Birth Story

The days may be numbered for the quatrefoil building at 333 E. Superior in Chicago, the old Prentice Women's Hospital, where both my children were born.

Northwestern Memorial Hospital, which opened a shiny new Prentice in 2007, plans to tear down the old building to put up a new research center. Preservationists are gearing up for a fight to preserve Bertrand Goldberg's 1975 design, which echoed some elements of his hugely successful Marina City downtown residential development, finished in 1964.

Hospital buildings don't have long lives; indeed, they are often obsolescent soon after they are built.

That was certainly true of NMH's Gothic-style Wesley Hospital, so impressive it was subtitled the "cathedral of healing." Wesley opened on Dec. 6, 1941, literally on the eve of U.S. involvement in World War II, which changed everything, as wars so often do.

The new Prentice now stands at 250 E. Superior, on precisely the spot Wesley once occupied on the NMH campus.

NMH's first women's hospital shared space at 333 E. Superior with the Stone Institute of Psychiatry, which stayed after labor and delivery et al. moved from the poured-cement structure into the new Prentice. The psychiatry department will move out in September, and the building will then be torn down, according to Northwestern University spokesman Al Cubbage.

The university explored and rejected the idea of recycling the existing building for another use, Cubbage says.

"At this point, the university’s plans are to take that building down and use that area for additional research facilities that would be constructed in the future,” Cubbage told the Chicago Tribune's Blair Kamin.

The "old" Prentice has many detractors who believe the building is ugly. Even when my younger daughter was born there 13 years ago, mothers (and doctors) were complaining the facility was outdated.

Prentice was built to last 30 to 40 years; however, the services it offered were so popular it barely made it past 20 years. Planned for 5,000 annual births, it was handling more than 10,000 a year at the end.

And, things changed. The obstetric anesthesiology department, which by 2007 was hugely important, was not on the drawing board when the facility was built.

I loved the old Prentice — its pie-shaped rooms, the intimacy of its floors, the stunning views of Lake Michigan and the city.

Preservationists are understandably upset about the building's impending demise, and are hoping to succeed with an end-run around NMH. Goldberg historically is an important Chicago architect, but his work isn't old enough to have gained the gravitas it deserves, or the protection it needs in terms of landmark status on a local or national basis — and that includes Marina City.

The local alderman, Brendan Reilly, has secured a 60-day delay, which might give friends of "old" Prentice a chance to organize.

Personally, I would bet on the hospital getting its way on the "old" Prentice. As Mark Twain said, they aren't making any more land these days.

Northwestern University/NMH, a major medical school/hospital/research complex, is likely to prevail in doing what it has done for decades on its lakefront campus — raze an old hospital building to create a new facility that reflects the latest knowledge, technology and priorities.

I'll be very sad to see the old girl go, if indeed that is how this story ends.

Here's a bit of irony: “Bertrand Goldberg: Architecture of Invention," opens September 10 at the Art Institute of Chicago.

Photo by Delia O'Hara

The Leapfrog Group, a 10-year-old hospital monitoring group, has found that doctors and hospitals are commonly scheduling women for elective deliveries before 39 weeks of gestation, even though studies have established a bright arrow that shows that babies are at risk of death or serious health problems if they are born before then.

A survey of 773 hospitals released this week shows that these institutions performed more than 57,000 inductions and Cesarean sections before 39 weeks just in the last year. The hospitals displayed a wide range of rates for early elective deliveries, from less than 5% to more than 40%.

"Leapfrog’s release of 2010 data is the first real evidence that the practice of scheduling newborn deliveries before 39 weeks without a medical reason is common and varied among hospitals even in the same state or community," the report stated.

The brain and lungs aren't fully developed until the very last weeks of pregnancy, said Alan R. Fleischman MD, senior vice president and medical director of the March of Dimes, a group that works to prevent birth defects, and is working with Leapfrog to cut the numbers of early births.

“Women need to protect themselves by refusing to schedule their deliveries before 39 weeks without a sound medical reason, and by knowing the facts about the hospitals they plan to deliver in,” said Leapfrog CEO Leah Binder.

Some hospitals, notably Hospital Corporation of America, have programs in place to encourage doctors to refrain from scheduling Cesarean sections and elective inductions for nonmedical reason, Leapfrog officials said.

Well, this is discouraging. Two recent studies indicate that, after a decade-long, nationwide campaign to make hospitals safer for patients, essentially no progress has been made.

A patient checking into a hospital today appears to face at least a one-in-four chance of coming to some degree of harm there.

A study published this week in the New England Journal of Medicine looked at the records of 2,341 patients discharged from 10 randomly selected hospitals in North Carolina, which was chosen because of that state's "high level of engagement in efforts to improve patient safety."

The study took place between January 2002 and December 2007. What it found was, in short, that "harm to patients resulting from medical care was common in North Carolina, and the rate of harm did not appear to decrease significantly during a 6-year period ending in December 2007, despite substantial national attention and allocation of resources to improve the safety of care," the report stated.

A total of 588 patients were injured — 25.1 percent of study subjects. Harm was caused by, in declining numbers, procedures, drugs, hospital-based infections, other therapies, tests, falls and other causes, the study found. Sixty-three percent of these injuries were deemed to have been preventable. Nine preventable errors resulted in death, and 13 in permanent damage.

In addition, a report from the U.S. Dept. of Health and Human Services released earlier this month documented the experiences of 780 randomly selected Medicare patients discharged from various hospitals in October of 2008.

About one in seven of these patients experienced "adverse events" — serious harm that comes to a patient as a result of medical care.

A second group of about the same size in the HHS study suffered "temporary harm," a transient injury like bedsores (here called "pressure ulcers") for example, or hypoglycemia. Twenty-seven percent of temporary harm events were caused by drugs.

Twenty-eight percent of patients who experienced more serious "adverse events" also suffered some temporary harm during the same hospital stay.

About 44 percent of all these events — adverse events and temporary harm — in the HHS study were deemed preventable — the result of errors, substandard care, or insufficient monitoring.

In 1999, the independent, not-for-profit Institute of Medicine published a report on hospital safety, "To Err is Human," which caused a sensation and produced a massive effort to improve protocols at hospitals across the country. The goal was to decrease errors by 50 percent over a five-year period.

"To Err is Human" asserted that as many as 98,000 patients die in hospitals each year because of medical error.

Commenting on the two discouraging new studies, the authors of the NEJM report on patient safety in North Carolina write, "All the findings about extent of harm should increase our commitment to prevent it."

The Black Plague, which wiped out perhaps a third of the population of Europe, demanded an explanation, and the medical establishment of the time responded as well as it could.

The most popular conjectures about the pestilence were variations on the miasmic theory of disease, an idea that went back at least to the ancient Greeks — that disease was essentially bad air. ("Miasma" was the Greek word for pollution.)

Hundreds of treatises about the epidemic survive, many of them written in the mid-14th century, when the plague was at its height. One written by members of the faculty at the medical school at the University of Paris, in response to a request from their king, Philip VI, mixed humoral and miasmic theories: The planets had aligned in such a way as to poison the air.

Another theory held that a series of earthquakes in Europe had released corrupt air from the middle of the earth. A third had the plague wafting in on noxious winds from the equator.

The cause of the plague was actually Yersinia pestis, a murderous bacterium spread by the bite of rodent fleas in the primary, "bubonic" phase, characterized by swollen lymph nodes and other symptoms. The plague can also be spread by infected droplets exhaled by its victims in a less common but deadlier "pneumonic" phase.

The plague was a catastrophe for Europe, but it did usher in reforms. It pushed the medical community toward a more professional approach to its practice, an increased emphasis on public health and the establishment of hospitals that would treat the sick, rather than merely warehouse them away from the healthy population, according to The Black Death: Natural and Human Disaster in Medieval Europe, by Robert S. Gottfried.

Frustration with the utter failure of the medical establishment to discern the pandemic's cause, stop its spread or treat it effectively helped create an environment from which the scientific method emerged.

"There is not a corner in Britain where this formidable disease has not made many mourners,”  John Mackintosh, an Edinburgh, Scotland "man-midwife" wrote of puerperal or "childbed" fever in the 1820s.

This bacterial disease of the upper genital tract typically began within the first three days after childbirth with abdominal pain, fever and respiratory difficulty, and very often ended with the new mother's death.

Medical writers had been remarking on childbed fever at least since Hippocrates, but in the early modern era, it began to attract attention for a number of reasons. For one, it began to appear in epidemics, with very high mortality rates. For another, accounts of outbreaks were written about and published. And at least some of the new, scientific man-midwives themselves were spreading the disease by going straight from autopsies to the birth chambers of homes and especially of hospitals, without cleaning up at all in between.

There were terrible epidemics of puerperal fever in the German city of Leipzig  in 1652 and 1665, at the Hôtel Dieu in Paris, France, in 1745 and 1746, and at the British Lying-In Hospital in London, England, in 1760. It is possible that these were the first ever epidemics of childbed fever.

The Baby Friendly Hospital Initiative, an international program, has created a list of things birth facilities in the United States can do to optimize the chances that mothers will choose to breast-feed their babies.

Here are "The Ten Steps To Successful Breast-feeding," from BFHI USA:

1. Have a written breast-feeding policy that is routinely communicated to all health-care staff.

2. Train all health-care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breast-feeding.

4. Help mothers initiate breast-feeding within one hour of birth.

5. Show mothers how to breast-feed and how to maintain lactation, even if they are separated from their infants.

6. Give newborn infants no food or drink other than breast milk, unless medically indicated.

7. Practice “rooming in” — allow mothers and infants to remain together 24 hours a day.

8. Encourage breast-feeding on demand.

9. Give no pacifiers or artificial nipples to breast-feeding infants.

10. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic.

The BFHI is underwritten by the World Health Organization and the United Nations Children's Fund (UNICEF).

Fewer than 4 percent of births in the United States occur at facilities that are considered "baby friendly," according to the latest Breast-feeding Report Card, issued this week by the Centers for Disease Control and Prevention.

That's interesting, in light of the fact that birth is the one point at which the nation's breast-feeding practices actually meet the goals set by Healthy People 2010.

And, it raises some questions: Are American women determined to breast-feed even in the teeth of an unsupportive environment? Or does strong support from the hospital not matter much in their decision? Do problems caused by settings where breast-feeding is not actively promoted only show up later?

Or are environments that come after the birth facility, including families, other medical advisers, child-care centers and workplaces, even less sympathetic to breast-feeding?

Only two hospitals in Illinois, my home state, are among the 99 "baby friendly" facilities recognized by the Baby-Friendly Hospital Initiative as providing "an optimal level of care for infant feeding." These are Pekin Hospital in Pekin and St. John's Hospital in Springfield.

Thirty of the hospitals on the list are in California.

"Although the hospital is not and should not be the only place a mother receives support for breastfeeding, hospitals provide a unique and critical link between the breastfeeding support provided prior to and after delivery," the BFHI's website states.

The BFHI is a joint global effort of the World Health Organization and the United Nations Children's Fund (UNICEF).

Pregnant women were more likely to die in last year’s outbreak of the so-called swine flu than other people were, the Journal of the American Medical Association reports in the issue published today.

Pregnant women represent only about 1 percent of the population of the United States, yet they accounted for 5 percent of deaths from the H1N1 flu between April and August of 2009, according to an analysis of data from the Centers of Disease Control in Atlanta, Georgia, by Alicia M. Siston, Ph.D., of the CDC, and colleagues.

Taking antiviral drugs soon after they became ill greatly helped pregnant women who were hospitalized.

Of 788 pregnant women who were reported to the CDC to have become ill with H1N1 virus between April and August, 30 died. That was 5 percent of all swine flu deaths for the period. Of 509 women who were hospitalized, 115 were so sick they were admitted to intensive care units.

If they had waited four days after the onset of symptoms to go to a doctor, pregnant women were six times more likely to wind up in an ICU than if they sought treatment after only two days.

Pregnant women should be vaccinated against H1N1, and should be treated quickly with antiviral drugs if they do become sick, the authors recommended.

Two-thirds of the women who died in the final tally for the year were in their final trimester of pregnancy. “Changes in the immune, cardiac, and respiratory systems are likely reasons that pregnant women are at increased risk for severe illness with influenza,” the authors wrote.

At the ACOG meeting last May, Dr. Robert Wachter talked about a case in a teaching hospital in which two women with similar names -- Jane Morrison and Joan Morris are the pseudonyms assigned to them -- were confused with one another, resulting in one of them receiving an invasive procedure intended for the other one. This case did not involve a birth story, but every medical specialty can take lessons away from it.

This case, which Dr. Wachter and colleagues published as "The Wrong Patient," in June, 2002, in the Annals of Internal Medicine, demonstrates how easily a series of oversights can cascade into a shocking medical error. (It could have been worse. The procedure was a cardiac electrophysiology study, not, say, a leg amputation.)

Oops

In fact, the team that analyzed the mishap identified 17 junctures at which the process could have been stopped but instead moved forward. No single mistake would have been enough to keep this juggernaut moving. Human error fed into institutional weaknesses, including "frighteningly poor communication," a lack of standardized protocols and a culture that had become sufficiently dysfunctional that more than one person thought, incredibly, Gee, this doesn't seem right, but I'm going to do it anyway.

"Human performance can be improved but not perfected," the team concluded. Protocols must be in place to head off the inevitable errors before they converge into tragedy.

As the first woman doctor in the United States, Elizabeth Blackwell had the dubious honor of showing the way for women to qualify for and enter a profession in which, at the time, they were pointedly unwelcome.

Blackwell endured repeated rejections on her way into medical school, where she was shunned by the male students and shut out of clinical opportunities by the teachers. After she finished medical school, when no one would hire her, she founded her own hospital and made her own opportunities.

Elizabeth Blackwell

Blackwell was born in England; her father was a wealthy Quaker and sugar refiner whose business eventually fell on hard times. The large family moved to the United States when Elizabeth was 11 and settled in Cincinnati, Ohio.

Blackwell''s father died when she was a teenager and the family opened a small private school, where Elizabeth began teaching.

When she decided she wanted to be a doctor, she was turned away from 29 medical schools before being accepted by the Geneva Medical School in Geneva, N.Y. In spite of the hostility she encountered there, she graduated at the top of her class in 1849, with plans to become a surgeon.

Blackwell traveled to Paris to take a course in midwifery, where she contracted an infection that cost her the sight in one eye. That put an end to her hopes of becoming a surgeon. Back in the United States, Blackwell found she couldn't get work in a hospital, so she went into private practice.

In 1853, along with her sister Emily, and Marie Zakrzewska, two other early female doctors, Blackwell founded the New York Infirmary for Women and Children, now New York Downtown Hospital. During the Civil War, Blackwell trained nurses to treat soldiers injured on the battlefield.

The Blackwell sisters also founded the Women's Medical College of New York in 1869, but within a few years, Elizabeth went back to England. She was a professor of gynecology at the London School of Medicine for Women for the rest of her working life. Blackwell died at the age of 89, in 1910.