The District's Blue Ribbon Commission on Infant Mortality has received a report that paints a bleak picture of the quality of hospital care given newborn babies who died here in 1977 and the treatment given their mothers.
The study of files of hospitals thoughout the city, a copy of which was obtained by The Washington Post, shows what one outside expert characterized as "a general tenor of substandard care" for tiny premature infants who make up the bulk of the District's infant deaths.
The District has one of the highest rates of infant mortality in the country, with three times the national average of babies who weigh only a few pounds at birth.
In hospitals that follow the most advanced obstetrical techniques, many of these low-birth-weight babies can be saved. But the commission's report found that many of these practices are not being followed in District hospitals.
Although only 3 percent of the 171 babies who died in 1977 during their first 28 days were born outside the hospital, 14 percent -- an "astounding" number, according to the report -- were born inside hospitals but not in delivery rooms.
That suggests "a failure to follow the patient adequately while she's in labor," said Dr. Lennox Westney, chief of obstetrics at Howard University Hospital. By comparison, at Boston Hospital for Women, less than 0.5 percent of the births occur outside the delivery room.
The report states that large numbers of the babies who died were born large enough to be considered "salvageable," but were not given the necessary lab tests to diagnose their problems and properly plan their care.
According to the report, neither teen-age pregnancy nor malnutrition, often cited by city officials as causes for the high infant-mortality rate here, plays a significant role in causing the problem.
One Washington hospital official asked to comment on the study said yesterday the city's high rate of pre-maturity inflates the infant mortality rate here.
The group that conducted the study, a committee of the federally chartered doctor peer review group here, found major gaps in the medical records kept by the hospitals. It said that failure to record data in a patient record is "in itself a serious deficit as the medical record itself is instrumental in patient care."
Among mothers whose babies died in the District in 1977, general anesthesia was used 15 percent of the time, despite the fact that general anesthesia makes a delivery far riskier for a premature newborn than using local anesthesia.
By comparison, at Beth Israel Hospital in Boston, one of Harvard University's teaching hospitals, only 7.2 percent of women giving birth received general anesthesia in 1978.
What some observers called one of the report's most disturbing findings was that more than half the women who received general anesthesia did not have a tube inserted in their traecheas to make sure they would not vomit and choke, and to ensure that enough oxygen reached their lungs -- and their babies.
Dr. Gerard Ostheimer, assistant professor of anesthesia at Harvard Medical School and Director of Anesthesia Research at Boston Hospital for Women, said, "I consider it malpractice" not to use a tube in such cases. f
The study, which the city's Department of Human Resources has refused to release at least until Monday, is not the only new look at the District's decade-old infant mortality problem.
A draft report prepared at the federal Center for Disease Control in Atlanta suggests that 40 percent of the babies who died in the District in 1976 could have been saved, if certain procedures had been followed.
Dr. Godfrey Oakley, chief of the center's birth defects section, compared the city's 1976 infant mortality statistics with those of Grady Memorial Hospital, Atlanta's public facility, whose patients are 85 percent black and virtually all poor, which is close to the patient mix of District hospitals.
Oakley projected what the District's over-all survival rate would have been if it had matched Grady Memorial's record for different races and weight groups.
His conclusion: Rather than the second highest infant mortality rate in the country, the District would have been close to the national average for number of infant deaths.
The District's high infant mortality rate has been an open secret in the city for more than 10 years.
As the report prepared for the Blue Ribbon Commission points out, large numbers of mothers do not receive any prenatal care, and many of those who do only go to clinics or physicians late in their pregnancies, when the care will be of only minimal help.
Following the publication of several articles in The Washington Post in late 1977 and early 1978, then-Mayor-elect Marion Barry set up the commission and told it to prepare a plan for reducing the infant death rate.
The commission, appointed in February, has so far published a pamphlet urging women to seek proper prenatal care, and commissioned the just-completed, 23,000 study, the first detailed look at the causes of infant deaths here.
Asked to comment on the study yesterday, Albert P. Russo, director of the Department of Human Resources, which paid for the report, criticized the premature release of the document instead of commenting on its contents.
"I don't even know if Carl Wilson (the director of health planning for the city) has had a chance to read it yet," said Russo.He said he received the report Wednesday and Wilson received it a week ago Friday.
"It's most inappropriate for these findings and recommendations to hang out," said Russo, whose department is responsible for health care in the city.
The report recommends that:
"Minimum standards" for the care of high-risk pregnancies must be established in District hospitals that deliver babies.
Women who face a high risk of delivering unsuccessfully should be transferred to the hospitals that have the best standards of care.
A fully trained anesthesiologist should be available for all obstetrical patients, and "this would seem particularly urgent for high-risk patients."
Because the vast majority of mothers who receive prenatal care do so in private clinics and hospitals, rather than public facilities, programs designed to reduce infant mortality must be designed for both public and private facilities.
If the city's infant mortality problem is to be properly understood, the city's data collection must be refined. In particular, the city should follow the practice of other cities and stop counting as infant deaths the deaths of babies weighing less than 1.1 pounds, who virtually never survive even with the best of care.
Experts said, however, that weeding out those deaths from the statistics would only reduce the mortality rate by about 11 percent or by three deaths per 1,000 births. The rate is now 25.8 deaths per 1,000 births.
The commission also suggested that the outcome would have been better if more women with high-risk pregnancies were delivered by appointment at certain hospitals and if more distressed babies delivered unexpectedly in less well-equipped centers were transferred to other hospitals after their condition was stabilized.
Survival rates for babies with low birth weights vary dramatically from hospital to hospital, according to the study.
At D.C. General, for example, only 14 percent of the babies weighing 1.1 to 2.2 pounds survived, and only 25 percent of those in the 2.2 to 2.7 pound category lived.
At Columbia Hospital for Women, however, 53 percent of the smallest babies lived, while 66 percent in the next weight category survived.
The report shows George Washington University Medical Center had a 33 percent survival rate in the 1.1 to 2.2 pound weight group -- the city's second highest -- while Greater Southeast Community Hospital did not have a signal baby in that weight category that survived.
Hospital officials in the city generally responded to the report by criticizing the data collection and accuracy, rather than commenting on the situation.
Officials at Greater Southeast, for example, said they did not have 10 out of 10 infants in the low-weight category die in 1977, as stated in the report. The hospital would not say what its rate was, but said that conditions at the hospital have improved markedly since 1977.
Dr. Dennis O'Learly, medical director of George Washington University Hospital, said, "I'm a little disturbed by this report and the reason is that probably the most striking finding is that the rate of prematurity is three times the national average, and that is a staggering fact. And if one corrects the infant mortality rate for prematurity, it is not only as good as the national average, it's better."