AMERICAN JOURNAL OF
Public Editorials Health September 1977 Established 191 1 Volume 67, Number 9
Maternal Mortality Studies-Time to Stop? EDITOR Alfred Yankauer, MD, MPH
EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF
William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant
CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
AJPH September, 1977, Vol. 67, No. 9
Maternal mortality study committees represent one of the earliest forms of physician peer review, dating back almost 50 years. A three-year public health study of obstetrics conducted by the New York Academy of Medicine' began on January 1, 1930, and focused on "puerperal death." In that same year, the Philadelphia County Medical Society established a Maternal Welfare Committee' and asked that an analysis of maternal deaths in Philadelphia be carried out. From that time on there was a slow but steady growth of primarily statewide maternal mortality committees, so that only four states are recorded as never having had such a committeel 2-Alaska, Arkansas, Idaho, and Vermont. In the past ten years, however, there has been a decline in the number of active state committees, accompanied by comments that the total number of direct maternal deaths in this country annually (now about 400) are not a major public health priority, and suggestions that our emphasis might better be directed to the numerically much larger problems of perinatal mortality. The two articles in this issue of the Journal by Grimes and Cates from the Center for Disease Control,2 and by Schaffner, et al, reporting experience in Michigan3 provide a point-counter-point focus on both the questions and the answers. Grimes and Cates perform a service, both by updating the status of maternal mortality committees in the United States since the last report in the late 1960s, and by pointing out that a simple cause and effect relation cannot be demonstrated between the existence of a committee in a given state and a decrease in maternal mortality. A committee cannot provide health care to a patient-a fact sometimes apparently overlooked by our elected and appointed representatives along the Potomac. Deaths from the classic "HIT" causes of maternal mortality-hemorrhage, infection, and toxemia-have diminished markedly with the advent of blood transfusion, antibiotics, better nutrition, prenatal care, and hospital delivery, but they still lead the categories in most studies of maternal mortality. The role of the maternal mortality committee in educating professionals to these advances is blurred in the aggregate, and probably spills across state lines. At the individual patient level though, benefits may be more specific. While serving on a midwestern state maternal mortality committee about ten years ago, a maternal death under study was identified as resulting from an excessive dose of local anesthesia. Further probing by the committee showed that many physicians in the region were unaware of maximum milligram dosages for local anesthetic agents. The university medical school's department of anesthesiology made this a new emphasis in continuing education programs, and the problem was discussed in the state medical journal. Did these actions prevent future maternal deaths or significant morbidity? Even grouped data are unlikely to provide a statistically acceptable answer, but we believed we had improved the care of patients. The paper of Schaffner, et al,2 on the other hand, points out how aggregate data reviewed over time can be of help. Identification of a higher age-adjusted direct maternal mortality rate in nulliparous women than in multipara is an important observation, particularly with both increasing adolescent pregnancies and the deliberate 815
EDITORIALS
postponement of childbearing by many couples. The continued fourfold higher maternal mortality among blacks demolishes the argument that we have now reached an "irreducible minimum" of maternal deaths. Finally, Schaffner notes the paradox of an increase in preventable maternal deaths over the years, apparently based on increased committee expectations for standards of care, which also serves to emphasize that the battle is not yet over. The subject of maternal deaths has been popular to study because they are fairly easy to identify and the end point of death is definite. As opposed to perinatal deaths, for example, there are no decisions about whether the patient was really alive, weight categories, anomalies incompatible with life, and so on. We all like to deal with the simple and clear cut. Witness any committee faced with long range planning or setting measurable objectives-the sole item that will be discussed to a decision is the time and place of the next meeting. Numbers of maternal deaths are small. They merit continued'study, but not at the intensity of former years, nor to the exclusion of perinatal mortality studies. As opposed to probably 400 direct maternal deaths in the United States in 1977, stillbirths and neonatal deaths will approximate 75,000. Committees already organized should concentrate their experience and consequent educational efforts on the fetus, and a committee geographic base tied into a regional maternal and perinatal health planning area seems most desirable. Lest we become complacent about maternal deaths, however, the world is larger than just the United States. If
one accepts the conservative* estimate of Ravenholt that there were 110 million births on this earth in the year 1975,4 there were at least 50,000 direct maternal deaths. Surely here is a public health problem of great magnitude. It should receive as much attention as smallpox, and one may hope it will have a similar outcome someday.
WARREN H. PEARSE, MD, FACOG *The word conservative is used since the Aird estimates given in the same publication are substantially higher, based primarily on different estimates of births in China. The estimate of at least 50,000 direct maternal deaths is my own, based on a conservative rate estimate of 46/100,000 births.
Address reprint requests to Dr. Warren H. Pearse, Executive Director, American College of Obstetricians and Gynecologists, One East Wacker Drive, Chicago, IL 60601.
REFERENCES
1. History of Maternal Mortality Study Committees in the United States; Marmol, J. G., Scriggins, A. L., and Vollman, R. F. Obstetrics and Gynecology 34:123-138, 1969. 2. Grimes, D. A., and Cates, W. Jr. The impact of state maternal mortality study committees on maternal deaths in the United States. Am. J. Public Health 67:830-833, 1977. 3. Schaffner,W., Federspiel, C. F., Fulton, M. L., Gilbert, D. G., and Stevenson, L. B. Maternal mortality in Michigan: An epidemiologic analysis, 1950-1971. Am. J. Public Health 67:821829, 1977. 4. Population Reports, George Washington University Medical Center, Series J 12, p J212, November, 1976.
A Tool for Health Planners For those who are involved with local health planning, a question that is immediately resolved into a non-issue is whether mortality statistics should be used as one of the measures of the health status of local area populations. No evidence on problems of quality of the data or on inadequacy of the information to identify significant health deficits and their correlates can override the unique characteristics of mortality statistics. Simply put, they represent the only continuous source of information on an unequivocal manifestation of health status that dates back many years and is assured of continuity into the foreseeable future, and the data can be examined on a geographically disaggregated level often down to subareas within a city, for example, or aggregated across civil subdivisions for medical market analysis. The question faced by the user of mortality statistics for planning purposes is how to maximize the utility of this resource. Here there are both conceptual and technical issues, a number of which have been receiving renewed attention. Important contributions on the subject are found in Statistical Notes for Health Planners, a cooperative effort of the National Center for Health Statistics and the Bureau of Health Planning and Resources Development. These reports 816
are systematically probing into the nature of mortality statistics, including their limitations, and presenting statistical approaches to the data that increase their power to measure variability among local areas and to assess trends. The paper, Age-Adjusted Mortality Indexes for Small Areas by Joel Kleinman, in the current issue of the Journal,1 is a significant addition to the primer on the calculation of such indexes and the measurement of sampling variability that appears in issue Number 3, February, 1977 of the Statistical Notes.2 The implications of options that are technically available for adjusting tabulated data on local area mortality to take into account age differentials among areas and changes over time are well known to the health statistician. However, a change from the past for many is the focus on the relative value of the indexes for health planners when faced with the need for indicators of relative health status among communities and changes taking place. Thus high marks are given to the Years of Life Lost (YLL) index which is based on the number of years between age at death and some advanced age; in Kleinman's illustration age 70 is used, others may argue for a more advanced age. Variations in mortality at the younger ages are accordingly emphasized by the YLL AJPH September, 1977, Vol. 67, No. 9
Public Editorials Health September 1977 Established 191 1 Volume 67, Number 9
Maternal Mortality Studies-Time to Stop? EDITOR Alfred Yankauer, MD, MPH
EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF
William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant
CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
AJPH September, 1977, Vol. 67, No. 9
Maternal mortality study committees represent one of the earliest forms of physician peer review, dating back almost 50 years. A three-year public health study of obstetrics conducted by the New York Academy of Medicine' began on January 1, 1930, and focused on "puerperal death." In that same year, the Philadelphia County Medical Society established a Maternal Welfare Committee' and asked that an analysis of maternal deaths in Philadelphia be carried out. From that time on there was a slow but steady growth of primarily statewide maternal mortality committees, so that only four states are recorded as never having had such a committeel 2-Alaska, Arkansas, Idaho, and Vermont. In the past ten years, however, there has been a decline in the number of active state committees, accompanied by comments that the total number of direct maternal deaths in this country annually (now about 400) are not a major public health priority, and suggestions that our emphasis might better be directed to the numerically much larger problems of perinatal mortality. The two articles in this issue of the Journal by Grimes and Cates from the Center for Disease Control,2 and by Schaffner, et al, reporting experience in Michigan3 provide a point-counter-point focus on both the questions and the answers. Grimes and Cates perform a service, both by updating the status of maternal mortality committees in the United States since the last report in the late 1960s, and by pointing out that a simple cause and effect relation cannot be demonstrated between the existence of a committee in a given state and a decrease in maternal mortality. A committee cannot provide health care to a patient-a fact sometimes apparently overlooked by our elected and appointed representatives along the Potomac. Deaths from the classic "HIT" causes of maternal mortality-hemorrhage, infection, and toxemia-have diminished markedly with the advent of blood transfusion, antibiotics, better nutrition, prenatal care, and hospital delivery, but they still lead the categories in most studies of maternal mortality. The role of the maternal mortality committee in educating professionals to these advances is blurred in the aggregate, and probably spills across state lines. At the individual patient level though, benefits may be more specific. While serving on a midwestern state maternal mortality committee about ten years ago, a maternal death under study was identified as resulting from an excessive dose of local anesthesia. Further probing by the committee showed that many physicians in the region were unaware of maximum milligram dosages for local anesthetic agents. The university medical school's department of anesthesiology made this a new emphasis in continuing education programs, and the problem was discussed in the state medical journal. Did these actions prevent future maternal deaths or significant morbidity? Even grouped data are unlikely to provide a statistically acceptable answer, but we believed we had improved the care of patients. The paper of Schaffner, et al,2 on the other hand, points out how aggregate data reviewed over time can be of help. Identification of a higher age-adjusted direct maternal mortality rate in nulliparous women than in multipara is an important observation, particularly with both increasing adolescent pregnancies and the deliberate 815
EDITORIALS
postponement of childbearing by many couples. The continued fourfold higher maternal mortality among blacks demolishes the argument that we have now reached an "irreducible minimum" of maternal deaths. Finally, Schaffner notes the paradox of an increase in preventable maternal deaths over the years, apparently based on increased committee expectations for standards of care, which also serves to emphasize that the battle is not yet over. The subject of maternal deaths has been popular to study because they are fairly easy to identify and the end point of death is definite. As opposed to perinatal deaths, for example, there are no decisions about whether the patient was really alive, weight categories, anomalies incompatible with life, and so on. We all like to deal with the simple and clear cut. Witness any committee faced with long range planning or setting measurable objectives-the sole item that will be discussed to a decision is the time and place of the next meeting. Numbers of maternal deaths are small. They merit continued'study, but not at the intensity of former years, nor to the exclusion of perinatal mortality studies. As opposed to probably 400 direct maternal deaths in the United States in 1977, stillbirths and neonatal deaths will approximate 75,000. Committees already organized should concentrate their experience and consequent educational efforts on the fetus, and a committee geographic base tied into a regional maternal and perinatal health planning area seems most desirable. Lest we become complacent about maternal deaths, however, the world is larger than just the United States. If
one accepts the conservative* estimate of Ravenholt that there were 110 million births on this earth in the year 1975,4 there were at least 50,000 direct maternal deaths. Surely here is a public health problem of great magnitude. It should receive as much attention as smallpox, and one may hope it will have a similar outcome someday.
WARREN H. PEARSE, MD, FACOG *The word conservative is used since the Aird estimates given in the same publication are substantially higher, based primarily on different estimates of births in China. The estimate of at least 50,000 direct maternal deaths is my own, based on a conservative rate estimate of 46/100,000 births.
Address reprint requests to Dr. Warren H. Pearse, Executive Director, American College of Obstetricians and Gynecologists, One East Wacker Drive, Chicago, IL 60601.
REFERENCES
1. History of Maternal Mortality Study Committees in the United States; Marmol, J. G., Scriggins, A. L., and Vollman, R. F. Obstetrics and Gynecology 34:123-138, 1969. 2. Grimes, D. A., and Cates, W. Jr. The impact of state maternal mortality study committees on maternal deaths in the United States. Am. J. Public Health 67:830-833, 1977. 3. Schaffner,W., Federspiel, C. F., Fulton, M. L., Gilbert, D. G., and Stevenson, L. B. Maternal mortality in Michigan: An epidemiologic analysis, 1950-1971. Am. J. Public Health 67:821829, 1977. 4. Population Reports, George Washington University Medical Center, Series J 12, p J212, November, 1976.
A Tool for Health Planners For those who are involved with local health planning, a question that is immediately resolved into a non-issue is whether mortality statistics should be used as one of the measures of the health status of local area populations. No evidence on problems of quality of the data or on inadequacy of the information to identify significant health deficits and their correlates can override the unique characteristics of mortality statistics. Simply put, they represent the only continuous source of information on an unequivocal manifestation of health status that dates back many years and is assured of continuity into the foreseeable future, and the data can be examined on a geographically disaggregated level often down to subareas within a city, for example, or aggregated across civil subdivisions for medical market analysis. The question faced by the user of mortality statistics for planning purposes is how to maximize the utility of this resource. Here there are both conceptual and technical issues, a number of which have been receiving renewed attention. Important contributions on the subject are found in Statistical Notes for Health Planners, a cooperative effort of the National Center for Health Statistics and the Bureau of Health Planning and Resources Development. These reports 816
are systematically probing into the nature of mortality statistics, including their limitations, and presenting statistical approaches to the data that increase their power to measure variability among local areas and to assess trends. The paper, Age-Adjusted Mortality Indexes for Small Areas by Joel Kleinman, in the current issue of the Journal,1 is a significant addition to the primer on the calculation of such indexes and the measurement of sampling variability that appears in issue Number 3, February, 1977 of the Statistical Notes.2 The implications of options that are technically available for adjusting tabulated data on local area mortality to take into account age differentials among areas and changes over time are well known to the health statistician. However, a change from the past for many is the focus on the relative value of the indexes for health planners when faced with the need for indicators of relative health status among communities and changes taking place. Thus high marks are given to the Years of Life Lost (YLL) index which is based on the number of years between age at death and some advanced age; in Kleinman's illustration age 70 is used, others may argue for a more advanced age. Variations in mortality at the younger ages are accordingly emphasized by the YLL AJPH September, 1977, Vol. 67, No. 9
