Cesarean section in detroit during 1945—A comparison with 1925 and 1930

Abstract In Detroit, during 1945, there were 1,000 cesarean sections, or one in 37 births, as contrasted to 154 or one in 217 deliveries in 1925 (Welz), and 203 or one in 167 in 1930 (Seeley). On the other hand, maternal mortality with cesarean section for these series were 13 per cent in 1925, 4.4 per cent in 1930, and only 0.8 per cent in 1945. The fetal death rates for the same years were 11, 12.8, and 7.8 per cent. The incidence of the operation during 1945 in the fourteen larger hospitals with 1,000 or more deliveries varied from one in 78 to one in 13 births, and, in most instances, the 1945 rates represented increases over those for 1925 and 1930, thus reflecting the general trend for the city as a whole. The low cervical operation had become the one most frequently employed by 1945 and, as before, showed distinct maternal advantage over the classical type. Cesarean-hysterectomy and extraperitoneal section were only forty in number but without mortality. The hospitals were divided into three groups according to numbers of deliveries as follows: 2,000 or more—5 hospitals; 1,000 to 1,999—9 hospitals; and less than 1,000—25 hospitals. In the first two groups there were 13,997 and 13,130 deliveries with a maternal mortality rate of 1.1 per 1,000 for both. In these same two groups, cesarean sections had incidences of 3.6 and 2.5 per cent, with death rates of 0.39 and 0.62 per cent, respectively. In the third group, there were 6,946 deliveries in the 25 hospitals, with a general maternal mortality of 3.46 per 1,000, and a cesarean section incidence of 2.4 per cent with 2.38 per cent deaths. Moreover, three of the four cesarean fatalities ascribable in whole or in part to questionable treatment occurred in these hospitals. The number of cesarean sections done for the various indications increased markedly in all important categories. However, the proportional variations remained remarkably constant except for the toxemias of pregnancy. Cesarean sections for these conditions had increased from 26 in 1925 to 73 in 1945, but these figures represented a decrease from 17 per cent of all sections in 1925 down to 7 per cent in 1945. The proportional and absolute increase under the heading “Miscellaneous” is explained in part by some new indications such as “Rh negative.” An outstanding feature, on comparing the three periods, is the marked reduction in cesarean section mortality—from the appalling rate of 13 per cent in 1925, to 4.4 in 1930, and down to only 8 cases or 0.8 per cent in 1945. In spite of this good record for 1945, there was, however, good reason to believe, on the basis of the available data, that poor judgment and disregard of indications and contraindications were largely responsible for two of the eight deaths. In at least two others, the indications for abdominal delivery were highly questionable. Regarding the conditions for which cesarean section was done, the toxemias remain the most serious—three deaths in 73 during 1945. There were also two fatalities among the 164 operations for placenta previa and premature separation of the placenta. No deaths occurred in 166 elective sections performed because of previous cesarean, and none in the 384 done for cephalopelvic disproportion. Only a few details were secured regarding the fetal deaths. Of the 78 infants lost, 28 (35.8 per cent) are known to have been stillborn, and 25 (32 per cent) were neonatal deaths. At least 13, or 16.6 per cent, were premature infants. Three were maldeveloped, and five deaths were attributed to erythroblastosis. This analysis of cesarean sections from Detroit led to some interesting conclusions, comparisons with other communities, and other data as follows: A rise in hospital confinements during the twenty years to more than 94 per cent of the deliveries in 1945 was accompanied by a reduction in the general maternal mortality to 1.6 per 1,000 live births. At the same time, there was an increase in cesarean sections from 154 in 1925 to 1,000 in 1945, a percentage of 2.7, or one in 37 births. This high incidence is in accord with the average (2.84 per cent) obtained from the recent studies in various states and cities. The Detroit cesarean section mortality rate of 0.8 per cent compared very favorably with that of these other communities. In Detroit's largest and, generally speaking, better organized obstetric services, there were 75 per cent of the city's deliveries with a substantially lower over-all mortality. In these hospitals there was also a definitely higher incidence of cesarean section, but again a very low death rate (0.48 per cent). In view of the markedly increased incidence of cesarean sections on the one hand and the greatly decreased mortality on the other, it is well to ask if too many are now being done or if too few were done before. There is evidence that, in 1945, many sections were done for scant reason, to say the least. Apparently there is widespread disregard of the fact that, though the death rate is low, surgically speaking, it represents a high immediate obstetric risk, as well as a definite hazard for future pregnancies. On the other side of the question, it is noteworthy that in 1945 at least 20 of the 58 maternal deaths were considered to have been preventable, a number of them by timely cesarean section. Both sides of the question, then, seem to involve a proper regard for established indications and contraindications. Specifically pointing the way to further improvement, as mentioned before, is the fact that, in at least four of the eight cesarean deaths in 1945, the fatal outcome was in considerable part due to faulty judgment or management. The fetal mortality rate of 7.8 per cent in the 1945 cesarean sections, though definitely better than in previous years, is still twice the over-all death rate for infants during the first year of life. The fact that 36 per cent were stillborn again emphasizes the fact that cesarean section does not necessarily offer the best chances for a living child. Hence, there is no justification for undue extension of the use of cesarean section for purely fetal indications.