The first step to be taken in the discussion is to enquire, What is the
real normal death-rate of lying-in women? And, having ascertained this
to the extent which existing data may enable us to do, we must compare
this death-rate with the rates occurring in establishments into which
parturition cases are received in numbers. We have then to classify the
causes of death, so far as we can, from the data, with the view of
ascertaining whether any particular cause of death predominates in
lying-in institutions; and, if so, why so? And finally, seeing that
everybody must be born, that every birth in civilised countries is as a
rule attended by somebody, and ought to be by a skilled attendant;
since, therefore, the attendance upon lying-in women is the widest
practice in the world, and these attendants should be trained; we must
decide the great question as to whether a training school for midwifery
nurses can be safely conducted in any building receiving a number of
parturition cases, or whether such nurses must be only trained at the
bedside in the patient’s own home, with far more difficulty and far less
chance of success.
_MIDWIFERY STATISTICS._
It must be admitted, at the very outset of this enquiry, that midwifery
statistics are in an unsatisfactory condition. To say the least of it,
there has been as much discussion regarding mortality and its causes
among lying-in women as there has been regarding the mortality due to
hospitals. Yet there appears to have been no uniform system of record of
deaths, or of the causes of death, in many institutions, and no common
agreement as to the period after delivery within which deaths should be
counted as due to the puerperal condition. Many of the most important
institutions in Europe merely record the deaths occurring during the
period women are in hospital, and they appear not unfrequently to do
this without any reference to the causes. Similar defects are obvious
enough in the records of home deliveries; and hence it follows that the
mass of statistics which have been accumulated regarding home and
hospital deliveries, admit of comparison only in one element, namely,
the total deaths to total deliveries, and this only approximately.
Dr. Matthews Duncan, in his recent work on the ‘Mortality of Childbed
and Maternity Hospitals,’ has dwelt forcibly on these defects in
midwifery statistics, and has made out a strong case for improvement in
records. But, as will be afterwards shown, with all their defects,
midwifery statistics point to one truth; namely, that there is a large
amount of preventible mortality in midwifery practice, and that, as a
general rule, the mortality is far, far greater in lying-in hospitals
than among women lying-in at home.
There are several of what may be called secondary influences also, which
must affect to a certain extent the results of comparison of death-rates
among different groups of lying-in cases. Such are the ages of women,
the number of the pregnancy, the duration of labour, and the like. It is
impossible, in the present state of our information, to attribute to
each, or all of these, their due influence; neither, if we could do so,
would it materially affect the general result just stated. But it is
otherwise with another class of conditions, of which statistics take no
cognizance. Such are the general sanitary state of hospitals, wards,
houses, and rooms where deliveries take place; the management adopted;
the classes of patients; their state of health and stamina before
delivery; the time they are kept in midwifery wards before and after
delivery. These elements are directly connected with the questions at
issue, and yet our information regarding them is by no means so full as
we could wish—indeed is almost nothing.
Our only resource at present is to deal with such statistical
information as we possess, and to ascertain fairly what it tells us.
This we shall now endeavour to do, beginning with an estimate of the
normal mortality due to childbirth in various European countries.
_NORMAL DEATH-RATE OF LYING-IN WOMEN IN ENGLAND._
In the Registrar-General’s Thirtieth Annual Report, 1867, there is an
instructive series of tables, giving approximately the present normal
death-rate among lying-in women in England.
One of these tables (abstracted on Table I.) shows that, including
deliveries in lying-in hospitals, there were in England, during the year
1867, 768,349 births, and that 3,933 women died in childbed. This gives
an approximate total mortality of 5·1 per 1,000 from all causes.
TABLE I.—_Mortality after Childbirth in England, 1867_
(_Registrar-General’s Thirtieth Annual Report_).
┌────────┬──────────┬─────────┬─────────┬───────────┬────────┬────────┐
│ Total │ Deaths │ Deaths │ Deaths │Deaths from│ Deaths │ Total │
│ Births │ from │ from │ from │Consumption│from all│ Deaths │
│ │Accidents │Puerperal│Miasmatic│ and Chest │ Other │ │
│ │ in │Diseases │Diseases │ Diseases │ Causes │ │
│ │Childbirth│ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
├────────┼──────────┼─────────┼─────────┼───────────┼────────┼────────┤
│768,349 │ 2,346 │ 1,066 │ 137 │ 230 │ 154 │ 3,933 │
└────────┴──────────┴─────────┴─────────┴───────────┴────────┴────────┘