MATERNAL MORTALITY IN CHILDBIRTH.
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fronted with the treatment of a difficult complication in of insanitation, overcrowding, deficient water-supply, or lack of effective lighting cannot apply those surgical principles which are so essential to prevent disaster. It is in this connexion that adequate antenatal supervision is so all-important. In the Sir GEORGE NEWMAN to the note by prefatory made fact is the clear abundantly Ministry’s report that no sound progress can be made in the reduction of maternal mortality apart from antenatal supervision. It is an astonishing fact that the event of childbirth, the most clearly foreseen of all "illfor. How often nesses," is inadequately prepared does an expectant mother " book " with her selected doctor, midwife, or maternity home, but fails to submit herself to the only safe method of control-
the presence
THE
LANCET.
LONDON:: S’AT URDAY, APRIL 19, 1924.
MATERNAL MORTALITY IN CHILDBIRTH. THE publication of the Ministry of Health report by Dr. JANET CAMPBELL upon the results of an inquiry into the question of maternal mortality must serve
one of the most serious which confronts the medical profession problems Whilst the death-rate has been general to-day. reduced since the beginning of this century by almost namely, systematic antenatal supervision Antenatal supervision implies a competent knowone-third, and the infant mortality-rate during the first year of life actually halved, it is a matter of ledge of all the accidents that may befall a woman her pregnancy and labour, and this requires concern that the maternal deaths associated with during a very thorough training not only in theory but in childbirth are practically the same to-day as they That the problem is very real practical obstetrics. The General Medical Council were 20 years ago. will be appreciated from the fact that approximately has taken cognisance of this fact in its recent recom3000 mothers in England and Wales lose their lives mendations and resolutions in respect of the professional examinations, assigning to the training of annually from what should be a purely physiological In a function. recent issue1 we reviewed briefly midwifery and gynaecology a status not inferior to Dr. CAMPBELL’S work, but the importance of the that of medicine and surgery. The medical schools are issues involved calls for a further reference to this to-day taking steps to put these resolutions into effect, valuable and painstaking report, a document which and the practitioner of to-morrow will not be able should be in the hands of all interested in the well- to say that he was taught surgery which he never and that he practised midwifery which he being of women and children, and which for this practised had never been taught. With improvements in the reason has been issued at the modest price of Is. education of the medical student, a better training The factors in the causation of this excessive of the midwife must hand-in-hand. Inasmuch go mortality, as the report points out, are numerous and complex. Puerperal sepsis in its various forms as the responsibility of the maternal welfare is shared medical profession and the accounts for by far the largest number of deaths. equally between the it is of the midwives, highest importance that the Next in order come the toxæmias of pregnancy, and the latter should of qualify them adequately training finally, haemorrhage takes its toll of victims. In all to such accept responsibility. Since the passing of these conditions it is obvious that factors are at work the Midwives Act in 1902 it is a matter for which, in the words of the report, " are more or less that so little improvement, if any, has been regret directly controllable and should be controlled." noted in the maternal statistics. In a series of 256 In other words, the problem with which the country is faced is rather one of organisation and education unselected cases of puerperal fever recorded by than of principles directly concerned with current Dr. CAMPBELL, in an appendix to her report, it is obstetric practice. That it is possible to conduct noted that 102 cases occurred in the practice of midwives as against 86 in which delivery was midwifery satisfactorily, and with little or no maternal effected alone, a doctor. by Figures such as this point to in humble and even the mortality, insanitary dwellings the of importance securing for a pupil-midwife the of the very poor, is proved conclusively by the reports best possible training over a sufficiently long period. of the extern departments of the various lying-in What this should be is a question which has period charities. In the clinical report of the Rotunda continued to engage the attention of the Central for 1922-23 issued we note that in recently Hospital the extern department in a series of 1824 cases the Midwives Board since the Midwives Act was passed. maternal mortality was 0-21 per cent. In the same There is no doubt that the original period of three months’ training was inadequate, and it is perhaps report, dealing with the intern department, Dr. G. FITZGIBBON calls attention to the evil results of questionable whether the present revised regulations bad midwifery in the following words : " Several are sufficiently stringent to deal with the grave problems involved. When it is remembered that cases were admitted in a moribund state, while five puerperal sepsis is the main cause of maternal mortality were admitted profoundly septic after protracted or and that it takes the medical and nursing to-day, labour." Of considerable interest in complicated this connexion is Dr. CAMPBELL’S observation that professions many years to assimilate the tenets of and aseptic technique, it is asking a great insanitary surroundings have probably much less antiseptic direct influence upon puerperal mortality than is deal of an uneducated woman to accept and practise those canons at the end of a few months’ training. generally supposed, and that unless infection is We are in absolute agreement with Dr. CAMPBELL introduced frcm without it does not appear, that in total abolition of the so-called at the aiming a woman who is accustomed to a low standard of woman, and with the suggestion that there handy is more to after an living prone develop sepsis ordinary confinement than one in a more hygienic dwelling. should be much closer cooperation between the Even if this is the case, there can be little doubt, doctor and the trained midwife. Cooperation on the suggested by Dr. JOHN FAIRBAiRN of shifting however, that uncleanliness and insanitary dwellings lines to the midwife those parts of medical service which and do in disaster the event of obstetrical may spell any are least essential, and relieving her of the responsioperation being necessary. The practitioner con- bilities of those which are most essential, would go a long way in removing many evils which at present 1 THE LANCET, April 5th, p. 716.
to concentrate attention upon
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Every prospective mother should have thf advantage of a considered medical opinion during her pregnancy, although the actual conduct of normal labour might safely be left in the hands of an efficient midwife. In other words, it is the duty of the medical profession to prevent disaster, and prevention can only be secured by adequate preparation and supervision. Midwifery so conducted should not unduly tax the time of any doctor, since antenatal and postnatal observations can, in the words of the report. " be carried out without conflicting with the claims of other patients " ; a very important factor in the day of the busy general practitioner. By contrast the time and energy that have to be devoted to coping exist.
with individual cases which, for whatever cause, have been allowed to progress too far without supervision is great indeed. Such cases form the bulk of those to which the practitioner is summoned by the midwife in distress, and we propose shortly to issue a special supplement designed to help him to deal With the adoption of an improved with them. antenatal and midwifery service on cooperative lines between midwives and practitioners, increased facilities must also be provided for dealing with obstetric problems. Where danger is anticipated there should be no obstacle in securing the services of adequate assistance whether it take the form of accommodation of a hospital bed, the provision of efficient nursing, or the help of a skilled obstetrician. The report of the Ministry calls attention to the fact that the returns of large cities such a,s Birmingham, Manchester, and Liverpool, where maternity work has been organised over a long period, show that systematic efforts over the whole country would undoubtedly lead to an appreciable saving of maternal life and health. It should not be to financial and other overcome the impossible difficulties involved in the building of a complete maternity service. A great deal has been accomplished within recent years in the reduction of infant mortality, and it can be anticipated with confidence that a similar concerted effort would result in a like benefit to the mothers of the nation. Dr. CAMPBELL is to be congratulated upon the work she has accomplished in accumulating such a mass of evidence and putting it forward in such a convincing manner.
THE THERAPEUTIC SUBSTANCES BILL. ON April 8th the Therapeutic Substances Bill was second time in the House of Lords. Under its provisions the manufacture and sale, by those who are not medical men, of vaccines, sera, salvarsan and its substitutes, insulin, and pituitary extract can only be carried out in this country under licence granted by the Minister of Health, and importation from abroad is restricted in conformity. Few of the many vaccines. sera, toxins, antitoxins, and antigens are at present capable of accurate titration. The potency of diphtheria and tetanus antitoxins, however, can be determined with a high degree of accuracy. In respect ,of these substances, powers similar to those sought for under the proposed Bill were secured in Germany in 1896 and in the United States in 1902. Diphtheria toxin to be used in the Schick test for susceptibility and toxin-antitoxin mixtures for immunising purposes should also be carefully evaluated before they are sold. There are, as yet, no accurate well-established m ;thods for determining the potency of therapeutic sera such
read
as
a
anti-dysentery
serum
and
anti-pneumococcic
serum, and in the case of vaccines all that is possible at present is to determine the number of organism:;
in
certain volume of the preparations. The firms manufacturing antitoxins and vaccines in this country are of high reputation and have supplied trustworthy products for many years, so that it may appear that the need for the control of the supply of these substances is not urgent. At any time, however, similar products may be imported from abroad, and in the absence of such legislation as is contemplated there is no m3ans of ensuring their purity and potency. There is reason to suppose that steps to control all these preparations will be welcomed by British manufacturers. For the remaining substances, except pituitary extract, control of a temporary nature exists already; a fortuitous circumstance has in the case of salvarsan and insulin enabled advantage to be taken of the patent laws to obtain a check on the manufacture. In the case of salvarsan, the circumstance was the outbreak of war ; at that tim3the supply of German salvarsan was cut off, and British manufacturers who had facilities for making it applied to the Board of Trade for licence to do so, in order to protect themselves from the possibility of post-war litigation for infringement of German patents. It was made a condition of holding such licences that the products should be subjected to biological tests designed to exclude unduly toxic samples, to be carried out by the Medical Research Council. After the war this arrangement cam to an end, and as a result of Board of Trade negotiations the manufacturers continued production with licences granted directly by the German patentees. Biological control of salvarsan and neo-salvarsan would then have stopped but for the circumstance that the Ministry of Health was the largest purchaser of these substances ; on this account the German makers were induced to insert in their licence to British manufacturers a clause providing for biological control of all products of this nature. At present, therefore, the accident of the war has enabled the Ministry of Health to persuade the German patentees to demand from the British makers biological control. To such circuitous courses does the absence of legislation lead. However, in a short time the salvarsan patents expire, and, as matters stand, the present checks will disappear ; those who are familiar with the reports of the Salvarsan Committee are aware that it will be easy in that case for serious changes in the toxicity and therapeutic value of the preparations to occur, however carefully and conscientiously the chemical preparation is effected. Control exists at present also for insulin, but again because of the accident that the original patent-holder is the University of Toronto, a body concerned to see that the manufacture of insulin is carried out for public rather than private interest. The patent rights in this country were offered to and accepted by the Medical Research Council for the very reason that as no legislation such as this Bill contemplates existed in England, it was only by holding these rights that any control over the efficiency and uniformity of the product sold could be maintained. There are those who have expressed doubts whether the part played by the Medical Research Council made for a rapid and adequate supply of insulin to diabetics ; to such we may recommend an inspection of the state of affairs in France, where, in the absence of central expert control, the insulin supply still remains inadequate. untrustworthy, and expensive It is not sufficiently realised that the large-scale manufacture of products such as insulin and pituitary extract is a comparatively new problem, which is almost as much outside the realm of a pure chem:st as is a surgical operation, so that even the largo manufacturers of drugs have been for the most part without the skill and experience necessary a