Analysis Reveals Perinatal Death Rates : Care for Newborns Varies, Studies of Hospitals Show

California’s hospitals vary widely in their ability to provide quality medical care to newborn babies, according to a sophisticated hospital-by-hospital analysis of perinatal death-rate data by researchers at the University of California, Santa Barbara.

In Southern California, 17 hospitals, including County-USC Medical Center and Martin Luther King Jr./Drew Medical Center in Los Angeles, have significantly higher-than-expected adjusted death rates when compared with the statewide average.

Ten others, including Cedars-Sinai Medical Center in Los Angeles, Loma Linda University Medical Center in Loma Linda and Memorial Medical Center in Long Beach, have significantly lower-than-expected adjusted death rates.

The UC Santa Barbara “Maternal and Child Health Data Base” is considered by many health care experts to be one of the most valid statistical measures of the effectiveness of medical care ever developed. It has been published annually since 1980 and distributed to hospitals, county health departments and major public libraries throughout the state, although it has essentially escaped public notice.

“This is not a one-dimensional index that can be used to rank hospitals,” said Ronald L. Williams, the health policy researcher at UC Santa Barbara’s Community and Organization Research Institute who devised the measure as a graduate student. “But for the most part, lower-than-average adjusted death rates equal better-than-average care.”

Williams and other experts believe that such data, properly interpreted, may be useful to parents in choosing a hospital to deliver their babies and to physicians and hospitals in improving the quality of care.

Differences between hospitals are most likely to be significant for mothers who are at high risk of delivering a sick or premature baby because these are the newborns who may require the greatest medical care.

But physicians caution that the perinatal death rate--deaths around the time of birth and during the first 28 days of life--primarily reflects hospital performance, not other important factors that influence infant survival and well-being, such as prenatal care and inherited birth defects.

“On balance, it is very useful information,” said Dr. Samuel Sapin, the associate medical director of clinical services for Kaiser Foundation Hospitals in Southern California. “It can serve as a flag for hospitals to make sure they are not having problems.”

According to Sapin, the data base helped Kaiser pinpoint problem areas with perinatal care at its Panorama City hospital in the early 1980s, such as delays in some cases in performing Caesarean sections and in putting babies with breathing difficulties on ventilators. The data also spurred Kaiser’s nine hospitals, which deliver more than 25,000 babies each year, to develop cooperative arrangements, including the transfer of high-risk mothers or babies to specialized facilities.

Methodology Rated ‘Valid’

Kaiser considers Williams’ methodology “sufficiently valid” to adopt it as part of the health maintenance organization’s computerized early warning system to monitor the quality of perinatal care, Sapin said.

Among the study’s most striking findings are the high perinatal mortality rates at County-USC Medical Center and Martin Luther King Jr./Drew Medical Center. The two giant county hospitals, which account for more than 15% of all the births in Los Angeles County each year, both have “standardized” death rates of about 20% higher than their predicted values, which are calculated on the basis of the statewide average. The death rate at the other large county hospital, Harbor-UCLA Medical Center, is equal to its predicted value.

In interviews, physicians at both County-USC and Martin Luther King expressed strong criticisms of the study.

“Given the fact that our nurseries are full, that we have patients delivering in the halls, that we don’t have enough monitors, given all those problems we do remarkably well,” said Dr. Richard Paul, chief of obstetrics at County-USC. “I don’t believe (the Williams study) is a fair appraisal because he can’t factor in for our limited resources and our size.”

Dr. Ezra Davidson, the chief of obstetrics at Martin Luther King Jr./Drew Medical Center, termed the study “warped” because the hospital comparisons were made “without factoring in whether the (mother) received prenatal care.” He added, “dollars to improve the availability and accessibility of good prenatal care” are just as important in saving the lives of newborns as improvements in the quality of hospital care.

Williams Responds

In response to these criticisms, Williams maintained that the effectiveness of perinatal medical care may be “less than average” at these hospitals. “It is unlikely that it is just a lack of prenatal care that is responsible,” he said. “Year after year after year, the adjusted perinatal mortality rate at these hospitals is higher than we would expect.”

The 1987 UC Santa Barbara study is based on a more than 98% complete set of birth and death certificate data for 2.15 million babies born in California between 1980 and 1984 at about 340 hospitals.

Such large numbers are necessary to analyze death rates because the actual number of perinatal deaths at any one hospital is very low. Over the five-year period, there were 24,229 perinatal deaths throughout the state, an average of 11.3 deaths for every thousand births.

The 764-page study, prepared under a contract from the state Department of Health Services by Williams and colleagues Frank P. Rust and Kam J. Rust, is designed to compare the mortality rate for individual hospitals to the statewide average. But it substantially improves upon the raw mortality data by adjusting for factors which influence the perinatal death rate that are beyond the control of the hospitals.

Birth Weight Factor

By far the most important of these factors is the infant’s birth weight, which is recorded on the birth certificate 99.8% of the time, according to the report. For example, despite good medical care, very low birth weight babies--those weighing less than 3.3 pounds--are about 130 times more likely to die around the time of birth than babies of normal weight. Such babies account for about 44% of all perinatal deaths in the state.

The three other factors are the sex and race of the baby and multiple births, such as twins. Together, the four factors account for more than 80% of the variation in the raw mortality rates, Williams said.

Finally, the analysis corrects for the number of babies delivered at each institution. This is necessary because in some cases high or low death rates may have occurred due to chance alone.

Critics contend that this analysis still falls short, because it does not include other potential factors that may significantly influence mortality rates, such as variations in prenatal care, socioeconomic status and the number of babies with fatal birth defects.

But including such factors has limited value, according to Williams. In part these factors are accounted for by correcting for birth weight variations. In addition, they are more difficult to measure and less accurately recorded. “It is fortuitous that birth weight is not only the most important predictor (of perinatal mortality) but it is the most accurately measured,” he said.

Other Findings Summarized

The 1987 UC Santa Barbara study also found:

- Perinatal mortality has fallen in California each year since 1970. From 1980 to 1984, the raw perinatal mortality rate fell from 12.3 to 10.2 per thousand births. About 80% of this improvement resulted from better medical care for low birth weight babies and the rest from a decrease in the number of low birth weight babies.

- Throughout the state, hospitals that deliver fewer than 1,000 babies a year have “standardized” death rates that average more than 7% above what would be expected. By comparison, hospitals which deliver more than 2,000 babies a year have “standardized” death rates that average 3.3% less than predicted values.

- Federal hospitals, county hospitals and for-profit hospitals all have perinatal death rates that average 7% or more above predicted levels. Death rates for home births average 9% above predicted levels. By comparison, University of California hospitals and private nonprofit hospitals have “standardized” death rates that average about 5% less than expected.

- “Standardized” perinatal mortality in Los Angeles, Riverside, Santa Barbara, San Diego and Ventura counties is significantly higher than the predicted levels. But “standardized” mortality is significantly lower than expected in such Northern California counties as Alameda, Sacramento and San Francisco. The explanation for these regional differences is not clear.

Specialized Nurseries

- Eight of the 10 Southern California hospitals with low “standardized” perinatal death rates have specialized “Level II” or “Level III” intensive-care nurseries for critically ill newborns. But five of the 36 hospitals with high “standardized” deaths rates also have such special nurseries--County-USC Medical Center, Kaiser Hospital, Panorama City, Martin Luther King Jr./Drew Medical Center, Presbyterian Intercommunity Hospital in Whittier and St. Francis Medical Center of Lynwood.

Overall, the state’s 60 hospitals with Level II or Level III nurseries have “standardized” perinatal mortality rates that are about 5% lower than predicted. Those with basic nurseries average mortality rates about 4% higher than predicted.

Another noteworthy finding is the “standardized” mortality statistics for Dr. Milos Klvana. Last month, Los Angeles Municipal Judge James F. Nelson ordered the Valencia physician and his midwife assistant to stand trial on second-degree murder charges based on “a strong suspicion” that their “gross negligence” had contributed to some of the deaths.

The six murder charges against Klvana stem from the deaths of babies he delivered at their mother’s homes or in his medical offices between December, 1982, and September, 1986. In 1984, the report says that Klvana’s personal perinatal mortality rate was 13.5% higher than his expected value, a significant difference.

Blythe Hospital Highest

Palo Verde Hospital in Blythe had the highest “standardized” perinatal mortality rate among all California hospitals, more than 40% above its predicted value, according to the report. “We have one of the highest percentages in the state of mothers who deliver with no prenatal care, including many women from Mexico,” said Dr. John Coddington, a general practitioner on the staff of the hospital.

Downey Community Hospital also had a “standardized” perinatal mortality rate that was more than 30% above its predicted value. A hospital spokeswoman attributed the statistics to a high number of babies who were born with fatal birth defects. After reviewing their data at the request of The Times, the physicians “felt very comfortable that the overall quality of care remained very high,” said Kathy Leaf, the hospital’s risk manager.

Sonora Community Hospital in the Sierra foothills had the lowest “standardized” mortality rate among all California hospitals, more than 40% below its predicted value. In Southern California, Memorial Medical Center in Long Beach had the lowest “standardized” death rate, almost 25% below its predicted value.

Reasons Ascribed

Dr. Houchang D. Modanlou, the hospital’s director of neonatal-perinatal medicine, credited Memorial Medical Center’s low mortality rate to good organization and extensive educational programs for physicians and nurses. “This is the best data available and not just because we rank very low,” he said. “To our knowledge, Williams did a very good job.”

Another hospital with favorable mortality statistics is Cedars-Sinai Medical Center in Los Angeles. Many Cedars-Sinai patients are affluent whites who receive comprehensive prenatal care from private physicians. In contrast, the majority of county hospital patients are poor and Latino or black. They often receive inadequate prenatal care.

Dr. Jeffrey Pomerance, a Cedars-Sinai neonatalogist, was asked how he believes Cedars would have rated if it cared for patients similar to those at County-USC and Martin Luther King Jr. “I think we’d do a better job than the county does but worse than we do with our own patient pool,” Pomerance said. “I think we’re privileged, for example, to have more personnel per baby than (those hospitals) are funded for.”

Times staff writer Claire Spiegel contributed to this story.

PERINATAL DEATHS IN SOUTHERN CALIFORNIA These Southern California hospitals have statistically significant high or low perinatal mortality rates as compared with the statewide average, according to an analysis of birth and death certificate data by the Community and Organization Research Institute at UC Santa Barbara.

The analysis is based on a linkage of birth and death certificate records performed by the Office of State Registrar. The data covers all live births in the state between 1980 and 1984 and all perinatal deaths--those that occurred around the time of birth or during the first 28 days of life.

The UC Santa Barbara researchers used a computerized statistical analysis to “standardize” raw mortality data. The analysis was designed to account for factors beyond the control of a hospital or county that influence the perinatal mortality rate, such as the infant’s birth weight, sex and race and multiple births, twins for example.

A standardized death rate of 100 represents average performance. A value of more than 100 represents more deaths than expected, while a value of less than 100 represents fewer deaths than expected.

For example, a value of 110 means that, on the average, for every 100 deaths expected in a hospital, 110 deaths occurred, or 10% more than would be expected on the basis of the statewide average. Similarly, a value of 90 means that, on the average, for every 100 deaths expected in a hospital, 90 deaths occured, or 10% fewer than would be expected.

The UC Santa Barbara analysis does not allow death rates at individual hospitals with either high or low death rates to be compared directly to each other--but only to the statewide average. Thus, for example, differences between the 20 Los Angeles County hospitals with high death rates and the six hospitals with low death rates may not be statistically significant.

There is a less than 10% probability that a hospital would be listed as having a high or low perinatal mortality rate because of chance variations in their death rate.

Copies of the “1980-1984 Maternal and Child Health Data Base” are available from the Community and Organization Research Institute, 2201 North Hall, UC Santa Barbara, Santa Barbara, Calif. 93106. A descriptive narrative costs $20 and a statistical appendix, including the individual hospital statistics, costs $30.

Deaths/ Standardized No. of 1,000 Death Births Births Rate Statewide 2,146,165 11.3 100.0

LOS ANGELES COUNTY

Deaths/ No. of 1,000 Births Births High Mortality Rates Downey Community Hospital 3,752 12.0 Memorial Hospital of Glendale 3,969 10.8 Martin Luther King Hospital, Los Angeles* 27,829 18.9 Santa Teresita Hospital, Duarte 2,978 10.7 Mission Hospital, Huntington Park 4,985 9.4 Queen of Angels Medical Center, Los Angeles 9,790 12.2 Charter Community Hospital, Hawaiian Gardens 2,901 13.4 Medical Center of North Hollywood 1,638 13.4 E. Los Angeles Doctors Hospital 4,679 9.6 Los Angeles Community Hospital 2,285 11.4 Presbyterian Intercommunity Hospital, Whittier* 9,892 10.9 Santa Marta Hospital, Los Angeles 4,745 10.1 County-USC Medical Center, Los Angeles* 75,737 17.2 AMI San Dimas Community Hospital 4,462 11.9 Dominguez Medical Center, Long Beach 5,572 16.5 Kaiser Hospital, Panorama City* 14,089 13.3 St. Francis Hospital of Lynwood* 6,741 21.2 Monterey Park Hospital 5,688 9.7 Lincoln Hospital Medical Center, Los Angeles 2,552 8.6 St. John’s Hospital, Santa Monica 6,614 10.1 Dr. Milos Klvana, Valencia 138 29.0 Low Mortality Rates Memorial Hospital Medical Center, Long Beach* 23,430 19.8 White Memorial Medical Center, Los Angeles* 11,332 11.6 Beverly Hospital, Montebello 8,128 6.9 Cedars-Sinai Medical Center, Los Angeles* 25,267 10.1 Valley Presbyterian Hospital, Van Nuys* 10,694 9.3 Glendale Adventist Medical Center* 10,408 9.9

Standardized Death Rate High Mortality Rates Downey Community Hospital 134.9 Memorial Hospital of Glendale 125.7 Martin Luther King Hospital, Los Angeles* 124.4 Santa Teresita Hospital, Duarte 123.5 Mission Hospital, Huntington Park 123.3 Queen of Angels Medical Center, Los Angeles 122.3 Charter Community Hospital, Hawaiian Gardens 121.1 Medical Center of North Hollywood 120.8 E. Los Angeles Doctors Hospital 119.4 Los Angeles Community Hospital 118.8 Presbyterian Intercommunity Hospital, Whittier* 118.6 Santa Marta Hospital, Los Angeles 118.4 County-USC Medical Center, Los Angeles* 118.2 AMI San Dimas Community Hospital 117.9 Dominguez Medical Center, Long Beach 117.1 Kaiser Hospital, Panorama City* 117.0 St. Francis Hospital of Lynwood* 117.0 Monterey Park Hospital 116.6 Lincoln Hospital Medical Center, Los Angeles 115.6 St. John’s Hospital, Santa Monica 114.8 Dr. Milos Klvana, Valencia 113.5 Low Mortality Rates Memorial Hospital Medical Center, Long Beach* 76.4 White Memorial Medical Center, Los Angeles* 80.6 Beverly Hospital, Montebello 81.6 Cedars-Sinai Medical Center, Los Angeles* 83.5 Valley Presbyterian Hospital, Van Nuys* 86.0 Glendale Adventist Medical Center* 87.1

ORANGE COUNTY

Deaths/ Standardized No. of 1,000 Death Births Births Rate High Mortality Rates Chapman General Hospital, Orange 4,138 8.7 124.9 St. Jude Hospital, Fullerton 11,900 8.8 112.1 Low Mortality Rates Martin Luther Hospital, Anaheim* 12,563 9.9 87.9

RIVERSIDE COUNTY

Deaths/ Standardized No. of 1,000 Death Births Births Rate High Mortality Rates Palo Verde Hospital, Blythe 1,960 17.9 143.1 Corona Community Hospital 3,240 10.5 120.7 Dixon Medical Corporation, Corona 140 14.3 105.7

SAN BERNARDINO COUNTY

Deaths/ Standardized No. of 1,000 Death Births Births Rate High Mortality Rates Naval Regional Medical Center, Palms 2,254 10.2 120.2 Redlands Community Hospital 6,764 9.2 117.6 Air Force Hospital, George 2,197 11.4 116.8 Low Mortality Rates Kaiser Hospital, Fontana* 18,355 9.0 83.5 Loma Linda University Medical Center* 8,015 36.1 88.1

SAN DIEGO COUNTY

Deaths/ Standardized No. of 1,000 Death Births Births Rate High Mortality Rates Fallbrook Hospital 3,025 14.2 125.6 Paradise Valley Hospital, National City 4,323 18.3 118.9 Naval Regional Medical Center, San Diego 20,934 14.1 117.9 Naval Regional Medical Center, Oceanside 9,416 11.5 116.9

VENTURA COUNTY

Deaths/ No. of 1,000 Births Births High Mortality Rates Simi Valley Adventist Hospital, Simi Valley 2,977 10.4 Santa Paula Memorial Hospital, Santa Paula 1,980 9.6 Anacapa Adventist Hospital, Port Hueneme 3,305 10.3 Ojai Valley Community Hospital, Ojai 1,615 10.5 Pleasant Valley Hospital, Camarillo 3,174 4.7

Standardized Death Rate High Mortality Rates Simi Valley Adventist Hospital, Simi Valley 123.6 Santa Paula Memorial Hospital, Santa Paula 123.3 Anacapa Adventist Hospital, Port Hueneme 122.7 Ojai Valley Community Hospital, Ojai 121.0 Pleasant Valley Hospital, Camarillo 82.0

Births and deaths are listed under the hospital where the baby was born, even if the baby was subsequently transferred to another facility.

* Hospitals with Level II (intermediate care) or Level III (tertiary) neonatal nursery for high-risk babies.

DEATH RATES BY HOSPITAL TYPE

Perinatal death rates between 1980 and 1984 by hospital ownership.

Deaths Per Standardized Ownership Births 1,000 Births Death Rate Birth Clinic 4,927 3.2 93.4 UC Hospitals 57,237 21.5 94.5 Nonprofit Hospitals 992,354 10.6 94.9 Kaiser Found. Hosp. 248,407 10.5 98.8 Doctor’s Office 716 2.8 99.0 District Hospitals 173,594 9.2 104.3 County Hospitals 268,116 15.6 107.0 For-Profit Hospitals 293,671 9.5 108.2 Federal Hospitals 78,564 11.0 109.1 Home Births* 8,871 12.1 109.1 Private Unlicensed 1,943 11.8 109.2

* Home birth statistics are for 1983 and 1984 only.

Perinatal death rates between 1980 and 1984 by hospital size.

Annual Number Deaths Per Standardized of Deliveries Births 1,000 Births Death Rate 1-250 32,041 8.2 106.9 251-500 93,222 9.1 110.9 501-1,000 347,815 9.3 108.3 1,001-1,500 329,095 10.6 100.3 1,501-2,000 313,418 10.9 99.4 More than 2,000 1,001,894 12.5 96.7

BIRTHS AND PERINATAL DEATHS IN SELECTED COUNTIES

Births Deaths Per Standardized Births 1,000 Births Death Rate STATEWIDE 2,146,165 11.3 100.0

Northern California

Deaths Per Standardized Births 1,000 Births Death Rate Sacramento 76,700 10.8 83.7 Alameda 99,257 11.2 88.8 San Francisco 66,885 13.5 89.2 Santa Clara 121,671 10.5 90.3 San Mateo 27,045 6.8 100.1

Southern California

Deaths Per Standardized Births 1,000 Births Death Rate San Bernardino 92,013 12.0 95.0 Orange 167,877 9.7 98.2 Ventura 42,463 10.8 103.4 San Diego 172,193 11.6 103.6 Los Angeles 717,816 12.6 104.4 Santa Barbara 24,906 8.9 105.7 Riverside 56,728 11.5 106.1

1980-1984 figures