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Maternal deaths in California from 1967 to 1971. A demonstration of the need for mortality review.

An evaluation of maternal mortality statistics in California from 1967-1971 has been performed. There has been a fall in the maternal mortality rate following the institution of a therapeutic abortion act. However, analysis of the data reveals that there was an increase in the deaths due to hemorrhage and sepsis. At this same time the maternal mortality study committee was discontinued. It is strongly felt that the data demonstrate the need for a continuing review of maternal deaths. A proposal is made to redesign the maternal mortality study committee so that it can fully meet the needs of the medical profession and the patient.

Abortion, Legal

Maternal deaths from ectopic pregnancy in the South Atlantic region, 1960 through 1976.

The authors have calculated the maternal mortality rates from ectopic pregnancy in the Southeastern United States. Between 1960 and 1975 81 per cent of 207 ectopic deaths occurred in nonwhite women. A more detailed study of 24 deaths from ectopic pregnancy in North Carolina shows that from 1961 to 1976 4.2 per cent of all direct obstetric deaths and 15.9 per cent of deaths from hemorrhage were due to reptured ectopic gestation. The most striking observation was the dramatic reduction in deaths from ectopic pregnancy among nonwhite women. Maternal mortality rates for ectopic pregnancy should properly be based on the conception rate, consisting of live births plus abortions rather than live births alone. Missed diagnosis of ectopic pregnancy as a factor in maternal mortality rate requires more intensive educational efforts directed toward primary-care physicians.

Black or African American

Legalized abortion: effect on national trends of maternal and abortion-related mortality (1940 through 1976).

Both non-abortion-related maternal and abortion-related mortality declined prior to the Supreme Court decisions of 1973. In order to determine the effect of legalized abortion on maternal mortality, we have analyzed the secular trends in national abortion mortality ratios for 1940 through 1976, compared the trends to those maternal mortality ratios, and hypothesized reasons for differences between these trends. Between 1940 and 1950 and after 1965, deaths from abortion declined more rapidly than deaths from other causes associated with childbirth. However, between 1951 and 1965, maternal mortality related to pregnancy of childbirth declined more rapidly than abortion-related mortality. Five possible explanations exist for the more rapid decline in abortion deaths since 1965--selected underreporting, changes in coding practices, improved safety of illegal abortion, introduction of more effective contraception, and increased availability of legal abortion. We consider the last two explanations as the most likely reasons for the accelerated decline in abortion-related deaths.

Abortion, Legal

George Stroh.

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Austria

Childhood morbidity and mortality in a large hospital over last four decades.

Pediatric statistics in a 50-year-old large hospital were analysed to find out any change in pediatric admission rate, morbidity and mortality and outcome of common disorders during the last four decades. Information was collected from four block years from each of the last four decades and compared. An increase of almost 250% in the total pediatric admissions as compared to an increase of 150% in total hospital admissions over last four decades suggest an increased awareness of maternal and child health by the community. The pediatric mortality excluding neonates has not shown a significant fall over the last four decades, being 14.6, 12.7 and 13.0% in 1955-1958, 1974-1977 and 1984-1987, respectively. Diarrheal disorders, pneumonia, tetanus and infections of central nervous system continue to remain the common causes of hospital admissions in children. The morbidity and mortality in these disorders, in general, have shown a significant decline though less appreciable in pyogenic meningitis, encephalitis and tetanus cases.

Brain Diseases

The quality of perinatal care in small rural hospitals.

Iowa birth and mortality statistics were reviewed to ascertain the outcome of perinatal care provided in hospitals with different-sized obstetric services. Although the data do not resolve the issue of the minimum number of deliveries necessary to ensure quality perinatal services, they do suggest that hospitals with small maternity services (fewer than 500 deliveries per year) can achieve acceptable perinatal outcomes when appropriate high-risk screening and prenatal referral occur.

Adolescent

Factors involved in immunization program for swine influenza.

The decision to undertake a nationwide program of vaccination against swine influenza requires assessment of the status of immunity of those in various age groups in our population against this agent. Pools of serum were collected from persons born in the years from 1889 to 1943; they were tested for hemaggultinin inhibiting (HI) antibody against the HSW 1N1 influenza virus strains isolated in 1931 and 1976. The titers secured serve as an indication of the average level of immunity of those of different ages. Persons less than 43 years of age are found to be without antibody protection. The need for vaccination of people in different age groups based on mortality statistics of previous epidemics is evaluated. It is realized that no epidemic may occur and that a reduced virulence of the viral agent and use of antibiotics may reduce the death rate if the infection recurs. The extraordinary high mortality in 1918 in people between 15 and 44 years of age deserves recognition together with the fact that those in the same age group are now without protection. The fact that women of childbearing age fall into this group deserves special consideration in view of increased mortality in puerperal women observed in the pandemics of 1918 and 1957. The degree of protection afforded the newborn by transplacental transmission of maternal antibodies is discussed. The need of increasing the level of immunity in those who have varying titers of HI antibodies is considered in relation to the prevalence of cardiopulmonary complications and other chronic diseases in older subjects.

Adolescent

In utero exposure to steroid contraceptives and survival during infancy.

A cohort study was conducted in Chiang Mai, northern Thailand, in 1,431 children of women who had used the injectable contraceptive Depo-Provera (The Upjohn Company, Kalamazoo, Michigan), 565 children of women who had used oral contraceptives during pregnancy, and a group of 2,307 control infants with no hormonal contraceptive exposures. In follow-up interviews, information was obtained on stillbirths and deaths. Cause of death was ascertained by interview, death certificate, or medical record, and underlying causes of death were ascribed by a panel. The children exposed in utero to Depo-Provera had higher neonatal and infant mortality rates (44.3 and 62.9 per 1,000 live births, respectively) than did the controls (19.8 and 29.1 per 1,000 live births). Mortality in infants exposed in utero to oral contraceptives was intermediate between that in the other two groups. Adjustment by logistic regression showed no significantly increased risk of mortality among infants exposed to oral contraceptives, but the odds ratio for death was significantly increased with Depo-Provera exposures due to accidental pregnancy (odds ratio (OR) = 1.8 (95% confidence interval (Cl) 1.1-3.0) for neonatal deaths; OR = 2.0 (95% Cl 1.3-3.2) for infant deaths). Adjustment for low birth weight reduced the risks, suggesting that low birth weight may act as an intermediate determinant of Depo-Provera-associated mortality. Among the accidental pregnancies with Depo-Provera, there was a relation between shorter injection-to-conception intervals, when maternal blood levels of the drug are high, and an increased risk of mortality. The odds ratios for neonatal mortality were 2.5 (95% Cl 1.1-5.7), 2.1 (95% Cl 1.0-4.6), and 0.9 (95% Cl 0.4-2.4) for injection-to-conception intervals of less than or equal to 4, 5-8, and greater than 9 weeks, respectively. Adjustment for low birth weight reduced these risks. Chi-square tests for trend were highly significant. Similar associations were also observed between Depo-Provera accidental pregnancies and risks of low birth weight. Thus, infants from accidental pregnancies that occur 1-2 months after a 150-mg Depo-Provera injection may be at increased risk for low birth weight and death. However, the attributable risk is low, because such pregnancies are uncommon.

Cause of Death

Increased risk of death from measles in children with a sibling of opposite sex in Senegal.

OBJECTIVE: To examine whether contracting measles from a sibling of the opposite sex affects mortality. DESIGN: Prospective registration during 15-20 years of all births and deaths, including 243 measles related deaths. Measles infection was not registered; however, as in fatal cases measles was probably contracted from a maternal sibling the risk of dying during measles outbreaks was examined in families with two boys, two girls, or a boy and a girl. SETTING: 31 small villages in two rural areas of eastern Senegal. SUBJECTS: 766 children living in families with two children aged under 10 years during outbreaks of measles, 107 (14%) of whom died of measles. MAIN OUTCOME MEASURE: Deaths from measles, size of village, age and sex of maternal siblings. RESULTS: The interval between outbreaks in the same village was greater than 10 years. The risk of dying of measles was significantly related to age, increasing with the age difference between siblings and decreasing with the size of village. In a multiple logistic regression analysis adjusting for these background factors, children in families with a boy and a girl had a significantly higher mortality than children in families with two boys or two girls (odds ratio = 1.81, 95% confidence interval 1.17 to 2.82). The increase in risk was the same for boys and girls in families with two children one of whom was a boy and one a girl. CONCLUSION: Cross sexual transmission may be an important determinant of severity of measles infection.

Age Factors

Mortality trends in Abidjan, Côte d'Ivoire, 1983-1988.

To assess changes in mortality in Abidjan since the development of the AIDS epidemic, we compared official city mortality statistics and hospital fatality rates in 1983, before AIDS was recognized in Abidjan, with those in 1988. Review of records in the city's major hospitals showed that fatality rates (deaths per 1000 admissions) in adult medical patients increased by 54% between 1983 and 1988, with increases of 106 and 98% in men 20-29 and 30-39 years of age, respectively, and 199 and 42% in women of the same age ranges. Mortality rates in surgical patients showed little change, while in children they declined. Over the same period, official mortality statistics for the city showed reduced mortality rates in children and women 20-29 years of age, but an increase in mortality rates of 54% in men 20 years of age and older, and of 28% in women aged 30 years and older. HIV infection may be a major cause of the increased adult mortality documented in hospital and city records, and jeopardizes improved survival from preventive measures such as maternal and child health services.

Acquired Immunodeficiency Syndrome

Perinatal mortality statistics in Harare 1980-1989.

Perinatal and neonatal mortality rates, in the Greater Harare Maternity Unit, which showed a modest decline from 1980 to 1985, have rise dramatically since then. Half of the rise in neonatal mortality rate is due to increased numbers and an increased mortality rate in babies of birth weight less than 1001g. There is also an increase in the numbers of deaths of large babies. There is a strong case for a broad-based on-going enquiry into the reasons for such changes.

Birth Rate

Nutrition and health in China, 1949 to 1989.

Since the establishment of a new social order in 1949, China's attempts to feed and nurture its large population has been a topic of serious study in many disciplines. This review focuses on dietary sources of Chinese population and incidence, increase and decline of important diet related health disorders in China during the last four decades. Literature published since 1949 on goiter, rickets, riboflavin deficiency, beri beri, vision impairment, favism, cancer, atherosclerosis and coronary heart disease, hypertension, dental and smoking related diseases, diabetes mellitus, pancreatitis, lactose intolerance, mineral deficiency, Kashin-Beck disease, parasitic diseases and genetic disorders are reviewed. Also presented selectively are reports related to ethnodietetics, health care, maternal health and pediatric care as well as longevity. In the 1980s, total caloric intake of Chinese population showed a 19% increase on a daily basis from that of late 1940s. In overall terms, plant derived foods supplied 93% of energy, 87% of protein and 55% of fat to the Chinese. Among the animal foods, pork remains the most common and least expensive form of meat, contributing more than 90% of China's total meat production excluding poultry and fish. In 1949, the life expectancy in China was only 36 years. In early 1980s, it has increased to 68 years. This increase in life expectancy is attributed mostly to improved nutrition and lowering of mortality due to decrease in infectious diseases. Though population, disease and mortality statistics of modern China are spotty and sometimes questionable, common consensus among the researchers is that since 1949 the public health situation in China has improved tremendously.

China

Causes of death: an assessment of global patterns of mortality around 1985.

Cause-of-death statistics are available for virtually the entire population of the developed world (1.17 billion in 1985) and thus estimates of the mortality pattern in these countries can be made with some confidence, notwithstanding the artefacts which arise due to differences in diagnostic and certification practices between countries. In the developing countries, cause-of-death estimation is much more difficult due to the paucity of mortality statistics. Nonetheless, there are several sources of information on mortality, ranging from surveillance systems and small-scale community studies to complete vital registration, which can be exploited to estimate mortality patterns. Of the 50 million deaths which occur throughout the world each year, roughly 39 million (78%) occur in developing countries. For the developing countries as a whole, infectious and parasitic diseases are estimated to have accounted for almost one-half of all deaths in 1985. Diarrhoeal diseases, acute respiratory diseases (primarily pneumonia) and tuberculosis each claimed about 3-5 million deaths in the developing world in the mid-1980s, with a further 2.6 million due to measles and whooping cough. Perinatal conditions are estimated to have been responsible for a little over 3.2 million deaths in 1985 in developing countries, one-quarter of which were due to neonatal tetanus alone. Maternal causes claimed the lives of about 0.5 million women. At the same time, the chronic diseases are emerging as a leading cause of death in several regions of the developing world, particularly Latin America and East Asia. Circulatory and specific degenerative diseases are estimated to have caused about 6.5 million deaths in 1985. Chronic lung diseases and cancer are each thought to have claimed about 2.5 million lives in 1985. External causes also probably accounted for 2.0-2.5 million deaths.

Australia