Toxemia mortality in the southern states: A critical study of 577 maternal deaths in North Carolina

Abstract

The high maternal mortality rate in the southern states from the toxemias of late pregnancy is possibly abetted by the hot, wet climate characteristic of this section of the United States. The graph study of 344 maternal fatalities in North Carolina from eclampsia classified according to the month of death as compared to the average temperature and rainfall, confirms or rather substantiates the greater danger of this disease during the hot, wet months of the year. A similar study of precipitation and temperature in various states in the country would indicate that there is less eclampsia in the dry climate and that heavy precipitation unassociated with high temperature is less likely to be accompanied by a high toxemia rate.A detailed study of 515 maternal deaths from late pregnancy toxemia occurring in North Carolina during the years 1932 through 1936 reveals other and more important contributing factors than those of climate. First among these is neglect. Only 12 patients received adequate prenatal care and competent medical supervision. Two hundred and fifty-two were seen for the first time by a physician late in their pregnancy, either in convulsions or with advanced toxemia. Seventy received their first medical attention when in labor, and 73 saw a physician for the first time after delivery. In 108 cases, there was prenatal care of an inadequate or faulty type.This study confirms the fact as repeatedly stated by Stander, Acosta-Sisson, and others, that the toxic multipara with a history of toxemia in a previous pregnancy is a grave risk. Approximately 45 per cent of the multiparas in this study gave a definite history of toxemia in a previous pregnancy, a figure that is too low because of the fact that incomplete obstetric histories were obtained on many of the 515 fatalities.This study also substantiates the additional likelihood of late pregnancy toxemia in the presence of multiple pregnancy and the increased danger in acute upper respiratory or pulmonary infections. It calls attention to the additional risk of premature separation of the placenta and post-partum hemorrhage in the toxemias of late pregnancy, because of their increased incidence as complications of the disease.The great danger of sudden cardiac decompensation in the acute preeclampsias, the surprisingly high incidence of cerebral hemorrhage (10 per cent) in the nonconvulsive toxemias, the high percentage of illegitimate pregnancy in fatal eclampsia (three times the incidence of illegitimacy in the state of North Carolina) are re-emphasized.While the incidence of operative interference upon the grave toxemia was probably unnecessarily high and hence a factor in mortality, the other extreme, namely the policy of laissez-faire or lack of early active intervention in the presence of advanced vasculorenal disease, often accompanied by a bad toxemia history, was a much more vital contributing factor to maternal mortality.The loss of infant life needs no further comment except to repeat that the approximate yield of living viable infants from the 515 maternal fatalities was less than 40 per cent.The increasing trend toward hospitalization of obstetric cases in North Carolina in the past decade (from 5 per cent of all births in 1926 to 20 per cent in 1937) has been accompanied by a reduction of the maternal mortality from eclampsia, which has fallen from 23 per cent in 1926 to 12 per cent in 1937.Social and economic factors are intimately woven into the maternal welfare problem in the southern states. In North Carolina approximately 85 per cent of the state's 3½million population are rural or live in towns of less than 10,000. Thirty-two per cent of the births are delivered by midwives and many of the remainder who are delivered by a physician are not seen until in labor.In conclusion, it is evident that the high maternal mortality rate from toxemia of late pregnancy in the southern states as represented by this analysis of 515 such deaths in North Carolina is primarily due to social and economic circumstances. A widely scattered and rural population, a high percentage of illiteracy, the inaccessibility of adequate prenatal supervision in the past in many remote sections, the failure of prompt utilization of hospital facilities and often the inaccessibility of competent obstetric consultation, and a midwife service untrained and poorly qualified, are among the contributing factors to this problem.The social implications necessary to cure this cancer are particularly realistic at this time. Adequate and competent maternity care for every expectant mother is a problem vitally dependent upon the active cooperation and direction of organized medical forces.