. Ethnic background of transport patients compared with the state of Arizona population 15.0
-E E
12.5
g j;
10.0 ,F 2 a2
g
5
t
0 14 16 18 20 22 24 2828
30 3234
38 384042
7.5
g g
5.0
=, -
2.5
jj
1 PmntugP
No. t/J Race
Anro?Xl stute
transports
0J total transport5
144 138
40.3 38.7
5.5 72.;
59
16.5
18.3
Indian Caucasian Spanish heritage
popthtion (%)
44 48
Age of mohx
Fig. 1. Maternal age at the time of admission for transport patients. The curve is an interpolation of birth rate data by age group for Arizona in 1974. During the time interval that these maternal transports were accomplished, there were 1,693 deliveries at Arizona Medical Center. Thus, 21.1 per cent of all patients delivered during the study interval were transport patients. Currently, some 20 to 25 maternity patients are transported to the Arizona Medical Center each month, and a distinct increasing trend is apparent. The data that follow are derived from the computerized data base generated for maternal transport patients. This information is presented not as a hallmark of care but rather as a substrate of data against which other institutions may compare transport data as they develop. Individual neonatal outcome data will not be presented herein but will be forthcoming. The following is, therefore, simply an overview of maternal transport experience at our institution.
Results and comment Characteristics of the transport patients. Ethnic background. The ethnic background of transported patients is presented in Table I. The percentage of transported patients for each ethnic group is contrasted with the percentages for the state population as a whole. The disproportionate number of transported lndian patients is apparently related to the increased incidence of obstetric problems among members of that group as well as to the early establishment of referral patterns for the Indian community in Arizona. Age. The age of maternal transport patients at the time of admission is shown in Fig. 1. Superimposed on the data is a curve representing the delivery rate by maternal age for the State of Arizona as a whole. This was derived as an interpolation of data obtained from the State Bureau of Vital Statistics. It should be noted that 108 transport patients were 19 years of age or younger at the time of admission. These teenagers
Table II. Previous maternal transport
0 i
157 53 73
3 4 5 6 7 8 9 10 11 12
25 18 12 9 * ; I 2 0 2
pregnancy group
43.9 20.4 14.8 7.0 5.0 3.4 2.5 1.4 0.0 0.3 0.6 0.0 0.6
experience
of‘ the
187 33 77
52.4 21.6 9.2
290 46 13
81.2 12.9 3.6
342 131
95.8 0.3 3.6
29 13 5 6 2 3 9
8.1 3.6 1.4 1.7 0.6 0.8 2.5
7 0 0 1
2.0 0.0 0.0 0.3
1
0.3
comprised 30.2 per cent of all transport patients. On the opposite end of the spectrum, 25 patient-s (7 per cent of the transport group) were 35 years or older. It is of interest that the disproportionate number of teenagers and elderly maternity patients in the transport series coincides with the increased obstetric risk reported in the literature for patients at both extremes of the childbearing age range. Previous pregnancy expetienre. From the computerized data base, the number of previous pregnancies, number of previous stillbirths and abortions, and the number of living children was extracted (TabIe II) for the maternal transport group. Parity ranged from zero to 12. Of all transport patients, 43.9 per cent were primagravid and almost 9 per cent had five or more previous deliveries. Almost one fourth of the patients had lost at least one prior pregnancy; 18.8 per cent had miscarried at least once and 2.3 per cent had- aborted three or more pregnancies. Fifteen patients in the series (4.2 per cent) had histories of one or more stillbirths. Sourer of prenatal CIIW. The source of prenatal care
Volume Number
Arizona high-risk maternal tansport
128 4
Difficult
Labor
403
19)
Rh 911s. (171 Abnormal
OB Hx (22)
No Prenatal Care (14) Abnormal
County Clinic (73)
Lllcz7) Bbedii
Private (106)
Other
Dbaan
bee Tabb
III) (5S)
I ~mbqusm
I
Inc. pbantll(38~
Hospital Clinic (161)
I i
Local
Facilitbs
Pmmatum Ruplum of hfambmnm
(731 (74)
Fm-scbmpsia ’ c
(78)
orno’
Pmmstum 0
I 5
I 10 Percantaga
I 15
I 20
Labor I 25
(108) 30
of Transports
Fig. 2. Source of prenatal care for transport patients prior to referral. The hospital clinic category includes government and private health services agencies, while the county clinic category refers to facilities totally financed by county governments.
Fig. 3. Indications for maternal transport in 357 patients. The total is greater than 100 per cent due to the multiple reasons for transport in 44 per cent of the cases.
for maternal transport patients prior to referral is presented in Fig. 2. Almost 4 per cent of the patients had received no prenatal care and were indeed walk-in patients with obstetric complications requiring immediate referral for specialized care. The largest source of referral was the primary hospital or a government or private health clinic facility, and the 161 patients from these sources accounted for 45 per cent of the total group. Almost 30 per cent of transport patients were referred directly by private practitioners, while 20 per cent came from county clinics. The term county clinics refers to facilities under the total administrative and financial control of county government. Frequency of prenatal visits. Fourteen patients received no prenatal care prior to the encounter requiring transport, and 61.9 per cent had made less than live prenatal visits (Table III). Indicationfor transport. The principal reasons necessitating maternal transport are presented in Fig. 3. The most often encountered problem requiring transport was premature labor, followed by pre-eclampsia and premature rupture of the chorioamnion. Due to the many difficulties encountered in transporting and adequate en route monitoring of a patient in active labor, referring physicans were encouraged to transport patients with ruptured membranes immediately rather than waiting to see whether active labor would
ensue. Thus, during the time interval of this study, the number of transports of patients with ruptured membranes was increasing somewhat, while the number of transports of patients in active premature labor showed a slight decreasing trend. Only nine patients (2 per cent) were actually transported because of a critical labor difficulty. In most cases of fetal distress or acute labor crisis, a consultant obstetrician, pediatrician, and nurse were dispatched to the outlying facility and delivery was accomplished there. In these instances, patients and their babies were excluded from the study. In Fig. 3, percentages are noted to add to more than 100 per cent due to multiple reasons for transport. One hundred and fifty-eight patients (44 per cent) were transported for more than one of the indications listed above. Associated medical problems. In addition to the primary indications for maternal transport, 37 patients (10.4 per cent of the group) had associated medical problems as shown in Table IV. Diabetes more severe than Class A was noted in 16 patients, chronic pulmonary disease in seven, and hypertension antedating the pregnancy in four. Only three transported patients had pregnancies complicated by drug addiction, as the majority of such patients are diagnosed and referred to the highrisk clinic well before delivery. Two of the three heroin-addicted transport patients had positive serologic tests for syphilis.
Giles et al.
404
June 15. 1977 Am. J.
Plo.of Tram-
ports
+
Obstel. Gyneroi.
%of Total
2
0.6
8
2.2
16
4.5
Fig. 4. Population distribution for the State of Arizona and isodistance curves from Tucson showing number of maternal transport patients and respective air distances from the Center.
Tabie group
III. Number of prenatal prior to transport No.
of visits
No.
None Less than 5 Five or more Unknown Table IV. Associated medical maternal transport patients
visits for study of patients
%
14 207
3.9 58.0 34.5 3.6
123 13
problems
of
Condition
% Patients
Epilepsy Pulmonary disease Pre-existing hypertension Thyroid disease Diabetes Drug abuse or addiction Venereal disease
0.6 2.0
1.1 0.3 4.5
0.8 1.1
Transport logistics. Population characteristics. The population distribution for the State of Arizona and 50 mile isodistance curves from Tucson are plotted in Fig. 4. The number of transport patients and their respective air distances from the tertiary center are recorded in the right-hand margin. One hundred fifty-two (42.5 per cent) were transported from within a 50 mile radius of Tucson, while 205 patients (57.5 per cent) were transported more than 50 miles. Fifty-two patients (14.7 per cent) traveled distances of 100 to 340 air miles.
Referral ken&. Fig. 5 depicts the maternal transport rate per 1,000 live births for each county of the state. Heaviest utilization of maternal transport in obstetric care was noted in the counties closest to the center in Tucson. The highest observed rate was for Cochise County, with 18.0 transport patients per 1,000 live births. For Pima County, in which Tucson is located, 14.4 mothers for every 1,000 live births were transported. Only one from Maricopa County (Phoenix) was transported to Tucson during the study interval, as excellent obstetric care facilities are available in Phoenix and the other tertiary care (transport) center is located there. Mode r!f‘transport. The transport mode for patients in the study group appears in Fig. 6. Most patients living 100 or more miles from the center were transported by air, especially when time en route was critical. Use of air transport also enabled members of the transport team (obstetrician, pediatrician, anesthesiologist, or nurse) to assess the patient at the distant facility and to accompany each patient during transit. Either the patient’s own physician or a physician from the center was in attendance throughout each air transport, whether by helicopter or fixed-wing aircraft. Forty-eight patients were transported by air. Patients living closer to ‘Tucson or with problems of lesser emergency nature were transported by private ambulance or personal automobile. The automobile category includes vans or public service vehicles utilized by somr of the outlying clinic facilities. Helicopter
Volume Number
Arizona
128 4
high-risk
maternal
transport
405
-r
Apache 0.0
Navajo 1.4 Airplane
i
3reenlee 10.7
(11%)
Automobile
(38%)
Ambulance
(44%)
20
30
10 Percentage
40
of Transports
Santa Cruz 8.1
Fig. 5. Arizona counties and respective rates of maternal transport to AMC per 1,000 live births. The overall rate for Arizona is 4.4 per 1,000 live births. To the nearest significant figure the rate of transport for Maricopa County (Phoenix) is 0.003 per 1,000 live births. transport has the great advantage of getting the patient virtually to the door of our facility, but the slowness compared with fixed-wing aircraft, the relatively short range without refueling, the compromised space for patients and equipment, and technical difficulties with take off and landing at 3,000 feet and greater altitudes in the desert at high ambient air temperatures are all reasons that our trend to helicopter use is decreasing. It would appear that helicopter use in densely populated metropolitan areas with surface traffic problems and relatively shorter transport distances would be of greater value. Outcome of maternal transports. The fetal and maternal outcome on a patient-by-patient basis provides detail beyond the scope of this initial overview of maternal transport and will be presented subsequently. Certain indicators of outcome are presented in Table V, however, and warrant comment. The live-born infant discharge rate of 93.1 per cent for high-risk maternal transport patients approaches and certainly compares favorably with the 95.8 per cent rate for the total service which is almost exclusively a high-risk service. The cost effectiveness of any such program is incalculable, since it is impossible to place a monetary value on a given obstetric situation or outcome. We can say that the average fixed-wing aircraft transport adds $485 to the other usual costs (based on a 200 mile
Fig. 6. Mode of transportation tients. Table V. Perinatal outcome 357 maternal transports)
for maternal
(during
the period
University of Arizona Medical Center obstetric service total Perinatal
outcome
No.
transport
pa-
of
Maternal tran.sf0rt.s only
%
No.
%
100
Deliveries
1,693
Live born
1,656 37 460
97.8 2.2 27.8
357 333 24 165
21.1 93.7 6.7 49.5
1,622
95.8
310
93.1
Stillborn Intensive Care Unit nursery admissions Live infants discharged
transport distance). The cost for maternal transport is no greater than for neonatal transport and is even less when the reduced equipment needs are considered. Our experience to date indicates that maternal transport is workable and does provide increased accessibility, acceptability, comprehensiveness, and quality of maternal and neonatal health services. The trend to increasing numbers of maternal transports would indicate that the physicians and patients of our area and state share in this opinion. The technical assistance of Doreen Lang, S. C. M., as well as the efforts of the senior staff and housestaff of the Obstetrical Services of the Arizona Medical Center is gratefully acknowledged.
406 Giles et al.
REFERENCES
1. Toward Improving the Outcome of Pregnancy-Recommendations of the Committee on Perinatal Health, H. Gardiner, Chairman, White Plains, N. Y., 1976, The National Foundation-March of Dimes.
Dkcussion DR. JACK G. HALLATT, Los Angeles,
California. In the practice of obstetrics, maternal transport to the hospital is peripheral to medical management except for the occasional rare emergency in which the commercial ambulance is used. Travel in pregnancy is not harmful and, as shown in’the Arizona experience, is the safest means of transport for the fetus. The unique geographic and demographic cifcumstances of Arizona have given us a preview of some of the problems of delivery of optimal medical care. Optimal medical care is now regarded as a basic human right which the medical profession must provide for all persons. This requires graded medical care which must be regionalized to be financially and professionally feasible. Optimal medical care for all is no longer dependent on the expertise of the available doctor, for he has become a part of a mechanized, centralized, and often computerized medical care delivery system that is dependent on highly specialized equipment and personnel. This has resulted in an obstetric and pediatric care cost explosion which the community hospital cannot and will not accept. The principle of regionalization of maternal and child care has been endorsed by the American Medical Association, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics. and the American Academy of Family Physicians. Dr. Christian has given us a prototype for the delivery of optimal care on a regional baiis. The logistics of transporting the high-risk patient to the appropriate center has been surfaced. About 20 per cent of all pregnancies are or will become high risk for the mother or the baby. These must be screened by early prenatal care, and 65 per cent of the high-risk population can be identified and transferred at the appropriate time and by the appropriate method if the objectives of regionalized care are to be realized. The success of regionalization depends on the cooperation and education of the patient, the primary physician, and the first-, second-, and third-level facilities. The coordinator is the third-level facility, which must also provide transportation and medical facilities and personnel. This is a medical problem and is the responsibility of the medical profession. I was recently in Arizona and was impressed by the pride of accomplishment of the medical profession of Arizona in the success of the Arizona perinatal program. The concerned medical community recognized the need to improve perinatal care and organized to meet that need within the structure of organized
June Am. J. Obstet.
2. Goals for Regionalized Perinatal Care, 1976, California Medical Association. 3. Sunshine, P.: Regionalization of Perinatal the Sixty-sixth Ross Conference, 1974, rector. Columbus, Ohio. Ross Laboratories.
San
I& 1977 Gynecol.
Francisco,
Care. Report A. Sehring,
of Di-
medicine in the state. This highly successful program bodes well for the future. I have two pertinent or impertinent questions for Dr. Christian relevant to nationalization of regionalization. Is it professionally possible to provide optimal perinatal care for the entire country at an acceptabie cost? What are the legal implications if there is a poor outcome in a patient who could have been, but was not, transferred to a third-level center? DR. ROBERTC. G~O~LIN, Stanford, California. Like the staff of many other teaching hospitals, we have been preaching that only we have a right to perform tertiary care. And it has worked out fairly well in our area, although, invariably, when the referring obstetrician phones us he explains that he can easily handle the obstetric problem, but he is sending in Mrs. X because he wants her near the intensive care nursery. I recently looked over 200 such transferred cases in our hospital and my worst fears were confirmed, because in only 18 of 200 cases did the infant actually end up in the intensive care unit. Most of these babies did well. Some patients were sent home undelivered. More and more of the regional hospitals in our area are delivering the mothers and sending the baby if he is ill. And I wonder if Dr. Christian, or anyone else, has any valid data which show that it is better to send the fetus in irs natural incubator-meaning the motherthan in an artificial incubator? Are there any data that show that it really is good to bring the mother to the hospital, rather than let her deliver and transfer the baby if he is ill? DR. DONALD MINKLER, San Francisco, California. I, too, want to congratulate Dr. Christian on his portrayal of Such a very intelligent and long overdue step in the regionalization of high-risk obstetric care. I want to ask him two questions: The first has to do with an intermediate step between in situ delivery of the high-risk mother and her transport and delivery in a tertiary care setting.. What brought this to mind was an experience that I recounted in a paper to this Society five years ago, based on an observation in East Africa where, according to a concept suggested by Dr. David Morley in West .Africa, the use of a “maternity village” or maternity waiting area” had been employed with some success. This consisted of a local “triage” process in which risk factors were identified, usually by village midwives. The patients at risk were then transported some weeks in advance of the anticipated term labor and housed, because of extremely limited resources in hospitals, in a little village or hut that was built just across the road
Volume Number
128
Arizona high-risk maternal transport
407
4
from the hospital. During this time they became a captive audience for late third-trimester therapeutic measures, whatever could be accomplished in the way of enhanced nutrition, health education, etc. Then, when labor began, the patient simply walked across the road to the hospital rather than walking four or five miles, as she might have, under her normal home circumstances. So I would like to ask Dr. Christian whether there is some counterpart, some “halfway house” or housing arrangement, that would reduce the cost and perhaps increase the practicality of maternal transport for patients for whom there is some delay between the time of transport and the time of expected delivery. My second question refers to his observation that close to 30 per cent of the patients involved in this transport operation had “premature labor” listed among risk factors involved in the obstetric situation. I would like to know what criteria are used for electing when and whether to transport patients at risk in whom labor may already have begun. DR. CHRISTIAN (Closing). In answer to Dr. Hallat: Optimum, of course, means the best you can do under any given set of circumstances. I suppose it is possible then to do the best you can under any given set of circumstances. Of course we are in a business in which the public’s expectations of health care will always exceed what we can do. We are always behind; I realize we always will be to some degree. The legal implications I do not know. We, of course, have not been concerned about them, but I think the relationships, quite honestly, that we are developing with the people who ask us to respond and to whoin we respond augur for them the feeling that we would be the first to go wherever and point out to whatever body the fact that they were well intentioned and had done good work, and so on. I think that would be a supportive measure for them, but legal implications I do not know. Intermediate facilities such as the small house that Dr. Minkler asked about are the sorts of things I speak about constantly to the dean and hospital manager. In Iowa, this was done for years in Quonset huts. Women, none of whom were high risk, were brought in two weeks prior to term. A second-year resident, if he would, came every morning and examined the cervix. How they managed that I do not know, but they did not have much trouble. They have given this up; I assume because transportation is quicker now. But it does not obviate our need for an intermediate center. The other part of this program is that we are happy to work with any hospital. People in Flagstaff are making a concerted effort to bring the Flagstaff hospital up to a Level II, an intermediate. Thirty per cent premature labor presents a problem. To transport a patient from 80 miles away with a breech and 5 cm. dilated is a judgment call.
In this series of patients there have been no maternal deaths. Since then, we have had two transported patients who were both moribund, one with acute yellow atrophy who was virtually dead upon arrival and one with pneumonia, who died within 2 hours of reaching our hospital. Dr. Goodlin’s comments are very keen. We attempted to make the state realize that the best way to transport an infant is in utero. But a pregnant woman does not attract any compassion from people who make those kinds of decisions. I would like to present a parable. It has to do with pediatricians and obstetricians. “Twas a dangerous cliff, as they freely confessed, though to walk near its crest was so pleasant. But o’er its terrible edge there had slipped a duke and fallen many a peasant. The people said something would have to be done but their projects did not at all tally. Some said put a fence around the edge of the cliff, some said an ambulance down in the valley. “The lament of the crowd was profound and was loud as their hearts overflowed with their pity. But the cry for the ambulance carried the day, as it spread through the neighboring city. A collection was made to accumulate aid and the dwellers in highway and alley, gave dollars or cents, not to furnish a fence, but to buy an ambulance down in the valley. “For the cliff is all right if you’re careful they said, and if folks ever slip and are dropping, it isn’t the slipping that hurts them so much as the shock down below when they’re stopping. So for years we have heard as these mishaps occurred, put forth with the rescuer’s sally, to pick up the victims who fell from the cliff with the ambulance down in the valley. Said one to his plea, it’s a marvel to me that you’d get so much greater attention, to repairing the results than to curing the cause. You’d have much better aim at prevention. For the mischief, of course, should be stopped at its source. Come neighbors and friends let us rally. It is far better sense to rely on a fence than an ambulance down in the valley. He is wrong in his head, the majority said, he would end all our earnest endeavor. He’s a man who would shirk his responsible work but we will support it forever. Aren’t we picking up all just as fast as they fall, and giving them care liberally. A superfluous fence is of no consequence, if the ambulance works in the valley. The story looks queer as we’ve written it here, but things often occur that are stranger. More humane we assert than to succor the hurt is to plan at removing the danger. The best possible course, is to safeguard the source, attend to things rationally. Yes, build up the fence and let us dispense with the ambulance down in the valley.” (Source unknown.)
C. D. Tucson
R. GILES, ISAMAN,
J.
MOORE,
M.D. M.A.
M.D.
CHRISTIAN, and Phoenix,
M.D. Arizona
There are two Level III Maternity Centers in Arizona at the present time. A statewide system of maternal transport to these two centers exists as part of the Arizona Perlnatal Program, and the characteristics of the first 357 maternal transports to one of these centers (Arizona Medical Center, Tucson) are reported herein. The manner in which the Prcgram was developed is described. It is our hope that this overview of our initial experience will be of interest to those persons developing a graded-care program for high&k maternal patients. (AM. J. OBSTET. GYNECOL. 128: 400, 1977.)
FROM THE TIME of the 1971 American Medical Association House of Delegates statement,* which states the position that community (regional) systems of graded care for the parturient patient and her offspring would further reduce maternal and infant mortality rates and morbidity, to the present, there have been many papers and position statements reiterating the gradedcare concept. One of the first states to take a positive position was California. The California Medical Association adopted the concept of centralized community care, and recently this view has been expanded into a publication2 The California Criteria for Levels I, II. and III (or rural, urban, and regional or primary, secondary, and tertiary-no one system of terminology is satisfactory to everyone) centers are those that have been adopted in general by most states or regions considering regionahzation of the graded-care concept for mothers and infants.
The recent publication by the National Foundation-March of Dimes, Toward Im@kng the @itcome oj Pregnancy, ’ is one of the more complete statements of the how and why of graded obstetric care. The report of the Ross Conference” and the statement of the American College of Obstetricians and Gynecologists are also recommended for further background reading.
Arizona presents some geographic and population distribution features that are unique to certain western and midwestern states. Sixth in land size, Arizona had an estimated population of 2,245,OOO persons in 1975, and ranked thirty-second among states in population. The majority of the population resides in two of the 14 counties. Maricopa County (Phoenix) contains 54.8 per cent and Pima County (Tucson) 20.1 per cent of the population of the state. AIthough the over-all popuiation density is some 19 persons per square mile, the density outside of the two metropolitan counties is only six persons per square mile. Likewise, the considerable majority of physicians of the state reside in these two counties. Of the 142 trained obstetricians-gynecologists of the state who are currently engaged in the practice of obstetrics, 90 are in the Phoenix area and 41 are in the Tucson area. Similar percentage figures exist for pediatricians in the state, and it was from the earlier neonatal and infant transport data that the establishment of a structured maternal transport system seemed to make such
From the Department of Obstetrics and Gynecology, University of Arizona College of Medicine, and the University Hospital Arizona Medical Center, the Arizona Perinatal Program. The maternal transports Were supported by a grant from the Robert Wood Johnson Foundation to thp University oj Arizona and the State of Arizona. The prenatal diagnostic laboratory was supported in part by a Medical Services Grant from the National Foundation-March of Dimes. Presented by invitation at the Forty-third Annual of the Pacific Coast Obstetrical and,Gynecological Kona, Hawaii, November 7-13, 1976.
Meeting Society,
Reprint requests: Dr. C. D. Christian, Department of Obstetrics and Gynecology, Arizona Medical Center, Tucson, Arizona 85724. 400
Volume 128
Arizona high-risk maternal transport
401
Number4
imminent good sense. In 1960, the statewide infant mortality rate ranked forty-fifth of the 50 states, and 43 per cent of the inpatients hospitalized for custodial care of severe retardation in the Arizona Children’s Colony became retarded during the perinatal period. A group of concerned physicians and nurses, among other citizens, created the Advisory Committee on the Premature to the Arizona State Division of Maternal and Child Health.3 In 1967, the State Health Department initiated a demonstration project to transport sick newborn infants from rural hospitals to one of two hospital centers in Phoenix. The experience was so salutary that, in 1970, The Arizona State Department of Health Services began funding neonatal transport services and a third hospital center was added in Tucson. Arizona improved in the national state ranking by infant mortality rate from forty-fifth to forty-third during the period from 1959 to 1966 and from forty-third to the eleventh during the five years from 1967 to 1972. The advantages of having the ready and willing cooperation of the neonatologists and their considerable and excellent experience and the opportunity to open a new 300 bed hospital center (University Hospital, University of Arizona, Tucson) fully equipped to meet all criteria of Level III care for obstetrics made maternal transport an obvious and desired end. From the opening in the fall of 197 1 until the beginning of 1973, however, transport took place in the usual ad hoc unstructured fashion. When the perinatologist (H. R. G.) joined the staff, transport was begun in a structured manner. Nurses and physicians were instructed in the vagaries of transporting high-risk maternity patients by ambulance, helicopter, and fixed-wing aircraft. The physicians of the state were notified that consultative services by phone are available around the clock and that transportation services exist. However, there was no funding for transportation, and each individual transport had to be managed in whatever manner available. The State Department of Public Safety was always cooperative and provided an airplane or helicopter whenever such was available. The Neonatal Transport System was also maximally cooperative and allowed some of the funding from the State Division of Maternal Child Health to be used for maternal transport. Funding of such a system poses a unique problem in Arizona. Arizona is the only state that does not have Medicaid. It has a relatively low tax base because only 17.5 per cent of land ownership is private (43.5 per cent is federally owned, 12.2 per cent is state owned, and 26.7 per cent comprises Indian reservations). The uniqueness of any funding situation is, of course, rel-
ative and exists for any state or area. However, funding is of absolute necessity, for such a program, and for this reason The Robert Wood Johnson Grant for regionalization of high-risk maternal services made our current structured transport system possible. At the present time, infants are transported to one of two hospital centers in Phoenix (St. Joseph’s Hospital or Good Samaritan Hospital) or to either of two hospitals in Tucson (Arizona Medical Center or Tucson Medical Center) under the auspices of the Arizona Infant Transport Program. The Infant Transport System is divided into two regions, with those transports from northern Arizona going primarily to Phoenix and those from the Southern portion generally going to Tucson. Maternal transports are made to St. Joseph’s Hospital in Phoenix or the Arizona Medical Center in Tucson. Transports to these hospital centers are not made along regional lines and a physician may transport a parturient patient to either center. Maternal transports are made under the auspices of the Arizona Perinatal Program (APP), which was developed on receipt of The Robert Wood Johnson Grant in September of 1975. The Grant is unusual in that it was made jointly to the University of Arizona and the State of Arizona through the offices of the Arizona Medical Association Foundation. Therefore, this is a privatesector specialized health-care program designed to the end of providing care to women during high-risk pregnancies. The APP provides the following services: (1) maternal care (a fixed but limited amount is paid to tertiarycare centers for each inpatient day for program beneficiaries); (2) maternal transport; (3) consultation services; (4) communication and data systems; (5) transportation for nonroutine laboratory specimens; (6) education (physician, patient, and public).
Material and methods Medical records of the University Hospital, Arizona Medical Center, have been reviewed, and the initial 357 consecutive maternal transport patients were identified. For purposes of the study, a maternal transport patient was defined as a high-risk parturient patient who was specifically referred for the purpose of specialized care. Criteria for inclusion in the study group included: (1) referral of the patient by a physician, nurse, or appropriate ancillary medical personnel, (2) physical transportation of the patient from another health service facility, and (3) certification of the appropriateness of the transfer by the perinatal coordinator. Outpatient referrals to the high-risk clinic and self-referred or walk-in patients to Arizona Medical Center were specifically excluded.
402
Giles et al.
June 15, 1977 Am. J. Obstet. Gynecol.
Table I. Ethnic background of transport patients compared with the state of Arizona population 15.0
-E E
12.5
g j;
10.0 ,F 2 a2
g
5
t
0 14 16 18 20 22 24 2828
30 3234
38 384042
7.5
g g
5.0
=, -
2.5
jj
1 PmntugP
No. t/J Race
Anro?Xl stute
transports
0J total transport5
144 138
40.3 38.7
5.5 72.;
59
16.5
18.3
Indian Caucasian Spanish heritage
popthtion (%)
44 48
Age of mohx
Fig. 1. Maternal age at the time of admission for transport patients. The curve is an interpolation of birth rate data by age group for Arizona in 1974. During the time interval that these maternal transports were accomplished, there were 1,693 deliveries at Arizona Medical Center. Thus, 21.1 per cent of all patients delivered during the study interval were transport patients. Currently, some 20 to 25 maternity patients are transported to the Arizona Medical Center each month, and a distinct increasing trend is apparent. The data that follow are derived from the computerized data base generated for maternal transport patients. This information is presented not as a hallmark of care but rather as a substrate of data against which other institutions may compare transport data as they develop. Individual neonatal outcome data will not be presented herein but will be forthcoming. The following is, therefore, simply an overview of maternal transport experience at our institution.
Results and comment Characteristics of the transport patients. Ethnic background. The ethnic background of transported patients is presented in Table I. The percentage of transported patients for each ethnic group is contrasted with the percentages for the state population as a whole. The disproportionate number of transported lndian patients is apparently related to the increased incidence of obstetric problems among members of that group as well as to the early establishment of referral patterns for the Indian community in Arizona. Age. The age of maternal transport patients at the time of admission is shown in Fig. 1. Superimposed on the data is a curve representing the delivery rate by maternal age for the State of Arizona as a whole. This was derived as an interpolation of data obtained from the State Bureau of Vital Statistics. It should be noted that 108 transport patients were 19 years of age or younger at the time of admission. These teenagers
Table II. Previous maternal transport
0 i
157 53 73
3 4 5 6 7 8 9 10 11 12
25 18 12 9 * ; I 2 0 2
pregnancy group
43.9 20.4 14.8 7.0 5.0 3.4 2.5 1.4 0.0 0.3 0.6 0.0 0.6
experience
of‘ the
187 33 77
52.4 21.6 9.2
290 46 13
81.2 12.9 3.6
342 131
95.8 0.3 3.6
29 13 5 6 2 3 9
8.1 3.6 1.4 1.7 0.6 0.8 2.5
7 0 0 1
2.0 0.0 0.0 0.3
1
0.3
comprised 30.2 per cent of all transport patients. On the opposite end of the spectrum, 25 patient-s (7 per cent of the transport group) were 35 years or older. It is of interest that the disproportionate number of teenagers and elderly maternity patients in the transport series coincides with the increased obstetric risk reported in the literature for patients at both extremes of the childbearing age range. Previous pregnancy expetienre. From the computerized data base, the number of previous pregnancies, number of previous stillbirths and abortions, and the number of living children was extracted (TabIe II) for the maternal transport group. Parity ranged from zero to 12. Of all transport patients, 43.9 per cent were primagravid and almost 9 per cent had five or more previous deliveries. Almost one fourth of the patients had lost at least one prior pregnancy; 18.8 per cent had miscarried at least once and 2.3 per cent had- aborted three or more pregnancies. Fifteen patients in the series (4.2 per cent) had histories of one or more stillbirths. Sourer of prenatal CIIW. The source of prenatal care
Volume Number
Arizona high-risk maternal tansport
128 4
Difficult
Labor
403
19)
Rh 911s. (171 Abnormal
OB Hx (22)
No Prenatal Care (14) Abnormal
County Clinic (73)
Lllcz7) Bbedii
Private (106)
Other
Dbaan
bee Tabb
III) (5S)
I ~mbqusm
I
Inc. pbantll(38~
Hospital Clinic (161)
I i
Local
Facilitbs
Pmmatum Ruplum of hfambmnm
(731 (74)
Fm-scbmpsia ’ c
(78)
orno’
Pmmstum 0
I 5
I 10 Percantaga
I 15
I 20
Labor I 25
(108) 30
of Transports
Fig. 2. Source of prenatal care for transport patients prior to referral. The hospital clinic category includes government and private health services agencies, while the county clinic category refers to facilities totally financed by county governments.
Fig. 3. Indications for maternal transport in 357 patients. The total is greater than 100 per cent due to the multiple reasons for transport in 44 per cent of the cases.
for maternal transport patients prior to referral is presented in Fig. 2. Almost 4 per cent of the patients had received no prenatal care and were indeed walk-in patients with obstetric complications requiring immediate referral for specialized care. The largest source of referral was the primary hospital or a government or private health clinic facility, and the 161 patients from these sources accounted for 45 per cent of the total group. Almost 30 per cent of transport patients were referred directly by private practitioners, while 20 per cent came from county clinics. The term county clinics refers to facilities under the total administrative and financial control of county government. Frequency of prenatal visits. Fourteen patients received no prenatal care prior to the encounter requiring transport, and 61.9 per cent had made less than live prenatal visits (Table III). Indicationfor transport. The principal reasons necessitating maternal transport are presented in Fig. 3. The most often encountered problem requiring transport was premature labor, followed by pre-eclampsia and premature rupture of the chorioamnion. Due to the many difficulties encountered in transporting and adequate en route monitoring of a patient in active labor, referring physicans were encouraged to transport patients with ruptured membranes immediately rather than waiting to see whether active labor would
ensue. Thus, during the time interval of this study, the number of transports of patients with ruptured membranes was increasing somewhat, while the number of transports of patients in active premature labor showed a slight decreasing trend. Only nine patients (2 per cent) were actually transported because of a critical labor difficulty. In most cases of fetal distress or acute labor crisis, a consultant obstetrician, pediatrician, and nurse were dispatched to the outlying facility and delivery was accomplished there. In these instances, patients and their babies were excluded from the study. In Fig. 3, percentages are noted to add to more than 100 per cent due to multiple reasons for transport. One hundred and fifty-eight patients (44 per cent) were transported for more than one of the indications listed above. Associated medical problems. In addition to the primary indications for maternal transport, 37 patients (10.4 per cent of the group) had associated medical problems as shown in Table IV. Diabetes more severe than Class A was noted in 16 patients, chronic pulmonary disease in seven, and hypertension antedating the pregnancy in four. Only three transported patients had pregnancies complicated by drug addiction, as the majority of such patients are diagnosed and referred to the highrisk clinic well before delivery. Two of the three heroin-addicted transport patients had positive serologic tests for syphilis.
Giles et al.
404
June 15. 1977 Am. J.
Plo.of Tram-
ports
+
Obstel. Gyneroi.
%of Total
2
0.6
8
2.2
16
4.5
Fig. 4. Population distribution for the State of Arizona and isodistance curves from Tucson showing number of maternal transport patients and respective air distances from the Center.
Tabie group
III. Number of prenatal prior to transport No.
of visits
No.
None Less than 5 Five or more Unknown Table IV. Associated medical maternal transport patients
visits for study of patients
%
14 207
3.9 58.0 34.5 3.6
123 13
problems
of
Condition
% Patients
Epilepsy Pulmonary disease Pre-existing hypertension Thyroid disease Diabetes Drug abuse or addiction Venereal disease
0.6 2.0
1.1 0.3 4.5
0.8 1.1
Transport logistics. Population characteristics. The population distribution for the State of Arizona and 50 mile isodistance curves from Tucson are plotted in Fig. 4. The number of transport patients and their respective air distances from the tertiary center are recorded in the right-hand margin. One hundred fifty-two (42.5 per cent) were transported from within a 50 mile radius of Tucson, while 205 patients (57.5 per cent) were transported more than 50 miles. Fifty-two patients (14.7 per cent) traveled distances of 100 to 340 air miles.
Referral ken&. Fig. 5 depicts the maternal transport rate per 1,000 live births for each county of the state. Heaviest utilization of maternal transport in obstetric care was noted in the counties closest to the center in Tucson. The highest observed rate was for Cochise County, with 18.0 transport patients per 1,000 live births. For Pima County, in which Tucson is located, 14.4 mothers for every 1,000 live births were transported. Only one from Maricopa County (Phoenix) was transported to Tucson during the study interval, as excellent obstetric care facilities are available in Phoenix and the other tertiary care (transport) center is located there. Mode r!f‘transport. The transport mode for patients in the study group appears in Fig. 6. Most patients living 100 or more miles from the center were transported by air, especially when time en route was critical. Use of air transport also enabled members of the transport team (obstetrician, pediatrician, anesthesiologist, or nurse) to assess the patient at the distant facility and to accompany each patient during transit. Either the patient’s own physician or a physician from the center was in attendance throughout each air transport, whether by helicopter or fixed-wing aircraft. Forty-eight patients were transported by air. Patients living closer to ‘Tucson or with problems of lesser emergency nature were transported by private ambulance or personal automobile. The automobile category includes vans or public service vehicles utilized by somr of the outlying clinic facilities. Helicopter
Volume Number
Arizona
128 4
high-risk
maternal
transport
405
-r
Apache 0.0
Navajo 1.4 Airplane
i
3reenlee 10.7
(11%)
Automobile
(38%)
Ambulance
(44%)
20
30
10 Percentage
40
of Transports
Santa Cruz 8.1
Fig. 5. Arizona counties and respective rates of maternal transport to AMC per 1,000 live births. The overall rate for Arizona is 4.4 per 1,000 live births. To the nearest significant figure the rate of transport for Maricopa County (Phoenix) is 0.003 per 1,000 live births. transport has the great advantage of getting the patient virtually to the door of our facility, but the slowness compared with fixed-wing aircraft, the relatively short range without refueling, the compromised space for patients and equipment, and technical difficulties with take off and landing at 3,000 feet and greater altitudes in the desert at high ambient air temperatures are all reasons that our trend to helicopter use is decreasing. It would appear that helicopter use in densely populated metropolitan areas with surface traffic problems and relatively shorter transport distances would be of greater value. Outcome of maternal transports. The fetal and maternal outcome on a patient-by-patient basis provides detail beyond the scope of this initial overview of maternal transport and will be presented subsequently. Certain indicators of outcome are presented in Table V, however, and warrant comment. The live-born infant discharge rate of 93.1 per cent for high-risk maternal transport patients approaches and certainly compares favorably with the 95.8 per cent rate for the total service which is almost exclusively a high-risk service. The cost effectiveness of any such program is incalculable, since it is impossible to place a monetary value on a given obstetric situation or outcome. We can say that the average fixed-wing aircraft transport adds $485 to the other usual costs (based on a 200 mile
Fig. 6. Mode of transportation tients. Table V. Perinatal outcome 357 maternal transports)
for maternal
(during
the period
University of Arizona Medical Center obstetric service total Perinatal
outcome
No.
transport
pa-
of
Maternal tran.sf0rt.s only
%
No.
%
100
Deliveries
1,693
Live born
1,656 37 460
97.8 2.2 27.8
357 333 24 165
21.1 93.7 6.7 49.5
1,622
95.8
310
93.1
Stillborn Intensive Care Unit nursery admissions Live infants discharged
transport distance). The cost for maternal transport is no greater than for neonatal transport and is even less when the reduced equipment needs are considered. Our experience to date indicates that maternal transport is workable and does provide increased accessibility, acceptability, comprehensiveness, and quality of maternal and neonatal health services. The trend to increasing numbers of maternal transports would indicate that the physicians and patients of our area and state share in this opinion. The technical assistance of Doreen Lang, S. C. M., as well as the efforts of the senior staff and housestaff of the Obstetrical Services of the Arizona Medical Center is gratefully acknowledged.
406 Giles et al.
REFERENCES
1. Toward Improving the Outcome of Pregnancy-Recommendations of the Committee on Perinatal Health, H. Gardiner, Chairman, White Plains, N. Y., 1976, The National Foundation-March of Dimes.
Dkcussion DR. JACK G. HALLATT, Los Angeles,
California. In the practice of obstetrics, maternal transport to the hospital is peripheral to medical management except for the occasional rare emergency in which the commercial ambulance is used. Travel in pregnancy is not harmful and, as shown in’the Arizona experience, is the safest means of transport for the fetus. The unique geographic and demographic cifcumstances of Arizona have given us a preview of some of the problems of delivery of optimal medical care. Optimal medical care is now regarded as a basic human right which the medical profession must provide for all persons. This requires graded medical care which must be regionalized to be financially and professionally feasible. Optimal medical care for all is no longer dependent on the expertise of the available doctor, for he has become a part of a mechanized, centralized, and often computerized medical care delivery system that is dependent on highly specialized equipment and personnel. This has resulted in an obstetric and pediatric care cost explosion which the community hospital cannot and will not accept. The principle of regionalization of maternal and child care has been endorsed by the American Medical Association, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics. and the American Academy of Family Physicians. Dr. Christian has given us a prototype for the delivery of optimal care on a regional baiis. The logistics of transporting the high-risk patient to the appropriate center has been surfaced. About 20 per cent of all pregnancies are or will become high risk for the mother or the baby. These must be screened by early prenatal care, and 65 per cent of the high-risk population can be identified and transferred at the appropriate time and by the appropriate method if the objectives of regionalized care are to be realized. The success of regionalization depends on the cooperation and education of the patient, the primary physician, and the first-, second-, and third-level facilities. The coordinator is the third-level facility, which must also provide transportation and medical facilities and personnel. This is a medical problem and is the responsibility of the medical profession. I was recently in Arizona and was impressed by the pride of accomplishment of the medical profession of Arizona in the success of the Arizona perinatal program. The concerned medical community recognized the need to improve perinatal care and organized to meet that need within the structure of organized
June Am. J. Obstet.
2. Goals for Regionalized Perinatal Care, 1976, California Medical Association. 3. Sunshine, P.: Regionalization of Perinatal the Sixty-sixth Ross Conference, 1974, rector. Columbus, Ohio. Ross Laboratories.
San
I& 1977 Gynecol.
Francisco,
Care. Report A. Sehring,
of Di-
medicine in the state. This highly successful program bodes well for the future. I have two pertinent or impertinent questions for Dr. Christian relevant to nationalization of regionalization. Is it professionally possible to provide optimal perinatal care for the entire country at an acceptabie cost? What are the legal implications if there is a poor outcome in a patient who could have been, but was not, transferred to a third-level center? DR. ROBERTC. G~O~LIN, Stanford, California. Like the staff of many other teaching hospitals, we have been preaching that only we have a right to perform tertiary care. And it has worked out fairly well in our area, although, invariably, when the referring obstetrician phones us he explains that he can easily handle the obstetric problem, but he is sending in Mrs. X because he wants her near the intensive care nursery. I recently looked over 200 such transferred cases in our hospital and my worst fears were confirmed, because in only 18 of 200 cases did the infant actually end up in the intensive care unit. Most of these babies did well. Some patients were sent home undelivered. More and more of the regional hospitals in our area are delivering the mothers and sending the baby if he is ill. And I wonder if Dr. Christian, or anyone else, has any valid data which show that it is better to send the fetus in irs natural incubator-meaning the motherthan in an artificial incubator? Are there any data that show that it really is good to bring the mother to the hospital, rather than let her deliver and transfer the baby if he is ill? DR. DONALD MINKLER, San Francisco, California. I, too, want to congratulate Dr. Christian on his portrayal of Such a very intelligent and long overdue step in the regionalization of high-risk obstetric care. I want to ask him two questions: The first has to do with an intermediate step between in situ delivery of the high-risk mother and her transport and delivery in a tertiary care setting.. What brought this to mind was an experience that I recounted in a paper to this Society five years ago, based on an observation in East Africa where, according to a concept suggested by Dr. David Morley in West .Africa, the use of a “maternity village” or maternity waiting area” had been employed with some success. This consisted of a local “triage” process in which risk factors were identified, usually by village midwives. The patients at risk were then transported some weeks in advance of the anticipated term labor and housed, because of extremely limited resources in hospitals, in a little village or hut that was built just across the road
Volume Number
128
Arizona high-risk maternal transport
407
4
from the hospital. During this time they became a captive audience for late third-trimester therapeutic measures, whatever could be accomplished in the way of enhanced nutrition, health education, etc. Then, when labor began, the patient simply walked across the road to the hospital rather than walking four or five miles, as she might have, under her normal home circumstances. So I would like to ask Dr. Christian whether there is some counterpart, some “halfway house” or housing arrangement, that would reduce the cost and perhaps increase the practicality of maternal transport for patients for whom there is some delay between the time of transport and the time of expected delivery. My second question refers to his observation that close to 30 per cent of the patients involved in this transport operation had “premature labor” listed among risk factors involved in the obstetric situation. I would like to know what criteria are used for electing when and whether to transport patients at risk in whom labor may already have begun. DR. CHRISTIAN (Closing). In answer to Dr. Hallat: Optimum, of course, means the best you can do under any given set of circumstances. I suppose it is possible then to do the best you can under any given set of circumstances. Of course we are in a business in which the public’s expectations of health care will always exceed what we can do. We are always behind; I realize we always will be to some degree. The legal implications I do not know. We, of course, have not been concerned about them, but I think the relationships, quite honestly, that we are developing with the people who ask us to respond and to whoin we respond augur for them the feeling that we would be the first to go wherever and point out to whatever body the fact that they were well intentioned and had done good work, and so on. I think that would be a supportive measure for them, but legal implications I do not know. Intermediate facilities such as the small house that Dr. Minkler asked about are the sorts of things I speak about constantly to the dean and hospital manager. In Iowa, this was done for years in Quonset huts. Women, none of whom were high risk, were brought in two weeks prior to term. A second-year resident, if he would, came every morning and examined the cervix. How they managed that I do not know, but they did not have much trouble. They have given this up; I assume because transportation is quicker now. But it does not obviate our need for an intermediate center. The other part of this program is that we are happy to work with any hospital. People in Flagstaff are making a concerted effort to bring the Flagstaff hospital up to a Level II, an intermediate. Thirty per cent premature labor presents a problem. To transport a patient from 80 miles away with a breech and 5 cm. dilated is a judgment call.
In this series of patients there have been no maternal deaths. Since then, we have had two transported patients who were both moribund, one with acute yellow atrophy who was virtually dead upon arrival and one with pneumonia, who died within 2 hours of reaching our hospital. Dr. Goodlin’s comments are very keen. We attempted to make the state realize that the best way to transport an infant is in utero. But a pregnant woman does not attract any compassion from people who make those kinds of decisions. I would like to present a parable. It has to do with pediatricians and obstetricians. “Twas a dangerous cliff, as they freely confessed, though to walk near its crest was so pleasant. But o’er its terrible edge there had slipped a duke and fallen many a peasant. The people said something would have to be done but their projects did not at all tally. Some said put a fence around the edge of the cliff, some said an ambulance down in the valley. “The lament of the crowd was profound and was loud as their hearts overflowed with their pity. But the cry for the ambulance carried the day, as it spread through the neighboring city. A collection was made to accumulate aid and the dwellers in highway and alley, gave dollars or cents, not to furnish a fence, but to buy an ambulance down in the valley. “For the cliff is all right if you’re careful they said, and if folks ever slip and are dropping, it isn’t the slipping that hurts them so much as the shock down below when they’re stopping. So for years we have heard as these mishaps occurred, put forth with the rescuer’s sally, to pick up the victims who fell from the cliff with the ambulance down in the valley. Said one to his plea, it’s a marvel to me that you’d get so much greater attention, to repairing the results than to curing the cause. You’d have much better aim at prevention. For the mischief, of course, should be stopped at its source. Come neighbors and friends let us rally. It is far better sense to rely on a fence than an ambulance down in the valley. He is wrong in his head, the majority said, he would end all our earnest endeavor. He’s a man who would shirk his responsible work but we will support it forever. Aren’t we picking up all just as fast as they fall, and giving them care liberally. A superfluous fence is of no consequence, if the ambulance works in the valley. The story looks queer as we’ve written it here, but things often occur that are stranger. More humane we assert than to succor the hurt is to plan at removing the danger. The best possible course, is to safeguard the source, attend to things rationally. Yes, build up the fence and let us dispense with the ambulance down in the valley.” (Source unknown.)