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The maternal mortality remainder
Special Article THE MATERNAL
MORTAUTY
BP%-BR”
CHARLES A. GORDON, M.D., BROOKLYN,N.Y.
T
HE United States is the first great nation to breach the wall of one maternal death per 1,000 live births. The National Office of Vital Statistics’ believes that the maternal mortality rate for 1949 will be nearly 20 per cent lower than for 1948 and estimates it as 8.2 per 10,000 live births and not as 0.8 per 1,000. This stRtistica1 innovation no doubt has its advantages, yet it fails to dramatize the startling decline to a new low which many have called the irreducible or inescapable minimum. For the first time the patient may be told that her chances of surviving pregnancy are better than 999 in 1,000 and getting better every year. It should be kept in mind too that this includes the considerable risk of ectopic pregnancy and abortion. There is, however, a wide racial differential in that the rate for the non-white races is more than three times as high as the rate for white women. From 1915 to 1929 the national maternal mortality rates2 remained at about the same level with the exception of the high points of 1918 (9.2) and 1920 (8.0). From 1930 to 1936 steady but Iittle improvement occurred. Since then the rate has speedily decreased. In 1948,2 the last year for which complete data are available, the number of maternal deaths was 4,122 and the mortality rate 1.2 per 1,000 live births. That year there were 3,535,068 live births or but 4.5 per cent less than the all-time high figure of 1947, or nearly one and one-half million more than in 1933 when the maternal mortality rate was more than five t,imes as high. Jt is now said3 that “the maternal death rate is no longer a serious national problem, but rather one for local action in those areas in which rates are relatively high. ” It will always remain a local problem, and not only where rates are high. In Brooklyn, for instance, where the rate has been below 1 since 1946, it is not a hazardous prediction to say that it will continue to decrease. It is not easy to figure a time scheme for further reduction, but it can be reduced. The greatest number of maternal deaths ever recorded in the United States was in 1928 when 44 states reported 15,461 deaths. Interest in the eomparability of national statistics was high shortly before 1930. The Children’s 13ureau compiled a table4 in which the maternal mortality rate of the United Stat,es from 1926 to 1928 exceeded that of any other country on the list. It was higher than in Australia, England and Wales, Ireland, Italy, Japan, New *Road
before
the
Medical
Society
of the
County
1132
of
Kings,
May
15,
1951.
Volume Number
62 5
MATERNAL
MORTALITY
REMAINDER
1133
Zealand, Scotland and Sweden. The low rate in the Scandinavian countries and in Holland, though not fully explained, was attributed to the great attention paid to the training and status of midwives in those countries. Haven Emerson5 maintained that “international comparisons based on national maternal mortality were misleading.” In another Children’s Bureau6 publication Tandy showed that the rates were directly comparable. As recently as 1940 cont,roversy was bitter. An editorial in The Journal of the American Medical Association said that “maternal mortality rates of the United States have been reported and discussed for several years apparently to conjure conclusions designed to throw discredit upon the medical profession. . . . Again and again the propagandist alleged that the United States was lagging behind most of the other modern nations in its maternal mortality rate. This conclusion was reached by comparing nations some of which were not larger than some counties in the United States, and with an exclusively white population less than that of some American cities, with the entire continental United States with its wide diversity of population including 10 per cent of Negroes with a peculiarly high maternal mortality rate. ” In the decade ending in 1930 obstetricians in this country appeared to divide themselves into conservatives and radicals in the management of normal labor.’ In 1929 Polak,s a powerful advocate of natural methods in the conduct of labor, thought that lack of prenatal care, interference with normal labor, and unnecessary cesarean sections contributed to the high maternal mortality, “the result of the teachings of some prominent obstetricians who have been busy inventing operative procedures to control the onset of labor, or shorten or eliminate the second stage of labor or improve the physiologic mechanism of placental delivery. One of these men induces labor in all women at term; another cuts the perineum of every primipara, while still another does a section on every tenth woman and a version on the other nine. Most remarkable of all is the teaching of one of our leading obstetricians who classes all labor as pathologic and advocates rapid delivery with forceps through a cut pelvic floor as soon as the head has passed through the cervix, folllowiug this by manual removal of the placenta.” In 1931 AdaiF who, with Holmes and Lynch, had long been active on the Advisory Council of the Children’s Bureau and later became chairman of the American Committee on Maternal Welfare, which was incorporated in 1934, said that “the high maternal death rate in this country is a reflection on the training and education of the personnel responsible for furnishing maternity care.” Prior to enactment of the Shepard-Towner Act of 1921, maternal health activities were carried on by but a few State Health Departments or State Aside from certain writers of the past who had touched Medical Societies.l” in one way or another upon the number of maternal deaths, general medical It is less than twenty years since the shortcomings of interest lagged. American obstetrics were paraded in the public press, and it is much less than that since victory over maternal death statistics was won-if it has been won, yet the impact of the conquest has been SO slight that they who have hen re-
1134
C:ORl)ON
!\rn. I. Obst. g; Gynec. November. 195 I
sponsible for the victory hardly know that there was a battle. The Brooklyn Committee on Maternal Welfare began its work in 1934, shortly after what was called the unnecessary deaths of mothers had become a common topic of discussion in the daily press. In 1933, the preceding year, the maternal morta1it.y rate for Brooklyn was 7 with 284 maternal deaths while the rate for the entire City of New York was 6.4. The great progress that has been macle since that time is largely due, in my opinion, to critical analysis and discussion of our own end results and steady increase in the number of qualified obstetricians. It has long been said That that general practice will always carry the heavy burden of obstetrics. is no longer true. The history of the great attack on maternal mortality has never been written, though it should be. It is not yet finished, for the maternal mortality remainder is an attractive target. Another generation of obstetricians will need inspiration. To turn aside for a few moments will not be a digression. It is good to look backward, for it will help us to go forward. As early as 1917, Kosmak,ll the first crusader, interested the New York Academy of Medicine in a five-year study of puerperal mortality in the hospitals of New York City; nothing was publishrd, however. In 1924 DeNormanclie, at the request, of t,he Children’s Bureau, formed a committee which clrew up standa,rds of prenatal care’?; and in 1926. R.Schairman of its Obstetric Advisory Committee, he presented to the Children’s Bureau a fine planI for detailed study of the maternal deaths in fifteen states which was published in 1933. In 1930 Lohenstinc and Kosmak, as a committee of the New York Obstetrical Society, joined the Children’s Welfare Federation of New York City’+ in. publication of standards for maternity care. In 1931 the Medical Society of New Jersey’” appointed a committee on maternal welfare to enlarge the educational program organized in Essex County by Bingham in 1923. Some postgraduate courses in obstetrics, not,ably by Calkins in Kansas and Oklahoma, and McCord in Qeorgia round out the medical scene fairly wellI .A quotation from the 1930 report of the Committee on Maternal Welfare of the American Association of Obstetricians, Gynecologists and Abdominal Surgecx@ (Irving WT. Potter, Willard R. Cooke, anal IA. A. Calkins) will help to illustrate the public interest in the problem : 1‘ An interesting side light has been thrown several times lately upon the question of maternal welfare by the invasion of this field by the lay woman, through the medium of the popular magazine. One such discussion . . . gives a history of the growth of the use of t,he Bwathmey method of synergistic analgesia. . . . When one considers the enormous circulation which this magazine enjoys, together with the fact that the author reports some 5,800 cases in which the method has been used in the New York Lying-In Hospital, in which 85 per cent of the patients had almost complete relief from pain, as well as the fact that, after quoting experiences of a similar type from Chicago, Madison, Cincinnati, Pittsburgh and Philadelphia, together with Ottawa and Montreal, she concludes the article with a challenge to women to demand that their obstetricians look into the matter
MATERNAL
MORTALITY
REMAINDER
1135
and see if it is not possible to give them well, live babies a.fter normal deliveries without surgical interference, and practically without pain, one realizes such a woman may have a great deal of influence ; good or bad as the case may be.” A little later articles in the same journal by de Kruif,l? under the title, “Why Should Mothers Die?” attracted wide attention. In 1929 a survey of the hospital and health facilities of Philadelphia conducted by Haven Emerson18 pointed out that the maternal death rate had been stationary for the previous ten years. The following year the Philadelphia County Medical Society set up a committee on maternal welfare under the direction of Philip F. Williams.** This committee, however, decided to follow the line of survey a.nd analysis then in progress by the Committee on Public Hea1t.h Relations of the New York Academy of Medicine.ll The New York survey had grown out of recommendations made by Ralph W. Lobenstine and George TV. Kosmak. It is generally held, and properly, I believe, tha.t the influence of the New York report has been very great. The Philadelphia report,18 equally outstanding, was published one year later. By that time the New York report had had tremendous publicity, not all favorable. The New York report emphasizecl preventability of maternal deaths, the relative safety of delivery at home, expansion of midwife training and opportunity, and said that “the hazards of childbirth in New York City are greater than they need be. Responsibility for reducing them rests with the medical profession.” With publication of the report, the Medical Information Bureau of the Academy of Medicine released an abstract to the daily newspapers under the title, “Why Women Die in Childbirth. ” A storm of lay and medical criticism followed. The New York Obstetrical Society believed that these newspaper articles had created unnecessarily alarming, misleading, and unfortunate impressions. A committee19 with Eliot Bishop as chairman commended the entire report but took issue with many phases of it. The report of this committee was printed and given to the daily press. to the undiminishing maternal mortality in the DeLeeZO said “Owing United States, vofces have been raised demanding the return of the midwife.” In Great Britain a debate in which the leaders of British obstetrics a.nd gynecology participated was conducted by the Fellowship of Medicine on the Mortality is a Discredit, motion, “That the Present High Rate of Maternal to Modern Obstetrics.” No decision was reached, but a verbatim report of t.he debate was published.21 In 1933 a survey of obstetrical facilities was made in Rochester, N. Y., and conducting an active campaign there, organized a group for Quigley,l” analysis. The county medical societies of New York City soon organized committeek following the lead of Philadelphia. In 1935 the maternal death conferences which Skeelz2 had organized in Cleveland in 1932 grew into the Hospital Obstetric Society of Ohio. Boston and the Pacific States conducted their own surveys. States and groups activated committees on maternal welfare and consciousness grew rapidly. This history of the “Great Crusade” is necessarily incomplete, yet I hope there are no major gaps in my record.
GORDON
1136
Am. J. Obst.& Gynec. November.1951
NOW as if our aim were to reduce the number of maternal deaths statistieally rather than aotually, we have an ally in the New International Statistical Clasaification2s which has been used in New York City since 1949. When multiple causes are mentioned in the certificate of death, the primary cause is no longer tabulated by rule but as stated by the certifying physician, except where the order of entries on the certificate is clearly incorrect. At the moment the exact importance of this change is not known, yet that it will change mortality trends is clear. It has been estimated that puerperal conditions till decline 7 per cent for this reason alone.24 In 1950 in the entire City of New York,25 112 puerperal deaths occurred. In Brooklyn there were 38. The puerperal death rate per 10,000 reported terminated pregnancies in Brooklyn was 5.4 while for all five bdroughs of the City it was 5.6. The non-white rate however was three times as high as the rate for white women. This extraordinarily low maternal death date for a great city with a large non-white population and varying social and economic levels, looks like a statistical minimum, yet it is not. In Brooklyn, for instance, hemorrhage continues to be the principal cause of maternal death. The causes of death appear in Table I. The controllable factors set down in Table II need no elaboration. .~~____-__--
_
TABLE I.
MATERNAL DEATHS, BROOKLYN, 1950
Abz-
TABLE II.
152* 3+ 12s 41 38 (provisional)
-.--__ __.-
--
CONTROLLABLE FACTORS, 1950
Anesthesia Abortion (all induced) Infection Toxemia Hemorrhage and shock Cevarean Sectlon.Anesthesia Hemorrhage Infection Toxemia
-
Total Official total _.__-___-
*One case officially nonpuerperal. -.-
x
: :
3 6 5 12
---
-
15
He?norrhage.Abortion Ectopic Cesarean section Rupture of uterus Other
I 2 : 4
It has always been true that diligent search through the nonpuerperal causes of death associated with pregnancy will reveal cases with clear-cut controllable factors. It seems clear that puerperal deaths assigned to nonWe are puerperal causes will increase in number under the new classification. not interested in the statistics, but in the deaths. In our search for the controllable factors of maternal death we cannot depend upon the statistician alone, but must continue to examine not only the certificate of death but actual
Volume Number
62 5
MATERNAL
MORTALITY
REMAINDER
1137
case reports. The risk of cardiac disease can be evaluated in no other way, and deaths directly due to anesthesia will either not be found or will be tabulated separately as “therapeutic misadventure in anesthesia” (E 954). Hemorrhage will continue to remain the principal cause of maternal death just as long as blood remains hard to get. In spite of the old statistics to the contrary, it, in all probability, was never any different. The mechanical form of good prenatal care will not reduce the death rate from toxemia until it is widely accepted that prenatal care requires as much experience as the conduct of delivery itself. Puerperal infection has not disappeared. It responds to our new therapy, but not always. The majority of cases are associated with prolonged labor and hemorrhage; and the organisms present before labor are not important in its causation. AS the death rate shrinks, interest will lag and consciousness of our responsibility may wane. Perhaps we have underestimated the size and scope of the problem, in that we have paid scant attention to infant mortality rates. The trend of infant mortality has been steadily downward, with the 1948 rate the lowest ever recorded.2 The mortality is much higher in the first day of life than in any succeeding age group. The mortality of infants under 1 day of age was a third of the total infant mortality in 194C2 Little ground has been gained in the reduction of infant mortality associated with the complications of pregnancy. As might be expected, nearly all deaths from premature birth, and injury at birth, and two-thirds of the deaths from congenital malformations ta.ke place during the first month of life. Just as the obstetrician is interested in fetal salvage, the pediatrician is concerned with prenatal and delivery care. The mechanism for maintenance of joint interest, however, is not the great obstetric conference which has been so effective in reduction of the maternal death rate. The very number of infant deaths, and the difficulty of obtaining positive death data make that impractical. It is not necessary and it may not be wise to add still another staff conference to the heavily weighted hospital program. In each hospital, however, the Department of Obstetrics and the Department of Pediatrics, as a joint project assigned to a responsible individual of each staff, should keep a running record of their infant mortality. Stillbirths and neonatal deaths, for example, may readily be set up in percentage columns ; and month after month in cumulative statistics and year after year experience will be known. In some areas a central agency may make comparisons or teaching conferences may be conducted. No longer may it be said, as it can now, that many obstetricians do not know what their infant mortality really is. For obstetricians and pediatricians the maternal mortality remainder lies just ahead. References 1. National Office of Vital Statistics: Estimated Numbers of Deaths and Death Rates for Specified Causes. United States, 1949. Current Mortality Analysis, Nov. 29, 1950. 2. National Office of Vital Statistics: Vital Statistics of the United States for 1948, Washington, 1950. 3. Dickinson, F. cf., and Welker, E. L.: J. A. M. A. 144: 1395,195O.
GORDON
1138 4.
White
.“9: 10.
11. 12. 13. it: 16. r ii: 19. 20. 21. Ii: 24. 25.
I. Obst.
8; Gynec.
November.195I
House Conference on Child Health: Obstetric Education, New York, 1932, Century Company, p.21. AX. J. C&m. & GYNEC. 23: 605,1932. Comparability of Maternal Mortality Rates in the United States and Certain Foreign Countries, United States Department of Labor, Children’s Bureau Publication No. 229, Washington, 1935. Editorial: What Is Progress in Obstetrics? J. A. M. A. 16: 1?58,, 1921. Polak, J. 0.: J. A. M. A. 93: 1436,1929. Adair, F. L.: AM. J. OBST. & GYNEC. 21: 767,193l. Quigley, 3. K.: Trans. Am. Assoc. Obst., Gynec. & Abd. Surg., p. 70, 1939. Maternal Mortality in New York City. New York Academy of Medicine. R. S. Hooker, M.D., Director of the Study, New York, 1933, Commonwealth Fund. Standards of Prenatal Care. IT. 8. Department of Labor, Children’s Bureau Publication No. 153. Maternal Mortality in Fifteen States. U. 8. Department of Labor, Children’s Bureau Publication No. 223, Washington, D. C. Standards for Maternity Care. New York, 1930 The Children’s Welfare Federation. Proceedings of Conference on Better Care for Mothers and Babies. U. 8. Department of Labor, Children’s Bureau Publication No. 246, p. 82. Report of the Committee on Maternal Welfare of the Am. Assoc. Obst., Gynec. L Abd. surg. : Ax J. OBST. & GYNEC. 21: 290, 1931. de Kruif, P.: Ladies’ Home J. 53: 8, March; 14 April; 26 May; 28 June, 1936. Maternal ‘Mortality in Philadelphia. Report of Committee on Maternal Welfare, Philip F. Williams, M.D., Chairman, Philadelphia County Medical Society, 1934. Report of the Committee of the New York Obstetrical Society to Review the Maternal Mortality Report of the Public Health Relations Committee of the New Yorlc Academy of Medicine, April 10,1934. DeLee, J. 3.: The Principles and Practice of Obstetrics, ed. 6, Philadelphia, 1933, W. B. Saunders Company, Introduction. Debate on Maternal Mortality. Post-Grad. M. J. 12: 447, 1935. Sk&, A. J.: AM. J. OBST. & GYNEC. 30: &X$1935. Manual of the International Classification of Diseases, Injuries, and Causes of Death. Geneva, Switzerland, IQ@, World Health Organization. Erharclt, C. L., and Weiner, L.: Am. J. Pub. Health. 40: 6, 1950. Bureau of Records and Statistics, Department of Health, City of New York.
5. Emerson, H. : 6. Tandy, E. C.: 5.
.\m.
32 REE~SEN STREET
MORTAUTY
BP%-BR”
CHARLES A. GORDON, M.D., BROOKLYN,N.Y.
T
HE United States is the first great nation to breach the wall of one maternal death per 1,000 live births. The National Office of Vital Statistics’ believes that the maternal mortality rate for 1949 will be nearly 20 per cent lower than for 1948 and estimates it as 8.2 per 10,000 live births and not as 0.8 per 1,000. This stRtistica1 innovation no doubt has its advantages, yet it fails to dramatize the startling decline to a new low which many have called the irreducible or inescapable minimum. For the first time the patient may be told that her chances of surviving pregnancy are better than 999 in 1,000 and getting better every year. It should be kept in mind too that this includes the considerable risk of ectopic pregnancy and abortion. There is, however, a wide racial differential in that the rate for the non-white races is more than three times as high as the rate for white women. From 1915 to 1929 the national maternal mortality rates2 remained at about the same level with the exception of the high points of 1918 (9.2) and 1920 (8.0). From 1930 to 1936 steady but Iittle improvement occurred. Since then the rate has speedily decreased. In 1948,2 the last year for which complete data are available, the number of maternal deaths was 4,122 and the mortality rate 1.2 per 1,000 live births. That year there were 3,535,068 live births or but 4.5 per cent less than the all-time high figure of 1947, or nearly one and one-half million more than in 1933 when the maternal mortality rate was more than five t,imes as high. Jt is now said3 that “the maternal death rate is no longer a serious national problem, but rather one for local action in those areas in which rates are relatively high. ” It will always remain a local problem, and not only where rates are high. In Brooklyn, for instance, where the rate has been below 1 since 1946, it is not a hazardous prediction to say that it will continue to decrease. It is not easy to figure a time scheme for further reduction, but it can be reduced. The greatest number of maternal deaths ever recorded in the United States was in 1928 when 44 states reported 15,461 deaths. Interest in the eomparability of national statistics was high shortly before 1930. The Children’s 13ureau compiled a table4 in which the maternal mortality rate of the United Stat,es from 1926 to 1928 exceeded that of any other country on the list. It was higher than in Australia, England and Wales, Ireland, Italy, Japan, New *Road
before
the
Medical
Society
of the
County
1132
of
Kings,
May
15,
1951.
Volume Number
62 5
MATERNAL
MORTALITY
REMAINDER
1133
Zealand, Scotland and Sweden. The low rate in the Scandinavian countries and in Holland, though not fully explained, was attributed to the great attention paid to the training and status of midwives in those countries. Haven Emerson5 maintained that “international comparisons based on national maternal mortality were misleading.” In another Children’s Bureau6 publication Tandy showed that the rates were directly comparable. As recently as 1940 cont,roversy was bitter. An editorial in The Journal of the American Medical Association said that “maternal mortality rates of the United States have been reported and discussed for several years apparently to conjure conclusions designed to throw discredit upon the medical profession. . . . Again and again the propagandist alleged that the United States was lagging behind most of the other modern nations in its maternal mortality rate. This conclusion was reached by comparing nations some of which were not larger than some counties in the United States, and with an exclusively white population less than that of some American cities, with the entire continental United States with its wide diversity of population including 10 per cent of Negroes with a peculiarly high maternal mortality rate. ” In the decade ending in 1930 obstetricians in this country appeared to divide themselves into conservatives and radicals in the management of normal labor.’ In 1929 Polak,s a powerful advocate of natural methods in the conduct of labor, thought that lack of prenatal care, interference with normal labor, and unnecessary cesarean sections contributed to the high maternal mortality, “the result of the teachings of some prominent obstetricians who have been busy inventing operative procedures to control the onset of labor, or shorten or eliminate the second stage of labor or improve the physiologic mechanism of placental delivery. One of these men induces labor in all women at term; another cuts the perineum of every primipara, while still another does a section on every tenth woman and a version on the other nine. Most remarkable of all is the teaching of one of our leading obstetricians who classes all labor as pathologic and advocates rapid delivery with forceps through a cut pelvic floor as soon as the head has passed through the cervix, folllowiug this by manual removal of the placenta.” In 1931 AdaiF who, with Holmes and Lynch, had long been active on the Advisory Council of the Children’s Bureau and later became chairman of the American Committee on Maternal Welfare, which was incorporated in 1934, said that “the high maternal death rate in this country is a reflection on the training and education of the personnel responsible for furnishing maternity care.” Prior to enactment of the Shepard-Towner Act of 1921, maternal health activities were carried on by but a few State Health Departments or State Aside from certain writers of the past who had touched Medical Societies.l” in one way or another upon the number of maternal deaths, general medical It is less than twenty years since the shortcomings of interest lagged. American obstetrics were paraded in the public press, and it is much less than that since victory over maternal death statistics was won-if it has been won, yet the impact of the conquest has been SO slight that they who have hen re-
1134
C:ORl)ON
!\rn. I. Obst. g; Gynec. November. 195 I
sponsible for the victory hardly know that there was a battle. The Brooklyn Committee on Maternal Welfare began its work in 1934, shortly after what was called the unnecessary deaths of mothers had become a common topic of discussion in the daily press. In 1933, the preceding year, the maternal morta1it.y rate for Brooklyn was 7 with 284 maternal deaths while the rate for the entire City of New York was 6.4. The great progress that has been macle since that time is largely due, in my opinion, to critical analysis and discussion of our own end results and steady increase in the number of qualified obstetricians. It has long been said That that general practice will always carry the heavy burden of obstetrics. is no longer true. The history of the great attack on maternal mortality has never been written, though it should be. It is not yet finished, for the maternal mortality remainder is an attractive target. Another generation of obstetricians will need inspiration. To turn aside for a few moments will not be a digression. It is good to look backward, for it will help us to go forward. As early as 1917, Kosmak,ll the first crusader, interested the New York Academy of Medicine in a five-year study of puerperal mortality in the hospitals of New York City; nothing was publishrd, however. In 1924 DeNormanclie, at the request, of t,he Children’s Bureau, formed a committee which clrew up standa,rds of prenatal care’?; and in 1926. R.Schairman of its Obstetric Advisory Committee, he presented to the Children’s Bureau a fine planI for detailed study of the maternal deaths in fifteen states which was published in 1933. In 1930 Lohenstinc and Kosmak, as a committee of the New York Obstetrical Society, joined the Children’s Welfare Federation of New York City’+ in. publication of standards for maternity care. In 1931 the Medical Society of New Jersey’” appointed a committee on maternal welfare to enlarge the educational program organized in Essex County by Bingham in 1923. Some postgraduate courses in obstetrics, not,ably by Calkins in Kansas and Oklahoma, and McCord in Qeorgia round out the medical scene fairly wellI .A quotation from the 1930 report of the Committee on Maternal Welfare of the American Association of Obstetricians, Gynecologists and Abdominal Surgecx@ (Irving WT. Potter, Willard R. Cooke, anal IA. A. Calkins) will help to illustrate the public interest in the problem : 1‘ An interesting side light has been thrown several times lately upon the question of maternal welfare by the invasion of this field by the lay woman, through the medium of the popular magazine. One such discussion . . . gives a history of the growth of the use of t,he Bwathmey method of synergistic analgesia. . . . When one considers the enormous circulation which this magazine enjoys, together with the fact that the author reports some 5,800 cases in which the method has been used in the New York Lying-In Hospital, in which 85 per cent of the patients had almost complete relief from pain, as well as the fact that, after quoting experiences of a similar type from Chicago, Madison, Cincinnati, Pittsburgh and Philadelphia, together with Ottawa and Montreal, she concludes the article with a challenge to women to demand that their obstetricians look into the matter
MATERNAL
MORTALITY
REMAINDER
1135
and see if it is not possible to give them well, live babies a.fter normal deliveries without surgical interference, and practically without pain, one realizes such a woman may have a great deal of influence ; good or bad as the case may be.” A little later articles in the same journal by de Kruif,l? under the title, “Why Should Mothers Die?” attracted wide attention. In 1929 a survey of the hospital and health facilities of Philadelphia conducted by Haven Emerson18 pointed out that the maternal death rate had been stationary for the previous ten years. The following year the Philadelphia County Medical Society set up a committee on maternal welfare under the direction of Philip F. Williams.** This committee, however, decided to follow the line of survey a.nd analysis then in progress by the Committee on Public Hea1t.h Relations of the New York Academy of Medicine.ll The New York survey had grown out of recommendations made by Ralph W. Lobenstine and George TV. Kosmak. It is generally held, and properly, I believe, tha.t the influence of the New York report has been very great. The Philadelphia report,18 equally outstanding, was published one year later. By that time the New York report had had tremendous publicity, not all favorable. The New York report emphasizecl preventability of maternal deaths, the relative safety of delivery at home, expansion of midwife training and opportunity, and said that “the hazards of childbirth in New York City are greater than they need be. Responsibility for reducing them rests with the medical profession.” With publication of the report, the Medical Information Bureau of the Academy of Medicine released an abstract to the daily newspapers under the title, “Why Women Die in Childbirth. ” A storm of lay and medical criticism followed. The New York Obstetrical Society believed that these newspaper articles had created unnecessarily alarming, misleading, and unfortunate impressions. A committee19 with Eliot Bishop as chairman commended the entire report but took issue with many phases of it. The report of this committee was printed and given to the daily press. to the undiminishing maternal mortality in the DeLeeZO said “Owing United States, vofces have been raised demanding the return of the midwife.” In Great Britain a debate in which the leaders of British obstetrics a.nd gynecology participated was conducted by the Fellowship of Medicine on the Mortality is a Discredit, motion, “That the Present High Rate of Maternal to Modern Obstetrics.” No decision was reached, but a verbatim report of t.he debate was published.21 In 1933 a survey of obstetrical facilities was made in Rochester, N. Y., and conducting an active campaign there, organized a group for Quigley,l” analysis. The county medical societies of New York City soon organized committeek following the lead of Philadelphia. In 1935 the maternal death conferences which Skeelz2 had organized in Cleveland in 1932 grew into the Hospital Obstetric Society of Ohio. Boston and the Pacific States conducted their own surveys. States and groups activated committees on maternal welfare and consciousness grew rapidly. This history of the “Great Crusade” is necessarily incomplete, yet I hope there are no major gaps in my record.
GORDON
1136
Am. J. Obst.& Gynec. November.1951
NOW as if our aim were to reduce the number of maternal deaths statistieally rather than aotually, we have an ally in the New International Statistical Clasaification2s which has been used in New York City since 1949. When multiple causes are mentioned in the certificate of death, the primary cause is no longer tabulated by rule but as stated by the certifying physician, except where the order of entries on the certificate is clearly incorrect. At the moment the exact importance of this change is not known, yet that it will change mortality trends is clear. It has been estimated that puerperal conditions till decline 7 per cent for this reason alone.24 In 1950 in the entire City of New York,25 112 puerperal deaths occurred. In Brooklyn there were 38. The puerperal death rate per 10,000 reported terminated pregnancies in Brooklyn was 5.4 while for all five bdroughs of the City it was 5.6. The non-white rate however was three times as high as the rate for white women. This extraordinarily low maternal death date for a great city with a large non-white population and varying social and economic levels, looks like a statistical minimum, yet it is not. In Brooklyn, for instance, hemorrhage continues to be the principal cause of maternal death. The causes of death appear in Table I. The controllable factors set down in Table II need no elaboration. .~~____-__--
_
TABLE I.
MATERNAL DEATHS, BROOKLYN, 1950
Abz-
TABLE II.
152* 3+ 12s 41 38 (provisional)
-.--__ __.-
--
CONTROLLABLE FACTORS, 1950
Anesthesia Abortion (all induced) Infection Toxemia Hemorrhage and shock Cevarean Sectlon.Anesthesia Hemorrhage Infection Toxemia
-
Total Official total _.__-___-
*One case officially nonpuerperal. -.-
x
: :
3 6 5 12
---
-
15
He?norrhage.Abortion Ectopic Cesarean section Rupture of uterus Other
I 2 : 4
It has always been true that diligent search through the nonpuerperal causes of death associated with pregnancy will reveal cases with clear-cut controllable factors. It seems clear that puerperal deaths assigned to nonWe are puerperal causes will increase in number under the new classification. not interested in the statistics, but in the deaths. In our search for the controllable factors of maternal death we cannot depend upon the statistician alone, but must continue to examine not only the certificate of death but actual
Volume Number
62 5
MATERNAL
MORTALITY
REMAINDER
1137
case reports. The risk of cardiac disease can be evaluated in no other way, and deaths directly due to anesthesia will either not be found or will be tabulated separately as “therapeutic misadventure in anesthesia” (E 954). Hemorrhage will continue to remain the principal cause of maternal death just as long as blood remains hard to get. In spite of the old statistics to the contrary, it, in all probability, was never any different. The mechanical form of good prenatal care will not reduce the death rate from toxemia until it is widely accepted that prenatal care requires as much experience as the conduct of delivery itself. Puerperal infection has not disappeared. It responds to our new therapy, but not always. The majority of cases are associated with prolonged labor and hemorrhage; and the organisms present before labor are not important in its causation. AS the death rate shrinks, interest will lag and consciousness of our responsibility may wane. Perhaps we have underestimated the size and scope of the problem, in that we have paid scant attention to infant mortality rates. The trend of infant mortality has been steadily downward, with the 1948 rate the lowest ever recorded.2 The mortality is much higher in the first day of life than in any succeeding age group. The mortality of infants under 1 day of age was a third of the total infant mortality in 194C2 Little ground has been gained in the reduction of infant mortality associated with the complications of pregnancy. As might be expected, nearly all deaths from premature birth, and injury at birth, and two-thirds of the deaths from congenital malformations ta.ke place during the first month of life. Just as the obstetrician is interested in fetal salvage, the pediatrician is concerned with prenatal and delivery care. The mechanism for maintenance of joint interest, however, is not the great obstetric conference which has been so effective in reduction of the maternal death rate. The very number of infant deaths, and the difficulty of obtaining positive death data make that impractical. It is not necessary and it may not be wise to add still another staff conference to the heavily weighted hospital program. In each hospital, however, the Department of Obstetrics and the Department of Pediatrics, as a joint project assigned to a responsible individual of each staff, should keep a running record of their infant mortality. Stillbirths and neonatal deaths, for example, may readily be set up in percentage columns ; and month after month in cumulative statistics and year after year experience will be known. In some areas a central agency may make comparisons or teaching conferences may be conducted. No longer may it be said, as it can now, that many obstetricians do not know what their infant mortality really is. For obstetricians and pediatricians the maternal mortality remainder lies just ahead. References 1. National Office of Vital Statistics: Estimated Numbers of Deaths and Death Rates for Specified Causes. United States, 1949. Current Mortality Analysis, Nov. 29, 1950. 2. National Office of Vital Statistics: Vital Statistics of the United States for 1948, Washington, 1950. 3. Dickinson, F. cf., and Welker, E. L.: J. A. M. A. 144: 1395,195O.
GORDON
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White
.“9: 10.
11. 12. 13. it: 16. r ii: 19. 20. 21. Ii: 24. 25.
I. Obst.
8; Gynec.
November.195I
House Conference on Child Health: Obstetric Education, New York, 1932, Century Company, p.21. AX. J. C&m. & GYNEC. 23: 605,1932. Comparability of Maternal Mortality Rates in the United States and Certain Foreign Countries, United States Department of Labor, Children’s Bureau Publication No. 229, Washington, 1935. Editorial: What Is Progress in Obstetrics? J. A. M. A. 16: 1?58,, 1921. Polak, J. 0.: J. A. M. A. 93: 1436,1929. Adair, F. L.: AM. J. OBST. & GYNEC. 21: 767,193l. Quigley, 3. K.: Trans. Am. Assoc. Obst., Gynec. & Abd. Surg., p. 70, 1939. Maternal Mortality in New York City. New York Academy of Medicine. R. S. Hooker, M.D., Director of the Study, New York, 1933, Commonwealth Fund. Standards of Prenatal Care. IT. 8. Department of Labor, Children’s Bureau Publication No. 153. Maternal Mortality in Fifteen States. U. 8. Department of Labor, Children’s Bureau Publication No. 223, Washington, D. C. Standards for Maternity Care. New York, 1930 The Children’s Welfare Federation. Proceedings of Conference on Better Care for Mothers and Babies. U. 8. Department of Labor, Children’s Bureau Publication No. 246, p. 82. Report of the Committee on Maternal Welfare of the Am. Assoc. Obst., Gynec. L Abd. surg. : Ax J. OBST. & GYNEC. 21: 290, 1931. de Kruif, P.: Ladies’ Home J. 53: 8, March; 14 April; 26 May; 28 June, 1936. Maternal ‘Mortality in Philadelphia. Report of Committee on Maternal Welfare, Philip F. Williams, M.D., Chairman, Philadelphia County Medical Society, 1934. Report of the Committee of the New York Obstetrical Society to Review the Maternal Mortality Report of the Public Health Relations Committee of the New Yorlc Academy of Medicine, April 10,1934. DeLee, J. 3.: The Principles and Practice of Obstetrics, ed. 6, Philadelphia, 1933, W. B. Saunders Company, Introduction. Debate on Maternal Mortality. Post-Grad. M. J. 12: 447, 1935. Sk&, A. J.: AM. J. OBST. & GYNEC. 30: &X$1935. Manual of the International Classification of Diseases, Injuries, and Causes of Death. Geneva, Switzerland, IQ@, World Health Organization. Erharclt, C. L., and Weiner, L.: Am. J. Pub. Health. 40: 6, 1950. Bureau of Records and Statistics, Department of Health, City of New York.
5. Emerson, H. : 6. Tandy, E. C.: 5.
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