THE PERIL OF CHILD-BIRTH
By OUR MEDICAL CORRESPONDENT
THE outstanding fact is well known. It was plainly stated by Sir George Newman in his Annual Report for 1931. " Since the beginning of the present century," he wrote, " the general death-rate has been reduced by one-third, tuberculosis mortality by one-third, and the infant mortality by more than one-half ; but maternal mortality has remained stationary." Even this statement was over-optimistic ; for whereas, twenty years ago, for every thousand live births registered, 4.87 women died through, or from causes associated with, pregnancy and child-bearing, by last year this figure had grown to 5.94. It is, manifestly, disturbing that something like three thousand women in this country die each year because they are fulfilling, or have fulfilled, one of their prime biological purposes. Pregnancy and child-bearing cannot be classified as diseases ; they are essentially physiological, not pathological, states and activities. From this, however, we have no right to infer that, left to themselves, they would be unattended by lethal risk. There is plenty of evidence that without the intervention of artificial technique our maternal • death-rate would be much higher even than it is.
Since public attention has been drawn to this toll on motherhood, all kinds of explanations have been offered, and a number of Scapegoats have been named. The obstetric specialist was early in the field, pointing to the incompetence of the general practitioner ; the latter blamed the dirty and ignorant ways of the then unregistered midwiveS ; whilst the representatives of these hardworking women claimed that the 'Vnterference of busy doctors in what was really woman's work was responsible for much of the trouble. The socially bene- volent naturally assumed that poverty, malnutrition and overcrowding 'must play an evil part ; whilst socid- scientific planners urged that, since many maternal deaths are due to bodily defects which are commonly not recognized until danger is present, the establishinent of ante-natal clinics was the outstanding need: Each of these criticisms and theories in turn received official blessing. In his Annual Report for 1920, Sir George Newman said : " Undoubtedly the solution of this grave situation (that is, the rising maternal mortality) is mainly dependent on improved midwifery." But, in his Report for 1923, Sir George told us that " the key to the prevention of maternal mortality is efficient ante- natal supervision ; if we can secure this, everything else is likely to follow as a matter of course." At about the same time, Dr. Comyns Berkeley made the more realistic comment : " There are two things known for certain about puerperal sepsis ; one is nothing, and the other is that the medical attendant will be blamed. . . . What do we know about the predisposing causes of puerperal sepsis ; of the immunity of the normal pregnant woman ; of how to assist this immunity ; of how to recognize if this immunity is failing ? " The Scottish Departmental Commit- tee on Puerperal Morbidity reported that their evidence did not show that unhygienic and crowded dwellings and dirty surroundings increased the incidence of puerperal fever.
It is a curious fact that poor people living in city slums, in spite of malnutrition, uneseapable dirt, and all. the other undesirable things that go with poverty and slum life, pass, and always have passed, far more safely through the ordeal of maternity than do or have done their richer sisters in the airier and more generally salubrious quarters of our cities and towns. Before the War, most confinements in the East End of-London took place in poverty-stricken tenements, under what any present-day doctor would regard as appalling hygienic conditions. Yet, in the four-year period, 1911-14; the maternal death-rate in Stepney, Shorediteh, Bethnal Green and Bermondsey was about half the rate that obtained in Hampstead, Stoke Newing- ton and Westminster. Ante-natal clinics, greater institu- tional facilities and ever-increasing antiseptic preCautions have not yielded the results expected of them. A week or two ago Dr. T. Watts Eden pointed out that in spite of the great extension of ante-natal work in the last ten years (" of expectant mothers 42 per cent. actually came to the clinics, while probably 80 per cent. had some sort of ante-natal supervision "), not only does maternal mortality continue to increase, but the death- rate of infants during the first month of life remains practically as high as ever. Nor has the extension of institutional treatment, with the facilities for skilled attendance and antiseptic precaution it affords, proved more effective in lowering the puerperal death-rate.
The Departmental Coinmittee which reported in 1932 came to the conclusion that 50 per cent. of our maternal deaths each year are preventable. Although such a conclusion must, of necessity, be little more than an intelligent guess, it quite likely roughly corre- sponds to present possibilities. But, if we want seriously to tackle this problem, we shall have to give up hunting for scapegoats, and airing our several prejudices and predilections. The nearer we approach to the aseptic ideal in the conduct of midwifery, the better. Yet the statistics -prove that this is not the only, or even the chief, factor involved. In order to find out what - these other factors are, we should make a serious attempt to study the nature of those differences of environment, of occupation, of heredity, and of technical practice which, presumably, account for the very great diversity of mortality rates over long periods of time in different towns, in different urban areas, in different maternity hospitals, and in the practices of different doctors and midwives. It is strange, for instance, that the maternal mortality rate of Bournenouth was, last year, more than twice that of Blackburn, and that of Darlington twice that of Derby. The divergence of results obtained in various hospitals is even more marked. These results sometimes differ by as much as 400 per cent, In the next place, we should provide for an altogether higher standard of technical training for those who arc to be the obstetricians of the future. These will, of course, be specialists ; for, now that an ever-increasing number of women are being confined in boSpitals and other institutions, the general practitioner ea nnot possibly get enough' practice to maintain even that small degree of proficiency which he is likely to have acquired during his student days. The sooner we recognize that, whatever its disadvantages and ineon• veniences may be, institutional midwifery is certain to become practically universal, the better will be the prospect of a reduction in our rates of maternal mortality and maternal morbidity. For it is certain that in mid. wifery no amount of aseptic precautions will compensate for lack of manipulative skill in the attendant ; and such skill can be acquired only by experience. It is not without significance that something like one-twelfth of all our maternal deaths are consequent on abortion ; and of these no small proportion may be put down to lack of skill. But it is probable that the factors contri- buting to our high mortality rate are many. Arc we quite sure that newly-emancipated woman has yet acquired a sound biological status, or secured for herself a harmonious psycho-physiological equilibrium ? It may well be that not the least of the problems involved is an educational and sociological one.
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