Using Six Sigma and Lean Methodologies to

Improve OR Throughput
CATHARINE B. FAIRBANKS, RN, MSN/ED, CNOR

mplementing improvements that will result in timely patient flow through the perioperative experience is both a challenge and an opportunity for a hospital, a department, managers, and staff members. Various stakeholders often have a variety of opinions and perceptions of what is wrong and what is needed tofixa problem. The challenge of delivering quality, efficient, and cost-effective services affects all health care personnel, and improvements affect not only the financial but the operational performance of a department and, ultimately, the organization itself. With a focus on and adherence to a sound methodology that identifies a problem and implements lasting improvements, change can occur and strategic goals can be achieved. Six Sigma is a methodology that offers a way to define problems systematically, provides a means to measure and analyze influential factors, identifies improvements that can be implemented, ensures that changes are sustained through a control phase, and maintains the gains over time.
SIX SIGMA DEFINED

faction, and overall quality. Sigma (o) is a letter of the Greek alphabet that is used by statisticians to denote the standard deviation or variability of a process. In a process with Six Sigma capability, process variation is reduced to no more than 3.4 defects per million opportunities (DPMO). This can be thought of in two ways: a process is correct 99.9964% of the time, or 99.9964% of processes fall within six standard deviations of the mean.^ Striving for excellence is an underlying philosophy of Six Sigma. In a health care setting, and specifically in an OR throughput project, a more realistic goal may lie somewhere between Four Sigma and Five Sigma. A patient's on-time arrival to the OR at Four Sigma would translate to 24 cases out of 100 missing the on-time start each day and at Five Sigma would translate to one case out of 100 (ie, five cases each week) missing the on-time start. A patient's on-time arrival to the OR, for the purpose of this article, is defined as being on time exactly to the scheduled hour and minute (eg, 0900).

ABSTRACT
IMPROVING PATIENT FLOW in the perioperative environment is challenging, but it has positive implications for both staff members and for the facility. ONE FACILITY IN VERMONT improved patient throughput by incorporating Six Sigma and Lean methodologies for patients undergoing elective procedures. THE RESULTS OF THE PROJECT were significantly improved patient flow and increased teamwork and pride among perioperative staff members. AORN / 86 (July 2007) 73-82. AORN, Inc, 2007.

Six Sigma was developed in the 1986 by Motorola, Inc, Schaumburg, Illinois,' and has been used successfully to reduce defects, redundancy, and waste in operational processes. As a result of implementing a Six Sigma process, companies may realize improvements in quality, customer satisfaction, and operational and financial performance.- This business strategy also has been adopted by health care systems and organizations to develop efficient and effective processes that improve workflow, customer satis-

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ADDING A LEAN PROCESS team. Green Belts are trained to be problem The project teini at ii soLithvvestern Vermont solvers and receive the samo training as Black medical center found that adding an additional Belts, with the exception of the statistical Lean improvement process dramatically helped analysis component. Green Belt team members to improve certain subprocesses within the larger often are operational specialists from various throughput process. Lean initiatives focus on areas of the organization. eliminating waste or nonvalued activities in a process.' These initiati\'es are identified by memTHE SIX SIGMA TEAM bers of a designated team, facilitated by a team Tlu^ Sigma team for the Oii throughput initialeader. This team walks through every step of ma- tive consisted of a Black Belt who was a perioperjt)r processes, measuring time, identifying activiative clinical nurse leader, and four Green Belts: ties, and making rapid impro\ ements through the a financial specialist, elimination of wasteful activi an information systems ties. Using Lean initiatives, the specialist, team was able to an OR scheduling special eliminate redundancy, ist, and Six Sigma team members a perioperative RN from resolve former patient transport issues, and preadmission teaching. were chosen for the skills Team members were chosen replace telephone con:imunication with person-tofor the skills and knowledge and knowledge that they person communication at that they brought to the projthe site of patient care. ect. This included knowledge brought to the project. The point-of-care site was of hospital finances, data prothe intake area for patients unThis included knowledge gramming and retrieval, scheduling, and day-to-day dergoing elective surgical prooperations. The contact person cedures. A combination of the of hospital finances, data for elective surgical patients statistical rigor of Six Sigma also was part of the team. The programming, scheduling, with the w\iste-reduction fomedical chief of staff was cus of Lean contributed to the chosen to be the champion of and day-to-day success of the project. the team. Subject matter exoperations in the OR, perts became involved in the THE DECISION TO PROCEED . process as needed. These inIn late 2004, leaders of this cluded a perioperative clinical medical center made a commitnurse specialist, two surgeons, ment to incorporate Six Sigma and an anesthesiologist. into their strategic philosophy Training began in August 2005 and major and goals. The cliief executive officer champichanges had been completed by July 2006. At this oned the initiative to incorporate a Six Sigma culpoint, the control phase was underway Tliis ture into the organization's way of thinking and phase was scheduled to last at least six months. strategic expectations. Individuals were nominated and chosen for the Sigma team by executive managers. An intensive training schedule was METHODOLOGY developed for the Sigma team members. The life cycle of a Six Sigma project comTwo types of team members comprise every prises five major phases. The phases are to Sigma team. Each team has one "Black Belt," a define, person who learns and practices proficiency in measure, statistical analysis and is an expert in the comanalyze, plete set of Six Sigma methods and tools.'' Apimprove, and proximately four other team members, called control.' "Green Belts," make up the remainder of the Ail Six Sigma projects begin with a problem.

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FIGURE 1

Problems Identified by Survey Respondents

120100-80 80c

-100

-60

I- 60
-40
40-

Case delay zvas the mostfrequentfactor This represents the "vital few" factor inuencing the system.
-20

20-

0 Case delay Number 81 Percentage (%) 73.6 Cumulative % 73.6 Excess paperwork 10 9.1 82.7 Other 6 Room unstocked 5 IV start 4 3.6 96.4 TAT* > 30 minutes 4

5.5 88.2

4.5 92.7

3.6 100.0

* TATturnaround tm\e between cases.

usually one that is systemic or chronic, affecting the success of a given process. The problem imdergoes a metamorphosis during the project, changing "from a practical business problem into a statistical problem, then into a statistical solution, and finally into a practical solution."^'f''''^' DEFINE. The OR throughput project began with the perception that surgical procedures could not be sdieduled in tlie OR in a manner that met surgeon or patient needs. A frequently cited cause of this was procedural delays. Sigma team members distributed surveys to surgical and nursing staff members. After receiving the completed surveys, the team grouped survey responses iiito major themes. The survey was designed to help identify problems, not to provide soluhons. A Pareto chart (io, a bar chart for categorical data in which categories are presented in descending order of frequency^) was then constructed to graph the problems that were identified. A Pareto chart illustrates that 80% of observed defects or problems can be attributed to 20"' of the causes. This sometimes is referred to as the 80-20 rule. In Figure 1, the highest frequency bars make up the bulk of the

categorical data (ie, the defects), indicating that the survey was an accurate measurement tool. When a problem in the data exists, the resulting Pareto diagram has equally dispersed defect categories. In instances when this is noted, the data are not useful in identifying or addressing the causes of a problem. To provide focus for the Six Sigma initiative, it was necessary to identify in-scope and out-ofscope attributes of the problem. The Sigma team chose to focus on orthopedic and general surgery procedures because these types of procedures have the highest x'olume. For measurements in this initiative, process time was defined as beginning when the patient arrives in the facility to register for surgery, and it includes inroom time (ie, time in the OR) to the time the patient leaves the room, as well as the time required to turn tlie room over for the next procedure. Afishbonediagram (ie, a pictorial diagram in the shape of a fishbone, which shows all possible variables that could affect a given process output measure') was used to portray the potential causes of nonoptimal time usage. The Pareto diagram developed from this survey showed that procedural delays made up
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TABLE 1

Supplier, Inputs, Process, Outputs, and Customers (SIPOC) for Surgical Throughput
Supplier
SiirgotMi I'erioperiitivf ind sterile processing dcpiirtment (Sl'D) staff mombor representatives Materials nidnagenit'nt representatives Surgeons Anesthesia staff members Periopertitive sttiff members SPD stuff members Per i ope r.i tive staff members and licensed nursing assistants (I.NA^ LNAs AmbuLitorv care center (ACC) RN OR RN " Anesthesia assistant/Certified RN anesthetist (AA/CRNA)

Inputs
Accurate schedule Accurate preference cards Equipment/instruments available Check inventory iiid pull instruments for procedure Case cart set up Correct equipment Sterility/asepsis Accuracy

Process
l\itient ready for surgery

i i < < i
4 <1 * i

Communication to OR team members Preparation complete (including counts) Patient transported to OR Patient transferred to bed Hand-off report I'atient identification Site identification and marking Time out All ready Anesthesia induction and emergence Communication to OR team members Patient transfer to stretcher/bed Disconnect anesthesia connections Destination reaciy Hand-off report

Patient in room

Siirgecni

Anesthesia care providers (ACP) Patient Staff members LNAs Team members AA/CRNA Postanesthesia care unit (PACU) or ACC RN

Start to end

< < < i 4

Staff members, LNAs, technicians m Sl^D staff members

* Contain instrumentation 41 Clean equipment 4 Clean room 4> Transfer patient 4> Pre\ious case torn down 4 Next case cart ready 4* Correct equipment and instrumentation 4I Sterile supplies 4k Information exchanged

m
1

Room

(.arjowii

Sl'D staff metnbers Perioperative staff members

^L ^H ^^^^^^^^^H ^^^^^^^^^| ^^^^^^^^H ^^^^^^^^^|

80% of the perceived problems. Interestingly, several items icHentified by the sur\'ey (eg, excess paperwork, unstocked rooms, missing instruments or equipment, IV starts, turnaround times) did not fall into the S0% case delay responses. The next step in the Six Sigma analysis was to diagram the process map of how the patient gets from registration to the OR and how he or she

leaves the OR so the next procedure can be set up. Tliis process map is referred to by the following steps: supplier, inputs, process, outputs, customers (SIPOC). Suppliers provide the inputs that are necessary for the process to tKcur. The process adds value and produces outputs that are pro\ ided to the customer, which meets or exceeds his or her expectations and requirements (Table 1).'

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TABLE 1

SIPOC for Surgical Throughput (continued)

Outputs
Patient and team member prepared Family members supported Accuracy, correct items On-time start OR ready for patient and team members Customers
Patient Facility

Patient Surgeon Perioperative staff members

for induction of anesthesia, for emergence from anesthesia, and for room teardown and cleanup. Room turnaround time also w a s measured. MEASURE. The measurement phase w a s the niost time-consuming and work-intensive portion of the process. It required computer prog r a m m i n g to capture data from OR data entered by the OR scheduling coorciinator and staff members. When this w a s accomplished, data trends could be identified. During the 13-month review period, the average n u m b e r of procedures per d a y w a s 18.57. Four or five ORs w e r e used each day. In December 2005, '[2% of the first procedures of the day started exactly on time a n d 53% started within five minutes of (ie, before or after) the scheduled time. Process capability g r a p h s (ie, a representation of a process that p r o d u c e s a defect-free service in a controlled environmenf^) w e r e u s e d to deterinine how well certain w o r k cycle times fell within the specification limits, a n d a design target time w a s chosen for each process, w i t h o u t a n y extra time allowance." Data o n the h o l d i n g area time (Figure 2) s h o w e d an average of 11.6 m i n u t e s with a target time allowance of 10 m i n u t e s . This translated to a D P M O of 403,846 (eg, a Sigma v a l u e of 1.74). Obviously, m u c h i m p r o v e m e n t w a s possible in this area. This sort of information w a s useful to n u r s i n g staff m e m b e r s to shovi' that i m p r o v e m e n t s couici be m a d e . Boxplot g r a p h s (ie, a graphic representation depicting the centering, spread, a n d distribution of data') of on-time starts of the physicians indicated the best performers in terms of starting on time with the least variability (Figure 3). Presenting this information to surgeons helped keep them interested and engaged in the imp r o v e m e n t process. ANALYZE. Tlie analysis phase of the Six Sigma life cycle "uses data a n d statistical tools to understand the cause-and-effect relationship in the process or system."^''^'^^' This step comprises the most important w o r k of the Black Belt team member, w h o determines the most sigiiificant data relationships and identifies whore improvement efforts can best be directed. The analysis phase produces data-driven solutions rather than solutions based orJy on assumptions. AORN JOURNAL 7 7

Surgery can begin

I'atient Team members Family members Patient Surgeon & ACP Staif members Family members

Correct surgery Safe surgery Timely surgery No waste t)f materials

Patient to PACU or ACC Begin communication for next patient

Staff members Next patient

Room ready for next procedure to be opened Open for next procedure

Next patient Staff members

Staff members

The process map is a valuable tool to help team members decide what to measure. The throughput project measured the time required for a patient to get ready for surgery, for an OR to be set up, from a patient being ready to enter the OR to his or her arrival in the OR,

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FIGURE 2

Patient in Holding Room Cycle Time

0 ininutc> 1 1 Opportunity 40.38% of cases take Longer than 10 minutes for holding time. Defects per million opportunities = 403,846 Average = 11.6 minutes n-52

\J
\
XI

\ \ \ N Dotted line represents Weibull cunv of normal distribution of the holding room time (ie, process).

18

24

30

36

48

Minutes spent in holding area

FIGURE 3

Procedure Start Times by Physician

50-

25-

Boxplot key -25Whiskers (indicate general J. extent of the data) Median The box represents the 25th to 75th percentile of the data. -75C D Physician E

-50-

In the OR throughput analysis, a fitted line plot {ie, a linear graph scoring the predicted values using a regression equation, depicting the relationship between a response and one or more predictors') (Figure 4) showed a statistically significant relationship between the
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.imount ot" time the patient spent in the holding area and on-time start {P = .Ot)O). Regression analysis (ie, a method ot analysis that qiiantil-ie^ the relationship between two or more \ ariables by fitting a line or plane through all points so they are evenly distributed along the line or

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FIGURE 4

Line PlotPatient Holding Room Time and On-Time Start

100 1
Null hypothesis: No relationship exists between time patient spends in holding area and on-time start. S* R-Sq" R-Sq(adj)'

Si

50-

16.8963 77.5% 77.1%

-50

Conclusion: Statistically significant relationship hetween amount of time patient presently spends in holding area and on-time start (P= .000).

-100-1
-100 -50 0 50 Molding area time in minutes to scheduled time

* S is a regression statistical output stiowing unexplained data variation. *' R-Sq and R-Sq(adj) indicate the strength of the conclusion.

TABLE 2

On-Time Starts and Key Players

Hypothesis: No reiationsliip exists between on-time start and when the key player arrives for the case (eg, difference between scheduled time and the time the individual shows up for the case) Regression analysis: The regression equation is on-time start = 7.089 + 0.533 MD-sched (ie, surgeon arrival to scheduled on-time start) + 0.108 ACP*-sched (ie, ACP ready to scheduled on-time start) + 0.276 team-sched (if, OR team preparedness to scheduled on-time start)

Predictor
Constant MD-schcd ACP-sched

Coefficient of variation
7.0890 0.1078 0.275S

SE** coefficient
2.0410 0.1282 0.1057 0.1.120

t
3.47 4.16 1.02

P
.001 .000 .313 ,042

5 = 11.6780 R-Sq - m.7% R-SqCadj) = 89.0%

(regression statistical output showing unexplained data variation) (indicating the strength of the conclusion) (indicating adjusted strength of the conclusion)

Analysis of Variance
Source SS'

F test
18970 136 139.10
.000

Regression Residual error Total

3 48 51

56911 6546 63457

Conclusions: Slatistii..illv significant relationship between physician arrival for procedure and on-time start (P = .000), and statistically significant relationship between team members' preparedness for procedure and on-time start (P = .042). cmv provider ACP = ** S = standard cmv ' SS = sum of squares " MS = mean square

December 2005 data

plane^) (Table 2) showed a significant relationship between surgeon nrri\'al for a procedure and on-time start {P - .000) and a significant relationship between team preparedness for procedure and on-time start (P = .042). Based on further team discussions, improvement efforts were directed toward reducing or eliminating the holding area time, measuring surgeon arrival times, anci demonstrating to surgeons that patients are transferred to the OR pending the timely arri\'al of surgeons. This information led to a cascade of changes aimed at improving the process. In the physical, structural design of the health care facility', the ambulatory care admission and discharge areas were located on the first floor, and the OR and postanesthesia care unit (PACU) were lcKated on the secondfloor.This setup created a longstanding challenge in tenus of patient transport and communication among staff members. Typically, physicians and OR care providers
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would meet with patients in the holding area. This created a problem because the ambulatory care center, which is the point of entry (ie, admission and preoperative preparation for surgical patients), was not on the same floor as the ORs. IMPROVE. The improvement phase required continual and open communication with all care providers, change facilitation, leadership, feedback solicitation, support, and coaching. It required all staff members to "step outside the box," to think about doing things differently from the way things had been done for many years. Support from clinical nurse leaders was critical to the success of the improvement phase.

cal patients were brought to the PACU staging area for admission and assessment before surgery. Patients also returned to the PACU staging area for phase 1 and phase 2 recovery and discharge to home. This change was perhaps the most difficult in terms of adjustment by staff members and in patient-flow strategies. It resulted in the PACU becoming the hub of patient and staff-member activity, and this increased noise, traffic, and privacy concerns. Focused surveys of patients conducted three separate times, however, indicated that patients perceived a greater level of attentiveness and care from providers, experienced reduced transport and waiting times, perceived a greater level of teamwt)rk among physicians and nurses, and generally were very satisfied with all aspects of care. On a few of the sur\'eys, patients mentioned a perceived decrease in privacy. This has become the next critical need to be addressed. Design changes currently are underway to renovate the former holding area into an intake area and to create partitions between phase 2 recovery bays to provide a greater sense of privacy and to facilitate family member presence during recovery. Turnaround times also have decreased from a mean of 23.8 minutes to 17.9 minutes. This is, in part, a result of the availability of patient care assistants who formerly were multitasking with transporting patients and assisting in the room turnover. Additionally, because staff members have increased access to anesthesia cart' providers and surgeons for questions and IV antibiotics and anesthetic blocks are administered in a more timely fashion, delays in turnaround have been reduced. An additional benefit is that nurses now have the opportunity for face-to-face hand-off communication preoperatively; hand-off communication previously occurred by telephone. Surgeons also began showing up on time or a bit early, and they voiced a greater confidence that there would be fewer procedural delays. When the reasons for the change in patient flow were explained to patients, they felt included in the improvement process. CONTROL. Control planning assures the sustainabiiity of a change, which makes the Six Sigma process unique from previous change initiatives

Facused survey of patients indicated that patients perceived a greater level af teamwork among perioperative '^ ' ' staff members.

Beginning in May 2006, all first cases of the day were brought to the PACU as the staging area for nursing, anesthesia,, and surgical assessment before surgery. Because of this change, the percentage of on-time starts improved dramatically from 12% in December 2005 to 89"/^,. This change was attributed to point-of-care admission and communication among all team members, the elimination of telephone calls to determine if a patient was ready or to send for a patient; the elimination of patient transport time, timely IV starts and administration of anesthesia blKks or morphine spinal anesthesia, and surgeon confidence that when they arrive on time for a procedure, the patient also will be transported to the OR on time. In July 2006, another dramatic and challenging change took place in the facility. As a result of the success of the team's initiative, all surgi8 0 .\ORN lOURNAL

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FIGURE 5

On-Time Starts, Before, During and After Intervention

'
"

0)

January to March 2006

April to June 2006

Juty to September 2006

UCL = 22.97 X = 4.74

1= 0 ?*i
.5^-20 -40 1 14 27 40 53 66 79 Observation Days Key UCL IT LCL upper control limit arithmetic mean lower control limit 92

11

* 1

11
105 118 131

LCL = -32.45

Late starts {+) On-time starts Early starts (-)

attempted in this setting (eg, attempting to track on-time starts, assigning licensed nurse assistants to specific tasks, assigning extra staff members to turn over rooms, tracking on-time starts by specific service or staff members). Changes can be difficult to maintain, and only by vigilant control of the gains can practices be keptfromslipping back to previous patterns. The control phase also protects against a loss of interest by stakeholders. This phase continued for six months to ensure the continuity of this project. On-time starts, timely physician arrivals, quick turnaround times, and reduced length of stay of surgical outpatients currently are being tracked to ensure that results are maintained. A control chart (Figure 5) was created to show ontime starts beginning in December 2005, a period of change that was not in control because only first patients of the day came to the PACU admitting area; the improved in-room times in better control began in July 2006. GAINS. Improved efficiency creates a greater capacity for more surgical cases and greater predictability in surgical start times. It also reduces the amount of overtime required to complete scheduled surgical procedures, Two staff members were assigned to work flexible time schedules each day to cover the last procedures of the day, which allowed the on-call team to be available for emergent cases. The Six Sigma team members speculated that staff member recruitment efforts also will be en-

hanced because prospective employees value efficiency in a job setting. Patient sur\ ey satisfaction scores improved during the quarter following the implementation of these changes. Wait times before surgical procedures improved 2.4 points (ie, a score based on percentage) from 85.7 to 88.1. Communication of information regarding delays that did occur improved 2.3 points from 85.9 to 88.2. Patient perception of how well staff members worked together improved 1.4 points from 95.8 to 97.2 with statistically significant gains at a .05 confidence level. The overall facility rating improved 1.2 points from 93.2 to 94.4, and ambulatory overall scores improved from the 84th percentile to the 97th percentile.
CONCLUSION

In a report of a similar Six Sigma initiative undertaken by another health care facility, Adams et al noted that before the initiative to decrease turnaround time between general surgery cases, "each part of the team was quick to blame someone [else] for long hjmaround times.""''''"^' A similar observation was made before the commencement of this Six Sigma project. After the Six Sigma initiatives were employed, staff members noted a greater sense of cohesiveness, collaboration, and pride in their accomplishments. Tliis initiative was data driven and produced sound, measurable results for patients, members of the health care team, and the orgaization overall.
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REFERENCES 1. Motorola University'. Six Sigma dictionary, http:// vvww.motorola.com/contL'nt.jsp?globa!ObjectId=3074 -5804. Acces.sed March 20, 2007. 2. Carrigan MD, Kiijawa D. Six Sigma in health cart' management .iiid strategy Health Ciuv Manag (Freilerick). 200b;25{2):\3?,-U]' 3. Juran Institute. Six Sigma introduction, http:// www.jiiran.com. Accessed May 16,2007. 4. Cygi C, DeCarlo N, Williams B. S/.v Sigmn for Dummies. Hoboken, NJ: For Dummies; 2005.' 5. Statistical Six Sigma definition. iSixSigma.com. http: //wwvv.isixsigma,com/library/content/cOlOl Ola.asp. Accessed March 19, 2007. " 6. Pexton C. Measuring Six Sigma results in the

healthcare industry. iSixSigma.com. http://health cam,isixsigma.com/library/contL'nt/c040623a.asp. Accessed March 19, 2007.' 7. Adams R, Warner P, Hubbard B, Goulding T Decreasing turnartiund time between general surgery cases: a Six Sigma initiati\'e. / Niif.s Aiim. 2004;34(3): 140-148.

Catharine B. Fairbanks, RN, MSN/ED, CNOR, is director of perioperative services at Southwestern Vermont Medical Center, Bennington, VT.

Moderate Drinking May Reduce Women's Heart Attack Risk

omen who regularly drink alcohol in moderation but do not get drunk may reduce their n'sk of having a nonfatal heart attack, according to a June 5, 2007, article in the New York Times. Women who had a daily alcoholic drink were 31% less likely to have a nonfatal heart attack than women who had less than one drink a day. Women who became drunk (eg, those who experienced slurred speech or unsteady gait) even once a month, however, were almost six times more likely to have a heart attack. Researchers studied 320 women between the ages of 35 and 69 years who had experienced heart

attacks and compared them with 1,565 healthy women of similar age. Data were adjusted for age, race, education, smoking, and body mass index. The data were collected through self reporting, which may be subject to error; however, the implications of the study are that there may be health benefits to the moderate consumption of alcohol.
Bakatar M. Heart health: women who drink a little may lower heart-attack risk. New York Times. June 5. 2007. http:// www. nytimes. com/2007/06/05/health/05hear. html. Accessed June 5, 2007.

Fetal Mortalities Decline but Radal Disparities Remain

he rate of fetal deaths (ie, stillbirths) occurring at 20 weeks of gestation or more decreased substantially between 1990 and 2003, according to a February 21, 2007, news release from the Centers for Disease Control and Prevention. The fetal mortality rate (ie, number of fetal deaths per 1,000 live births and fetal deaths) showed a steady decline of an average of l.t% per year from 1990 to 2003, particularly among pregnancies at 28 weeks of gestation and longer. Although the rates declined across all racial and ethnic groups, the rate for non-Hispanic black women (ie, 11.56 per 1,000) was more than double that of non-Hispanic white women (ie, 4.94 per 1,000). Researchers also found that the fetal mortality rate for American Indian women (ie, 6.09 per 1,000) was 24% higher than that for non-Hispanic white women; Hispanic women (ie, 5.46 per 1,000) was slightly higher than that for non-Hispanic white

women; and Asian or Pacific Islander women (ie, 4.98 per 1,000) was comparable to that for non-Hispanic white women. Relatively little is known about the causes of fetal mortality. Researchers have identied risk factors for a fetal death, however, including placental and cord problems and intrauterine growth retardation as well as the mother smoking during pregnancy, being obese, having severe or uncontrolled high blood pressure, having diabetes, having infections, and having had a previous perinatal death.
New Report Shows Decline in Stillbirths; Racial Disparities Persist [news release}. Atlanta, Go: Centers for Disease Control and Prevention: February 21, 2007. Available at: http://www.cdc.gov/od/oc/media/pressrel/2007/r070221 .htm. Accessed March I. 2007.

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