Part 2

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 │ └────────┴──────────┴─────────┴─────────┴───────────┴────────┴────────┘

The causes of mortality are also given in Table I. as follows:—

1. There were 2,346 deaths by accidents of childbirth (hæmorrhage, convulsions, exhaustion, mania, &c.).

2. There were 1,066 deaths due to puerperal diseases (puerperal fever, puerperal peritonitis, metritis, pyæemia, &c.).

3. Of the remaining 521 deaths, 137 were due to non-puerperal fevers and eruptive fevers; 230 were occasioned by consumption and other chest diseases, and 154 by other causes.

4. By adding together deaths from puerperal diseases and those from fevers, we find that, out of a total mortality of 3,933, the deaths from diseases more or less connected with what is called ‘blood-poisoning’ amounted to 1,203, or rather more than 30 per cent. of the total mortality.

5. The mortality per 1,000 deliveries (or rather per 1,000 births) from each class of causes in England, in 1867, stands thus:—

Accidents of childbirth 3 per 1,000 Puerperal diseases 1·4 „ „ Others, including non-puerperal fevers ·7 „ „ ——— Total 5·1 „ „

The same Report gives the following puerperal death-rates for all England during 13 years, 1855 to 1867 (see Table II.).

Accidents of childbirth 3·22 per 1,000 Puerperal diseases 1·61 „ „ ———— Total, exclusive of other deaths 4·83 „ „

An important element in the analysis of these death-rates is their relative prevalence in town and country. This is abstracted on Table II. from the Registrar-General’s Report for a period of ten years, as follows:—

_Deaths from Accidents of Childbirth and Puerperal Diseases._

England, 64 healthy districts, 312,402 deliveries 4·3 per 1000 Ditto, 11 large towns, 1,402,304 deliveries 4·9 „ „

In other words, out of every 5,000 deliveries in towns there are three more deaths from accidents of childbirth and puerperal diseases than occur among the same number of deliveries in healthy districts.

These facts, with a small deduction for the higher death-rates in lying-in hospitals, give the present mortality in English homes. They appear to show that puerperal women are subject to something of the same law of increase of death-rates in towns as other people, but part of the increase is no doubt due to the higher death-rates in delivery wards in these towns. The facts also appear to indicate a probable reduction of death-rates among lying-in women in England, from the extension of public health improvements both in town and country.

TABLE II.—_Table Showing the Mortality per Thousand after Delivery from Puerperal Diseases and Accidents of Childbirth._ ┌────────────────────────────────────┬────────────────────────────────┐ │ Places │ Mortality Per Thousand │ │ │ Deliveries │ ├────────────────────────────────────┼──────────┬──────────┬──────────┤ │ „ │ │ │Puerperal │ │ │ │ │ Diseases │ │ │ │ │ and │ │ │ │Accidents │Accidents │ │ │Puerperal │ of │ of │ │ │ Diseases │Childbirth│Childbirth│ ├────────────────────────────────────┼──────────┼──────────┼──────────┤ │King’s College lying-in ward, 5 │ │ │ │ │ years │ 29·4│ 0│ 29·4│ │12 Parisian Hospitals 1861 │ │ │ 75·2│ │ 1862 │ │ │ 56·7│ │ 1863 │ │ │ 60·6│ │Queen Charlotte’s Lying-in Hospital,│ │ │ │ │ 40 years │ 14·3│ 5·3│ 19·6│ │27 London workhouses, in which both │ │ │ │ │ deliveries and deaths have taken │ │ │ │ │ place │ 4·1│ 2·1│ 6·2│ │40 London workhouses, including │ │ │ │ │ those without deaths, 5 years │ 3·3│ 1·7│ 5·0│ │Liverpool Workhouse lying-in wards, │ │ │ │ │ 13 years │ 3·4│ 2·2│ 5·6│ │All England, 13 years │ 1·61│ 3·22│ 4·83│ │Ditto, 64 healthy districts │ │ │ │ │(312,402 deliveries), 10 years │ │ │ 4·3│ │Ditto, 11 large towns (1,402,304 │ │ │ │ │ deliveries), 10 years │ │ │ 4·9│ │8 military lying-in hospitals, 2 to │ │ │ │ │ 12 years │ 3·9│ 3·4│ 7·3│ └────────────────────────────────────┴──────────┴──────────┴──────────┘

_NORMAL MORTALITY AMONG LYING-IN WOMEN IN DIFFERENT COUNTRIES._

The next step in the enquiry is to ascertain, so far as it may be possible to do so, what is the death-rate among lying-in women delivered at their own homes in different European countries. Besides the mortality statistics for healthy districts in England, already given, the only available data for this information are reports of public institutes having outdoor midwifery practice, and any records of private practice which may have been published. In adducing these data, however, it is necessary to do so with the reservation already made that their accuracy is only approximate.

The most extensive series of data of this class is given by Dr. Le Fort in his able treatise ‘Des Maternités,’ for a number of institutions in different European countries. The facts from Dr. Le Fort’s book are abstracted on Table III., in which it is shown that out of 934,781 deliveries at home, in Edinburgh, London, Paris, Leipzig, Berlin, Munich, Greifswald, Stettin, and St. Petersburg, there were 4,405 deaths, equivalent to a mortality of 4·7 per 1,000. When compared with the Registrar-General’s returns for town districts, this rate is apparently somewhat too low; it is only an approximation, but still sufficiently near the rate given by the Registrar-General to show that there is a true death-rate for home deliveries not far removed from the Registrar-General’s figure.

TABLE III.—_Table Showing the Death-rate from all Causes amongst Women Delivered in their own Homes._ (_Abstracted from Dr. Le Fort’s Tables._) ┌────────────────────────────┬───────────┬──────────┬────────┬────────┐ │ Places │ No. of │ │ │ Deaths │ │ │ Years of │ │ │ per │ │ │Observation│Deliveries│ Deaths │Thousand│ ├────────────────────────────┼───────────┼──────────┼────────┼────────┤ │Edinburgh │ 1│ 5,186│ 28│ 5│ │London: │ │ │ │ │ │ Westminster │ │ │ │ │ │ General │ │ │ │ │ │ Dispensary │ 11│ 7,717│ 17│ 2│ │ Ditto Benevolent│ │ │ │ │ │ Institution │ 7│ 4,761│ 8│ 1│ │ Royal Maternity │ │ │ │ │ │ Charity │ 5│ 17,242│ 53│ 3│ │ London │ │ │ │ │ │ population │ 5│ 562,623│ 2,222│ 3·9│ │ St. Thomas’ │ │ │ │ │ │ Hospital │ 7│ 3,512│ 9│ 2·5│ │ Guy’s Hospital │ 8│ 11,928│ 36│ 3│ │ Ditto │ 1│ 1,505│ 4│ 2│ │ Ditto │ 1│ 1,702│ 3│ 1·7│ │ Ditto │ 1│ 1,576│ 11│ 6│ │Paris: │ │ │ │ │ │ 12th │ │ │ │ │ │ Arrondissement│ 1│ 3,222│ 10│ 3│ │ Bureau de │ │ │ │ │ │ Bienfaisance │ 1│ 6,212│ 32│ 5│ │ Ditto │ 1│ 6,422│ 39│ 6│ │ City of Paris │ 1│ 44,481│ 262│ 5│ │ Ditto │ 1│ 42,796│ 226│ 5│ │Leipzig Polyclinique │ 11│ 1,203│ 13│ 10│ │Berlin „ │ 1│ 500│ 7│ 14│ │Munich „ │ 5│ 1,911│ 16│ 8│ │Greifswald „ │ 4│ 295│ 6│ 20│ │Stettin „ │ 17│ 375│ 0│ 0│ │St. Petersburg │ 15│ 209,612│ 1,403│ 6·6│ ├────────────────────────────┼───────────┼──────────┼────────┼────────┤ │ Total │ │ 934,781│ 4,405│ 4·7│ └────────────────────────────┴───────────┴──────────┴────────┴────────┘

St. George’s Hospital Statistics for ‘the 6 years preceding 1870 show only one maternal death in every 305 cases’ in the Out-door Maternity Department.

From home records, it is hoped at some future time to give many more data of this kind, and to distinguish the causes of death: puerperal from non-puerperal mortality, as well as that caused by puerperal diseases from that caused by accidents of childbirth. At present the data for doing this are lamentably deficient, if not almost altogether wanting.

One good recorded fact will here be given. Among 1,929 mothers delivered at home by Guy’s Hospital in 1869, 5 deaths only are recorded, and none from puerperal diseases; 2 were from heart disease, 2 from pneumonia, 1 from exhaustion.

_OBJECTIONS TO THE DATA._

The value of the Registrar-General’s results, and of those given by Le Fort, has been called in question by Dr. Duncan in his work already cited, partly on the authority of certain results of home practice, quoted from Dr. M’Clintock, who has collected the statistics of 16,774 deliveries exclusively from home practice. There were among these 45 deaths from accidents of labour, 52 deaths from puerperal diseases, and 34 deaths from non-puerperal diseases; giving a total mortality of 131, or nearly 8 per 1,000. On considering these figures, the first impression they convey is not that either the Registrar-General or Le Fort is wrong. But it is a very painful impression of another kind altogether. One feels disposed to ask whether it can be true that, in the hands of educated accoucheurs, the inevitable fate of women undergoing, not a diseased, but an entirely natural condition, at home, is that one out of every 128 must die? If the facts are correct, then one cannot help feeling that they present a very strong _prima facie_ case for enquiry, with the view of devising a remedy for such a state of things. It must be seen, however, that these statistics of home practice are as open to the charge of want of accuracy as those of the Registrar-General or Le Fort. The question can only be settled by enquiry, and by more carefully kept statistics of midwifery practice; but in the meantime here are a few facts, kindly placed at my disposal by Mr. Rigden, of Canterbury, which are by no means so hopeless as those given by Dr. Duncan.

‘An analysis of 4,132 consecutive cases in midwifery occurring in private practice during a period of 30 years, particularly in reference to mortality. Eight mothers died: three from convulsions and coma; 4 from puerperal fever; and one from heart disease, about an hour after a comparatively easy labour.’

The report states 8, but after it was supplied another death took place, the day after delivery, making 9 in all. The cause of death is not given.

Mr. Rigden explains that these figures relate only to the first fortnight after delivery; but he states that if any other deaths had taken place within the month, he must have heard of them.

Assuming the Deliveries at 4,133 and the Deaths at 9, Mr. Rigden’s facts show a total mortality of 2·17 per 1,000, of which less than 1 per 1,000 was due to puerperal fever.

_ESTIMATED APPROXIMATE HOME DEATH-RATE._

In estimating the probable accuracy of statistical data in which there may be both excesses and deficiencies, sources of error are diminished by largeness in the numbers employed in striking averages. Bearing this in mind, and after considering the objections brought against the accuracy of the figures, there seems no reason for rejecting the Registrar-General’s average total mortality among lying-in women in England of 5·1 per 1,000, as affording a sufficiently close approximation to the present real death-rate among lying-in women delivered at home, for all practical purposes of comparison with the death-rates in lying-in hospitals.

_DEATH-RATES IN LYING-IN INSTITUTIONS._

We shall next show approximately what are the death-rates in establishments for lying-in women.

We will give an abstract of mortality statistics for a number of these institutions, the general results of which may be stated as follows:—

In eight military lying-in hospitals (Table IV.), in which 5575 deliveries took place, in periods of from 2 to 12 years, there were 50 deaths (excluding a death before admission)—a death-rate of 8·8 per 1,000.

TABLE IV.—_Return of the Number of Admissions for Parturition, and Deaths occurring in the undermentioned Women’s Hospitals (Military)._ (_Supplied by the Director-General, Army Medical Department._)

┌───────────┬──────┬──────────┬───────────────────────────────────┐ │ Station │Period│ No. of │ │ │ │ │Deliveries│ Causes of Death │ ├───────────┼──────┼──────────┼────────────┬──────────┬───────────┤ │ „ │ „ │ │ Puerperal│ │ │ │ │ │ │ Feve and│ │ │ │ │ │ │Peritonitis,│ │ │ │ │ │ │ Pyæmia,│ │ │ │ │ │ │ Phlebitis,│ │ Puerperal│ │ │ │ „ │ &c.│Scarlatina│Convulsions│ ├───────────┼──────┼──────────┼────────────┼──────────┼───────────┤ │Devonport │April │ │ │ │ │ │ │1861 │ │ │ │ │ │ │to │ │ │ │ │ │ │Dec. │ │ │ │ │ │ │1869 │ 158│ │ │ 1│ │Colchester │1865 │ │ │ │ │ │ │to │ │ │ │ │ │ │Oct. │ │ │ │ │ │ │187 │ 252│ │ │ │ │Portsmouth │1861 │ │ │ │ │ │ │to │ │ │ │ │ │ │Dec. │ │ │ │ │ │ │1869 │ 302│ 2│ │ 1│ │Aldershot │1857 │ │ │ │ │ │ │to │ │ │ │ │ │ │Dec. │ │ │ │ │ │ │1869 │ 3,028│ 14│ │ 1│ │Shorncliffe│Up to │ │ │ │ │ │ │Dec. │ │ │ │ │ │ │1869 │ 702│ │ 1│ │ │Chatham │Dec. │ │ │ │ │ │ │1863 │ │ │ │ │ │ │to │ │ │ │ │ │ │Dec. │ │ │ │ │ │ │1869 │ 342│ │ 2│ │ │Woolwich │Nov. │ │ │ │ │ │ │1863 │ │ │ │ │ │ │to │ │ │ │ │ │ │Dec. │ │ │ │ │ │ │1869 │ 751│ 5[5]│ │ │ │Curragh │1868 │ │ │ │ │ │ │and │ │ │ │ │ │ │1869 │ 40│ │ │ │ ├───────────┼──────┼──────────┼────────────┼──────────┼───────────┤ │ Total │ │ 5,575│ 21│ 3│ 3│ └───────────┴──────┴──────────┴────────────┴──────────┴───────────┘

┌───────────┬────────────────────────────────────────────────────┐ │ Station │ │ │ │ Causes of Death │ ├───────────┼───────────┬────────┬──────────┬─────────┬──────────┤ │ „ │ │ │ │ │ │ │ │ │ │ │Premature│ │ │ │ │ │ │ Labour│ │ │ │ │ │ Syncope│ and│ │ │ │Hæmorrhage,│Ruptured│ and│ Adherent│ │ │ │ Effects of│ Uterus│Exhaustion│ Placenta│Craniotomy│ ├───────────┼───────────┼────────┼──────────┼─────────┼──────────┤ │Devonport │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │Colchester │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │Portsmouth │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ 1│ │Aldershot │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ 4│ 1│ 4│ 1│ 1│ │Shorncliffe│ │ │ │ │ │ │ │ │ │ │ │ │ │ │ 1│ │ │ │ 2│ │Chatham │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │Woolwich │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ 1│ │ │ │Curragh │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ├───────────┼───────────┼────────┼──────────┼─────────┼──────────┤ │ Total │ 5│ 1│ 5│ 1│ 4│ └───────────┴───────────┴────────┴──────────┴─────────┴──────────┘