The Special Committee on Infant Mortality of the Medical Society of the County of New York was activated in 1938, almost four decades ago - with Dr. Locke L. Mackenzie, chairman - as an adjunct to the Maternal Analysis Committee.1 The latter comprised prominent obstetricians and administrators of hospital centers with lying-in services. The members met regularly to study causes responsible for fatalities in high-risk pregnancies. Investigations were carried out under the direction of Dr. Alfred M. Hellman. Guidelines were established for the management of complicated pregnancies, including labor, delivery, and the immediate aftercare of the mother. A gratifying progressive reduction soon took place in avoidable maternal deaths, until today these deaths have been virtually eliminated.
As the study by the Maternal Analysis Committee continued, questions arose concerning the prevalence of unusually high fetal and newborn infant death rates. Vague, often nondescript primary and secondary causes of death were thoughtlessly entered on stillbirth and newborn infant death certificates. Autopsy verifications of the causes of death were either absent or grossly incomplete. Substantiating microscopic studies were seldom available.
The recommendation was therefore made to organize and activate the Special Committee on Infant Mortality to analyze all stillbirths and newborn infant deaths for determination of the many underlying causes of death. Questionnaires were sent to the hospitals of birth and, if transfers of newborn infants had taken place, to hospitals of death. The replies were sorted and studied in committee. The subsequent revised and updated fetal and newborn infant death certificates were analyzed in greater depth by the Bureau of Vital Records and by the Bureau of Health Statistics and Analysis of the New York City Department of Health.2
FUNCTIONS OF THE SPECIAL COMMITTEE
Postgraduate lectures, conferences, and symposiums. In 1949 the Special Committee on Infant Mortality, under the leadership of Dr. Carl Goldmark, Jr., launched a series of open postgraduate lectures and conferences on problems of maternal, fetal, and newborn infant care. The discussions focused on the influences of predisposing and contributory factors that accounted for inordinately high perinatal death rates - that is, the death rates of fetuses and newborn infants. Much later, symposiums were presented on closely related problems.37
As knowledge of the perinatal period advanced, the postgraduate presentations were broadened in content to encompass fetal and newborn infant growth and development, estimation of fetal and newborn infant rates of maturity, pathophysiology, perinatal pathology and pathology of the placenta, neuropathology, resuscitation of the newborn infant, the maintenance of acid-base equilibrium, problems of immunity and isoimmunization, the gamma globulins, hormone dysfunction, radiology of the fetus and newborn infant, transplacental transport, infections of the fetus and newborn infant, ultrasonography, genetic problems of homogenicity and heterogenicity, the hemoglobin molecular complex, inborn errors of metabolism, enzymology, pharmacology, and electrocardiography and electroencephalography. Therapeutic procedures and measures of preventive medicine were emphasized. The postgraduate presentations were delivered by experts in each area, either by individuals or in panel or symposium form. Each presentation was followed by a questionand-answer period.
Revision of fetal and newborn infant death certificates. During the closed meetings of the Special Committee, deliberations were held concerning the advisability of revising the fetal and newborn infant death certificates to give greater accountability regarding the circumstances of death and the course of labor and delivery and to provide confidential information that could not otherwise be obtained either conveniently or economically. In 1934 a few items were added to the bottom of the birth certificate concerning the mode of delivery, to aid a special study by the New York Academy of Medicine. In 1938 a confidential medical report was adopted by the Board of Health of the City of New York for fetal death and for birth certificates. In 1939 the confidential report on the causes of death was adopted experimentally in the Borough of Manhattan. This was extended to the entire City of Greater New York in 1947.2
RESUSCITATION OF THE NEWBORN INFANT
Development of techniques. At one committee conference, a query was raised: "How is a newborn infant in respiratory distress at birth successfully resuscitated?" - a query that at the time could not be easily answered. Research was then begun to resolve the problem. In 1953 the well-known Apgar score, which provided a qualitative appraisal of the newborn infant, came into wide use.8 Subsequent reports presented data on follow-up studies to indicate that the qualitative Apgar score proved to be a good index of performance in children in later life.9 It should be noted at this point that a quantitative biochemical rating on the condition of infants at birth was devised by Saling in 1972.10,11 Augmenting the value of the Apgar score, it is based on arterial blood pH samples from cord blood or fetal scalp vessels.
Published reports. Let us go back to 1956, when the Special Committee on Infant Mortality published an initial report on the medical and technical aspects of resuscitation of newborn infants with asphyxia on delivery.12 The procedures were developed by Drs. L. Stanley James and Virginia Apgar, in collaboration with the members of the Special Committee.
Following the report, the first edition of Resuscitation of the Newborn Infant appeared in 1960, edited by me, with contributions by active members of and consultants to the Special Committee on Infant Mortality. The publication received world-wide acceptance and was followed in 1966 by the second edition, which included the techniques of mouth-to-mouth breathing and closed-chest cardiac massage. A considerably updated third edition was published in 1973, emphasizing the special intensivecare infant nurseries in approved lying-in hospital centers.13 In all editions, the point was made that although the technical aspects of resuscitation are of paramount importance in clearing the airways and quickly establishing respirations, of even greater importance is the need to determine the causes leading to respiratory distress at birth, with prompt institution of indicated therapeutic measures to overcome the causes responsible for respiratory failure.
Audiovisual presentations of resuscitation of the newborn infant. In 1960 the first motion picture was produced to demonstrate resuscitation of the newborn infant.14 Dr. James directed the production of this first edition, as well as the second edition that was released in 1966. The latter film shows mouth-to-mouth breathing in rhythmic sequence with closed-chest cardiac massage. The running time for the films is about 30 minutes. Over 200 copies have been circulated throughout the world on a free-loan basis. They are now available on request from the educational film library of the American Medical Association.
Exhibits and awards. Many local, national, and international exhibits have been presented on resuscitation of the newborn infant. The films have been given four scientific awards and certificates of appreciation, national and international, for their presentations on resuscitation of the newborn infant.
OTHER PROGRAMS ON PERINATAL CARE AND POSTGRADUATE EDUCATION
Regionalization of perinatal care. The objective of regionalization is to solve the problems of continually mounting health costs and wasteful duplication of expensive hospital facilities and to assure the assignment of highly trained and skilled professional and paraprofessional personnel in most needy areas of concern. Another aim is the elective rotation of residents and fellows through the regionalized centers on a programmed basis.
Considered broadly, regionalization affects not only perinatal care but all specialties as well (e.g., kidney dialysis and transplant, heart transplant and pacemaker insertions, the more specialized diagnostic and therapeutic radiologic procedures, ultrasonography, and highly technical medical, pathologic, and biochemical analyses).
Tentative plans have been prepared during conferences by committees representing the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the American Medical Association, to implement the concepts of regionalization.15 Dr. James, chairman of the Committee on the Fetus and Newborn of the American Academy of Pediatrics, is nationally active in planning that calls for designation and certification of three levels of hospital centers with lying-in services, depending on available personnel expertise and facilities and equipment on each level.
Dr. Angelo Ferrara is surveying the United States and areas of Canada to determine where regionalization is now in operation and to compare legislation that has already been enacted in each state and province. Symposiums and other publications. The Special Committee on Infant Mortality has presented symposiums dealing with the placenta,3 genetic counseling,4 and sickle cell disease,5 which were sponsored by the Greater New York Chapter of the National Foundation-March of Dimes. A symposium on the physiopathology of the fetus and neonate was presented under the sponsorship of the Association for the Aid of Crippled Children.6 A symposium was also presented on "Comprehensive Health Care: Its Impact on Community Wellness and on Perinatal Survival,"7 sponsored by the New York County Medical Society.
In all, the Special Committee on Infant Mortality, since its activation in 1938, has presented and published over 50 lectures and conferences dealing with the perinatal period, in addition to symposiums, exhibits, and motion pictures.
1. Abramson, H. History of the Special Committee on Infant Mortality: A blueprint of planned programs for postgraduate medical education. New York Medicine 27 (1971). 272-280. 289-303.
2. Schwartz, M., Director, Bureau of Health Statistics and Analysis; Marcus, M., Registrar, Bureau of Vital Records.
3. Symposium on the Placenta, Its Form and Functions, with Particular Reference to Birth Defects and Fetal Deaths. Presented by the Special Committee on Infant Mortality of the Medical Society of the County of New York and sponsored by the Greater New York Chapter of the National Foundation-March of Dimes, Harold Abramson, Horace Hodes, and Kurt Benirschke, cochairmen. Birth Defects 1: 1 (1965).
4. Symposium on Genetic Counseling, with Particular Reference to Anticipatory Guidance and the Prevention of Birth Defects. Presented by the Special Committee on Infant Mortality of the Medical Society of the County of New York and sponsored by the Greater New York Chapter of the National Foundation-March of Dimes. Birth Defects 2: 1 (1970).
5. Symposium on Sickle Cell Disease: Diagnosis, Management, Education, and Research. Presented by the Special Committee on Infant Mortality of the Medical Society of the County of New York and cosponsored by the Greater New York Chapter of the National Foundation-March of Dimes and the Foundation for Research and Education in Sickle Cell Disease, New York, Harold Abramson, John F. Bertles, and Doris L. Wethers, cochairmen and editors. St. Louis. C. V. Mosby Company, 1973.
6. Symposium on the Functional Physiopathology of the Fetus and Neonate: Clinical Correlations. Presented by the Special Committee on Infant Mortality of the Medical Society of the County of New York and sponsored in part by the Association for the Aid of Crippled Children. New York. St. Louis: C. V. Mosby Company, 1971.
7. Symposium on Comprehensive Health Care: Its Impact on Community Wellness and on Perinatal Survival. Presented by the Special Committee on Infant Mortality of the Medical Society of the County of New York, Harold Abramson, chairman and editor. N. Y. State J. Med. 68 (1968), 2265.
8. Apgar, V. A proposal for a new method of evaluation of the newborn infant. Curr. Res. Anes. Anaiges. 32 (1953), 260.
9. Drage, J. S., et al. The Apgar Score as an index of infant morbidity. Dev. Med. Neurol. 8 (1965), 141.
10. Saling, E. Technical and theoretical problems in monitoring of human fetal heart. Int. J. Gynecol. Obstet. 10 (1972). 211.
11. Apgar, v., and James, S. L. The first sixty seconds of life. In Abramson, H. (ed.). Resuscitation of the Newborn Infant, and Related Emergency Procedures in the Perinatal Center Special Care Nursery, Third Edition. St. Louis: C. V. Mosby Company, 1973, ch. 10. Table 10-2.
12. Resuscitation of Newborn Infants, A Report by the Special Committee on Infant Mortality of the Medical Society of the County of New York. Obstet. Gynecol. 8 (1956), 336.
13. Abramson, H. (ed.). Resuscitation of the Newborn Infant, and Related Emergency Procedures in the Perinatal Center Special Care Nursery, Third Edition. St. Louis: C. V. Mosby Company. 1973.
14. Resuscitation of the Newborn. Motion-picture film planned by the Special Committee on Infant Mortality of the Medical Society of the County of New York, Carl Goldmark, Jr., chairman, Harold Abramson, secretary; medical direction by L. Stanley James, with Subcommittee of Virginia Apgar, Frank Moya. Edwin Gold, and Harold Abramson; sponsored by Smith Kline & French Laboratories, Philadelphia, and produced by Sturgis Grant Productions. New York. 1960.
15. Committee on Perinatal Health. Guidelines for Regional Perinatal Programs: Facilities. Services, Personnel. Sponsored by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecology, and the American Medical Association. Secretariat, the National Foundation-March of Dimes, White Plains, N.Y.