An Address ON THE MATERNAL MORTALITY OF CHILD-BEARING : ITS CAUSES, AND HOW TO DEAL WITH THEM
DEATH when it comes to the young is always a pathetic occurrence, but a peculiar pathos-attaches to the death ofa young woman in childbirth. In -the year 1920, 5413 women, six out of every seven of whom were under 35 years of age, died in the United Kingdom from causes incidental to child-bearing. A good deal of this loss of life cannot be avoided, nevertheless it is an incontestable fact that large numbers of women who enter upon the process of labour in good general health, and free from
... and free from obstetric complications, none the less lose their lives. The loss of so many young mothers entails so much disruption of family life and consequent economic loss to the State, that it has rightly come to be regarded as one of the burning questions of the hour. A special responsibility for this particular form of mortality is usually laid at the door of the medical profession, and my conviction that there is a certain rough justice in this attitude has led me to desire to discuss the matter with this great society. A good deal of attention has been directed from time to time to the fact that the mortality-rate from sepsis in childbirth has shown no noteworthy diminution in the last 20 years, although during the same period great progress has been made in the elimination of septic complications from all branches of surgical work. The facts are undeniable, and I shall give some figures which bring us up to the end of the year 1920, and which show that the most recent tendency of the mortality-rate from sepsis in childbirth is to rise, rather than to fall. I am very glad to discuss this subject with a society in which general practitioners are largely represented, because the great bulk of midwifery practice is in their hands. We must first get a clear idea of the nature of the problem of protection against the dangers of childbearing. Attention has been directed to the consideration of sepsis, to the practical exclusion of other causes of death in childbirth, some of which may prove more easily dealt with than infection. We must look at the mortality as a whole, and review its principal elements, in order to avoid taking steps which, useful in one respect, may prove harmful in another. To many minds the dominating consideration in the conduct of labour is the antiseptic technique which should be adopted during the process of birth and the subsequent lying-in. Some three years ago my friend, Mr. Victor Bonney, addressed himself to this subjectl ; his three principal points were that midwifery should be regarded as a branch of surgery, that labour should be conducted as a surgical operation, and that the chief source of puerperal infection was the rectum. He accordingly advocated a technique designed to prevent infection of the genital canal from the rectum. Narrow views of such a vital subject as that we are now discussing are to be deprecated, and I shall ask you to look at it not merely as a problem in antiseptics, but as a complex problem which in some of its aspects is medical rather than surgical, and is also related to pediatrics. TOTAL MORTALITY OF CHILD-BEARING. Our information as to the causes of death in childbirth comes from the three annual reports of the Registrars-General for England and Wales, Scotland. and Ireland respectively. Unfortunately these reports are not drawn up upon an identical plan, but I have found it possible to take out sets of figures strictly comparable with one another, which are set out in the tables. These figures represent what we may call the net mortality of child-bearing. Table T . and Chart I give the total mortality of child-bearing in each of the three divisions of this country for the 10 years 1911 to 1920 inclusive, the TABLE I.-Total Mortality of Child-Bearing. latest for which the figures are available. This period includes the war years ; the figures are interesting on account of the fact that the profession was then depleted of nearly all its young men, and the midwifery work of the country was, to a much greater extent than is usual, done by senior men, who too often worked under great pressure. Taking 1915--1918 inclusive as the war years, the average rates for these years are 4-01 for England and Wales, 5-16 for Scotland, and 5-14 for Ireland. These figures approximate so closely to the average figures for ten years in each division that we may say that the efficiency of the midwifery services in the country was well maintained during the war. In the last two of the war years-viz., 1917 and 1918, the rates for England and Wales and for Ireland were abnormally low, while the Scottish rate rose somewhat. The birth-rate in 1918 fell to a level lower than has ever been known in recent times, the total births for England and Wales being 25 per cent. less than in 1911. This reduction in the amount of midwifery work no doubt compensated to some extent for the shortage of medical men. The rise in the Scottish rate suggests that the shortage may have been more severely felt in that country. I have tried to obtain information as to the proportion of cases attended annually by midwives and doctors respectively, for it is reasonable to suppose that midwives would attend a larger proportion during the war years than in ordinary years. Unfortunately the information is not obtainable, as the Ministry of Health only began to collect statistics of the number of births notified by midwives in 1918, although the Notification of Births Act came into force in 1915. In England and Wales over one-half of the total births were notified as having been attended by midwives during 1918 and 1919, the exact figures being 51'8 per cent. in 1918 and 54.5 per cent. in 1919. The returns for 1920 are incomplete, but the proportion was apparently a little higher than in 1919. The influence of the practice of midwives upon the maternal mortality of childbirth is therefore important ; but we cannot tell to what 2 Readers of Mr. Bonney's paper will notice that his figures of the total mortality of child-bearing exceed those given in Table I . This is because he has included deaths from intercurrent affections, such as enteric fever, influenza, pneumonia, &c. This mortality cannot fairly be considered as part of the mortality of child-bearing, and it has consequently been excluded from consideration here.