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UNITED STATES DEPARTMENT OF LABOR Frances Perkins, Secretary « C H IL D R E N ’ S BUREAU G race A bbott, Chief MATERNAL DEATHS A B R IE F R E P O R T O F A S T U D Y M ADE I N 15 S T A T E S Bureau Publication N o. 221 m LIBRARY Agricultural & Mechanical College of Texas UNITED STATES " i l e i . .7 GOVERNMENT PRINTING OFFICE WASHINGTON : 1933 i* 0 ^ 1 For sale by the Superintendent of Documents, Washington, D.C. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Price 5 cents https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Page Scope and method of the study__________________________________ 1 General considerations_________________________________ I I I I I I I I 4 Comment by advisory committee____________________________ 12 Maternal care______________________________________ “ 14 Comment by advisory committee_______ __________ ____ I I __ 19 Operations____________________________ _______________ “ I I “ 21 Comment by advisory committee_________________________ I __ 27 Cesarean section_____________________________________ “ _____ 29 Comment by advisory committee____________________________ I 31 Abortions_______________________________________ “ 33 Comment by advisory committee_________________________ ___ 35 Puerperal septicemia________________________________ ” _I_________ 37 Comment by advisory committee_________________________I I __ 40 Puerperal phlegmasia alba dolens, embolus, sudden death____________ 42 t Comment by advisory committee_____________________________ 43 Toxemias of pregnancy________________________________ “ _H IH _ 44 47 Comment by advisory committee___________________________ I_I Puerperal hemorrhage_____________________________ >111111_I_ I_ 49 Comment by advisory committee________________________ __I 51 Other accidents of labor, including rupture of the uterus_____________ 53 Comment by advisory committee_______________________ ~ 54 Ectopic gestation________________________________ _ H _ I I I I I I I I I I I 58 Comment by advisory committee________________________ I __ ~ 57 58 Recommendations by advisory committee____________________ I __ I To the medical profession__________________________________ 58 T o the general public______________________ III~~~~I I I I __ II_~ 59 Standards of American College of Surgeons for hospitals taking obstetric patients___________________________________________ _ qq I I ni https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis C H A R T 1.—s t a t e s i n c l u d e d https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis in * m a te r n a l - m o r t a l it y s t u d y . MATERNAL DEATHS SCOPE AND METHOD OF THE STUDY The maternal mortality rate in this country is generally recognized as high, and it has shown comparatively slight changes over a period o± years. Moreover, information hitherto available concerning ma ternal deaths consisted only of such limited data with regard to all deaths m a given area as are contained in death and birth certificates and more detailed studies o f selected groups. The former were not S1J i ? ently detailed nor latter sufficiently general to give a picture o f the conditions contributing to the 16,000 deaths assigned an nually m the United States to causes that are associated with preg nancy and childbirth. A t the 1926 conference o f State directors in charge o f the Maternity and Infancy Act, the chairman o f the Chil dren s .Bureau obstetric advisory committee1 presented a plan for a comprehensive study o f maternal mortality. It was decided to undertake such a study only in States which were included in the blT r » 10n a1r.ea and in which both the State board o f health and the State medical society made formal request for it. The P United States Children’s Bureau undertook to prepare, with the assistance o f its obstetric advisory committee, a schedule for use in all the States studied, and to report the findings.2 In the preparation o f the schedule standards o f prenatal care previously set up by the obstetric advisory committee were considered,8 as were hospital standards and standards o f obstetric care in hospitals approved by the American College of Surgeons.4 The material here presented is an abstract o f the full report,5 with tables and careful analyses, of the resulting study made by the United States Children’s Bureau of all the maternal deaths which occurred Jn 13 States in 1927 and in these same States and 2 others m 1928. Ihe States in which the study was conducted for both years were^Alabama, Kentucky, Maryland, Michigan, Minnesota, Nebraska, New Hampshire, North Dakota, Oregon, Rhode Island’ me.mbl rl o f the obstetric advisory committee a r e : Dr. Robert L DeNormandie 111 obstetrics, Harvard M edical School, ch airm an ; Dr. Fred L. Adair professor o f obstetrics and gynecology, U niversity o f C h ica g o; Dr. Rudolph W Hoimes professor o f Northwestern University M edical School, C h ica g o ; Dr. Frank w’ Lvnch nro McOor<?f n rofeE 1 « 8 a ? d gynecology, U niversity o f C alifornia M edical S c h o o l; Dr^James^R A fin n?«’- Pro f osso r ° t otlstetrlcs and gynecology, Em ory University School o f Medicine o f Medici^e N e wU^rieaiis, a n ^ ’- Dr. n r Otto Ott°n S nH ec0l° Sy’p rofessor Tu, lane University o f Louisiana School cíne, rref H. g£ Schwarz, o f obstetrics and irvnprnloe-v W ashington U niversity School o f Medicine, St. L o u is; Dr. A lice N P icket^ assfstent P “ fS L l ? bstetricsJ University o f Louisville School o f M edicine, Louisville ’ assistant . study ^ as m»de under the supervision o f Dr. B lanche M. Haines, form erly director o f the m aternity and infant hygiene division o f the Children’ s Bureau The taking o f in different States was coordinated by Dr. Frances C. R othert o f ’ the Rtd'dren s Bureau, who also analyzed the m aterial and w rote the complete report with the cooperation o f members o f the obstetric advisory committee. ** ’ Standards o f Prenatal C a re ; an outline fo r the use o f physicians. U.S Children’ s Bureau Publication No. 153. W ashington, 1925. ^ ’ laren 8 ! Am erican College o f Surgeons, Fourteenth Year Book, 1927, p. 71. W ashington1 1933tali^y iQ States* U.S. Children’s Bureau Publication No. 223. 1 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 M AT E R N A L DEATH S Virginia, Washington, and Wisconsin. California and Oklahoma were included in the 1928 study only. In Michigan, Wisconsin, Minnesota, North Dakota, California, and Oklahoma all or most o f the schedules and in Alabama some o f them were taken by physicians on the staffs o f the State departments of health. In the remaining States the schedules were taken by physicians on the staff of the Children’s Bureau.6 The States o f the study are fairly well distributed geographically and fairly typical o f the sections in which they are located. The composition o f the population for the group of States conforms very closely to that o f the entire United States according to the census o f 1920. In these 15 States, during the years o f the study, the deaths o f 7,537 women were assigned to puerperal causes by the United States Bureau o f the Census in accordance with the International List o f Causes o f Death. This number o f deaths was 26 percent o f the 29,298 deaths from puerperal causes in the entire United States birthregistration area for these 2 years. In the States o f the study 3,546 (47 percent) o f the maternal deaths were urban and 3,991 (53 per cent) rural; in the birth-registration area for these 2 years 54 per cent were urban and 46 percent rural (rural including towns o f less than 10,000). Eighteen percent o f the deaths in this study and 19 percent o f the maternal deaths in the birth-registration area were o f colored women. Colored women, according to the definition used by the Census Bureau, include Negroes, Japanese, Indians, and Chinese. As there were 1,176,603 live births in the States during the years o f the study, these 7,537 deaths gave a maternal mortality rate o f 64 per 10,000 live births ; in the birth-registration area for 1927 and 1928 together the maternal mortality rate was 67. Conditions as regards maternal mortality were evidently better in the States studied. The four States admitted to the birth-registration area in 1928 all had higher rates than the area as a whole for that year; if they had been in the area in both years o f the maternal-mortality study the rate for the area for the 2 years would probably have been higher. The regions studied, then, are probably fairly representative o f the United States as a whole, with some overemphasis on the Pacific Coast and North Central States, and some underemphasis on the Rocky Mountain regions, the far South, and the eastern industrial centers. Conditions as regards maternal mortality were apparently better in the regions studied—they were certainly not worse—than those obtaining in the United States as a whole. The collection o f data was begun in February 1927, and most o f the schedules were completed before July 1, 1929. A ll the finished 6 The follow in g persons made the interviews in the different S ta tes: Alabama— Dr. W ade H. Garner, Dr. Charles M. Lacy, Dr. Robert A. Berry, Dr. W illiam H. Abernathy, and M argaret Murphy, R. N .; Kentucky-—Dr. Frances C. Rothert. Dr. Frances M. Hennessy, and Dr. Janice R a fu se ; M aryland— Dr. Margaret S w ig a rt; Michigan— Dr. Joseph H. Curhan, Dr. Dorothy L. Green, and Dr. Florence K n o w lton ; M innesota— Dr. W illiam H. Rum pf and Dr. Ruth G. N y strom ; Nebraska— Dr. Herman M. Jahr and Dr. M aBelle T r u e ; New Hampshire and Rhode Island— Dr. H en n essy; North Dakota— Dr. M aysil M. W il liams, Dr. M. May Allen, and Dr. Iva Stevens M erritt; Oregon— Dr. Mildred M cB ride; Virginia— Dr. Swigart, Dr. Rothert, Dr. Hennessy, and Dr. R a fu se ; W ashington— Dr. H arold L. Kennedy, Dr. H arvey J. Felch, and Dr. Paul W. S pickard; W isconsin— Dr. C harlotte J. C a lv e rt; California— staff physicians o f the State department o f health under the supervision o f Dr. Ellen S. Stadtmuller and Dr. S w ig a rt; Oklahoma— Dr. True, Dr. David M. Cowgill, Dr. Margaret Dubois, and Dr. Louise Smith King. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SC O P E A N D M E T H O D OF STU D Y 3 schedules were sent to the Children’s Bureau for statistical examina tion, and tabulations were made there. A very close contact between the interviewers and the Bureau was maintained in order to keep the interpretation o f the schedules uniform. The routine used was as follow s: A ll certificates o f deaths assigned to puerperal causes as reported to the State departments o f health were copied. Birth certificates were matched when possible. The physicians or other persons signing the death certificates were then interviewed. The families were not visited, except where there were no physicians. The hospitals and clinics in which the patients had received care were visited, and the case records were studied with the consent of the attending physician. In some cases in which the interview was delayed the physician had forgotten many of the details o f the case. Very few of the physicians kept case histories, and usually no laboratory work other than a urinalysis and a bloodpressure examination had been done. However, most o f them remembered the cases vividly. The physicians interviewed cooper ated most heartily, giving freely o f their time and helping in every possible way. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL CONSIDERATIONS CAUSE OF DEATH Classification o f deaths according to international list The International List o f Causes of Death (edition o f 1920)7 was used as the general basis for the analysis of these deaths. The titles included in the group “ the Puerperal State ” are as follow s: 143. Accidents o f pregnancy. This includes (a ) abortion, (b) ectopic ges tation, and (c) others under this title. ( “ Abortion” will be re ferred to throughout this report as “ abortion or premature labor.” The word “ abortion ” as generally used in this report does not have the same meaning as it does in the international classification, but is defined as the termination o f a uterine pregnancy before the period o f viability, i.e., in the first two trimesters.) 144. Puerperal hemorrhage, which includes (a) placenta previa, (b) others under this title—postpartum hemorrhage, accidental hemor rhage, etc. 145. Other accidents o f labor. (a ) Cesarean section. (b) Other surgical operations and instrumental delivery. (c) Others under this title. 146. Puerperal septicemia. 147. Puerperal phlegmasia alba dolens, embolus, sudden death. 148. Puerperal albuminuria and convulsions. This title also includes pyelitis, nephritis, tetanus, and uremia. 149. Following childbirth (not otherwise defined). 150. Puerperal diseases of the breast. When more than one puerperal cause appears on a death certifi cate, the death is assigned to one o f them in accordance with definite rules published in the Manual o f Joint Causes o f Death,8 which the Children’s Bureau has followed literally in all cases. It is well to realize what the general rules o f the classification are. I f one of the more serious acute infectious diseases, such as typhoid fever, small pox, diphtheria, or if cancer or syphilis, or if an external cause such as an accident or homicide, appears on a woman’s death certificate with a puerperal cause, her death is assigned to that cause and not to the puerperal cause. (Influenza, however, takes precedence over no puerperal cause except “ other accidents o f pregnancy ” , “ follow ing childbirth (not otherwise defined)” , and “ puerperal diseases of the breast.” ) Puerperal septicemia takes precedence over all puer peral and nonpuerperal causes except the ones mentioned. Tubercu losis in most forms takes precedence over all puerperal causes except puerperal septicemia. Other serious chronic diseases, such as cardiac valvular disease and chronic nephritis, take precedence over all puerperal causes except the most severe complications o f child birth. The term “ pregnancy ” on a death certificate causes a death 7 Manual o f the International List o f Causes o f Death, 1920. U.S. Bureau o f the Census. W ashington, 1924. „ 8 M anual o f Joint Causes o f Death Showing Assignment to the Preferred T itle o f the International List o f Causes o f Death When Two Causes Are Simultaneously Reported. U.S. Bureau o f the Census. W ashington, 1925. 4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL CONSIDERATIONS 5 to be classified as puerperal only when it appears alone or with a term denoting a mild disorder or with a cause implying a compli cation of pregnancy. Com parison o f causes origin ally assigned and those found through interviews The 7,537 deaths classified by the United States Bureau o f the Census as due to puerperal causes include not only those originally so certified by the physician but those added as a result o f the answers to queries by the Bureau of the Census and by State bureaus o f vital statistics. O f this total 7,380 were found, by means of the interviews in connection with the study, to have been actually puerperal in the meaning o f the international classification, and 157 were found to have been nonpuerperal. The detailed tabulations and the analyses that are in the complete report are based on these 7,380 puerperal deaths. Cause o f death1 as given on the death certificate and as shown by interview , and m ortality rate among women whose deaths w ere assigned to puerperal causes T a b l e 1.— Deaths from causes as given on death certificate Deaths from causes as shown by interview Cause of death1 Num ber All causes....................... 7,537 Puerperal.......... .............. Accidents of pregnancy________ Abortion, premature labor......... ........ Ectopic gestation____ __________ Others................................. Puerperal hemorrhage__________ Other accidents of labor....... ...... Cesarean section___________ Other surgical operations and instrumental delivery_________ _____ Others......................................... Puerperal septicemia........................ Puerperal phlegmasia alba dolens, embolus, sudden death____ _________ Puerperal albuminuria and convulsions . Following childbirth (not otherwise defined). Puerperal diseases of the breast___ Nonpuerperal.................... ......... per Percent Rate 10,000 distri live bution births Num ber Percent Rate per 10,000 distri live bution births 7,537 _ 7,537 100 64.1 7,380 100 770 10 6.5 719 10 6.1 S68 264 188 6 4 2 3.1 2.2 1.2 363 248 118 6 3 2 3.0 2.1 1.0 758 812 10 11 6.4 6.9 791 652 11 9 6.7 5.5 1S6 2 1.3 186 2 1.2 76 681 1 8 .6 4-9 109 407 1 6 .9 3.6 2,827 38 24.0 2,948 40 25.1 337 2,006 24 3 4 27 2.9 17.0 .2 (») 344 1,900 23 3 5 26 2.9 16.1 .2 (3) («) « > (2) (a) 62.7 157 •According to the Manual of the International List of Causes of Death, 1920. 8 Less than 1 percent. 8 Less than one tenth per 10,000. The causes o f death of the cases excluded from this study because they were found to be nonpuerperal were: Chronic nephritis, 32; lobar pneumonia, 18; tuberculosis, 17; other infectious disease, 8; appendicitis, hernia, intestinal obstruction, 12; chronic cardiac valvu lar disease, 13; salpingitis and pelvic abscess, 21; other diseases of the female genital organs, 17; and all other diseases, 19. Sixty-eight o f these 157 women had not been recently pregnant. 179179°— 33------- 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 6 M ATERN AL DEATHS Changes in classification within the puerperal group As a result o f the interviews changes in classification were made in many o f the 7,380 cases (table 1). Clerical errors had led to erroneous classification. Lack of knowledge o f the International List o f Causes o f Death had led to the omission of statements which, if present, would have caused a different classification. Moreover, some o f the 558 autopsies in the group of 7,380 deaths were performed after the death certificates had been signed. Deaths will be spoken o f throughout the report as Laving been “ assigned ” or “ attributed ” to the individual causes o f death. The term “ assigned ” is used o f the official classification by the Bureau o f the Census, as in the first three columns o f table 1; the term “ attributed ” is used as referring to the classification after inter view, for purposes of this study, as in the last three columns of table 1. The International L ist o f Causes o f Death was revised by the international commission late in 1929. The ch ief changes a r e : (1 ) Puerperal septicemia (no. 146) is divided into A bortions with septic conditions (no. 140), Ectopic gestation w ith septic conditions speci fied (no. 142a), and Puerperal septicemia not specified as due to abortion (no. l4 o ) , (2 ) Puerperal albuminuria and convulsions (no. 148) is divided ^nto Puerperal albu m inuria and eclampsia (no. 146) and Other tpxemias of pregnancy ( b o . 14 7). w hich also includes chorea and pernicious vom iting o f pregnancy from the old subtitle 1 4 3 c, id ) tne title numbers o f 143a, b, and c are changed to 141, 142b, and 143, respectively . t i t l e 147 becomes 148, and 145 becomes 149, w ithout change o f name or content , (4 ) Following childbirth not otherwise defined (no. 149) and Puerperal diseases o f the breast (no. 150) are combined into Other and unspecified conditions o f the puerperal state (no. 15U). Although analysis in this report w as based largely on the 1920 list, which was in use at the time these deaths were classified, the subdivisions o f the topics follow very closely the subdivisions in the 1929 list. AUTOPSIES Autopsies were known to have been performed in 571 o f the 7,537 deaths certified as puerperal. They were performed in 130 (36 per cent) o f the 362 cases in which the coroner signed the death certifi cate and in 441 (6 percent) o f the 7,046 cases in which a physician other than the coroner signed the death certificate. Thirteen of the autopsies were included in the 157 cases in which the death was cer tified as puerperal but was found at the interview with the attending physician to have been nonpuerperal. The remaining 558 consti tuted only 8 percent o f the 7,380 cases found on interview to have been puerperal. SIGNATURE ON DEATH CERTIFICATE Death certificates were signed in 7,046 cases by physicians, in 362 cases by coroners, in 62 cases by others (a few by irregular practi tioners not listed in the medical directory and some by husbands or parents), and 67 certificates were not signed. O f the 188 cases of women who had no medical attention, the death certificate was signed in 65 cases by physicians, in 47 cases by coroners, and in 76 cases it was signed by some other person or was unsigned. RACE A N D N A TIV ITY Deaths of colored women made up 18 percent o f those included in the study. The maternal m ortality rate o f colored women in the years o f the study was nearly twice that o f the white women (table 2). The maternal mortality rates were significantly higher among colored women for every main cause of death except puerperal phlegmasia https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 7 GENERAL CONSIDERATIONS alba dolens, embolus, sudden death. For Cesarean section, other surgical operations and instrumental delivery, and “ others ” under the title “ accidents o f pregnancy ” the differences were insignificant. The greatest difference was in the deaths from puerperal albuminuria and convulsions, which caused more than twice as many deaths per 10,000 live births among the colored women as among the white women. T able 2 .— Cause o f d eath 1 as shown by interview, and m ortality rate among white and colored women dying from puerperal causes Women dying from puerperal causes White Colored Rate per Num Percent distri 10,000 ber bution live births Rate per Num Percent distri 10,000 ber bution live births Cause of death i as shown b y interview Total All causes________________________ , 7,380 6,072 100 57.5 1,308 100 Accidents of pregnancy____________________ 719 613 10 5.8 106 8 8.8 S58 U8 118 SOI 810 108 5 S 8 8.9 8.0 1.0 68 S8 16 4 S 1 4.3 S.8 1.3 . 791 652 670 525 11 9 6.3 5.0 121 127 9 10 10.0 10.5 186 18S 8 1.8 IS 1 1.1 109 407 97 SOS 8 6 .9 8.9 18 108 1 8 1.0 8.6 Puerperal septicemia.................................. 2,948 Puerperal phlegmasia alba dolens, embolus, sudden death............ .................... 344 Puerperal albuminuria and convulsions______ 1,900 Following childbirth (not otherwise defined) . 23 Puerperal diseases of the breast.................. 3 2,437 40 23.1 511 39 42.4 314 1,493 17 3 5 25 3.0 14.1 .2 (3> 30 407 6 2 31 (J) 2.5 33.8 .5 Abortion, premature labor_______________ Ectopic gestation_____________________ Others____ ____ _____ ___________ Puerperal hemorrhage_________________ Other accidents of labor______________ Cesarean section___________ Other surgical operations and instrumental delivery________________________ Others........ ...................... ........ (>) « 108.5 1 According to the Manual of the International List of Causes of Death, 1920. 3 Less than 1 percent. 3 Less than one tenth per 10,000. O f the 6,072 white women whose deaths were included in the study, 5,109 were native born and 805 were foreign bom ; the nativity o f 158 was not reported. DEATHS IN U RBAN A N D RURAL A R E A S The Vital Statistics Division of the United States Bureau of the Census includes in urban areas all cities o f 10,000 or more population as shown in the 1920 census. The maternal mortality rate was higher in urban areas (75 per 10,000 live births) than in rural areas (55 per 10,000 live births). The rates for the groups “ accidents o f pregnancy ” , “ other accidents o f labor ” , “ puerperal septicemia ” , “ puerperal phlegmasia alba dolens ” were significantly higher in urban than in rural areas. There was no significant difference in the other main groups. The greatest difference was in the mortality https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis C H A R T II.—M A T E R N A L M O R T A L I T Y R A T E S , B Y C A U S E (j) 5 10 15 20 25 30 35 D e a th s per 10,000 live b irth s 4 0 45 50 55 60 65 70 75 00 80 85 90 95 100 IPS— HO >15 ---------------------------- Total Urban Rural ■M Whit© m o Fir s t tw o tr i m e s te r s * 5 10 15 20 25 30 0 S 10 15 20 25 L ast tr i mester"* 30 35 40 45 SO 55 60 65 70 75 80 Total m Urban Rural White m Ê Ê Ê a B sm m m ysÆ F :m m m Colored I Puerperal Septicemia .Puerperal albuminuria and convulsions Puerperal phlegmasia alba dolens, embolus, sudden death Puerperal h e m o rrh ^ e IV/.VM All other puerperal ca u ses * In the bars show ing rates fo r total, urban, rural, and white, the rate fo r puerperal hemorrhage (1 tenth per 10,000 live births) is too small to appear. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M AT E R N A L DEATH S Colored GENERAL 9 C O N S ID E R A T IO N S rates from puerperal septicemia, and the difference in this rate was largely due to the higher rates from septic abortion in the cities than in the rural areas. The urban rates are undoubtedly raised by the deaths o f nonresidents who are brought to hospitals after delivery and who die there. LA C K OF M E D IC A L A TT E N T IO N A N D IN A C C E SSIB IL IT Y Nine percent of all the deaths were of women who had had no medical care or care only when dying. In strictly rural areas the distance from a physician may become an important cause for lack o f early and sufficient medical attention, partly because o f the actual distance and partly because o f the charge for country travel on a mileage basis in addition to the usual medical fees. Lack o f medi cal attention was not always associated with inaccessibility o f the C h a r t i i i .— m a t e r n a l m o r t a l i t y r a t e s b y c a u s e a n d b y T R IM E S T E R O F P R E G N A N C Y Oeaths per 10,000 live births 0 4 8 lg 16 20 24 g8 38 36 40 44 48 52 ' S6 60 64- Puerperal septicemia Puerperal albuminuria Puerperal hemorrhage Accidents o f pregnancy Other accidents o f labor Puerperal phlegmasia alba KSS dolens,embolus,sudden death 1 ^ 1 Following*childbirth l (not otherwise defined) > First "two trim esters L ast t r i m e s t e r ''” physician, but it was more frequent when there was no physician living in the vicinity. Yet even in cases of women having a physi cian nearby, 7 percent o f the number for whom medical attention was reported had no care or care only when dying. Poor roads and slow transportation are greater factors in inaccessibility than mere distance, for apparently more patients are really inaccessible in the Kentucky and Virginia mountains than in the western States where the distances are very much greater. HOSPITALIZATION O f the 7,380 women included in the study there was a report on hospitalization for all but 14. More than half were hospitalized at some time during their final illness. The deaths o f 4,066 occurred in hospitals, but the deliveries or abortions o f only 2,629 occurred in hospitals. Relati/oely few o f these patients who died in hospitals had planned hospitalization. O f the 4,066 women whose deaths occurred in hospitals, 2,501 had reached the last trimester; 1,558 had not https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 10 M A T E R N A L D E A TH S reached the last trimester; and for 7 the period o f gestation was not reported. O f the 2,501 who were known to have reached the last trimester o f pregnancy, only 1,893 were in the hospital for delivery, pP and less than half o f these (845) were known to have had planned hospitalization. Hospitalization was less frequent and more of it was o f an emergency nature among the colored women than among the white women. PERIOD OF GESTATION About one third o f the women included in the study died before they reached the lust trim ester o f 'pregnancy. Puerperal septicemia was the most important cause o f death prior to the seventh month and accounted for 59 percent o f the deaths in this period. But puer peral albuminuria and convulsions equaled puerperal septicemia in importance in the last trimester, to each being attributed 31 percent o f the deaths (table 3). (See charts I I and III.) T able 3.— Cause o f death as shown by interview , and period o f gestation among women dying from puerperal causes Women dying from puerperal causes Period of gestation Cause of death as shown by interview Total First two trimesters Last trimester Percent Percent Number distri Number distri bution bution Not re ported All causes...................... .............................. 7,380 2,381 100 4,965 100 34 Accidents of pregnancy.......................................... Puerperal hemorrhage________________________ Other accidents of labor......................................... Puerperal septicemia.............................................. Puerperal phlegmasia alba dolens, embolus, sudden death__________________ ____________ Puerperal albuminuria and convulsions________ Following childbirth (not otherwise defined)___ Puerperal diseases of the breast............................ 719 791 652 2,948 575 11 24 59 3 16 13 31 2 1,403 142 779 651 1,529 16 53 338 2 14 291 1,549 22 2 6 31 13 344 1,900 23 3 1 1 1 1 1 Less than 1 percent. LIVE BIRTHS A N D STILL BIRTHS Only 3,091 (43 percent) o f the 7,226 women for whom the type o f issue was reported gave birth to living children. Twenty percent were delivered o f still-born children (that is, children born dead at 7 or more months’ gestation). Twenty-nine percent had nonviable issue (born dead at less than 7 months’ gestation), and 8 percent died undelivered. (See chart IV .) PARITY A N D AGE Primiparse made up one third and multiparse two thirds o f the 6,854 women in the study for whom the number of pregnancies was reported. This study shows, as do other published figures, that the risk o f childbearing is comparatively great for mothers under 15 years https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL CONSIDERATIONS 11 o f age, that the most favorable age is from 20 to 25 years, and that from that age onward the maternal mortality rate increases, reaching a maximum in the age period 45 years and over. This is true both for white and for colored women. ILLEGITIM ACY The deaths o f 509 unmarried women are included in the study. Approximately one half (51 percent) o f the deaths, as compared with 39 percent o f the deaths of married women, were from puer peral septicemia. O f the deaths from septicemia, almost two thirds occurred before the women reached the third trimester. Puerperal albuminuria and convulsions also caused a larger proportion o f deaths o f unmarried (32 percent) than o f married women (25 per cent) . The other deaths of unmarried women were due to accidents o f pregnancy (7 percent), other accidents o f labor (5 percent), puerperal hemorrhage (3 percent), and puerperal phlegmasia alba dolens, embolus, sudden death (2 percent). More than one half of CH ART I V .— T Y P E O F I S S U E A M O N G W O M E N D Y I N G F R O M P U E R P E R A L CAU SES Percent White Colored H I Live births Previa ble □ f2 2 Stillbirths Undelivered^"-’ the unmarried women were colored, as compared with 18 percent colored in the total group. O f the 506 unmarried women for whom the period o f gestation was reported 219 (43 percent) died at less than 7 months’ gestation, as compared with 2,152 (32 percent) o f the 6,819 married women for whom this was reported. This larger proportion o f early terminations o f pregnancy among the unmarried women who died was confined, however, to the white women. Among the white women for whom the period o f gestation was reported, 60 percent o f the unmarried and 32 percent o f the married women died before reaching the last trimester of pregnancy. The maternal mortality rate for unmarried mothers in the States included in the study (except California, where data on legitimacy do not appear on the birth certificate) was 143 per 10,000 illegiti mate live births; for married mothers it was 60 per 10,000 legitimate live births. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis V 12 MATERNAL DEATHS COM M ENT B Y ADVISORY CO M M ITTEE This study apparently represents a fair sampling o f maternal deaths throughout the registration area. In this study the International List o f Causes of Death together with the Manual of Joint Causes in use by the United States Bureau of the Census has been used as the chief basis of classification. While this procedure was not entirely satisfactory from a medical point o f view, the inherent disadvantages seemed counterbalanced by the fact that it provides a definite and understandable classifica tion and that its use would assist the comparison o f the findings with those of other investigators. Certain changes in classification resulted after the interviews. These alterations, which were made necessary by various causes, emphasize the dependence o f the official statistics on the original death certificate and the apparent unavoidability of a small percent age o f error. A relatively small number of cases were excluded as nonpuerperal. These cases are easily equaled or exceeded by those that were actually puerperal but that were classed in the vital statistics as nonpuerperal and so were not included in the study. Therefore, maternal mortality rates as given in this study are prob ably lower than the actual rates. Autopsies were held in less than 8 percent of the cases, and many of the autopsies were done by coroners merely to determine the cause o f death. It is apparent that there was gross lack o f scientific study of the puerperal deaths included in the study. ^ The exceedingly high death rate among colored mothers is espe- cially challenging when considered in connection with the poor maternal care that was received by these colored women, as will be shown in succeeding sections. The differences between urban and rural rates cannot be fully explained by this study, as complete information on residence is not available. It is apparent, however, that two o f the factors con tributing to the higher urban rates are the larger proportion of abortions in the urban than in the rural communities and the deaths in urban hospitals of women who were delivered in rural areas. The exact value o f the second factor cannot be determined from this study for reasons given in the report. Nine percent of the women had no medical attention whatsoever, or else had attention only when they were actually dying. Only part o f this was due to physical inaccessibility. Inaccessibility due to distance and bad roads, however, was a serious problem in certain localities o f the States studied. The part played by inaccessibility in the lack o f early, as distinguished from any, medical attention was not measured; but the larger proportion o f deaths from hemorrhage and the toxemias in the less accessible groups is suggestive, especially when considered in conjunction with the lack o f prenatal care among women who died in the rural areas. It is impossible to draw conclusions as to the relative safety of deliveries in hospitals and homes from a study o f deaths alone. Data regarding the total number o f deliveries in hospitals and homes were lacking. Many hospital deaths followed home deliveries, and many o f the hospital deliveries were emergency cases. However, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL CONSIDERATIONS 13 there were too many deaths (899) o f women who had planned hospital deliveries in the last trimester. The figures relative to still births and live births indicate strikingly the appalling loss o f fetal life associated with maternal deaths; 37 percent were either undelivered or previable infants, 20 percent were o f viable age but stillborn, and only 43 percent are credited as being live births. The number of these infants who died or were damaged survivors was not possible to determine from this investiga tion. One third o f all the deaths were o f women who had not reached ihe last trimester o f pregnancy. Duration o f pregnancy is a most important consideration in the evaluation of any statistics on maternal mortality. Illegitimacy contributes to maternal mortality, as 7 percent o f the deaths in this study were of unmarried women, and the mortality rate is much higher for unmarried than for married mothers. There was a larger proportion o f abortions among the unmarried, and the deaths from such preventable causes as sepsis and toxemia were relatively more numerous among the unmarried mothers. Social and economic factors doubtless play an important role in creating this mortality and they should be adjusted to prevent this loss of life. 179179° •33 - 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis y M ATERNAL CARE ® Maternal care in the fullest sense includes very many factors— the woman’s food, her living conditions, her mental condition, the conditions under which her confinement takes place, how she spends the lying-in period. O f particular importance is the type o f medical and nursing care that she obtains. In this study attention was con fined largely to the medical aspects o f maternal care. O f the 7,380 women whose deaths are included in this study only 933 were known to have had no complication o f pregnancy. Six hundred and sixteen o f these women were reported to have had no intercurrent disease. Only 263 o f the 616 were known to have had normal spontaneous deliveries in the last trimester, and only 199 of C H A R T V .—P R E N A T A L C A R E A M O N G W O M E N D Y I N G F R O M P U E R P E R A L CAUSES » P ercent 0 10 20 30 40 50 60 TO 80 90 ___ 100' T o ta Urban R u ra l w hite/“ C o l o r e d /“ H i None I*“*-! Ungraded In d iffe re n t Y/A Poor* Good^-"'’ the 263 were reported to have had a normal third stage o f labor and no postpartum hemorrhage. And yet 100 o f these 199 women with apparently normal pregnancy and labor died o f puerperal sepsis, 55 o f puerperal phlegmasia alba dolens, embolus, sudden death, 23 o f other accidents of labor, 15 o f puerperal albuminuria and con vulsions, and the other 6 o f other puerperal conditions. It should be borne in mind in connection with these figures that a large num ber o f women who had no prenatal care or about whose care during pregnancy nothing was known were not included in the discussion. PRENATAL CARE A ll pregnant women should receive prenatal care. In practice prenatal care is seldom sought before the third month o f pregnancy. Also, it is not sought by women who are sufficiently hostile to their pregnancy to resort to self-induced or criminal abortions. As 1,154 1 Excludes women fo r whom pregnancy terminated before the third m onth and wom en w ho had induced abortions. 14 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L CARE 15 o f the 7,380 women in this mortality group had pregnancies which terminated before the third month, either spontaneously or intention a l or had later induced abortions other than therapeutic, there were 6,226 to whom it might reasonably be expected that prenatal care would have been given. A report on prenatal care was obtainable concerning only 5,636 o f the 6,226 who might be expected to have had such care. O f these 5^636j 3,025 (54 percent) had had no prenatal examination by a physician. For the most part, physicians had no opportunity to give prenatal care to these women, for they were not consulted. Prenatal care was much more frequent among the white than among the colored women, and in both groups prenatal care was more frequent in the urban areas than in the rural areas (table 4). T able 4 .—Prenatal care received by white and colored women dying in urban and rural areas from puerperal causes Women dying from puerperal causes Grade of prenatal care Total In urban areas In rural areas Percent Percent Percent Number distri Number distri Number distri bution bution bution Total___________________ Report on prenatal care_________ Grade I _____________ Grade I I........................... Grade III........................ Ungraded............................. None___ _______ No report on prenatal care__ _________ Inapplicable1............................. 7,380 3,462 3,918 5,636 100 2,452 100 3,184 100 725 490 1,337 50 3,025 13 9 24 1 54 484 320 630 32 986 20 13 26 1 40 241 179 707 18 2,039 8 6 22 1 64 590 1,154 313 697 277 457 W HITE Total............................................. 6,072 2,951 3,121 Report on prenatal care............................ 4,568 100 2,061 100 2,507 100 Grade I . . ................. ................... Grade II........................ . Grade III_______ ____ Ungraded________________ None__________________ 694 458 1,157 45 2,214 15 10 25 1 48 463 291 540 28 739 22 14 26 1 36 231 167 617 17 1,475 25 No report on prenatal care...... ................ Inapplicable1________________ 458 1,046 7 59 212 402 246 644 COLORED T o ta l............................................. 1,308 ____ 511 Report on prenatal care............................ 1,068 100 391 100 677 100 Grade I................... ................... Grade II________________ Grade III_____________ Ungraded__ ____ _________ None___________________ 31 41 180 5 811 3 4 17 21 29 90 4 247 5 7 23 1 63 10 12 90 1 564 1 2 13 No report on prenatal care___________ Inapplicable1____________ 132 108 (2) 76 797 67 53 1 Induced abortions and cases in which pregnancy terminated before the third month. 2 Less than 1 percent. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 65 55 (>) 83 16 MATEBNAL. DEATHS Prenatal care in the different States The quality and amount o f prenatal care given varied greatly in the different States included in the study. O f the women who might be expected to have had prenatal care, 71 percent in Oregon and 70 percent in Rhode Island had had some care, but only 22 percent in Alabama and 30 percent in Oklahoma. In every State except one, more o f the women who died in cities than o f those who died in the rural areas had had prenatal care. In general, the States in which more o f the women who died had had grade I care had lower mor tality rates from puerperal albuminuria and convulsions. Grading of the prenatal care received The prenatal care given was divided into three grades: Grade I includes (1) a complete physical examination, (2) pelvic measurements, internal and external, except in pregnancies termi nating before the eighth month and for multiparse who had had a previous normal delivery, and (3) regular monthly visits to a physi cian, beginning with or before the fifth month, with examination o f urine and blood pressure at each visit. This care, which is on the whole good, although not up to highest standards, was received by 725 women (13 percent). Only 1$ women (less than 1 percent) had adequate care as described in Standards o f Prenatal Care (Chil dren’s Bureau Publication No. 153). This includes chiefly, in addi tion to the above, a Wassermann test and visits beginning with the second month. Grade II includes a general physical examination, regular monthly visits to the physician, beginning not later than the seventh month, with examination o f the urine and blood pressure; this can be classi fied only as indifferent care. Four hundred and ninety-nine women (9 percent) had had this care. Grade I I I included in some cases only a single visit to the physi cian; in some cases there were repeated visits, but blood pressure was not taken or other essentials o f the better grade o f care were omitted. Care o f this kind must be classified as poor. There were 1,337 women (24 percent) included in this group. (See chart Y .) M ore than three fourths had had poor or indifferent care or none at a lt. Ordy 16 percent had had a Wdssermann test. O f the 1,478 women who first consulted the physician before or during the fifth month o f pregnancy, 725 (49 percent) received grade I care, 243 (16 percent) received grade I I care, and 501 (34 percent) received grade I I I care; for 9 the grade was not reported. In the grading o f prenatal care no account was taken o f the treat ment given, for the methods of treatment are not so standardized as are the methods o f examination. , Prenatal care and trimester of pregnancy Fifty-five percent o f the women who died before they reached the last trimester died too early in pregnancy to have been expected to have prenatal care, or they had induced abortions, or else information concerning their care was not obtained. But o f the remaining 1,064 women 17 percent had had grade I care, 3 percent had had grade I I care, 14 percent had had grade I I I care, 1 percent had had care that was ungraded, and 66 percent had had no care. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MATERNAL CARE 17 O f the 4,570 women who died after reaching the last trimester and for whom a report was obtained concerning prenatal care, 12 percent had had grade I care, 10 percent grade I I care, and 26 percent grade I I I care; 1 percent had had care that was ungraded, and 51 percent had had no care. Twenty-four percent of those who died following grade I care and 34 percent of those who had had no care died o f puerperal albuminuria and convulsions. Prenatal care and number of pregnancies O f the 2,334 known primiparse whose deaths were included in this study, a report as to prenatal care is available and applicable for 1,924. O f these 14 percent had had grade I care, 14 percent grade I I care, 24 percent had had poor care (grade I I I ) , and 46 percent had had no prenatal care whatsoever. O f those in their second preg nancy 22 percent had grade I care, 11 percent grade I I care, 27 per cent grade I I I care, and 39 percent no care. A fter the second preg nancy the percentage o f those who had good prenatal care decreased, and the percentage o f those who had no prenatal care rose with the number of pregnancies. Prenatal care in relation to live births and still births Among the 4,843 cases o f women who had reached the last tri mester in which there was a report on the character o f issue, 70 per cent were live births for the mothers who had had grade I and grade I I prenatal care, 63 percent for those who had had grade I I I care, and 58 percent for those who had had no prenatal care. | DELIVERY CARE The paramount importance o f adequate care at the time o f de livery is conceded by all. Adequate delivery care requires the careful management o f normal labor, the maintenance o f aseptic technique, and the proper handling of any abnormalities. These in turn imply an attendant who has not only skill but patience and good judg ment, sufficient trained assistants, and clean surroundings with facilities for dealing with emergencies. The actual evaluation of all these factors is obviously difficult. In this study no attempt was made to grade the types o f delivery care given. The simplest and most objective o f the factors involved were merely studied separately. Hospitalization at delivery O f the 4,965 women who reached the last trimester o f pregnancy, 1,971 were in hospitals for delivery or at the time o f death if they died undelivered. The hospitalization o f 899 of these 1,971 women was planned, but for 1,018 it was an emergency measure, and for 54 there was no report as to whether it was planned or not. Two thou sand nine hundred and ninety women were delivered or died unde livered outside o f hospitals, and for four women the place of delivery was not reported. The hospitalization of white women was much more frequent than o f colored women. Maternal mortality rates for hospitals and for homes cannot be given, because data regarding the total number o f deliveries in hospitals and in homes are not available; but even if there were such data, the large and varying proportions o f complicated cases among those delivered in hospitals invalidate comparisons. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 18 M ATE R N A L DEATH S Attendant at confinement Information on the attendant at delivery or at death if the patient died undelivered was obtained for 4,903 of the 4,965 women who died after reaching the last trimester. O f these 4,903, 4,065 (83 percent) were attended exclusively by physicians, internes, or medical stu dents (3,915 by physicians only, 87 by physicians preceded by in ternes or medical students, 63 by internes or medical students only). Midwives attended 550 (11 percent) o f the 4,903 women, including 193 for whom physicians (in 2 cases internes) were called in before the delivery was completed. Nonmedical attendants such as rela tives attended 172 women (4 percent), including 47 for whom a phy sician was called in before the delivery was completed, and 116 women (2 percent) were said to have been unattended. Practically all the midwives who cared for these women were un trained, although there were a few foreign-trained midwives. A ll cases in which the patient was delivered by a midwife and all cases in which a midwife was known to have been in attendance for the purpose o f delivering the patient, even if the physician made the actual delivery, were classified as having been attended by midwives. Four hundred and sixty-two o f the five hundred and fifty women attended at confinement by midwives died in Alabama, Kentucky, Maryland, and Virginia, and these 4 were the only States o f the 15 in the study in which the number o f deaths of women attended by midwives constituted 10 percent or more of the total number o f deaths o f mothers who had reached the last trimester. In 3 o f these 4 States (Alabama, Maryland, Virginia) the proportion o f midwifeattended confinements among the women who died was very slightly smaller than the proportion o f midwife-reported births among the total live births o f the State. In these 4 States the midwives were employed rather than physicians because the patients were not ac customed to the services o f a physician at childbirth or could not afford a physician’s care. The inaccessibility o f a physician was also an important factor. Technique o f the principal physician The technique of the principal physician at confinement was re ported in 3,619 o f the 4,305 cases in which a physician attended women in the last trimester. In 1,740 cases (48 percent) an aseptic technique was said to have been used. This included shaving, scrub bing, sterile drapes, instruments, and rubber gloves, and adequate assistance at delivery. In 510 cases (14 percent) the technique was not so good and was classed as attempted aseptic. In 1,099 cases (30 percent) the technique was classified as clean but not sterile. This meant only ordinary cleanliness and usually sterilization o f any instruments used. In many cases the principal physician whose technique was assigned to 1 o f these 3 classes was preceded by some one whose technique was less careful. In 270 cases (7 percent) not even ordinary cleanliness was used. The technique as described may not coincide in some cases with that which was actually used, for the grading was based on the physician’s subsequent description o f his technique as he remembered it. The principal physician made vaginal examinations in 2,765 cases and made no vaginal examination in 1,089 cases; in 451 cases there was no report on this matter; and in 660 cases no physician was in https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MATEEN-AL CARE 19 attendance. The principal physician had made 1 vaginal examina tion in 871 cases, 2 in 565 cases, and 3 or more in 771 cases; in 558 cases the number was not given. O f the 2,765 cases in which the principal physician made vaginal examinations, rubber gloves were reported used in 2,188 cases, not used in 484 cases, and there was no report on their use in 93 cases. Rectal examinations were re ported as having been made by the principal physician in 778 cases; in 326 o f these he made 1 or more vaginal examinations also. There was a report on the use o f pituitrin in 3,718 o f the 4,305 last-trimester cases with a physician in attendance. Pituitrin was said to have been used before the delivery o f the child in 711 cases, after the delivery o f the child only in lj004 cases, and at an unre ported stage o f labor in 24 cases. In 1,979 cases pituitrin was said not to have been used. In the group o f cases in which pituitrin had been used before the delivery o f the child larger proportions o f the deaths were from puerperal septicemia and puerperal hem orrhage and a smaller proportion was from puerperal albuminuria and convulsions than in the group in which no pituitrin had been used. COM M EN T B Y ADVISORY CO M M ITTEE This section shows clearly what a serious situation exists in regard to the quality o f the maternal care that many women receive in this country during their pregnancy. Although this study covered but 15 States, they represent a fair cross section of the country, and therefore it is probably fair to assume that the findings in this sec tion are applicable to the country as a whole. It is discouraging to find that of the women on whom a report as to prenatal care could be obtained and who could reasonably have been expected to have such care, 54 percent had had no prenatal examination by a physician. In only 1 percent was the care given up to the standard that it is the right of every pregnant patient to have and to demand. For the deaths o f the women who had had no prenatal examina tion the attending physician could hardly be held responsible, for he was not consulted until an emergency had arisen. Gross igno rance, carelessness, and sociological and economic problems all had a share in this responsibility. However, in those cases in which the physician was consulted he was responsible for providing adequate maternal care; and in many o f these cases physicians failed in their responsibility, for half the women who did consult a physician had poor prenatal care. Although the question o f prenatal care was considered for only 45 percent o f the women who died before they reached the last trimester of pregnancy, 80 percent of these 1,064 women had no care or poor care. Furthermore, many of the 20 percent who had good or indifferent care already had troublesome symptoms before they consulted a physician. O f those women who died after reach ing the last trimester and for whom a report was obtained, 78 percent had poor prenatal care or none. Evidence o f the value of prenatal care may be found in the fact that smaller proportions of the women who died after good pre https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 MATERNAL DEATHS natal care than o f those who died after poor prenatal care died o f puerperal albuminuria and convulsions. Further evidence may be found in the larger proportion o f live births in those cases in which there had been good prenatal care, and in the fact that those States with more good prenatal care, even among the women who died, had lower death rates from albuminuria and convulsions. Primipara and the mothers o f many children particularly need prenatal care, but many o f these women failed to receive it. Prenatal care, such as it was, was much more frequent among the white than among the colored women, and in both groups it was more frequent in the urban than in the rural areas. In the rural areas among the colored women there was practically no prenatal care, for 83 percent had none and 13 percent had grade III, which is poor care. Delivery care, though as important as prenatal care, was more dif ficult to evaluate, but certain facts were noted. For more than half the women who died in hospitals after reaching the last trimester, hospitalization was an emergency measure. Among the colored women emergency hospitalization was much more frequent than among thè white women. Eighty-three percent of the women were attended by physicians, internes, or medical students, 11 percent by midwives, 4 percent by nonmedical attendants; 2 percent of the women had no attendant at the delivery or at the death if the patient died undelivered. Figures given in the report would indicate that, though the mid wives played a part in the mortality, they could not have been^K responsible for any large proportion of the deaths because t h e y ^ attended a relatively small percentage of the cases. No study of the qualifications o f the individual physicians or mid wives was attempted. As it was known, however, that the majority o f the midwives were ignorant “ grannies” , it may safely be assumed that these midwives did not use a satisfactory aseptic technique at delivery. In 48 percent of the cases the physicians described their technique, as they remembered it, in such a way that it was classified as aseptic; but obviously this is not a sure way of determining how good this technique was. The point to be noted is that the physi cians themselves admitted it was unsatisfactory in more than 50 percent o f the cases. The frequency o f vaginal examinations, often times without gloves, is clear, and the relatively small number of rectal examinations must be noted. Although the data on the use of pituitrin are incomplete, its use is shown to be common and to be associated with serious accidents. Higher percentages o f maternal deaths from sepsis and from hemor rhage occurred among those who had it than among those who did not have it. The percentages o f ruptured uterus and o f stillbirths also were higher. The almost total lack of adequate prenatal care and the relative infrequency of any prenatal care were outstanding. Besides permit ting the unchecked development of unfavorable factors during preg nancy, this situation led to delivery care that was unsatisfactory because given without previous knowledge of the case and frequently in circumstances that necessitated emergency hospitalization. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OPERATIONS In this study more than half o f the women had had some operative 'procedure before dealh. O f the 7,234 women concerning whom there was a report on this point, 3,370 (47 percent) had had no opera tions, while 2,649 (37 percent) had had an operation directed toward delivery and 1,131 (16 percent) had had some operation other than for delivery. By an operative delivery is meant an operation for the purpose o f delivering the fetus or for the immediate removal o f the placenta. _ Attempts at these operations, as well as completed operations, are included. Other operations were secondary, usually on account o f sequelae o f the delivery. OPERATIONS IN THE LAST TRIMESTER OPERATIONS FOR DELIVERY O f the 4,965 women who reached the last trimester o f pregnancy, 2,225 (45 percent) were known to have had an operative delivery or c h a r t v i .—o p e r a t i o n s f o r d e l i v e r y in t h e l a s t t r i m e s t e r o f PREGNANCY AMONG WOMEN DYING FROM PUERPERAL CAUSES P ercent 0 20 40 60 80 100 U rban Rural White Colore- ct Forceps Version Other operations C e sa r e a n s e c t i o n I I None an attempt at operative delivery. Forceps operations were per formed 718 times. In addition, there were 98 cases o f forceps and version combined. Usually when forceps failed the delivery was completed by version. In 150 o f the 718 cases the application o f forceps followed induction of labor or artificial dilatation o f the cervix.1 In 24 cases the use o f forceps was followed by manual removal o f the placenta. In 12 cases all 3 procedures were used. In 14 cases forceps were used in combination with some other operation^of'labor11^ rePorl ** artificial dilatation of the cervix ” includes mechanical induc- 179179°— 33----- 4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 21 22 M ATE R N A L DEATH S tion. In 162 cases, including 12 with manual removal o f the pla centa, the use o f forceps followed induction o f labor or artificial . dilatation o f the cervix. O f these women 106 were not in labor when 9 the artificial dilatation o f the cervix was begun; in 56 cases o f women in labor the dilatation o f the cervix was done to facilitate delivery. The 718 cases include 2 in which the forceps operation failed and the women delivered themselves spontaneously later, and 13 in which they died undelivered after unsuccessful attempts at delivery by forceps. The deaths o f 35 percent o f these 718 women who had forceps operations were attributed, according to the international classifica tion, to puerperal albuminuria and convulsions, 26 percent to puer peral septicemia, 7 percent to embolus and sudden death, 5 percent to placenta previa, 11 percent to other puerperal hemorrhage, 15 percent to other accidents of labor, and 1 percent to other puerperal causes. O f the 162 cases in which artificial dilatation o f the cervix preceded the use of forceps, the deaths were attributed to puerperal albumi nuria and convulsions in 62 percent, placenta previa in. 10 percent, other puerperal hemorrhage in 9 percent, septicemia in 9 percent, sudden death in 2 percent, and other causes in 8 percent. In 98 cases attempts at both forceps and version were made, in some cases with dilatation o f the cervix or manual removal o f the placenta, or both. The delivery in 51 cases was completed by version after forceps had failed; 25 women were delivered by version with forceps on after-coming head; there were 5 cases in which forcepsjp had failed and the delivery was completed by version with forceps on after-coming head; 5 women were delivered by forceps after attempts at version had failed; there were also 5 cases in which attempts at version and forceps delivery both failed and the woman died undeliv ered. Seven women who were delivered o f twins each had one baby delivered by version and one by forceps. O f these 98 cases in which several operative attempts had been made to deliver the patient, 32 percent o f the deaths were attributed to puerperal septicemia, 20 percent to puerperal albuminuria and convulsions, 12 percent to placenta previa, 12 percent to other puer peral hemorrhage, 18 percent to other accidents o f labor, and 5 percent to other causes. There were 44 attempts at forceps or version, or both in some cases, in which the woman was finally delivered by Cesarean section. Version was the principal operation for delivery in 618 cases, in cluding the cases in which a forceps operation was used in conjunc tion with version— or 520 cases in addition to the 98 already discussed. In 272 o f these 520 cases version follow ed artificial dilatation o f the cervix; in 48 of these 272 cases it was also followed by manual re moval o f the placenta. In 26 cases version was followed by manual removal o f the placenta, and in 4 cases it was accompanied by some other operation or a combination of operations. In 172 o f the 272 cases in which version was preceded by dilatation o f the cervix the dilatation was done to induce labor as well as to facilitate delivery. Six of the 520 women died undelivered after attempts at version had failed. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OPERATION'S 23 O f these 520 deaths following version, 32 percent were attributed, according to the international classification, to placenta previa, 10 V Percent to other puerperal hemorrhage, 28 percent to puerperal albu minuria and convulsions, 19 percent to puerperal septicemia, 2 per cent to embolus and sudden death, and 9 percent to other causes. In addition to the cases o f dilatation o f the cervix performed with some other operation for delivery, the cervix was dilated manually, by bag, or by other artificial means in 112 cases. Eighty-nine women later delivered spontaneously, but 23 women died undelivered with out further attempts at delivery. Four o f the 89 women who de livered spontaneously after dilatation of the cervix also had manual removal o f the placenta. There were also 87 women who had manual removal o f the placenta following an absolutely spontaneous labor and delivery. Sixty-five women were delivered by breech extraction. Eight of these had labor induced, 55 went into labor spontaneously, and for 2 the type o f onset was not reported. Fifty-seven women were delivered by craniotomy or embryotomy. Two o f these had labor induced. Eight women with abdominal pregnancy were delivered by laparotomy in the last trimester. Twenty women had had some operation or combination of operations for delivery other than those already mentioned. Nine women had some operation for delivery, but its type was not reported. For 133 women no report could be obtained as to whether or not there had been an operative delivery. Cesarean section preceded the deaths o f 531 women who had reached the last trimester. For 62 of them attempts had been made at some other method o f delivery. The Cesarean-section cases are discussed later (p. 29). The technique o f the operating physician as regards asepsis was analyzed. The term “ aseptic ” is used to indicate the usual good hos pital delivery or operating-room technique without reported breaks. This was applicable in 1,328 cases. The term u attempted aseptic ” is applicable to 275 cases, indicating that conditions as regards asepsis were not so good. Four hundred and fifty cases were as signed to the classification “ clean, not sterile.” “ Dirty ” indicated usually no preparation of the patient and sometimes no preparation even o f the physician’s hands; 89 cases were so assigned. Table 5 shows the duration o f labor o f primiparae and multiparae who had reached the last trimester o f pregnancy and whose deaths were preceded by various operations for delivery. Two hundred and eighty-six primiparm and 1,170 multiparm were in labor less than 6 hours. Three hundred and seventy-three primiparae and 538 multiparae were in labor 6 but less than 12 hours. Cesarean sections were performed 56 times on primiparae and 31 times on multiparae after 36 hours or more of labor. Almost all these operations were o f the classical type. Onset and termination of labor Artificial onset and artificial termination o f labor were more fre quent among the white than among the colored women who died. Not only did a larger proportion o f colored women die undelivered, but a larger proportion died before the onset o f labor. O f the 1,990 women who died following operative termination of labor in the last trimester o f pregnancy, there was a report as to https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis to T able 5.— H ours in labor and type o f principal operation fo r delivery performed on primiparse and m u ltip a rt dying fro m puerperal causes who had reached the last trimester o f pregnancy Women dying from puerperal causes who had reached last trimester Hours in labor Type of principal operation for delivery 1 Includes 17 with dilatation of cervix. ^Includes 9 with dilatation of cervix. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 718 531 818 296 108 87 57 65 32 9 2,607 133 1,746 204 286 373 306 408 59 93 111 86 85 19 13 292 164 74 37 26 22 15 7 1 747 27 133 2 2 67 15 49 20 31 27 23 39 16 6 11 3 1 3 145 14 4 4 207 130 184 263 3,041 229 1,170 538 282 90 151 581 178 32 28 9 6 58 53 34 301 93 66 59 23 9 6 76 8 10 4 5 19 19 22 9 234 445 43 3 918 6 3 9 7 2 2 4 4 4 1 56 33 7 3 3 8 2 3 123 1 19 23 4 2 3 2 1 1 163 26 70 60 35 48 25 4 1,757 62 116 23 196 14 68 24 56 13 27 31 39 13 59 5 9 137 94 15 11 9 99 6 2 9 10 1 3 114 1 17 L3 1 11 4 2 1 25 2 4 5 15 9 13 8 7 12 4 103 764 1 345 1 5 34 35 5 1 1 6 14 3 6 3 3 389 57 1 1 2 4 103 44 M A T E R N A L D E A TH S Forceps (without version)------------With dilatation of cervix______ Cesarean section............................... Version......... ................................... With dilatation of cervix........... Dilatation of cervix only.................. Manual removal of placenta only—. Craniotomy or embryotomy........... Breech extraction 1........................... Other operation s.............................. Type not reported________ _____ No operation for delivery—.......... . No report on operation for delivery. 4,965 Parity not reLess 6, less 12, less 24, less 36 and Notre- ported than 6 than 12 than 24 than 36 more ported Less 6, less 12, less 24, less 36 and Not re- 1 (jt/cil TiT than 6 than 12 than 24 than 36 more ported Total Total______________________ Multíparas Primíparas Total OPERATIONS 25 prenatal care for 1,879. O f these, 807 are known to have had no prenatal care; that is, 43 percent o f the operative deliveries were on women whom the physician had not seen before labor or before the acute emergency. Operative deliveries and parity The percentage o f deaths preceded by version and version com binations increased with the number o f pregnancies, from 10 percent in the first pregnancy to 16 percent for those with five pregnancies. It decreased slightly for the sixth and seventh pregnancies and rose again to 21 percent o f those dying after eight or more pregnancies. Dilatation o f the cervix preceding version was also more common in the later than in the earlier pregnancies. The frequency o f forceps operations dropped rapidly from 24 percent in the first pregnancies to 11 percent in the second pregnancies, 9 percent in the third, and 8 percent in the fourth pregnancies, after which it rose slightly. The incidence o f operations for delivery increased with age both for primiparse and for multiparse. Among primiparse there was a definite increase with age for Cesarean section. Among multiparse there was a definite increase with age for forceps, version, and Cesarean section. Incidence of operative delivery The deaths o f white women were more often preceded by operative deliveries than those o f colored women, and the deaths were more often preceded by operative deliveries in the urban than in the rural areas. The proportion o f maternal deaths that were preceded by operations for delivery varied in the different States. Some opera tion for delivery in the last trimester preceded 57 percent o f the maternal deaths in California and Wisconsin but only 34 percent in Alabama. OPERATIONS OTHER THAN FOR DELIVERY Some operation other than the actual delivery o f the child or o f the placenta was performed on 636 women who died after reaching the last trimester. Three hundred and one o f these women also had an operative delivery. Most o f these other operations were done for conditions resulting from the delivery. In 62 cases transfusion was the only operation. In other cases there was a curettage or incision and drainage for infection, packing o f the uterus, or enterostomy. Packing o f the uterus was recorded in 138 cases. In 73 cases packing followed an operative delivery, and in 65 cases it followed after a normal delivery. A curettage was done in 109 cases, usually on women who died from sepsis. It followed an operative delivery in 22 cases and a normal delivery in 82 cases. In 5 cases the type o f delivery was not reported. Some o f these women also had a blood transfusion. Incision and drainage o f an abscess was reported for 45 cases. In 32 cases a laparotomy for drainage o f peritonitis was done. Practically all these secondary operations were performed as a result o f sepsis. Fourteen women had appendectomies, 7 antepartum and 4 post partum, 2 at Cesarean section, and 1 at laparotomy for abdominal https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 26 MATERNAL DEATHS pregnancy. In some cases the appendectomy had apparently little to do with the death; in other cases it was a factor o f greater importance. Another group o f women had enterostomy operations done subse quent to the delivery. Still another group had hysterectomies for one cause or another. A few o f these secondary operations were for accidental complications, but most o f them were intended to relieve conditions arising from the delivery, and most o f the deaths that were preceded by these operations were from sepsis. OPERATIONS IN THE FIRST TW O TRIMESTERS Nearly all the operations for delivery performed on women who died before reaching the third trimester were classified either as therapeutic abortions or as laparotomies for ectopic gestation. Laparotomies for ectopic gestation were performed on 195 women. In 3 cases abdominal pregnancies o f 5 or 6 months were found. Various other operations were performed in conjunction with the operation for ectopic gestation or on account o f sequelae o f the first operation. In 13 cases the appendix was removed at the time o f the operation. Fifteen o f the women were curetted before the laparot omy was performed, in some cases for diagnosis and in other cases because o f mistaken diagnosis. The deaths o f 52 o f these 195 women were attributed to puerperal septicemia. The other deaths in this group were attributed to ectopic gestation; in other words, the women died o f hemorrhage and shock. Only 26 o f the 195 women who had had laparotomies for ectopic gestation had blood transfusions. O f the 205 therapeutic abortions 84 were performed in the first trimester and 117 in the second trimester; the time at which the re maining 4 were performed was not reported. Pernicious vomit ing was given as the principal indication for 112 of the 205 thera peutic abortions; other toxemias for 52; hemorrhage, placenta previa, or premature separation for 14; dead fetus for 12; and other causes for 15. Most o f the therapeutic abortions were done from below, but in four cases a hysterectomy and in at least seven cases an ab dominal hysterotomy was the method used. O f these 205 women who had had therapeutic abortions, 38 had some other operation besides— a second curettage, a blood trans fusion, or packing o f the uterus because o f hemorrhage. Fourteen o f the 38 women had laparotomies subsequent to the therapeutic abortion. Most o f the additional operations were for complications, and sepsis caused the death of most o f these 38 women. A t least one curettage had been done on 585 women who had had a spontaneous or induced abortion other than a therapeutic abortion, and most o f the deaths o f these women were attributed to puerperal septicemia. Fifty-three o f the women who died in the first two trimesters had had blood transfusions as their only operation. Most o f these deaths also were due to sepsis. Another group (82) who had had no operation for delivery, had laparotomies performed for various complications, such as peritonitis or salpingitis, and the majority o f these deaths were due to sepsis. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OPERATION'S 27 COM M ENT B Y ADVISORY CO M M ITTEE In this series of cases all the women died (and many of the babies), and, therefore, it is a record o f failure. One cannot say that the operative procedures followed in many cases caused the deaths, but analysis o f these procedures leads to many criticisms o f the management of these cases. The physicians who delivered these cases cannot be blamed in all cases for the results obtained, for in 43 percent o f the operative . deliveries they had not seen the women before labor or before the acute emergency had occurred. Under these circumstances it is a well-recognized fact that the operation of election is not always possible; the physician many times is forced to do something which he appreciates may not be the best but which, at the time, seems justifiable. This shows, from another point o f view, the absolute necessity, if maternal mortality is to be lowered, o f insisting upon continuous prenatal and adequate delivery care. In a study o f this type the physician’s ability to do well the oper ation he has chosen can be evaluated only by the results, which show that many o f the operations either were badly chosen or were poorly done. In nearly 40 percent o f these operative deliveries it was admitted by the physicians that their technique was at least unsatisfactory with regard to asepsis. It is therefore not to be wondered at that 26 percent o f the deaths following forceps deliver ies and 19 percent of the deaths following versions were due to sepsis. Had those women whose deaths were assigned to eclampsia w and placenta previa lived longer, many of them also would prob ably have died o f sepsis. An operative delivery is a surgical pro cedure and should not be undertaken by physicians untrained in surgical technique. It is evident that many o f these physicians did not have such training. Many o f these patients were operated upon after very little or no labor, and this explains the frequency of artificial dilatation o f the cervix in both forceps and version deliveries. The number o f cases in which manual dilatation o f the cervix, forceps or version, and manual removal o f the placenta occurred, or forceps failed and ver sion was done, was deplorably large. From this it is evident that accouchement forcé was resorted to many times, and accouchement forcé is not regarded as good obstetrics today; it gives bad results and should not be performed. That attempts at delivery by vagina were followed by Cesarean section in 62 cases is to be noted and condemned. (For further com ment on the Cesarean sections done in this series see p. 31.) That 57 women died following delivery by craniotomy or em bryotomy shows clearly the lack o f care these women had. The frequency with which a curettage was done on women who had developed sepsis is surprising, for such treatment has long been condemned. Secondary operations for various conditions, usually o f a septic nature, were much too common. Most of the operative deliveries in the first two trimesters were classified either as therapeutic abortions or as laparotomies for ectopic pregnancy. The main comment on the deaths occurring from these • https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 28 MATERNAL DEATHS two conditions is made in their respective sections, but a few com ments may be made here. The removal o f the appendix at the time o f operation for an ectopic gestation is not good surgery. The fact that o f the 195 women who had had a laparotomy for ectopic gesta tion only 26 had transfusion is to be noted. It must be recognized that preparation to transfuse is almost as essential as operation in ectopic pregnancy. That 52 women died o f sepsis shows clearly how perfect one’s technique should be if sepsis is to be avoided. It is to be expected that the operative incidence would be higher in a group o f fatal cases such as those included in the present study than among women who survived. Without having all the data for all areas studied it would be difficult to draw too many absolute conclusions. Necessarily the more serious operation would make up a higher percentage in a mortality study than the less dangerous operations. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis CESAREAN SECTION Five hundred and thirty-seven of the maternal deaths included in the study followed Cesarean section. This is 7 percent o f the 7,211 deaths for which information concerning operations was secured. Five hundred and thirty-one women whose deaths followed Cesarean section had reached the last trimester of pregnancy. A Cesarean section was done on 11 percent of the 4,832 women who died after reaching the last trimester and for whom there was a report on oper ation for delivery. Twenty-four percent o f all operations for de livery on women who died after reaching the last trimester were Cesarean sections. The percentages of maternal deaths that were preceded by Cesarean section in the last trimester ranged in the various States from 2 in North Dakota to 24 in California. Deaths following Cesarean section were twice as frequent in the urban as in the rural areas. For 8 percent o f the white and 6 percent of the colored women death was preceded by Cesarean section. For those women who died following Cesarean section in the last trimester, the inci dence was 17 percent among the urban white, 16 percent among the urban colored, 7 percent among the rural white, and 4 percent among the rural colored. CAUSE OF DEATH For these women who died following Cesarean section the num ber o f deaths from each cause, as given on interview by the attend ant physicians and classified according to the international list was: Accidents o f pregnancy, 3; puerperal hemorrhage, 42; other accidents o f labor, 146 (including Cesarean section, 136) ; puerperal septicemia, 143; puerperal albuminuria and convulsions, 202; and embolus and sudden death, 1. INDICATIONS The indications for Cesarean section were very numerous. Combi nations of indications were very frequent ; in one fourth o f the cases more than one indication was given. Eclampsia was given alone or in combination in 165 cases. Contracted pelvis was given in 107 cases, but this probably does not represent the actual number o f women with contracted pelves in the group, as in many cases the principal indication given was a long and difficult labor with no word about contracted pelvis. Preeclamptic toxemia was the indication in 47, uremia in 27, placenta previa in 38 cases. Twenty-five o f the 537 women who had a Cesarean section are known to have had a previous Cesarean ; but this fact was used as the sole indication for operation in only 6 cases, and as the principal indication in 17. 29 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 30 M A T E R N A L D E A TH S The following list shows the principal indications for Cesarean section: Women who died follow ing Cesarean section Indication fo r operation as given by attending physician T ota l_______________________________________________________________ 537 Principal indication reported______________________________________________ 534 Eclampsia_______________________________________________________ 165 Preeclampsia________________________________________________________ 47 Uremia______________________________________________________________ 27 Placenta previa______________________________________________________ 38 Premature separation of placenta----------------15 Ruptured uterus___ _________________________________________________ 9 Previous Cesarean section____________________________________________ 17 Contracted pelvis____________________________________________________ 28 Contracted pelvis and other indication_______________________________ 55 Abnormal presentation_______________________________________________ 33 Disproportion and long or difficult labor--------------------------------------------- 61 Other indication_________________________________________________ 39 Principal indication not reported________________________________________ 3 PARITY A N D AGE The deaths o f 13 percent o f primiparae, 8 percent o f secundiparae, 5 percent o f the women who had had three to five pregnancies, and 4 percent o f those who had had six or more pregnancies, followed Cesarean section. When the percentages are based only on those women who died after reaching the last trimester, it appears that the deaths o f 17 percent o f all primiparae and 33 percent o f primiparae of 30 years or older were preceded by Cesarean section. DURATION OF LABOR The duration o f labor was reported for 495 o f the 531 women dying from Cesarean section in the last trimester o f pregnancy. Two hundred and fifty o f these were not in labor, and the cause of death in 59 percent of these cases was puerperal albuminuria, in 12 percent puerperal hemorrhage, and in 11 percent puerperal septi cemia. O f the 245 women in labor for whom the number o f hours was reported, 38 were in labor less than 6 hours; 35 from 6 to 12 hours; 51 from 12 to 24 hours; 32 from 24 to 36 hours; and 89 more than 36 hours. With increase in the duration o f labor, the per centage o f deaths that were attributed to puerperal septicemia rose rapidly from 29 percent for those in labor less than 12 hours to 51 percent for those in labor 36 hours or more. RUPTURE OF THE MEMBRANES There was a report on rupture o f the membranes for 491 of the 531 Cesarean-section cases occurring in the last trimester. In 324 cases the membranes had not ruptured. They were ruptured artificially in 34 cases and had ruptured spontaneously in 109 cases; there was no report on this point in 24 cases. O f the 324 women with un ruptured membranes, 15 percent died of perperal septicemia, 51 percent o f albuminuria and convulsions, 10 percent of hemorrhage, and the rest of other causes. O f the 167 women with ruptured https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis CESAR EAN SECTIO N 31 membranes, 49 percent died of puerperal septicemia, 14 percent of albuminuria and convulsions, 4 percent o f puerperal hemorrhage, and the rest o f other causes. PLANNED A N D EMERGENCY OPERATIONS Eighty-two o f the five hundred and thirty-seven Cesarean sections were planned, 452 were emergency, and in 3 cases there was no report. ATTEM PTS A T OTHER OPERATIONS Cesarean section followed attempts at other forms of operative delivery in the cases o f 62 women, 42 o f whom were primiparse. V A G IN A L E XA M IN ATIO N S Vaginal examinations by the operating physician preceded the Cesarean section in 254 cases, or 52 percent o f the 485 women dying in the last trimester for whom this information was secured. O f the 231 women who had had no vaginal examination by the operating physician, 20 percent died o f sepsis, 43 percent of albuminuria and convulsions, and the rest from other causes; but of the 254 women who had vaginal examinations 34 percent died o f sepsis, 30 percent of albuminuria and convulsions, and the rest o f other causes. LIVE BIRTHS AND STILL BIRTHS Live-born infants resulted from 393 (74 percent) o f the 534 Cesareans for which the type of issue was reported. The largest proportion o f stillbirths was obtained in those Cesareans for which the indication was premature separation o f the placenta or ruptured uterus. A N E STH E SIA Ether was the most common anesthetic used. It was used alone in 275 o f the 480 cases for which this information was obtained. In other cases nitrous oxide, ethylene, chloroform, or local anesthesia was used. Ether was used alone in 90 of the 150 cases in which Cesarean section was done on account o f eclampsia and in which a report on the anesthetic used was obtained. Nitrous-oxide oxygen anesthesia was used alone in 56 cases, with ether in 62 cases, and in a few cases with local anesthesia. Ethylene was used in 41 cases, 1 o f which was with spinal anesthesia. Chloroform was used in 14 cases, 7 o f which were eclamptic. Local anesthesia was used in only 19 cases, in 5 of which it was supplemented by nitrous oxide or ether and in 1 o f which it was used with sacral anesthesia. Spinal anes thesia was used in 8 cases. COM M EN T B Y AD VISORY COM M ITTEE The very fact that Cesarean section was done on one fourth of all the women who died following operation for delivery suggests that there had been unwise selection o f cases for the operation, or of the types o f operation, or both, as Cesarean sections constitute only a https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32 M A T E R N A L D E A TH S small percentage o f all operative deliveries in general. Additional evidence to this effect is found in the causes o f the deaths following Cesarean section. According to statements of the physicians upon interview, 27 per cent o f the women died o f sepsis, but careful study of each record indicates that 47 percent were probably septic. The conditions under which the operations were done may account for this high percentage o f sepsis. Eighty-five percent o f the operations had not been planned. In 34 percent the membranes were ruptured before the operation was done. Fifty-two percent of the women had had one or more vaginal examinations. Twelve percent had had at tempted delivery from below. The number o f sections done for various types of dystocia after long and exhausting labors is appalling. There was evident lack of recognition of the fact that the mortality from classical Cesarean section increases with the length o f time the woman has been in labor and with attempts at delivery from below. In any discussion o f sepsis following Cesarean section it is to be remembered that the operating surgeon often does not have “ first chance” with his patients. Yet this should be no reason for unwise selection o f the operation to be performed. In many of these cases a Porro or low cervical operation should have been done instead of the classical Cesarean; in others no type of Cesarean operation should have been done. Probably many of the surgeons could appropriately analyze the selection o f their cases and study their operative technique and the surgical technique of their institutions, for death resulted from sep sis in many cases in which it apparently should not have occurred. The most frequent indication for the Cesarean section was some toxemia—in many cases eclampsia. Although the mortality from eclampsia in Cesarean-section cases is known to be higher than in those treated conservatively, this fact was apparently not appre ciated. Women with recognized toxemia were kept under observa tion for long periods of time and finally developed convulsions and were delivered by emergency Cesarean; women having convulsions were carried long distances to hospitals and operated on immediately upon arrival—both inexcusable procedures. Many of the cases resulting in death from hemorrhage were equally mismanaged. In many cases the operation was done after great loss of blood when the patient was in shock, and without transfusion or other treatment for shock. Unwise selection of anesthetic was frequent. In the cases of Cesarean section for eclampsia ether was the most common anes thetic, and even chloroform was occasionally used (7 cases). Ether was also used in the presence of acute respiratory infection. Local anesthesia was used in surprisingly few cases (19). The tremendous mortality attending Cesarean sections throughout the United States warrants a careful review of the indications in the choice of operation. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ABORTIONS A bortion as used in this study maty be defined as the termination o f a previable uterine pregnancy. Attempted abortions and inevit able abortions are also included, even if the woman died without actual expulsion o f the fetus. The term therefore includes all ter minations of uterine pregnancy in the first two trimesters except the very few cases already spoken of that resulted in live births. A bor tion thus defined is not the same as the title “ Abortion ” (no. 143a) in the International List o f Causes of Death, which includes pre mature labor and does not necessarily denote previability. Deaths certified as due to criminal abortion are assigned to homi cide in the International List o f Causes of Death, and therefore are not included in “ maternal mortality.” However, abortions not certified as criminal were not excluded from this study, even if the attending physician knew or was convinced that they were criminal. O f the 2,381 deaths before the seventh month of gestation, 1,825 followed abortion. Five hundred and fifty-four did not follow abortion, and for 2 it could not be ascertained whether they did or did not follow an abortion. The 554 women whose deaths before they reached the last trimester did not follow abortion had had ectopic pregnancies or died without a termination of pregnancy; a few (32) gave birth to living, and probably viable, children. The type o f abortion was reported in 1.588 o f these 1,825 cases. O f these, 794 (50 percent) were induced (other than therapeutic), 589 (37 percent) were spontaneous, and 205 (13 percent) were therapeutic; that is, were done for medical indications. O f the 1,825 deaths following abortion 1,324 were attributed, according to the international classification, to puerperal septicemia, 290 to accidents of pregnancy, 163 to puerperal albuminuria and convulsions, 44 to puerperal phlegmasia alba dolens, embolus, and sudden death, and 4 to puerperal hemorrhage.1 Puerperal septicemia was the cause attributed after interview for deaths o f 1,321 (73 percent o f the 1,825 women who died follow ing abortion. These 1,321 deaths from sepsis follow ing abortion con stituted IfS percent o f the total number o f deaths from puerperal septicemia in the study. Ninety-one percent o f the deaths following induced abortion, 60 percent of those following spontaneous abor tion, and 21 percent o f those following therapeutic abortion were due to sepsis. Eighty-six percent o f the deaths following abortion for which the type o f abortion was not reported were also due to sepsis, this fact suggesting that most of these abortions of unreported type were actually induced abortions. The period o f gestation was reported for 1,461 of the 1,825 cases. In 548 cases it was less than 3 months, in 444 cases 3 months, in 219 cases 4 months, and in 250 cases 5 or 6 months. ) 1 A ccording to the 1929 classification 1,324 would be attributed to abortion writh septic conditions, about 250 to abortion w ithout mention o f septic conditions, and about 200 to other toxemias o f p regn ancy; the others would remain the same. 33 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 34 M A T E R N A L D E A TH S A report concerning operations was obtained for 1,777 o f the 1,825 cases. Nine hundred and ninety-two (56 percent) had opera tions o f some sort, including 265 o f the 583 women who had spon taneous abortions, and 403 o f the 778 women who had induced abortions. O f the 205 women who had therapeutic abortions, 38 had other operations as well. The most frequent operation was curet tage. O f the women who had spontaneous abortions 212 (36 per cent) and o f those who had induced abortions 289 (37 percent) had been curetted. Evidently many physicians did not consider fever a contraindication for curettage, for 448 (69 percent) o f the 652 women who had had abortions and were curetted were reported to have had fever before the curettage. Puerperal sepsis caused 9^ percent of the deaths of these IfJfi women, as compared with 50 per cent o f the deaths of women who were afebrile before the curettage and 68 percent o f the deaths of the women who had no curettage. CHART V II.—A B O R T IO N S A M O N G W O M E N D Y I N G F R O M P U E R P E R A L CAUSES Percent O___________ 20___________40___________ 60___________flO 100 K All causes Septicemia Eli All other causes ■ Induced ES3 Spontaneous l&ftl Therapeutic E 3 Type not specified □ No abortion Hemorrhage was reported for 328 o f the 652 cases in which there had been a curettage. It was absent in 235 cases, and it was not reported on for 89 cases. O f the 1,086 women who died following abortion and who had not been curetted, 430 were reported as having had hemorrhage and 459 as having had no hemorrhage; there was no report for 197. Pernicious vomiting was given as the principal indication for 112 o f the 205 therapeutic abortions. Other toxemias accounted for 52, hemorrhage, placenta previa, or premature separation o f placenta for 14, dead fetus for 12, and various other causes for 15. Married women made up 90 percent of the women whose deaths followed abortion, but abortion was a more frequent cause o f death among unmarried than among married mothers, for abortion pre ceded the deaths of about one fifth o f the married mothers and o f more than one third o f the 509 unmarried mothers included in the study. The proportion o f maternal deaths that were preceded by abortion increased with the age o f the mother up to 30 and then decreased. The mortality rate for deaths following abortion was higher among the colored than among the white women and among urban https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 35 a b o r t io n s women than among rural women. The difference between urban and rural groups was most marked in induced abortions, for which the mortality rate was 11 per 10,000 live births in urban areas as compared with 4 in rural areas. The proportion o f maternal deaths that followed abortion in the various States ranged from 18 percent in Alabama and W is consin to 37 percent in Washington. The variation in the perC H A R T V III.—M O R T A L I T Y R A T E S F O R D E A T H F O L L O W IN G A B O R T IO N A M O N G W O M E N D Y IN G FR O M PUERPERAL CAUSES Deaths per 10,000 live births Total U rb a n Rural W hite C olored H Induced. Spontaneous I t y p e n o t sp ec ifie d - T h e r a p e u tic centage of maternal deaths was greatest for induced abortions, which ranged from 3 percent o f all maternal deaths in Alabama to 23 percent in Washington. Three percent o f all the maternal deaths followed therapeutic abortion. COM M ENT B Y ADVISORY CO M M ITTEE In reading the section on abortion it must be carefully kept in mind that the definition of “ abortion” as used in this report is different from that of the international list. In this report the term “ abortion” is used to mean the termination of a previable uterine pregnancy. Undoubtedly among this number o f deaths were some due to crim inal abortions. If the abortions were known to be criminal and death followed, the deaths were assigned by the Bureau of the Census, according to the International List o f Causes of Death, as homicides and were not included in the maternal mortality. It was impossible, however, to separate the known self-induced abortions from possible criminal abortions, and therefore they were included in the figures analyzed. That one quarter o f all the maternal deaths in this study followed some type o f abortion is probably the most outstanding finding of the study. The further finding that three quarters of the deaths https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 36 M A T E R N A L D E A TH S following abortion were due to puerperal septicemia is equally sig nificant. As 1,825 deaths followed abortion out of the total o f 7,380 deaths in this series, abortion is evidently one of the greatest problems in lowering the maternal mortality o f the country. The large proportion o f induced abortions shows a very serious situation. Fifty percent o f abortions o f known type were induced and 13 percent of all the abortions were of “ type not reported” , so that many of these may have been induced. The seriousness of this situation is further shown by the fact that 73 percent o f the deaths following abortion were due to puerperal septicemia. The high pro portion o f deaths from sepsis (91 percent) among deaths following induced abortion was perhaps to be expected. It is difficult to understand, however, the number o f deaths from sepsis among those having spontaneous and therapeutic abortions, and one cannot help wondering if many o f the so-called spontaneous abortions were not really induced. As was to be expected in those women who had induced abortions, more than half were done in the first 2 months of pregnancy. A surprising number o f therapeutic abortions were done in the second trimester of pregnancy. The most frequent operation in the management o f these abortions was curettage (usually with sharp instruments, which is a procedure definitely to be condemned). It is clear that many physicians did not consider fever a contra-indication for curettage; yet in those cases in which it was known that fever existed and curettage was done, 94 percent o f the deaths were due to sepsis. In marked contrast is the fact that only 50 percent o f the deaths o f the women who were afebrile at time of operation were due to sepsis. In not a few cases the history o f an induced abortion was not discovered until after the patient had been curetted or even after she had died. Evidently a careful history in many o f these cases was not obtained. Hemorrhage was o f frequent occurrence in these abortion cases, but the fact that the patient had had a hemorrhage had very little effect on the proportion o f deaths from sepsis after curettage in febrile cases. As pernicious vomiting was the principal indication given for 112 o f the therapeutic abortions, it would seem that the physicians had delayed in doing the abortion or had been called in consultation too late to save the patient’s life, or else had improper technique. Analysis o f the figures on illegitimacy brings up the whole prob lem o f abortion in unmarried mothers, for abortions accounted for more than one third of the deaths of unmarried mothers in this series. This study shows very clearly the seriousness o f the problem created by the great number of abortions that are induced each year. It also shows that the practice o f curetting every patient who has an abortion is common. Physicians must be made to appreciate the seriousness o f curetting these potentially septic cases. The manage ment o f an abortion calls for the best medical care that can be given, and in many o f the cases in this series it is obvious that such care was not given. The abortion problem is a widespread sociological and economic problem, which the medical profession must have help in solving. However, the physician has one great obligation— to teach the public the dangers entailed by abortion, whether spontaneous or induced. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis PUERPERAL SEPTICEMIA Puerperal septicemia, as has been shown (p. £»;, was the most important cause of death connected with pregnancy or childbirth. It caused 40 percent o f the 7,380 deaths included in the study. Women who have been weakened by hemorrhage, by eclampsia, or by the exhaustion o f a long and difficult labor are an easy prey to infection; and infection is the chief cause of death o f women for whom an operative delivery is necessary and who survive the shock of the operation itself. It is also the chief cause of death following abortion from any cause. From death certificates and subsequent queries o f indefinite cer tificates, 2,827 o f the 7,537 deaths studied were assigned by the Bu reau o f the Census to puerperal septicemia. On interview with the attendant, 110 o f these were found to be due actually to other causes; 64 of these 110 were not strictly puerperal and therefore were omit ted from the study. Interviews also disclosed that 231 deaths as signed to other puerperal causes were really due to puerperal septi cemia, and these deaths were so classified in the study. These changes involve only those cases in which the sepsis, although not mentioned on the death certificate, was diagnosed by the attending physician or in which the history o f septic temperature, positive blood culture, or autopsy findings made the change in diagnosis inevitable. This gives a total o f 2,948 deaths considered due to puerperal septicemia. The term puerperal septicemia as used in this report means obvious and unmistakable sepsis and the number o f deaths here attributed to this cause is the minimum. O f these 2,948 deaths 1,324 (45 percent) were preceded by abortion. Ectopic pregnancy was a factor in 65 cases.1 Placenta previa was present in 53 cases, and 84 women had other puerperal hemorrhage o f such severity that it was considered the principal contributory cause o f death. One hundred and sixty-nine women who died o f sepsis following delivery were reported to have had postpartum hemorrhage as a contributing factor. Eclampsia or severe toxemia o f pregnancy was a principal contributory cause in 168 cases. Operations aimed at delivery were performed on 573 women who died o f sepsis at 7 or more months’ gestation. O f these operations, 140 were Cesarean sections. Information as to whether there had been any intrauterine manipulation, such as induction o f abortion, operative delivery, or curettage, was obtained for 2,549 of the 2,948 cases of deaths from sepsis. There had been some intrauterine manipulation in 1,546 o f these cases, or 61 percent. The time o f this manipulation with reference to the appearance of symptoms of sepsis was reported for 1,526 o f these cases. In 748 (49 percent) the intrauterine manipulation had occurred only before “ , ” 1 A bortion w ith septic conditions and ectopic gestation with septic conditions are separate titles in the 1929 revision o f the International L ist o f Causes o f Death. 37 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 38 M ATE R N A L DEATH S the onset o f sepsis; in 517 (34 percent) it had occurred after the onset o f sepsis; and in 261 (17 percent) it had occurred both before and after. In septic cases of less than 7 months’ gestation the intrauterine manipulation before the onset of sepsis was usually the induction o f abortion; after the onset it was usually curettage. In the last tri mester the manipulation before the onset of sepsis was usually an operative delivery, and the manipulation after the onset o f sepsis was usually a curettage. In the last trimester of pregnancy puerperal septicemia caused the deaths o f 1,529 women. Most o f these (1,386, or 94 percent, of the women for whom a report as to onset was obtained) had a spon taneous onset o f labor. Labor terminated spontaneously in 65 per cent o f the cases in which information concerning termination was obtained; in 34 percent termination was artificial. O f the 1,474 deaths o f women who had reached the last trimester, for whom there was a report on operations aimed at delivery, 573 (39 percent) had had such an operation. Operations in the last trimester other than those for delivery were far more numerous among women who died of sepsis than among those who died o f other causes. Blood transfusion was known to have been performed on 64 women who later died o f sepsis and who did not have hemorrhage. The time between delivery and the appearance o f the first symptoms o f sepsis was reported in 1,303 o f the 1,529 cases o f women who died from sepsis after reaching the last trimester. Symptoms o f sepsis appeared before the actual delivery in 196 cases (15 percent); within 2 days after delivery in 328 cases (25 percent); between 2 days and a week after delivery in 602 cases (46 percent); and a week or more after delivery in 177 cases (14 percent). The 196 cases in which symptoms o f sepsis appeared before the actual delivery were care fully studied for the presumable cause of sepsis. Long labor, early rupture o f the membranes, or attempts at delivery were apparently responsible in 53 cases; one or more o f these, and some other factor, were responsible in 7 cases. Infectious disease, usually respiratory, at the time o f labor was the probable source o f sepsis in 38 cases. Macerated fetus was associated with sepsis in 18 cases, pyelitis in 15, gonorrhea or pelvic inflammatory disease in 11, and some other cause m 22. In 32 cases no probable reason for the development o f sepsis was given. Symptoms o f sepsis developed more quickly among the women who had operative deliveries than among those who had spontaneous deliveries. In general, symptoms o f sepsis appeared earlier in women who had longer labors. Attendance at birth, technique at delivery, and nursing and aftercare o f the patient are o f particular interest in these cases o f death from sepsis. A larger proportion o f the deaths o f women who had been attended by midwives were from sepsis than o f the deaths o f women who had been attended by physicians. O f the 550 women dying at 7 or more months’ gestation who had midwife attendance either alone or with a physician or interne, 239 (43 percent) died o f sepsis, while o f the 4,065 who died after being attended at delivery by physicians, 1,177 (29 percent) died o f sepsis. The delivery technique o f the physician in charge was reported in 1,114 cases o f women who died of sepsis after reaching the last https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis P U E R PE R AL S E P T IC E M IA 39 trimester. It was said to be aseptic in 445 cases (40 percent). Most o f these cases occurred in hospitals. Asepsis was attempted under conditions making its attainment unlikely in 158 cases (14 percent). Ordinary cleanliness was present in 405 cases (36 percent), and in 106 cases (10 percent) ordinary cleanliness was lacking. More of the women who died o f sepsis than o f those who died o f other puerperal causes had 3 or more vaginal examinations, and a smaller proportion o f those who had as many as 3 vaginal exami nations had had attendants who used rubber gloves. Inquiries were made as to the preparation of the patient for opera tion, and information was obtained as to shaving and scrubbing for 3,348 cases. O f these, 645 (48 percent) had been shaved and scrubbed; 263 (20 percent) were neither shaved nor scrubbed; 428 (32 percent) had been scrubbed only; and 12 (1 percent) had been shaved only. Some antiseptic had been used in 1,094 cases; none had been used in 262 cases. In at least 172 cases women who died o f sepsis had been neither scrubbed nor shaved, nor had an anti septic been used. O f the 2,948 women who died o f puerperal septicemia, 1,950 (66 percent) had had hospital treatment. Only 618 o f them, however, were known to have had their delivery or abortion in the hospital. One thousand three hundred and one were known to have had their delivery or abortion outside o f the hospital, 25 died undelivered, and for 6 tne place of delivery or abortion was not reported. Fatal sepsis developed in the hospital in 420 cases (70 percent) of the 601 women delivered in hospitals for whom the place o f development o f sepsis was reported, and in 26 cases o f women delivered elsewhere. How ever, at least 69 o f these 420 women had had vaginal examinations or other vaginal manipulations before admission to the hospital. In most cases it was impossible to obtain information whether other septic patients were in the hospital at the same time as were these that died. There were 898 hospital deaths from sepsis o f women who had reached the third trimester; but only 454 o f these women were delivered in the hospital, and 105 o f the 454 were reported to have had vaginal examinations or attempted operative delivery before admission to the hospital. The mortality rates from sepsis were higher among the colored than among the white women, and higher in the cities than in the rural areas. This is true o f sepsis following delivery as well as o f sepsis following abortion. Deaths from sepsis following abortion make up a large proportion o f deaths assigned to puerperal septicemia in the international classi fication. In the 15 States studied 45 percent o f the sepsis deaths followed abortion and 25 percent followed induced abortion. In the separate States the proportion of sepsis deaths following induced abortion varied considerably, being 48 percent in Washington and only 7 percent in Alabama. The mortality rates from septic abor tion ranged from 6 deaths per 10,000 live births in New Hampshire to 18 in Washington. The death rates from this condition were low in the New England States o f New Hampshire and Rhode Island, and in Wisconsin, Minnesota, and North Dakota, and were highest in Washington, Oregon, and Oklahoma. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 40 M A T E R N A L D E A TH S CO M M EN T B Y AD VISO RY CO M M ITTEE That 40 percent of all the deaths in this study were o f women who had such obvious and unmistakable signs o f sepsis that there could be no question how they should be classified shows clearly the serious condition presented by this cause of maternal death. The outstanding findings in regard to abortions followed by septi cemia have already been commented on in the section on that subject. No matter how the figures are. analyzed, it is clear that the loss of life from sepsis is enormous. That in the last trimester o f preg nancy 1,529 women of this series died of sepsis, 94 percent o f whom had a spontaneous onset of labor and 65 percent a spontaneous termination of labor, is nothing short of appalling. In this series of deaths the midwives had a larger percentage of deaths from sepsis than physicians. This fact, however, does not by any means take the onus of this state of affairs from the physi cians. Lack of adequate nursing care at home undoubtedly had something to do with these bad results, but the ultimate responsi bility for these deaths rests on the delivery technique o f the physi cian. That technique was classed as aseptic in only 40 percent of the cases in which it was reported upon, and these usually occurred in hospitals. The frequency of vaginal examinations without gloves is to be noted, as well as the relative infrequency o f rectal examina tions. Preparation of the patient in the majority of the cases was inadequate. It is not surprising to find that under these conditions sepsis developed much earlier in operative cases than in spontaneous deliveries. It is also to be noted that in cases of long labor signs of sepsis appeared earlier. The deaths of 420 women delivered in hospitals from sepsis that developed in the hospital show clearly that the technique in the hospitals was unsatisfactory. In many of the septic deaths classified as abortions the physician surely cannot be held responsible. It is admitted that many were induced, and there is no way of telling how many of the so-called spontaneous abortions also were induced. Moreover, infection was present in many of these cases when the physician was called. But the frequency with which curettage was done on these septic cases is not justifiable. In the cases in the last trimester there is no such excuse for the bad results obtained as may be offered in the abortions. Complica tions were present in many instances in the last trimester, and operative procedures were necessary, but these facts do not excuse the physicians for the poor technique which they themselves admitted. What is the reason for the existence o f this condition? It is due to lack of proper teaching of obstetrics in some of the medical schools, lack o f opportunity to deliver a sufficient number of normal cases, and almost total lack o f experience in the simplest obstetric operating, or else it is due to the willful disregard by careless physicians o f the fundamentals of asepsis. The large number of fatal cases o f puerperal infection are in the majority o f instances due to infection that is introduced from https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis PTJEEPEBAL S E P T IC E M IA 41 without. Its prevention, therefore, lies in carrying out proper obstetric procedures, consisting chiefly of proper aseptic technique and carrying out only definitely indicated obstetric operations. It must be remembered, however, that there are a certain number of cases o f puerperal infection which are endogenous in character; that is, they are due to organisms which the patient harbors chiefly in her birth canal. This type of infection forms another obstetric problem. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis PUERPERAL PHLEGMASIA A L B A DOLENS, EMBOLUS, SUDDEN D E A T H 1 Three hundred and thirty-seven deaths were assigned to puer peral phlegmasia alba dolens, embolus, sudden death, from informa tion given on death certificates. A t the interview with the attending physician 48 o f these deaths were attributed to other puerperal causes, most o f them to puerperal sepsis or puerperal hemorrhage, and 3 to nonpuerperal causes. But 58 deaths were added to these as a result of additional information or as a result o f the physician’s change o f opinion. Not all deaths for which this cause is given on the certificates are so assigned in the international classification, for certain other causes take precedence over this classification. There were 242 deaths assigned to puerperal causes for which puerperal phlebitis or em bolus was given as the principal contributory cause o f death. For 123 o f these the primary cause o f death was puerperal sepsis. An autopsy was performed in only 25 cases. O f the 344 deaths attributed after interview to phlegmasia alba dolens, embolus, sudden death, 303 were attributed to embolism, 10 to thrombosis, 10 to phlegmasia alba dolens, and 21 to sudden death. Phlebitis was diagnosed either clinically or at autopsy in 52 o f the 303 cases in which death was thought due to embolism. O f these 303 deaths, 10 occurred during delivery. The diagnosis can be questioned particularly in these cases, but in one case embolism was proved by autopsy. O f the 303 women whose deaths were attributed to embolus, 220 were said to have had respiratory distress, 41 were said not to have had it, and for 42 there was no information on this point. Cyanosis was reported present in 197 cases, 53 were reported as not cyanotic, and for 53 there was no report. That the absence o f reported cyano sis or respiratory distress does not rule out embolism is shown by a case in which an autopsy was done, and a large embolus was found in the left pulmonary artery. Abortions preceded 44 of the 53 deaths at less than 7 months’ ges tation. The abortion was said to have been spontaneous in 25 cases, induced in 13, therapeutic in 4, and of unknown type in 2 cases. The deaths o f 291 women who died after reaching the last tri mester were attributed to phlegmasia alba dolens, embolus, sudden death. O f these women, 12 died undelivered. For 7 the termination o f labor was not reported. O f the 272 who were delivered, delivery was spontaneous for 203 (75 percent) and artificial for 69 (25 per cent). In 40 cases phlegmasia alba dolens, embolus, sudden death was given as the principal contributory cause where the death was attributed to Cesarean section or other operative delivery. 1 This title, no. 147 in the 1920 revision o f the International List, is no. 148 in the 1929 revision, w ithout change o f name, or content. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis P U E R P E R A L P H L E G M A S IA A L B A D O LE N S 43 Death occurred within the first day after delivery in 33 percent of the 316 cases for which the interval between delivery or abortion and death from phlegmasia alba dolens, embolus, sudden death was re ported, and within the first week in 46 percent. Twenty-nine percent o f the deaths took place in the second week, 9 percent in the third week, 8 percent in the fourth week, and 9 percent in the fifth week or later. COM M ENT B Y ADVISORY COM M ITTEE Little comment on this section is necessary. This number in the international list may cover many deaths of uncertain cause. A death certificate under this heading is oftentimes accepted without proper understanding of the circumstances of the death. Twenty-five percent of the women who reached the last trimester died following operative delivery. Some had symptoms clearly sug gestive of embolism, but in others the history obtained was of rup tured uterus. Many of the spontaneously delivered patients showed the classical symptoms o f embolism with no demonstrable phlebitis. Thrombosis and embolism are the results o f infection; and so far as infections are preventable, thrombosis and embolism are preventable. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis TOXEMIAS OF PREGNANCY Thirty percent (2,221) of all the deaths in the study were pre ceded by some presumably toxic condition as the chief cause or the chief contributory cause. Most of these deaths— 1,900, or 26 percent o f the total— were due to puerperal albuminuria and convulsions (no. 148 in the International List o f Causes of Death), and 220 that were attributed to other primary causes had albuminuria and con vulsions as the principal contributory cause. Sixty-one deaths were attributed to pernicious vomiting of pregnancy, and 40 more that were attributed to causes other than albuminuria and convulsions had pernicious vomiting as the chief contributory cause.1 Deaths resulting from the toxemias of pregnancy are assigned in the International List of Causes o f Death to various numbers, most o f them, as has been noted, to puerperal albuminuria and convul sions. According to the definite rules of classification, some death certificates on which the cause would otherwise be assignable to puerperal albuminuria and convulsions are assigned to puerperal septicemia, puerperal hemorrhage, ectopic gestation, or ruptured uterus, when these conditions accompany the toxemia. For the same reason, because chronic nephritis takes precedence over certain puer peral causes, a number of deaths o f pregnant or parturient women from this cause are lost entirely to the puerperal group. Deaths from acute yellow atrophy of the liver are likewise omitted from the puerperal group unless puerperal septicemia appears on the death certificate. PUERPERAL ALB U M IN U R IA A N D CONVULSIONS Puerperal albuminuria and convulsions (no. 148 of the inter national list) was the cause of the death of 1,900 women—26 percent o f all those included in the study. As a puerperal cause of death it was exceeded in importance numerically only by puerperal septi cemia. In the last trimester of pregnancy it was of equal impor tance with puerperal septicemia, each accounting for 31 percent of the deaths at or after 7 months’ gestation. Among the rural women, both white and colored, after 7 months’ gestation, it was a cause of death of numerically greater importance than sepsis. The 1,900 deaths were finally attributed to the group albuminuria and convulsions, after interview with the physicians in charge o f these patients. Physicians had certified 2,006 deaths as due to this cause, but the interviews showed incomplete or incorrect informa tion for 180, which were therefore not included; 74 deaths, however, were added to this group after interview. No attempt at pathological classification o f these deaths was made. Convulsions were known to have preceded the deaths o f 1,305 of the 1,900 women. Five hundred and twenty-one had no convulsions, and in 74 cases information as to convulsions was not obtained. In 130 cases the toxemia was a pernicious vomiting o f pregnancy. 1 In the 1929 revision o f the International L ist the toxemias are divided into puerperal albuminuria and eclampsia (no. 146) and other toxemias o f pregnancy (no. 147), which includes pernicious vomiting. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 45 T O X E M IA S OF P R E G N A N C Y Death occurred in the first or second trimester in 338 cases, and in the third trimester in 1,549 cases; in 13 cases the duration o f preg nancy was not known. A few o f these cases seemed to be true cases o f fulminating eclamp sia, fatal convulsions developing a few days after a thorough exam ination at which nothing abnormal was found, but the great m ajority o f toxem ic deaths were o f women who lacked some or all o f the ordinary safeguards. Approximately one half o f the 1,756 women who died of puerperal albuminuria and convulsions after the sec ond month of pregnancy and for whom a report as to prenatal care was obtained had presented themselves for prenatal care, but only 12 percent of the total had received good care. After the patient was seen by the physician the cooperation o f the patient was said to have been good in a little more than one half o f the cases in which a report on this point was obtained. It is of interest to note that about one third o f the women who died o f albuminuria and convulsions could not ha/oe cooperated because they Were in convulsions or in coma when first seen by a physida/n or they were not seen by a physician before death , , . C H A R T I X .—C O N D IT IO N W H E N F IR S T SEEN B Y P H Y S IC IA N O F W O M E N W H O D IE D F R O M P U E R P E R A L A L B U M IN U R IA A N D C O N V U L S IO N S Percent 20 40 60 80 100 Total White U rban Rural Colored U rban y /////////A ? m R ural Inconvulsions or coma Fair0 Poor* GoocU’ In 1,723 cases the condition of the patient when she was first seen by a physician was known. O f these women, 546 (32 percent) were in coma or were having or had had convulsions; 508 (29 per cent) were otherwise in poor condition; 313 (18 percent) were in fair condition; and only 356 (21 percent) were in good condition. Thirty-six percent of the women who died in the rural areas as compared with 25 percent of those in urban areas were in coma or had had convulsions when first seen. Fifty-six percent o f the colored women and 25 percent o f the white women were in this condition. It must be noted that only 54 percent o f the urban white, 39 percent o f the rural white, 20 percent o f the urban colored, and 11 percent o f the rural colored women who died o f albuminuria and convulsions were in good or even fair condition when first seen by a physician. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 46 M ATERN AL DEATHS One thousand and twenty-nine (54 percent) of the 1,900 women whose deaths were attributed to albuminuria and convulsions were hospitalized, 869 (46 percent) were not, and for 2 cases this infor mation was not reported. The great majority o f the patients who were sent to the hospital did not reach it until they were in a serious condition. One hundred and thirty-eight were sent to a hospital or were already in a hospital on the first appearance of symptoms. O f the 866 women who were not hospitalized until they were in a serious condition, only 15T were reported to have been put to bed at home at the first appearance o f symptoms. More o f the white women who died than o f the colored had had hospitali zation and bed treatment. A number o f the women who were sent to the hospital early improved under treatment and were allowed to go home and later returned in convulsions. Operative delivery comprised part or all o f the treatment o f many o f the women. Twenty-six percent of those who died after reach ing the last trimester had an artificial onset o f labor. This includes 224 women who had labor induced mechanically, 146 who had Cesarean section when not in labor, 10 who had medical induction, and 3 for whom the exact method was not reported. Fourteen percent died before the onset of labor. O f the women who died before reaching the last trimester, 47 percent died before the onset o f labor, 21 percent had spontaneous onset, and 32 percent had artificial onset o f labor. A larger pro portion o f the white women than o f the colored women had labor induced. O f those women who reached the last trimester nearly one fifth died undelivered. O f the remainder about half were delivered spontaneously and half artificially. O f the total o f 1,900 women who died o f albuminuria and convul sions 437 (23 percent) were not delivered before death, and o f this group 69 percent were reported to have had convulsions. A number o f patients died in their first convulsion. More than half (56 per cent) o f the women who died undelivered and had convulsions died less than 12 hours after the first .convulsion, and about two thirds (63 percent) less than 24 hours afterward. O f the women who were delivered before death and who died after having convulsions, 90 percent died within the first week after delivery and 56 percent within the first day. O f the women who were delivered before death and who did not have convulsions, 63 percent died within the first week and 31 percent within the first day. O f the women who were delivered in the last trimester 807 gave birth to liveborn and 457 to stillborn children. Eighteen mothers had 1 liveborn and 1 stillborn twin. No data were obtained, how ever, as to the survival of these children. Puerperal albuminuria and convulsions caused 36 percent o f the deaths o f primiparse and 21 to 24 percent o f the deaths o f women in subsequent pregnancies. O f primiparae less than 20 years o f age it caused 41 percent o f the deaths. Both the percentage o f total deaths due to puerperal albuminuria and convulsions and the rate per 10,000 live births were higher among the colored than among the white women. The highest death rates from this cause among the white women were in Alabama and New Hampshire, the lowest in Wisconsin and Minnesota. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis T O X E M IA S OP P R E G N A N C Y • 47 Among the colored women in the States having 2,000 or more colored births annually, the highest rates were in Alabama and Okla homa, the lowest in California and Maryland. The death rate from this cause was, in general, higher in the urban than in the rural areas. PERNICIOUS VOMITING Although pernicious vomiting of pregnancy was the primary cause o f death given for only 61 of the 7,380 women included in the study, it was a contributing factor in 191 other cases. Nearly all the women whose deaths were associated with pernicious vomiting died before the seventh month, and most of them died before the fifth month. The duration o f the vomiting before the physician was called was given in 164 o f the 252 cases. It had lasted less than a week in 49 cases, from 1 to 2 weeks in 24 cases, from 2 to 4 weeks in 28 cases, and 4 weeks or longer in 63 cases. Ninety-three o f these cases were said to have been in poor condition when first seen. The condition that 227 of these 252 women were in when they were first seen by the physician was noted. Twenty-nine women were said to have been in good condition, 62 in fair condition, 136 in poor condition. Pregnancy was interrupted artificially for 121 women. Labor or abortion took place spontaneously in 47 cases, and 82 women died without labor or abortion. Operation was known to have been re'Qk fused by 19 o f the 127 women dying without operation whose deaths were associated with pernicious vomiting. A few of these women had a spontaneous abortion. There were also other patients who refused interruption o f pregnancy for varying periods, and finally consented to operation only when they were in very poor condition. O f the 112 women with pernicious vomiting who had therapeutic abortions, 16 died of sepsis. COM M EN T B Y AD VISORY CO M M ITTEE The chief method o f attack against the severe toxemias o f preg nancy is conceded to be their early detection and control. For this it is necessary to have continuous intelligent medical supervision o f the prospective mother from early in pregnancy, early recogni tion o f untoward symptoms, prompt and judicious treatment o f symptoms as they appear during pregnancy as well as during and after actual delivery o f the patient, and the cooperation o f the patient. It is true that a few patients developed toxemias and died who apparently had all these safeguards. A small number o f these seemed to be true cases o f fulminating eclampsia— fatal convulsions developing a few days after a thorough examination at which noth ing abnormal was found. Evidently, in the present state o f medical knowledge, death from toxemia cannot be entirely prevented. But the vast majority of toxemic deaths were o f women who lacked some or all o f the safeguards mentioned. For many o f the toxic deaths studied the physician was not re sponsible because he saw the patient for the first time when the condition was already acute or because the patient failed to follow https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 48 his advice. Three fifths o f the women were in convulsions or coma or otherwise in poor condition when the physician saw them for the first time. Moreover, some o f the women were seen early in pregnancy and advised concerning prenatal care— but the advice was not accepted. Others were seen in the preclamptic stage and in duction of labor was advised— and the advice was not accepted. Evidently there is great need for the education o f patients and families. On the other hand, the study reveals serious conditions for which the physicians were responsible. Even though the occurrence o f toxemia cannot be entirely prevented, many of the deaths from this cause can and should be prevented by the early recognition of symp toms and prompt and judicious treatment by the physician in charge. Some o f the women (12 percent) had had what could be considered as good prenatal care, and the symptoms o f approaching toxemia were promptly recognized during the latter part o f gestation, but treatment was at fault. Induction o f labor (as distinguished from accouchement, forcé) was done in surprisingly few of these cases. Prenatal care, so far as the toxemias o f pregnancy are concerned, will not save lives unless good clinical judgment and treatment are used. The number o f women who died during the first convulsion was rather surprising. Probably many more women die in this way than is realized. Probably it is now generally conceded that radical treatment in eclampsia is never indicated except in the best environment and with proper anesthetic. The dire results of teaching radical treatment for eclampsia were manifest— almost universal resort to immediate operative interference in all kinds of cases and by all kinds o f prac titioners. Cesarean section seemed to be too often regarded as proper treatment for eclampsia. Oftentimes the sections were done without regard to the profound shock from which many o f the patients were suffering and without due consideration for the proper anesthetic. Operative interference of all sorts was frequent, even in the cases o f multiparous women; a majority o f the operations were done under general anesthesia, ether being used commonly and even chloroform occasionally. Epigastric pain, which is a prodromal symptom o f eclampsia, was occasionally observed, and was almost always treated as acute indigestion. There were more than occa sional instances in which rising blood pressure was noted, but its importance evidently was not realized. In many cases treatment other than vague advice as to diet, or the prescription of a diuretic, was far from prompt. In other cases (202) the treatment was an immediate accouchement forcé, which, though prompt, would be called judicious by no leader in obstetric thought today. Few o f these women were treated along the conservative lines now accepted— with fluids, glucose, magnesium sulphate, and morphine or other sedative and induction of labor. There can be no question that failure to institute prompt treatment and the injudicious treat ment they did receive contributed to many of the deaths. It is evi dent, therefore, that some safe, conservative treatment for eclampsia should be agreed upon and that knowledge o f it should be widely disseminated. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 4 M ATERN AL DEATHS % A ^ * ^ fw PU ERPERAL HEMORRHAGE Puerperal hemorrhage accounted for 791 deaths (11 percent) of the total deaths o f this study. This includes 347 deaths attributed to placenta previa (no. 144a o f the International List) and 444 deaths attributed to no. 1445, which includes postpartum hemorrhage and accidental hemorrhage.1 O f these 444 deaths 374 were from post partum hemorrhage and 70 from premature separation o f the placenta, adherent placenta, or undefined puerperal hemorrhage. Puerperal hemorrhage was definitely related to both parity and age. A m on g primiparoe, this condition caused 7 percent of all deaths as com pared w ith 13 percent am ong multiparce. It caused 5 percent o f the deaths o f primiparse under 20 years of age and 15 percent of the deaths from 35 to 39 years. Among the multiparse 8 percent died from puerperal hemorrhage in the group under 20 years of age, 16 percent in the group from 35 to 39 years. The percentage of deaths from puerperal hemorrhage rose rapidly from 7 for primi parse to 10 for women in their second pregnancy and to 13 for women in their third pregnancy, and rose again to 17 percent in the seventh pregnancy, 22 percent in the eighth pregnancy, and 24 percent in the ninth pregnancy. It caused 21 percent o f the deaths of women having 10’or more pregnancies. Puerperal hemorrhage caused a slightly larger proportion of the deaths in rural areas (12 percent) than in urban areas (10 percent). It caused a larger percentage o f deaths among the white women than among the colored, but the maternal mortality rate (deaths per 10,000 live births) from puerperal hemorrhage was higher for the colored than for the white women. PLACENTA PREVIA For 347 o f the 408 women who were known to have had placenta previa, it was given as the primary cause o f death. Fifty-three o f the 408 deaths were attributed to puerperal septicemia and 8 to other causes. O f these 408 women who were known to have had placenta previa, 327 had some bleeding before the onset o f labor, 38 had no bleeding then, and for 43 it was not known whether or not there was hemorrhage before the onset of labor. In 310 cases of bleeding be fore the onset o f labor for which the extent of bleeding was ascer tained, it was scanty in 44 cases, moderate in 82 cases, and profuse in 184 cases. . The bleeding was said to have begun before the thirteenth week m 7 cases, from the thirteenth to the twenty-fifth week in 31 cases, from the twenty-sixth to the thirty-ninth in 201 cases, and in the fortieth week in 49 cases; in 39 cases the week in which the bleeding began was not reported. 1 Puerperal hemorrhage International List. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis (no. 144) remains the same in the 1929 revision of the 50 M AT E R N A L DEATH S The first hemorrhage— occurring in some cases before the onset o f labor and in others at the beginning o f labor—was said to have been dangerously profuse in 107 of the 408 cases, in 236 cases there had been a warning hemorrhage earlier in pregnancy, and in 65 cases there was no report as to warning hemorrhage. It was re ported that the warning hemorrhage resulted in prompt treatment for the placenta previa in 18 cases, but that in 216 cases treatment was delayed. O f the 107 who had no warning, it was reported that 87 had prompt treatment, 14 had delayed treatment, and 8 died at once without time for treatment. In all, 239 women were reported to have had delayed treatment. The delay was apparently due to the physician in 129 cases, and to the patient, her family, or circum stances in 110 cases. A t least 9 women died without medical atten tion. In 46 cases the physician did not arrive until the patient was moribund, but in 351 cases there had been earlier medical care. O f the 408 women who died following placenta previa; a report concerning operations for delivery was obtained for all but 7. Three Jiundred and twenty-five (81 percent) were known to have had some operation aimed at delivery. About half (207) o f the women were reported to have been delivered by some form of version, in 124 cases preceded by artificial dilatation o f the cervix. This was nearly always a version with immediate extraction. In only 2 of these 207 cases was there said to have been a Braxton Hicks version without immediate extraction. Cesarean section was the method of delivery in 41 (10 percent) of the cases. It was done upon at least 7 women who had been packed before admission to the hospital. A forceps operation alone or in combination. with some operation other than version was used in 33 cases (8 percent), and dilatation o f the cervix—usually manual or bag dilatation—was the only operation for delivery in 17 cases (4 percent). Only 27 of the 408 women were known to have had a blood transfusion. The uterus was reported packed postpartum in 31 cases. It was apparently done as a routine procedure in only 6 cases. In the other 25 cases the packing was done after the onset o f a postpartum hemorrhage. A ruptured uterus was diagnosed by the attending physician after treatment in 3 cases o f death associated with placenta previa. There was a report on postpartum hemorrhage in the cases o f 335 women whose deaths were associated with placenta previa and who had been delivered in the third trimester. O f these women, 156 had a postpartum hemorrhage. O f the 347 women whose deaths were assigned to placenta previa, 50 women died undelivered, and the rest died soon after delivery. The interval between delivery and death was reported for 290 women. O f these, 88 percent died less than a day after delivery, and 97 percent died within the first week. OTHER PUERPERAL HEMORRHAGE Puerperal hemorrhage other than placenta previa caused the deaths of 444 women, 443 o f whom were known to have reached the last trimester. O f these 443 women the termination o f labor was reported for all but 10. It was spontaneous in 249 cases and arti ficial in 178 cases; the patient was undelivered in 6 cases. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis £ PU ERPERAL HEM ORRHAGE 51 O f the 444 women 374 died from postpartum hemorrhage and the other 70 from adherent placentae, premature separation of the placenta, or some bleeding during or after labor the exact cause o f which was unknown. Postpartum hemorrhage In addition to the 374 deaths o f ‘ which postpartum hemorrhage was the primary cause, it was present as a complication in the deaths o f 519 other women, so that 893 women, or 21 percent o f the 4,188 who died after reaching the last trimester o f pregnancy and for whom a report was made on this condition, had postpartum hemorrhage. O f the 374 women dying o f postpartum hemorrhage, 50 had no physician at the time o f delivery; in 185 cases the physi cian did not leave the patient until after her death, and in 94 cases the patient’s condition was satisfactory when he left; in 28 cases she was in unsatisfactory condition, and in 17 cases a statement as to her condition or as to attendant was not made. O f the 893 women who had postpartum hemorrhage (including those whose deaths were assigned to other causes), only 78 were known to have had a blood transfusion. Premature separation of the placenta The diagnosis of premature separation o f the placenta was made by the attending physician in 106 cases. In 21 cases the delivery was spontaneous; in 31, there was manual dilatation, usually fol lowed by forceps or version; in 24, forceps or version without manual ^ d ila ta tio n ; and in 17, Cesarean section. In 8 cases there was some ^ o t h e r method o f delivery, in 2, the method o f delivery was not reported, and in 3, the patient died undelivered. The uterus was known to have been packed after delivery in only nine cases. The women whose deaths were associated with premature separa tion o f the placenta were, in general, older and had had more pregnancies than the total group included in the study. Eighteen percent o f these deaths were among primiparse; 69 percent were known to have had three or more pregnancies. Eighty o f the one hundred and six women were delivered opera tively, but in 21 cases the deliveries were reported as spontaneous; 3 died undelivered; and for 2 there was no report. COM M EN T B Y ADVISORY CO M M ITTEE If the onset o f hemorrhage in placenta previa were accompanied by pain, patients would apply for treatment sooner and would not be content with inactivity on the part of the physician. O f 236 cases in which warning bleeding occurred, it was ignored by the patient or by the physician in 216, and in more than half these cases it was the physician who was responsible for the delay. Even among the 107 cases in which the first hemorrhage was profuse, and it could therefore be said that no warning was given, there were a few cases o f delayed treatment, for a small number o f which the physician was responsible. Placenta previa is not a condition that can safely be treated expectantly, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 52 MATERNAL DEATHS A Braxton Hicks version, which is of greatest use to control bleed ing, was rarely done, but manual dilatation of the cervix with internal podalic version and immediate extraction was done many times. The frequent occurrence o f rupture o f the uterus, tears, hemorrhage, shock, and immediate death illustrates the seriousness o f these pro cedures and the fact that they, are not proper in the treatment of placenta previa. So many o f these women died immediately after delivery that relatively few lived long enough to die o f sepsis; as it was, 53 died o f sepsis. Treatment for shock in connection with hemorrhage was rarely mentioned in the histories as given in the schedules. Fluids o f any sort were infrequently used. That the buttocks of the child could be used to control hemorrhage and that shock could be treated at this time, the labor being terminated by the patient’s own efforts, was apparently seldom thought of. Many women with placenta previa died o f hemorrhage after labor. Only 31 of the women were packed after delivery. This would suggest that if proper packing were at hand it would be used more often, and certainly blankets and sheets would not be used as emer gency packing, with later death from sepsis. Unfortunately rupture of the membranes was seldom done in the appropriate cases of lateral placenta previa. Long distances and bad roads would seem to have contributed to some of the deaths from placenta previa. It should be emphasized that Cesarean section is contraindicated in the treatment of placenta previa when the patient is suffering from shock or hemorrhage or potential or actual sepsis. I f dirty packing had previously been used or if there had been misman agement o f any sort, the delivery should be by vagina whenever possible. But in this study the Cesarean sections for placenta previa were not limited to cases in which the mother and baby were in good condition. The operation was often done after great loss of blood and without coincident blood transfusion, though transfusion would doubtless have been given more frequently if equipment for blood typing and for giving the transfusion had been at hand. The Cesarean sometimes followed dirty packing done before the women were admitted to the hospital. Naturally many women who did not die at once from shock and hemorrhage died from sepsis. The treatment o f placenta previa is to control bleeding and treat shock and acute anemia; it is not to effect the immediate delivery of the fetus, except as a means to this end in properly selected cases. In the cases diagnosed as placental separation also, shock, even when severe, did not seem to be sufficiently considered in determining treatment. Only one fifth of the women in this group had sponta neous deliveries. About one half the women in the group were delivered immediately. The frequent use of pituitrin before delivery in cases o f women who later died of puerperal hemorrhage other than placenta previa is worthy o f comment. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OTHER ACCIDENTS OF LABOR, INCLUDING RUPTURE OF THE UTERUS OTHER ACCIDENTS OF LABOR O f the 7,380 deaths in the study, 652 were attributed after inter view to “ other accidents o f labor ” (no. 145 o f the international list). O f these 652, 136 deaths were attributed to Cesarean section (no. 145«); these deaths have already been discussed. One hundred and nine deaths were attributed to instrumental delivery and other op erative procedures (no. 1455). These were not deaths resulting from hemorrhage, sepsis, or toxemia but were thought by the attending physician to be due to shock, exhaustion, or embolism. The remaining 407 deaths were attributed to “ others ” under the title “ other accidents of la bor” (no. 145c). Sixty-five o f these were attributed to no. 145al, which includes rupture o f uterus or bladder during delivery. Sixty-three of these were due to ruptured uterus and will be taken up later. Forty-six were attributed to no. 145<?#, a group including deaths said to be due to difficult or abnormal labor, faulty presentation, inversion o f the uterus, or similar causes. The immediate cause o f death in these cases was usually thought to be either shock or exhaustion. There was a group o f 296 deaths about which so little was known that it was not pos sible to attribute them to a more definite cause than “ others under this title ” (no. 145c-?). This also includes deaths in which influenza, pneumonia, and certain other diseases complicated an otherwise xairly normal childbirth.1 In this latter group there was a report on intercurrent disease for 203. One hundred and thirty-seven (67 percent) o f these had some intercurrent disease, and 66 (33 percent) had none. Not only inter current disease during pregnancy but various complications after de livery contributed to some o f these deaths. Influenza, various types o f pneumonia, cardiac disease, cerebral hemorrhage, intestinal ob struction, and anemia were given as nonpuerperal contributory causes o f death in 242 of the 296 cases. RUPTURE OF TH E UTERUS In addition to the 63 deaths attributed to ruptured uterus (no. 145cl) 28 had a diagnosis o f ruptured uterus made by the attending physician or at autopsy— a total of 91 out o f the 7,380 deaths included in the study. O f these 28 deaths 17 were attributed to puerperal septicemia, 5 to puerperal hemorrhage, and 6 to accidents o f pregnancy. 1 In the 1929 revision o f the International List o f Causes o f Death, other accidents o f labor (n o. 145) becomes other accidents o f childbirth (no. 149), consisting o f Cesarean section (no. 149a), and others under this title (no. 1496). Rupture o f uterus or bladder is now no. 14961; the conditions form erly grouped under nos. 1456, 145c2, and 145cS are now included In no 14962 , https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 54 MATERNAL DEATHS Ten o f these 91 women were primiparse, and 77 were multiparse; the parity o f 4 was not reported. Six o f these women were not in labor. One had a rupture o f a uterine sinus as shown by autopsy; 2 had had previous Cesarean sections; there was no adequate explanation for the other 3. F if teen o f the patients had been in labor less than 6 hours; the others varied to 36 hours or more. In 8 cases a Cesarean section had been done in a previous pregnancy. The type o f presentation was reported for 78 o f the 91 cases; it was vertex in 59 cases, face in 6 cases, breech in 6 cases, and trans verse in 7 cases. There was a report as to the use o f pituitrin in 75 cases. It was not used in 36 cases and was used for induction in 1 case; in the first stage, in 10 cases; in the second stage, in 13 cases; in the third stage or postpartum only, in 14 cases; and at an unreported stage, in 1 case. O f the 91 women, 64 had an operation for delivery and 27 did n ot; 15 o f these 27 died undelivered and 12 were delivered spontaneously. As some o f the operations were unsuccessful, 6 of the 64 who had operations for delivery died undelivered. There were many other cases in which the symptoms suggested ruptured uterus, although the attending physician had not made the diagnosis. A careful study o f the schedules showed that the history pointed clearly to ruptured uterus in 68 cases and made such a diag nosis probable in 109 other cases. INVERSION OF TH E UTERUS Twenty cases of inversion of the uterus were reported. In three o f these cases the condition was not discovered until necropsy was done. Whether these cases are a true index o f the frequency o f this complication cannot be stated, for there were many unexplainable deaths that occurred in severe shock, some o f which may have been due to this condition. The causes o f death were as follow s: Postpartum hemorrhage, 13; accidents o f labor, 5; sepsis, 1; embolism, 1. COM M EN T B Y AD VISORY CO M M ITTEE A satisfactory analysis of the deaths in this miscellaneous group o f 652 cases, “ other accidents of labor” , is difficult. This is true particularly o f the largest subgroup o f 296 “ other” deaths, although here the nonpuerperal contributory causes of death play an important part. It is a well-recognized fact that the diagnosis o f a rupture o f the uterus is not always made in spite o f the suggestive history that is often obtained. This statement is supported by the relatively small number in this series o f cases so diagnosed and the many probable ruptures not so diagnosed by the attending physician which were revealed by careful study of the schedules. Though spon taneous rupture is uncommon, the possibility of its occurrence, es pecially when a previous Cesarean section has been performed, must be kept in mind. The relative infrequency o f this accident in https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OTHER ACCIDENTS— OF LABOR 55 primiparae is conclusively shown in this series. Abnormal pre sentations were common However, many of the ruptures followed apparently needless, and certainly premature, interference with labor. Study of the case histories of the women whose deaths were caused by rupture o f the uterus emphasizes the need for further education o f physicians regarding the danger of pituitrin. The use o f pituitary extract during labor is still causing maternal deaths from rupture of the uterus. Although inversion o f the uterus was reported as a cause of death in but 20 cases, some o f the unexplainable deaths may have been caused by this condition. For, unless the physician in charge is alert and keen, an inversion may be overlooked. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ECTOPIC GESTATION O f the 7,380 maternal deaths ectopic gestation was associated with 314 (4 percent). Two hundred and forty-nine o f these were attrib uted to accidents o f pregnancy (no. 143 o f the International List), 248 to ectopic gestation (no. 1435), and 1 (a case o f ruptured cornual pregnancy) to “ others under this title” (no. 143d). The other 65 patients developed sepsis, and their deaths were accordingly attributed to puerperal septicemia.1 The deaths reported to be associated with ectopic gestation were more frequent in urban than in rural areas of the States, 194 occurring in urban areas and 120 in rural areas. In every State except Nebraska and North Dakota, the mortality rates from deaths associated with ectopic gestation were higher in urban than in rural areas. The mortality rate for white women was less than for colored women. These rates are probably minimum because the differences in the mortality rates from ectopic gestation in the va rious States are influenced by the opportunity for exact diagnosis. O f the 314 women whose deaths were known to be associated with ectopic gestation, 4 had no medical care by a physician, and 44 were seen by a physician only when moribund. Two hundred and sixtythree, however, had been under the care o f a physician for a time. For 3 medical care was not reported. O f the 314 women, 253 (81 per cent) received hospital care. The parity was reported for 262 o f the 314 women. O f these, 93 were primigravidse and 169 were multigravidse. The period o f pregnancy at which symptoms began was reported in 239 o f the 314 cases. Symptoms were noted by the third month in all instances in which a report was obtained. In 30 cases symp toms began before the fourth week, from the fourth to the sixth week in 39 cases, from the sixth to the ninth week in 116 cases, from the ninth to the thirteenth week in 38, and at 3 months in 16. Two hundred and four o f the 314 women were operated on for this condition, but 109 died without operation. Twenty-six o f the 204 operations were described as elective, 175 as emergency, and there was no report on 3. Sixteen percent o f the women operated on for ectopic gestation for whom duration o f symptoms was known had had symptoms for less than a day, 43 percent for less than a week, and 35 percent from 1 to 3 weeks. Twenty-three percent had had symptoms for 4 weeks or more. O f the 26 women who died after elective operations, 17 were known to have had symptoms for more than a week. The duration o f the symptoms o f the other 9 was not reported. O f the 86 women who died without operation and for whom duration o f symptoms was reported 34 percent had had symptoms for less than a day and 60 percent for less than a week. In all but one case the operation performed was a laparotomy, and in this case there was a puncture o f the posterior cul-de-sac only. 1The 314 would all be included in ectopic gestation (no. 142) o f the 1929 revision, 65 in no. 142a “ w ith septic conditions specified ’ and 249 in no. 1426 “ w ithout mention o f septic conditions.” 56 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ECTOPIC GESTATION 57 Six women had a hysterectomy done, and three o f the women who had an ectopic pregnancy o f 7 or more months’ gestation had dilata tion o f the cervix in an attempt to bring on labor. Eighty-six of the women who died following ectopic gestation had other operations. Only 86 o f the 314 women had blood trans fusions. Eight o f the women who died following ectopic gestation had had attempts at induced abortion in the present pregnancy, and five o f them died o f sepsis. In 12 cases the period o f viability o f the child was reached, the diagnosis being made either at operation or at autopsy in 6 cases. One living child was delivered. The abdominal pregnancy was dis covered in the course o f an operation that was intended to be a Cesarean section with appendectomy. COM M ENT B Y ADVISORY COM M ITTEE Ectopic gestation is more frequently reported as a cause of death in urban than in rural areas. But when one considers the nature of this complication and the fact that it was given as the cause of death for only four women who died without medical care, it is fair to assume that, especially in the rural areas, some of the deaths from this condition are not recognized and the cause of death is not properly assigned. This assumption is further supported by the fact that in those States where hospitalization was more fre quent the diagnosis o f ectopic gestation was made more frequently. Of the 314 women whose deaths were known to be associated with ectopic gestation, 4 had no medical care and the condition was discovered at autopsy, and 44 were moribund when first seen. Eighty-one percent o f these cases received hospital care. It is interesting also to note the large percentage of these cases that occurred in multigravidae. It is likewise surprising to find that 109 of these women died without operation. As is to be expected, a very large percentage of the others had emergency operations. The fact that only 36 of these 314 women had blood transfusions shows that this life-saving procedure was not available in many o f these cases, for if it had been it undoubtedly would have been used. That emergency operating was common and that the deaths of 65 of these patients were classified as due to puerperal septicemia makes it very clear that the operative technique must be as perfect as is possible if deaths from sepsis are to be avoided. The removal of the appendix in cases o f ruptured ectopic is a dangerous pro cedure and adds to the deaths from sepsis. (There were 11 such cases.) It has long been recognized that the opening of the gut when there is much blood in the peritoneal cavity should be avoided. A review of the duration o f symptoms suggestive of ectopic preg nancy before the operation was performed shows that only 16 percent of these cases had symptoms less than a day, while 43 percent had symptoms for a week, 35 percent had symptoms for 1 to 3 weeks, and 23 percent had symptoms for 4 weeks or more. These figures show clearly that in many cases the symptoms of the serious condition of ectopic pregnancy were ignored. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis RECOMMENDATIONS BY ADVISORY COMMITTEE Maternal deaths are due in large part to controllable causes. But how is control o f these causes to be established? First, the medical profession and the public must know the facts, and then each group should take appropriate and decisive action. Physicians have the responsibility for leadership in both the medical and the community program for such control. As the facts become more widely known, others will assume this leadership if they do not. Recommendations for action looking to prevention of maternal deaths are addressed to the medical profession and to the general public. To th e M edical Profession A. Physicians must assume leadership in the field of maternal care by: 1. Informing the public that the high mortality during preg nancy, delivery, and the postpartum period is due largely to controllable causes. 2. Recognizing that every mother must have adequate pre natal, delivery, and postpartum care. (For definition o f ade quate see pp. 16, 17.) 3. Instructing the public as to what constitutes adequate maternal care. 4. So organizing the available resources of their communities that every mother can receive adequate maternal care. 5. Warning the public as to the dangers occasioned by abor tions, spontaneous or induced. B. In order that more accurate information may be secured relative to cause and prevention of maternal deaths: 1. Physicians should make a greater effort to study by autopsy and other scientific means every maternal and fetal death, for in many cases this is the only means o f ascertaining the true cause of death. 2. Physicians are urged to exercise the greatest possible care in making out maternal and fetal death certificates, so that vital statistics may be more accurate and therefore more valuable. 3. Bureaus of vital statistics are urged to query maternal and fetal death certificates recording an indefinite cause of death; for example, “ Cesarean section” alone. 4. Medical societies and departments of health in cooperation should investigate each maternal death within a few weeks of the death. 58 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis R E C O M M E N D A T IO N S B Y A D V IS O R Y C O M M IT T E E 59 C. In order that physicians in general may have a better under standing o f the fundamentals of obstetric care: 1. There should be larger and better facilities for clinical training in obstetrics. 2. Undergraduate students should have a much wider contact with obstetric patients. 3. The State medical societies, the medical schools, and State departments of health shojild provide or arrange for postgrad uate teaching in the various counties in order to keep the local practitioner in touch with the best obstetric thought and practice. D. It is recommended that all physicians practicing obstetrics give particular consideration to: 1. The importance of good aseptic technique, including the use o f rubber gloves and masks that cover nose and mouth. 2. The danger to mothers from carriers of infection. 3. The dangers o f the use of pituitrin during labor. 4. The dangers of multiple, forcible, and radical procedures in obstetrics. 5. The proper indications and contraindications for various obstetric operations, especially (a) the dangers of major opera tions in the presence of shock and hemorrhage and (b ) the dangers of Cesarean section after vaginal manipulations or long labor. 6. The proper selection o f anesthetics. 7. The value o f blood transfusions. 8. The dangers of intrauterine manipulation in cases of infected abortion. 9. The dangers o f abortion or delivery to women suffering from acute diseases, especially infectious diseases. 10. Knowledge o f the symptoms of some o f the less common but more serious complications o f delivery such as rupture of the uterus. E. It is recommended that State medical societies working in coop eration with the State departments of health consider the develop ment of some plan by which well-trained regional obstetric consultants may be made available. To th e G eneral P ublic There should be widespread education of the public as to the following: 1. That the high maternal death rate is due largely to con trollable causes. 2. That it is necessary for all women to have adequate supervi sion and medical care during pregnancy, labor, and the postpar tum period, such supervision and care to begin early in pregnancy and to be continuous through the postpartum period— a. In order to safeguard the health o f both mother and child. b. In order especially to control the infections, toxemias, and hemorrhages that this study and others have shown to be real menaces to life. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 60 M ATERN AL DEATHS 3. That there is danger o f death or serious invalidism following abortions, spontaneous or induced. 4. That the community has a definite responsibility to provide jfcadequate medical and nursing facilities for the care o f w om en'w during pregnancy, labor, and the postpartum period. This predi cates the proper organization o f hospitals, outpatient services, and medical and nursing personnel and applies to both home and hospital care. The community, should know the standards for hospitals taking obstetric cases that have been drawn up by the American College o f Surgeons. (See below.) 5. That judicious selection o f the hospital to be used for ma ternity care is of the greatest importance when hospitalization is planned. 6. That the better education of those caring for women during this period is essential and should have public support. This includes adequate obstetric training for medical students, post graduate obstetric training for physicians in practice, to keep them abreast o f modern developments, the training o f nurses in good maternity care, and the training and supervision of mid wives in communities where midwives still practice. 7. That it is important to make careful and intelligent selection of the attendant for maternal care. S T A N D A R D S O F A M E R IC A N C O L L E G E O F S U R G E O N S F O R H O S P IT A L S T A K IN G O B S T E T R IC P A T IE N T S [American College o f Surgeons; Twentieth Year Book. 1933. Pp. 68-69. Chicago] (1) S egrega tion o f obstetric p a tien ts from all others in th e in stitu tio n . (2) S p e cia l facilities a va ila b le for im m ed iate segregation and isolation o f all cases o f in fectio n , tem p erature, or other con dition s in im ical to th e s a fe ty and w elfare o f p atients w ithin th e d ep artm en t. (3) A d e q u a te ly trained personnel, th e entire nursing s ta ff to be chosen sp ecially for w ork in th is d ep artm en t and n o t per m itted to a tte n d other cases during tim e on o bstetric service. (4) R e a d ily a v a ila b le , ad eq uate lab o rato ry and sp ecial-treatm en t facilities under co m p eten t supervision. (5) A c c u r a te and com p lete clinical records on all o bstetric p a tien ts. (6) F re q u e n t co n su ltatio n s encouraged on o bstetric service, a co n su lta tio n m ade o b liga to ry in all cases where m ajo r opera tiv e procedures m a y be in d ica ted . (7) T h o ro u gh an alysis an d review o f th e clinical w ork o f th e d ep artm en t each m o n th b y th e m edical s ta ff w ith p articu lar considerations to d ea th s, in fectio n s, com p licatio n s, or such con dition s as are n o t co n d u cive to th e b est end results. (8) A d e q u a te th eo retical in stru ctio n and p ra ctical experience for stu d en t nurses in p re n a ta l, p a rtu rie n t, and p o stp a rtu m care o f th e p a tie n t, as well as th e care o f th e new born. O https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis #
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