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Mortality associated with maternity
MORTALITY FRED
ASSOCIATED I,.
ADAIR,
WITH
Ml).,*
MATERNITY
XAITLANI+
FLA.
T
HE casualties associated with maternity are relatecl to empiric experjence and scientific knowledge and the interest in and ability to apply such knowledge. Empiricism may or may not be confirmed by subseyuent esperi7TnIess there is interest in receiving t11c beneence or scientific investigation. fits of such experience and knorvletlgc and applying them by those who are responsible for their utiliza,tion the results are negligible. If they are applied to the few by the few then the results are limited, but if generally used the> become of great interest and value. For progressive improvement, certain ideas must prevail : (I) t,he et11piric and scientific knowledge must he sound, (2) it must, he applicable, (:3) it, must 11~ applied, (1) the a,gent must, he informed and capableF (5) the agencies must he avsilahle. (6) the recipients must be willing and cooperntire, (7) thr &sting of esist.ing knowledge irmi lltethotis must i)e continuous, (8 1 Ihe stla~h for new facts must 1~ ctmstant, ( 9) the subst,itution of provecl new knowledge for older unsubstantiated ideas Inust be made, (10) the expansion of ecluc~~tional and institutional facilities must IW commensurate with the nerds. Maternity presents a unique I)rohlem in medical practice hecn.use two individuals, tnother and fetus, have their healt,h and lives involved at the same time. The saving of one may involve hamds which may result in disability or death for the other. At times this involves critical decisions hased LI~OJ-I personal attitutles, professional ethics, legal or ethical or religious concepts. Fortunately, medical progress has ui;aIe the liec>essity for suc~h dwisicms less frequent now than tlurjng past cleca.tles and caenturies. The scope of this discussion will lw litnitetl primarily to the present wtury and in subject matter it will be genrml and iherc will not 1~ elahurate stat,istica.l presentat,ions or analyses. SOIIIC trentls will of necessity 1~ iItclncled relative to feta,l, neonata.1, ant1 trlaternal mortality. As n hac*kground, certain historical references will he rnatle to (aertain Fn~tors which have tendctl to impede or accelerate progressive improvement. One factor has been the resistance on the part of solve to the apc*ept;ltlc*cb of newer ideas which tended to ~~e~f.lmfw /,rrv;tiling ~~nccpts. ‘pjie espet+ences of such protagonists as Holmes. Semmelweiss, and Pastcur illustrate this point. The contagiousness of puerperwl fever was clearly recognized by Holmes about 1843. His deductions from study of clinical experiences were clear and COltVillCillg bUt met Wit11 opposibion from clinicians of promillence, ltTh,-, should have heen persuaded hy his logical reirsoninp that this (ljscase T+-as conveyed of
TEmeritus ChIcago.
Mary
Cammu
R~erson
Professor
of “0
Obstetrics
awl
Cynccolcgy,
~hc
University
MORTALITY
ASfiOt’IATED
TVITH
MATERNJT-i
21
ptients by contaminated hands of the attendants. A few years later Semmelweiss by carefully made comparative clinical studies should have convinced his colleagues that the disease was carried by unclean hands from the autopsy r00n1 and diseased patients to those new patients who subsequently came under care. His ideas were not accepted generally and met, with much skepticism even in the higher medical circles. Some 30 years later Pasteur ushered in the bacteriologic era and the scientific basis for the contagion was established. Even then there were many skeptics, and others unfamiliar with this knowledge. Many of those who were graduated from the medical schools prior to 1890 received inadequate medical education and clinical experience in the schools and under preceptors who were poorly qualified and not abreast of the newer knowledge. Many of these men continued to practice well into the present century. Through the work of Pasteur, Koch, Lister, and others, bacteriology became an established science and a part of clinical medicine and filtered into the medical schools after 1900 often as a stepchild of pathology. There were many low-grade medical schools (diploma mills), but even those who were graduated from the better schools prior to 1890 had little basic knowledge of bacteriology. At that time there were practically no facilities for postgraduate or continuing education. These earlier graduates had little opportunity for subsequent education in the basic sciences or in clinical training. A technical advance of great importance contributing to clean hands was the introduction of rubber gloves. Their use met with the opposition of some who felt that they interfered with dexterity and the tactile sense. Improvement in the gloves themselves and the gradual extension of their use in hospitals and eventually in home deliveries have contributed greatly to the safety of deliveries. The important factor was that the infectious theory of diseases involved, in the minds of those educated during the nineteenth century, a fundamental change in their ideas regarding the causation and spread of these contagious Their practice was naturally influenced dominantly by their educadiseases. tion and training. It seems fair to conclude that this present century ushered in a marked change which among other things had a favorable but gradually developing influence on the incidence of puerperal fever. Statistical reports at the national level, as issued by the National Office of Vital Statistics, of the new Department of Health, Education and Welfare, give much valuable information but the more specific it is the less accurate it is likely to be because detailed and reliable data are dependent upon the comThis material has become propleteness and accuracy of the original reports. gressively more accurate and inclusive as the years have passed since 1900. It is logical that death reports shoulcl be the first to be accumulated at the national level and these are of some value as far back as 1900. The Registration Area was started in 1915 with 10 States and the District of Columbia. Birth and death reports are not given for the continental United States until 1933. Prom 1915 to 1932 this area was an expanding one and certain estimates were made to show the national picture. During this time certain procedures have been changed so that the data from year to year had to be to
adjusted according to certain set rules regarding live births. stillbirths, tleat Its. etc., and their causes, thus affecting the rclativc frequency in cdertain (*ai egorios. Ra.tes are set 17~ for comparison of deaths from variolls V:I~M~.S l)as~‘cl upon polmlation, live births, either estimated or reported. and tlepe~~tling IIJJC~II the purpose for which the clata arc used. R;ltes should not. he c:~~~~i*usetlwilh percentages. Data, relative to stillbirths (f&l (leaths) are given beginning in 1942 aJJfl now include those of 20 weeks’ gestation or more born without sign (lf life. The it~c,)Jnpletetless and inaccuracy of these reports is probably c~~JiSicb?J’;lI)lt’ l)ut like other reports they are improving year 1)~ year. The mass data (lo, however. show certain trends which are important am’1 clea,rly (Ietnot~strate the improvement in obstetric practice 3s meaS7md l)y Maternal mortality rates in 1915 lowered mortality of mothers and infants. There was a precipitous rise to over 91. were about 61 per 10,000 live births. during the years of World War I, due to epidemic infections, but the rate was persistently higher, ranging between 62 ancl 80, until 1934 when it was a little above 59. Since then the decline has heen steady until now the rate is below 10 per 10,000 live births. Jt seems obvious that something must have happened about 1930 to cause this rapid improvement.. A general improvement in health conditions is shown by the progressive reduction in total mortality per 1,000 of population, from 37.2 in 1900, to 18.2 in 1915, to 10.9 in 1932, and less than 10 since 1948. The infant death rate has shown a progressive downward trend since 191% but the drop is not as abrupt as that for maternal mortality. One of the most striking changes since 7930 has been the rapid increase in In the early thirties the percentage of the number of hospital deliveries. deliveries in the hospital was about 35 but at t,he present time it is over 90 for the nat.ion at, large and nearly 100 per cent iu many a.reas, especially the metropolitan. This has been accompanied by a reduction in t,he total number of deliveries by midwives who now deliver less than one-third as many as in 1930. with a corresponding increase in the number of deliveries by doctors mostly in hospitals. It is interesting to note that the fetal death rate (stillbirths) in terms of’ live births varied only slightly from 1922 to 1930, the low being 38.1 in 1925 and the high 40.2 in 1928. Since 1931 there has been a steady reduction from 38.2 to 22.9 in 1950. This is probably even greater as there is uncloubtecll~ more complete reporting, especially of earlier gestations, with the increased number of hospital deliveries. Tt would he logical to expect a corresponding reduction in the rates of neonatal dea.ths, which include those during the first month of life. This rate was 41.5 (1920) per 1,009 live births, the low rate was about 24 in 1932, in 1933 it was approximately 32, in 1940 around 30, and by 1950 it was 20.5. During this period the deaths under one day remained rather constantly at a rate of about 15 from 1915 to about 10 in 1950. There is room for considerable error in evaluating these reports as the statistical practices have changed and are still far from uniform in the various states. There is confusion between live birth and stillbirth or fetal death which was greater in times past than it is today; there are also errors relative to the gestational age and signs of life. Earlier there was no separate stillbirth certificate but instea.tl there way a birth certificate and an ordinary death certificate to be filled out for each stillbirth. It is therefore difficult to show accurately trends in fetal (lea,ths an,1
early infant deaths. There does seem to be a definite improvement since the thirties though it is not as marked for the first month of life as for the subsequent eleven months. It hardly needs mentioning that now more of this neonatal period would be spent in the hospit,als, especially by the premature% Their mortality rate is obviously high. Hospitalization does not necessarily mean greater safety but it is a means to that end. There have been some in the past who have argued that it was safer, from t,he standpoint of infection, to br at home rather than in a hospital. That may have been true in the past but now it would seem to be no longer valid. Increased hospitalization has undoubtedly been an important factor in the retluction of the mortality of mothers, fetuses, and newborn infants. There has been a fundamental change responsible for the increased hospitalization which is the development of the idea that health is a community responsibility and t,hat mothers and their babies are entitled to better and more complete care. .lncreasetl hospitalization required an increase in the number of available beds by remodeling, additions, or new construction, or a.11of these. This was necessary even though the number of births remained about the same but there was also a marked increase in the total number of births. The estimated number in 1915 was 2,965,OOO ; 2,155,105 were registered in 1935, with a progressive increase to 3,632,OOO in 3950. In 1935, 36.9 per cent were delivered in hospitals but in 1949 the percentage was 86.7 which means a numerical increase of 3,404,424 deliveries. More recently some institutions have favored the earlier discharge of patients which would mean that more women could be (lelivered during a year. There are many factors which have contributed to t,his increased utilization of hospitals but undoubtedly the chief one is that it is possible to obtain better care for mother and babies, especially premature infants. The recognition of maternal care as a community problem, instead of solely as an individual relationship between a doctor and a patient. is one of t,he most important factors in the reduction of maternal and infant mortalit,y during the current century. Complete and adequate maternal care which is being developed in practically all areas of the United States has ushered in an era of prophylactic obstetrics. A beginning was made in Boston about 1901 by cooperation between the Instructive Visiting Nurse Association and the Boston Lying-in Hospital in the establ&hment of home visits on prospective maternity patients. An early, if not the first, attempt at citywide coverage for maternal care was started in Minneapolis, in 1911. This was a cooperative program involving the Municipal Hospital, The Department of Obstetrics and Gynecology of the University of Minnesota, The Visiting Nurse Association, and the Infant Welfare Society. It included prenatal and postnatal clinics, home and haspita1 delivery, and puerperal care, with nursing and medical attendants. These clinics were available for the education of medical students and nurses. Home nursing as well as hospital care was available to practitioners for their private cases. At that time hospital facilities were not available for all of these patients but hospital facilities have been gradually increased so that now midwife care and home deliveries have practically disappeared. This program was extended to practically the entire state of Minnesota, as is true of many other states. In 1933 about 43 per cent of all births were in hospitals and in 1950 it was 98.3 per cent. In 1936 doctors attended 96.7 per cent of the births and in 1950 it was 99.8 per cent. A mortality study made in 1941-1942 showed a maternal mortality rate of 2.0 per 1,000 live births and a similar study in 1950-1951 gave a rate of 0.6.
ln other states the situation is more complicated largely due tcl I’~CV ilIk( I environmental conditions. In Georgia, for esample, though the maternal 11iortality rate has hcen remarkablv rducwl, tttuclt remains to bc doltct. 111 l!CH1 this rate was 109 per 10,000 iivc births, in 19% it was 72, ant1 in i!W it was 13.2, but the rates for white antI nonT;.hite were 5.9 ant1 25.X. rt~spec*tivc81y. If this is viewed from anot,her angle, one-third OP t,he live births were in the nonwhite, l)ut 70 per cent, of the Illittel.llill cleaths occurred in the nonwhil(~ group. fn 19% the relative percentage of maternal tleaths atnortg whites illit nonwhites was 52.8 and 1’7.2, so ii is il],])al’etlI that, there was a greatc,r itnIt1 1935, 86 per cc11t oi’ 111~‘ provcmcnt among the former than the latter. 1II whites were confined hy physicians :rntl 21 per’ c+etlt of the nonwhites. 1952 t,he corresponding percentages were !)8.5 and 59.S. Hospital deliveries for* the whites were 95.2 per cent and For the nonwhites the I)ercentage was 44.0. All causes c~f maternal deaths are nio~‘e ])rrvalent for the nonwhites thiltt for* the whites, indicating a lower ]evcl ot’ totill rl~aterna] ~a1.c for. thtalll th:IIt fog the whites. Infant mortality is of interest to all Imt t,he neonatal Illorlality is of special importance in connection with ltl~lt~~~tlill ant1 obstetric (‘:Lrr. I’l’em;L turity remains as the principal problem so fill* as infant mortality is con~t*ned though per se it should not be consi(leret1 as the cause of death. ln Minnesota in 1950, Xi per cent of’ the neonatal deaths o~nrred in t,he ])rematnre gr0~1) The causes of’ these tleaths. as statctl and 65 per cent were in the term illl’il?ltS. on the death certificates, unless confirmetl by autopsy, are not, very accurate. It is of great importance to determine from ctlillical history ant1 auto])sJ thtL real (pauses of these deaths. Unt1t.r il. grant from the United States I!hiltlretl’s Bureau a study was undertaken :It the Irniversity of Mitnlesota. Ix?ginniiig about 1920, to check the causes given on the cleath certificates with Ihr clinicill hist,ory and the findings at autopsy. It was not always ])ossihle to tleterniine the causes even then but the findings ~m~vetl thiit the Causes assigned on the J,ater, after 1931, death certificates were both incompletje and inaccurate. similar studies were l,egun at, the University of (‘hicago and esp~~detl with the coo])eration of the Chicago Board of IJealth am1 others. Obviously :I knowletlge of the causes of death is essential before ;Iny preventive 01’ cul’iltlV(’ measures can be established. These causes may arise from hereditary, congenital, int,ranatal, or ]WSInatal conditions. Malformations, birth injury, and anosia are among thcl mador CilUSt?,S. No\v all infants born with any sign of life Itrust, be re],ortet/ ils ]i~el)()~*ll even though those of less than 2X weeks’ gestatiou and weighillg less than 1,000 grams have little chance of survival. Most of these shonl(l lw I)l;lcetl ill a previable group as they are not, equipped for extrauterine life. ‘l%use 01 lesser weight fall into the abortion group which together \vith th(,sc (alas& as previable make up ;I large number which may ],e c:onsideret/ as fetal \vastage. The problem of abortion is a c~omplicat~ed one in\-olving me
her of abortions. In 1949 of the 3,216 maternal deaths, 394, or 12 per cent, were attributed to abortions and in 1950 of 2,960 maternal deaths, 316, or 10.7 per cent, were assigned to abortions; of the latter, 108, or about one-third, were admittedly induced for legal or unspecified reasons. Sepsis was the assigned cause in 66 per cent in 1949 and 60 per cent in 1950. The Maternal Mortality Study of the Children’s Bureau of 1927-1929 comprised 7,380 maternal deaths. Abortion was a factor in about 24.5 per cent of the cases, and infect,ion was the cause in over three-fourths of the cases. It appears that the reduction of maternal deaths from abortion and its complications has been a factor of some importance. In this study there was a total of 2,948 women who died of puerperal septicemia, of whom 618 were delivered in the hospital and 2,299 were not. Sepsis developed in the hospital in 181 ancl outside in 1,262. The rates were definitely higher in the rural areas than in the urban and among the nonwhites than the whites. The technique was more nearly and more frequently but not always more satisfactory in the hospitals than in the homes. Among .4,965 women who were delivered in the last trimester, only 1,740 were known to have had satisfactory aseptic technique. Rubber gloves were used, for vaginal examination and delivery in 3,162 of these women but the prior examination without the use of rubber gloves by midwives or doctors is not excluded. In any case the use of rubber gloves does not, per se, rule out poor technique as they are simply a safeguard if properly usecl. This study also showed that the rate per 10,000 live births was higher in rural than in urban areas which was particularly true of deaths from infection and during There was little difference in the rates of death the first two trimesters. from t,oxemias. The rates for the nonwhites were about twice as great as those for the w-bites, which ~vas pan~ticularly true of deliveries in the last trimester. Our national statistics show the rates for puerperal deaths per 10,000 live births in 1930 were 67.3, for the whites 60.9, for the nonwhites 117.4. By 1949 these rates were reduced to 9.0 for all races, 6.8 for the whites and 23.5 for the nonwhites. For the urban areas of 10,000 or more population the rates were 7.4. for the whites 5.7, for the nonwhites 19.2. the corresponding rates for the rural areas were 11.4, for the whites 8.4, for the nonwhites 28.9. There may be some racial differences but it appears logical to conclude that environmental conditions played a very considerable role. Among these factors are the increased percentage of care by physicians, from less than 40 per cent in 1935 to about 95 per cent in 1949, the increased percentage of hospital deliveries from 36.9 to 86.7 per cent in the corresponding periods. The percentages for the corresponding periods for the whites were 39.6 per cent ancl 91.6 per cent and for the nonwhites they were 18.2 per cent and 55.1 per cent. The care by physicians for the same years was for the whites 93.6 per cent and 98.5 per cent and for the nonwhites 44.6 per cent ancl 71 per cent, respectively. The number of deliveries by midwives diminishecl proportionately but some midwife cases were eventually delivered by physicians. In addition to these environmental conditions there are many for which the physicians cannot assume responsibility, such as poverty, ignorance, with the accompanying faulty nutrition, housing, clothing, etc. Some of this can he overcome by better lay education and improved facilities for health to which physicians can contribute as good citizens but governmental and voluntary agencies must assume the major responsibilities. An important role has been played in the clevelopment of better materrlal care by voluntary and governmental health and welfare agencies at local, regional, ancl national levels. Most important have been the activities of the American Medical Association and other professional and lay groups in inl-
proving medical education in general anti more specifically itt t,ht graclu;tl development, of better didactic and clinical teaching and experience irt oI&ett*ics. Another vifal improvement has tJ?en the better hospit,al standartls which have been promotetl by the American Medical Association, the i\tt~~rican ( ‘()IIege of Surgeons. the American ITospit.:tl Association. and ot.hrrx. This has IwI not only to better care of the paticJtts hut also to improrctl tJtluc.atiott att(l training of the various professional gr0ups. particular] y the tnt~dical ;I 1111 nursing personnel. The increased nl~tihty of hospitals &lh interttships anal residencies with maternity servicaes an(l the great,et* use of’ these institutions, stt~at~egic?ally located for student etlucation ;ttttl training, have l~ctl ()I: tt3mendous value in furthering the itttrrest itt ant1 esperience with tttittet*ltil> problems and their solution. 13egintting wit,h this century there seems to have heen at) ittc~reasirtgly This wits not limitecl active interest in the care o-f mothers and their infa.nts. to the T’nited States, as JUlantgnr wrote prophetically in 1!)01i : “The 01)stetrician of ISlO will find it difficult to understand why his ltrethren of thth early part of the century paid so tttuch attention to the oue month of lhr~ puerperal period and so little to t.he ttitte tttonths of ~Jt’d?gsIlittl~‘y.” The American Association for the Stutly ant1 I%\-entiott of In t’nnt Mot.tality (1909-191fi), later the American C!hild Health AssocGttion, was liquitlatecl in ?!)35 after the suc~cessful conelusion of the ‘IVhitt House t ‘onferenct* on Child Tlealth ant1 Protection which hcgan in 1929. (jut of the formrr CWIIIC the ,Joittt Maternal Welfare Vommittee ( I91 9) from which clevrlope(l 1he American C’omntittec 011 Mat~et~nal Welfare. l~lc.. in 1931. The tttemhrt~s of this organization have pal’tiaip;ltetI in tnosl- govet~tllnelltal ;ttrtl \-oll~lltal~~ agency activities pet*t;tining to mat.rt~n;tl (‘are and have sparked tt~any of them. Prohahly the most, important fitci 01’siu the reduction of tttatrrttal. fetal. and infant morhality have heen the :tcquisition and tlisseminatiott of kncr\vJedge and its applicat,ion among professional and lay grwnps. Th;-t 01’the professional group might be called the vet+ic;tI as it, involves the few xvho hec~orne the teachers and practitioners of the 01~1and of t,he new while Ihe tlissemin;ttion of this knowledge and ltract,i
Volllme
Numlw
68
I
hIORTAT,lTP
ASSO(‘lATED
WITH
MATERNITY
27
Along with this there has been a tremendous increase in the number of special obstetrical and gynecological societies and their membership, at local, state, regional, and national levels. The American Congresses of Obstetrics and Gynecology, of which there have been five in the past fourteen years, have brought together specialists, general practitioners, nurses, hospital and public health personnel, and educators to present and to discuss matters of both special and general interest. All of these activities have stimulated greater interest in the acquisition of knowledge both old and new and the search for further knowledge and bett’er means of its applic*ation. The acceptance of the ideas of prevention and their application has been most important and has been made possible by preconceptional and prenatal care. Preparation for the anticipated pregnancy and expected delivery is most important and means not only proper care but also the earlier detection and treatment. of threatening conditions and complications. Personal hygiene, the control of venereal diseases, proper nutrition. the detection and alleviation of toxemias have all been important. Convulsive attacks have been largely eliminated where prenatal care is well established. Proper nutrition is 110~ recognized as most essential in the prevention and correct,ion of certain disorders which complicate pregnancy. These are a few examples of the value of such care. So far as drugs are concerned notable adrances have been made in chemoand biotic therapy and their influence upon the course of infections is great but they should not lead us to slight or ignore the preventive measures which accomplished so much in reducing mortality before their advent. The use of blood is now so commonplace that it is difficult to realize the present safety and availability compared with the situation a few decades ago. Clood banks are most essential and their establishment requires foresight,. Obstetric hemorrhages are often not only sudden but profuse and n1a.y he rapidly fata, unless blood of the proper type and in sufficient quantity is promptly available. These efforts require cooperation, as do many others, such as mortality studies. Such a one was the three-year study of maternal mortality in New York C’ity published in 1930 by the New York Academy of Medicine. This work had a definite effect in reducing maternal mortality by pointing out the preventability of many such deaths. Many of the leaders in education who have been interested in securing better maternal care, with a resultant reduction of maternal, fetal, and neonatal deaths, have been instrumental in developing such studies by means of state and local committees. Such committees are cooperative in their work as medical practitioners, both general and special, health agencies, hospitals, and other interested agencies must work together. Death certificates with clinical data and autopsy reports and all pertinent data available are studied to determine as accurately as possible the factors causing the deaths of mothers, fetuses, and infants in the neonatal period. These studies are primarily educational and prophylactic as they seek to remedy the conditions which brought about the casualty. This may be due to the patient’s negligence, to professional mismanagement, to lack of proper facilities, or may have been unavoidable. Such appraisals have been very important m the reduction of mortality by correcting errors or deficiencies. The purpose of this paper has been to present a discussion of the factors which have contributed to the remarkable reduction which has occurred in the mortality associated with maternity. The spot,ty character of results at the
28
SDAIK.
\I,1 I. Olht. & Gym. ILlI!.. 19c1
present time indicates that further reductions are possible in certain geegraphic as well as in some medical areas. Perhaps the optimal or new it has been attained in certain favored plaves but, there are many much less i’a\-ot*cd areas. There is no other field of medicine in which t.he lives of two or more individuals are so intimately associa.ted an<1 so dependent ul)ul\ the tyl>e r)f care which is received. The loss of any one of the individuals should be Wgarded as a failure but,, with our present knowledge, not all can be saved from disabi1it.y or death. There are still many areas in which OUJ’ knowledge is incomplete and there are still many segments of our population which do not receive t,he full benefit, of the application of our present knowledge. The reduction of mortality suggests tha.t morbidity has also been ent lmt specific data about this are not available and were not within the scope of this paper. Tn some instances disability itlay result for mother or illt'ilrlt in C~SVS ilk which, without improved care, tle;tth would haye resulted. During the past 50 years st,atistical tlata have undergone marked changes both as t,o their form and completeness, as well as accura.cy. This applies part.iclularly to birth and tlea.th certificates of mothers. fetuses, ant1 early or neonatal infants. I have made no at.tempt to snlqmrt stat,ements with elaborat,e statistical tables or graphs. Some statistical data have heen given from various sources which seem bo support the evidence relative to certain factors. It wonltl Ilot have been feasible to give all the factors and some have been omitted either intentionally or otherwise. There could be much personal difference as t.o the It various factors and as to the influence of certain agencies or activities. would have been difficult even to enumerate all of the activities of governmental and voluntary agencies t,o sap nothin, 1~of evalua.ting their influence. It has been possible to give a picture of the faders with which my personal experience is most familiar. In conclusion it could be stated that in times past some taboos al)out, certain conditions and diseases have seemetl to check progress in preventicnl. This has been particularly true of reproductive processes about which the e&rcational souxes were fsr from ideal. Muc.h cha.nge has taken 1)lace in Ihis regard. It is probable that t,he widespread showing of “The Birth of iI Bi11)y” as an educational film had something to do with improved maternity care. dust. how far sex education shoultl go and how it should IW har~cllrtl, 1 ani but :I sensible and not prepared to discuss, nor is it germane to this paper, appropriat~e knowletlge of the processes of human reproiiuction should l)e acquired at the appropriate time in a proper atmosphere. References Vital
Statistics-Special Reports. Sstional Summaries. U. S. Department of Healt.11, Education and Welfare. Maternal Mortality in Fifteen States, Children’s Bureau h’o. 223. Minnesota Department of Health: Maternal, Infant and Childhood Mortality, 1950. Drs. E. D. Calvin! Edwin F. Daily, W. T. Dannreuther, W. J. Dieckmann. H. I,. Dunn, Palmer Flndley, I”. C. Irving, H. B. Matthews, R. D. Mussey, H. C. Taylor, Jr.: and F. E. Whitacre: Personal communications.
ASSOCIATED I,.
ADAIR,
WITH
Ml).,*
MATERNITY
XAITLANI+
FLA.
T
HE casualties associated with maternity are relatecl to empiric experjence and scientific knowledge and the interest in and ability to apply such knowledge. Empiricism may or may not be confirmed by subseyuent esperi7TnIess there is interest in receiving t11c beneence or scientific investigation. fits of such experience and knorvletlgc and applying them by those who are responsible for their utiliza,tion the results are negligible. If they are applied to the few by the few then the results are limited, but if generally used the> become of great interest and value. For progressive improvement, certain ideas must prevail : (I) t,he et11piric and scientific knowledge must he sound, (2) it must, he applicable, (:3) it, must 11~ applied, (1) the a,gent must, he informed and capableF (5) the agencies must he avsilahle. (6) the recipients must be willing and cooperntire, (7) thr &sting of esist.ing knowledge irmi lltethotis must i)e continuous, (8 1 Ihe stla~h for new facts must 1~ ctmstant, ( 9) the subst,itution of provecl new knowledge for older unsubstantiated ideas Inust be made, (10) the expansion of ecluc~~tional and institutional facilities must IW commensurate with the nerds. Maternity presents a unique I)rohlem in medical practice hecn.use two individuals, tnother and fetus, have their healt,h and lives involved at the same time. The saving of one may involve hamds which may result in disability or death for the other. At times this involves critical decisions hased LI~OJ-I personal attitutles, professional ethics, legal or ethical or religious concepts. Fortunately, medical progress has ui;aIe the liec>essity for suc~h dwisicms less frequent now than tlurjng past cleca.tles and caenturies. The scope of this discussion will lw litnitetl primarily to the present wtury and in subject matter it will be genrml and iherc will not 1~ elahurate stat,istica.l presentat,ions or analyses. SOIIIC trentls will of necessity 1~ iItclncled relative to feta,l, neonata.1, ant1 trlaternal mortality. As n hac*kground, certain historical references will he rnatle to (aertain Fn~tors which have tendctl to impede or accelerate progressive improvement. One factor has been the resistance on the part of solve to the apc*ept;ltlc*cb of newer ideas which tended to ~~e~f.lmfw /,rrv;tiling ~~nccpts. ‘pjie espet+ences of such protagonists as Holmes. Semmelweiss, and Pastcur illustrate this point. The contagiousness of puerperwl fever was clearly recognized by Holmes about 1843. His deductions from study of clinical experiences were clear and COltVillCillg bUt met Wit11 opposibion from clinicians of promillence, ltTh,-, should have heen persuaded hy his logical reirsoninp that this (ljscase T+-as conveyed of
TEmeritus ChIcago.
Mary
Cammu
R~erson
Professor
of “0
Obstetrics
awl
Cynccolcgy,
~hc
University
MORTALITY
ASfiOt’IATED
TVITH
MATERNJT-i
21
ptients by contaminated hands of the attendants. A few years later Semmelweiss by carefully made comparative clinical studies should have convinced his colleagues that the disease was carried by unclean hands from the autopsy r00n1 and diseased patients to those new patients who subsequently came under care. His ideas were not accepted generally and met, with much skepticism even in the higher medical circles. Some 30 years later Pasteur ushered in the bacteriologic era and the scientific basis for the contagion was established. Even then there were many skeptics, and others unfamiliar with this knowledge. Many of those who were graduated from the medical schools prior to 1890 received inadequate medical education and clinical experience in the schools and under preceptors who were poorly qualified and not abreast of the newer knowledge. Many of these men continued to practice well into the present century. Through the work of Pasteur, Koch, Lister, and others, bacteriology became an established science and a part of clinical medicine and filtered into the medical schools after 1900 often as a stepchild of pathology. There were many low-grade medical schools (diploma mills), but even those who were graduated from the better schools prior to 1890 had little basic knowledge of bacteriology. At that time there were practically no facilities for postgraduate or continuing education. These earlier graduates had little opportunity for subsequent education in the basic sciences or in clinical training. A technical advance of great importance contributing to clean hands was the introduction of rubber gloves. Their use met with the opposition of some who felt that they interfered with dexterity and the tactile sense. Improvement in the gloves themselves and the gradual extension of their use in hospitals and eventually in home deliveries have contributed greatly to the safety of deliveries. The important factor was that the infectious theory of diseases involved, in the minds of those educated during the nineteenth century, a fundamental change in their ideas regarding the causation and spread of these contagious Their practice was naturally influenced dominantly by their educadiseases. tion and training. It seems fair to conclude that this present century ushered in a marked change which among other things had a favorable but gradually developing influence on the incidence of puerperal fever. Statistical reports at the national level, as issued by the National Office of Vital Statistics, of the new Department of Health, Education and Welfare, give much valuable information but the more specific it is the less accurate it is likely to be because detailed and reliable data are dependent upon the comThis material has become propleteness and accuracy of the original reports. gressively more accurate and inclusive as the years have passed since 1900. It is logical that death reports shoulcl be the first to be accumulated at the national level and these are of some value as far back as 1900. The Registration Area was started in 1915 with 10 States and the District of Columbia. Birth and death reports are not given for the continental United States until 1933. Prom 1915 to 1932 this area was an expanding one and certain estimates were made to show the national picture. During this time certain procedures have been changed so that the data from year to year had to be to
adjusted according to certain set rules regarding live births. stillbirths, tleat Its. etc., and their causes, thus affecting the rclativc frequency in cdertain (*ai egorios. Ra.tes are set 17~ for comparison of deaths from variolls V:I~M~.S l)as~‘cl upon polmlation, live births, either estimated or reported. and tlepe~~tling IIJJC~II the purpose for which the clata arc used. R;ltes should not. he c:~~~~i*usetlwilh percentages. Data, relative to stillbirths (f&l (leaths) are given beginning in 1942 aJJfl now include those of 20 weeks’ gestation or more born without sign (lf life. The it~c,)Jnpletetless and inaccuracy of these reports is probably c~~JiSicb?J’;lI)lt’ l)ut like other reports they are improving year 1)~ year. The mass data (lo, however. show certain trends which are important am’1 clea,rly (Ietnot~strate the improvement in obstetric practice 3s meaS7md l)y Maternal mortality rates in 1915 lowered mortality of mothers and infants. There was a precipitous rise to over 91. were about 61 per 10,000 live births. during the years of World War I, due to epidemic infections, but the rate was persistently higher, ranging between 62 ancl 80, until 1934 when it was a little above 59. Since then the decline has heen steady until now the rate is below 10 per 10,000 live births. Jt seems obvious that something must have happened about 1930 to cause this rapid improvement.. A general improvement in health conditions is shown by the progressive reduction in total mortality per 1,000 of population, from 37.2 in 1900, to 18.2 in 1915, to 10.9 in 1932, and less than 10 since 1948. The infant death rate has shown a progressive downward trend since 191% but the drop is not as abrupt as that for maternal mortality. One of the most striking changes since 7930 has been the rapid increase in In the early thirties the percentage of the number of hospital deliveries. deliveries in the hospital was about 35 but at t,he present time it is over 90 for the nat.ion at, large and nearly 100 per cent iu many a.reas, especially the metropolitan. This has been accompanied by a reduction in t,he total number of deliveries by midwives who now deliver less than one-third as many as in 1930. with a corresponding increase in the number of deliveries by doctors mostly in hospitals. It is interesting to note that the fetal death rate (stillbirths) in terms of’ live births varied only slightly from 1922 to 1930, the low being 38.1 in 1925 and the high 40.2 in 1928. Since 1931 there has been a steady reduction from 38.2 to 22.9 in 1950. This is probably even greater as there is uncloubtecll~ more complete reporting, especially of earlier gestations, with the increased number of hospital deliveries. Tt would he logical to expect a corresponding reduction in the rates of neonatal dea.ths, which include those during the first month of life. This rate was 41.5 (1920) per 1,009 live births, the low rate was about 24 in 1932, in 1933 it was approximately 32, in 1940 around 30, and by 1950 it was 20.5. During this period the deaths under one day remained rather constantly at a rate of about 15 from 1915 to about 10 in 1950. There is room for considerable error in evaluating these reports as the statistical practices have changed and are still far from uniform in the various states. There is confusion between live birth and stillbirth or fetal death which was greater in times past than it is today; there are also errors relative to the gestational age and signs of life. Earlier there was no separate stillbirth certificate but instea.tl there way a birth certificate and an ordinary death certificate to be filled out for each stillbirth. It is therefore difficult to show accurately trends in fetal (lea,ths an,1
early infant deaths. There does seem to be a definite improvement since the thirties though it is not as marked for the first month of life as for the subsequent eleven months. It hardly needs mentioning that now more of this neonatal period would be spent in the hospit,als, especially by the premature% Their mortality rate is obviously high. Hospitalization does not necessarily mean greater safety but it is a means to that end. There have been some in the past who have argued that it was safer, from t,he standpoint of infection, to br at home rather than in a hospital. That may have been true in the past but now it would seem to be no longer valid. Increased hospitalization has undoubtedly been an important factor in the retluction of the mortality of mothers, fetuses, and newborn infants. There has been a fundamental change responsible for the increased hospitalization which is the development of the idea that health is a community responsibility and t,hat mothers and their babies are entitled to better and more complete care. .lncreasetl hospitalization required an increase in the number of available beds by remodeling, additions, or new construction, or a.11of these. This was necessary even though the number of births remained about the same but there was also a marked increase in the total number of births. The estimated number in 1915 was 2,965,OOO ; 2,155,105 were registered in 1935, with a progressive increase to 3,632,OOO in 3950. In 1935, 36.9 per cent were delivered in hospitals but in 1949 the percentage was 86.7 which means a numerical increase of 3,404,424 deliveries. More recently some institutions have favored the earlier discharge of patients which would mean that more women could be (lelivered during a year. There are many factors which have contributed to t,his increased utilization of hospitals but undoubtedly the chief one is that it is possible to obtain better care for mother and babies, especially premature infants. The recognition of maternal care as a community problem, instead of solely as an individual relationship between a doctor and a patient. is one of t,he most important factors in the reduction of maternal and infant mortalit,y during the current century. Complete and adequate maternal care which is being developed in practically all areas of the United States has ushered in an era of prophylactic obstetrics. A beginning was made in Boston about 1901 by cooperation between the Instructive Visiting Nurse Association and the Boston Lying-in Hospital in the establ&hment of home visits on prospective maternity patients. An early, if not the first, attempt at citywide coverage for maternal care was started in Minneapolis, in 1911. This was a cooperative program involving the Municipal Hospital, The Department of Obstetrics and Gynecology of the University of Minnesota, The Visiting Nurse Association, and the Infant Welfare Society. It included prenatal and postnatal clinics, home and haspita1 delivery, and puerperal care, with nursing and medical attendants. These clinics were available for the education of medical students and nurses. Home nursing as well as hospital care was available to practitioners for their private cases. At that time hospital facilities were not available for all of these patients but hospital facilities have been gradually increased so that now midwife care and home deliveries have practically disappeared. This program was extended to practically the entire state of Minnesota, as is true of many other states. In 1933 about 43 per cent of all births were in hospitals and in 1950 it was 98.3 per cent. In 1936 doctors attended 96.7 per cent of the births and in 1950 it was 99.8 per cent. A mortality study made in 1941-1942 showed a maternal mortality rate of 2.0 per 1,000 live births and a similar study in 1950-1951 gave a rate of 0.6.
ln other states the situation is more complicated largely due tcl I’~CV ilIk( I environmental conditions. In Georgia, for esample, though the maternal 11iortality rate has hcen remarkablv rducwl, tttuclt remains to bc doltct. 111 l!CH1 this rate was 109 per 10,000 iivc births, in 19% it was 72, ant1 in i!W it was 13.2, but the rates for white antI nonT;.hite were 5.9 ant1 25.X. rt~spec*tivc81y. If this is viewed from anot,her angle, one-third OP t,he live births were in the nonwhite, l)ut 70 per cent, of the Illittel.llill cleaths occurred in the nonwhil(~ group. fn 19% the relative percentage of maternal tleaths atnortg whites illit nonwhites was 52.8 and 1’7.2, so ii is il],])al’etlI that, there was a greatc,r itnIt1 1935, 86 per cc11t oi’ 111~‘ provcmcnt among the former than the latter. 1II whites were confined hy physicians :rntl 21 per’ c+etlt of the nonwhites. 1952 t,he corresponding percentages were !)8.5 and 59.S. Hospital deliveries for* the whites were 95.2 per cent and For the nonwhites the I)ercentage was 44.0. All causes c~f maternal deaths are nio~‘e ])rrvalent for the nonwhites thiltt for* the whites, indicating a lower ]evcl ot’ totill rl~aterna] ~a1.c for. thtalll th:IIt fog the whites. Infant mortality is of interest to all Imt t,he neonatal Illorlality is of special importance in connection with ltl~lt~~~tlill ant1 obstetric (‘:Lrr. I’l’em;L turity remains as the principal problem so fill* as infant mortality is con~t*ned though per se it should not be consi(leret1 as the cause of death. ln Minnesota in 1950, Xi per cent of’ the neonatal deaths o~nrred in t,he ])rematnre gr0~1) The causes of’ these tleaths. as statctl and 65 per cent were in the term illl’il?ltS. on the death certificates, unless confirmetl by autopsy, are not, very accurate. It is of great importance to determine from ctlillical history ant1 auto])sJ thtL real (pauses of these deaths. Unt1t.r il. grant from the United States I!hiltlretl’s Bureau a study was undertaken :It the Irniversity of Mitnlesota. Ix?ginniiig about 1920, to check the causes given on the cleath certificates with Ihr clinicill hist,ory and the findings at autopsy. It was not always ])ossihle to tleterniine the causes even then but the findings ~m~vetl thiit the Causes assigned on the J,ater, after 1931, death certificates were both incompletje and inaccurate. similar studies were l,egun at, the University of (‘hicago and esp~~detl with the coo])eration of the Chicago Board of IJealth am1 others. Obviously :I knowletlge of the causes of death is essential before ;Iny preventive 01’ cul’iltlV(’ measures can be established. These causes may arise from hereditary, congenital, int,ranatal, or ]WSInatal conditions. Malformations, birth injury, and anosia are among thcl mador CilUSt?,S. No\v all infants born with any sign of life Itrust, be re],ortet/ ils ]i~el)()~*ll even though those of less than 2X weeks’ gestatiou and weighillg less than 1,000 grams have little chance of survival. Most of these shonl(l lw I)l;lcetl ill a previable group as they are not, equipped for extrauterine life. ‘l%use 01 lesser weight fall into the abortion group which together \vith th(,sc (alas& as previable make up ;I large number which may ],e c:onsideret/ as fetal \vastage. The problem of abortion is a c~omplicat~ed one in\-olving me
her of abortions. In 1949 of the 3,216 maternal deaths, 394, or 12 per cent, were attributed to abortions and in 1950 of 2,960 maternal deaths, 316, or 10.7 per cent, were assigned to abortions; of the latter, 108, or about one-third, were admittedly induced for legal or unspecified reasons. Sepsis was the assigned cause in 66 per cent in 1949 and 60 per cent in 1950. The Maternal Mortality Study of the Children’s Bureau of 1927-1929 comprised 7,380 maternal deaths. Abortion was a factor in about 24.5 per cent of the cases, and infect,ion was the cause in over three-fourths of the cases. It appears that the reduction of maternal deaths from abortion and its complications has been a factor of some importance. In this study there was a total of 2,948 women who died of puerperal septicemia, of whom 618 were delivered in the hospital and 2,299 were not. Sepsis developed in the hospital in 181 ancl outside in 1,262. The rates were definitely higher in the rural areas than in the urban and among the nonwhites than the whites. The technique was more nearly and more frequently but not always more satisfactory in the hospitals than in the homes. Among .4,965 women who were delivered in the last trimester, only 1,740 were known to have had satisfactory aseptic technique. Rubber gloves were used, for vaginal examination and delivery in 3,162 of these women but the prior examination without the use of rubber gloves by midwives or doctors is not excluded. In any case the use of rubber gloves does not, per se, rule out poor technique as they are simply a safeguard if properly usecl. This study also showed that the rate per 10,000 live births was higher in rural than in urban areas which was particularly true of deaths from infection and during There was little difference in the rates of death the first two trimesters. from t,oxemias. The rates for the nonwhites were about twice as great as those for the w-bites, which ~vas pan~ticularly true of deliveries in the last trimester. Our national statistics show the rates for puerperal deaths per 10,000 live births in 1930 were 67.3, for the whites 60.9, for the nonwhites 117.4. By 1949 these rates were reduced to 9.0 for all races, 6.8 for the whites and 23.5 for the nonwhites. For the urban areas of 10,000 or more population the rates were 7.4. for the whites 5.7, for the nonwhites 19.2. the corresponding rates for the rural areas were 11.4, for the whites 8.4, for the nonwhites 28.9. There may be some racial differences but it appears logical to conclude that environmental conditions played a very considerable role. Among these factors are the increased percentage of care by physicians, from less than 40 per cent in 1935 to about 95 per cent in 1949, the increased percentage of hospital deliveries from 36.9 to 86.7 per cent in the corresponding periods. The percentages for the corresponding periods for the whites were 39.6 per cent ancl 91.6 per cent and for the nonwhites they were 18.2 per cent and 55.1 per cent. The care by physicians for the same years was for the whites 93.6 per cent and 98.5 per cent and for the nonwhites 44.6 per cent ancl 71 per cent, respectively. The number of deliveries by midwives diminishecl proportionately but some midwife cases were eventually delivered by physicians. In addition to these environmental conditions there are many for which the physicians cannot assume responsibility, such as poverty, ignorance, with the accompanying faulty nutrition, housing, clothing, etc. Some of this can he overcome by better lay education and improved facilities for health to which physicians can contribute as good citizens but governmental and voluntary agencies must assume the major responsibilities. An important role has been played in the clevelopment of better materrlal care by voluntary and governmental health and welfare agencies at local, regional, ancl national levels. Most important have been the activities of the American Medical Association and other professional and lay groups in inl-
proving medical education in general anti more specifically itt t,ht graclu;tl development, of better didactic and clinical teaching and experience irt oI&ett*ics. Another vifal improvement has tJ?en the better hospit,al standartls which have been promotetl by the American Medical Association, the i\tt~~rican ( ‘()IIege of Surgeons. the American ITospit.:tl Association. and ot.hrrx. This has IwI not only to better care of the paticJtts hut also to improrctl tJtluc.atiott att(l training of the various professional gr0ups. particular] y the tnt~dical ;I 1111 nursing personnel. The increased nl~tihty of hospitals &lh interttships anal residencies with maternity servicaes an(l the great,et* use of’ these institutions, stt~at~egic?ally located for student etlucation ;ttttl training, have l~ctl ()I: tt3mendous value in furthering the itttrrest itt ant1 esperience with tttittet*ltil> problems and their solution. 13egintting wit,h this century there seems to have heen at) ittc~reasirtgly This wits not limitecl active interest in the care o-f mothers and their infa.nts. to the T’nited States, as JUlantgnr wrote prophetically in 1!)01i : “The 01)stetrician of ISlO will find it difficult to understand why his ltrethren of thth early part of the century paid so tttuch attention to the oue month of lhr~ puerperal period and so little to t.he ttitte tttonths of ~Jt’d?gsIlittl~‘y.” The American Association for the Stutly ant1 I%\-entiott of In t’nnt Mot.tality (1909-191fi), later the American C!hild Health AssocGttion, was liquitlatecl in ?!)35 after the suc~cessful conelusion of the ‘IVhitt House t ‘onferenct* on Child Tlealth ant1 Protection which hcgan in 1929. (jut of the formrr CWIIIC the ,Joittt Maternal Welfare Vommittee ( I91 9) from which clevrlope(l 1he American C’omntittec 011 Mat~et~nal Welfare. l~lc.. in 1931. The tttemhrt~s of this organization have pal’tiaip;ltetI in tnosl- govet~tllnelltal ;ttrtl \-oll~lltal~~ agency activities pet*t;tining to mat.rt~n;tl (‘are and have sparked tt~any of them. Prohahly the most, important fitci 01’siu the reduction of tttatrrttal. fetal. and infant morhality have heen the :tcquisition and tlisseminatiott of kncr\vJedge and its applicat,ion among professional and lay grwnps. Th;-t 01’the professional group might be called the vet+ic;tI as it, involves the few xvho hec~orne the teachers and practitioners of the 01~1and of t,he new while Ihe tlissemin;ttion of this knowledge and ltract,i
Volllme
Numlw
68
I
hIORTAT,lTP
ASSO(‘lATED
WITH
MATERNITY
27
Along with this there has been a tremendous increase in the number of special obstetrical and gynecological societies and their membership, at local, state, regional, and national levels. The American Congresses of Obstetrics and Gynecology, of which there have been five in the past fourteen years, have brought together specialists, general practitioners, nurses, hospital and public health personnel, and educators to present and to discuss matters of both special and general interest. All of these activities have stimulated greater interest in the acquisition of knowledge both old and new and the search for further knowledge and bett’er means of its applic*ation. The acceptance of the ideas of prevention and their application has been most important and has been made possible by preconceptional and prenatal care. Preparation for the anticipated pregnancy and expected delivery is most important and means not only proper care but also the earlier detection and treatment. of threatening conditions and complications. Personal hygiene, the control of venereal diseases, proper nutrition. the detection and alleviation of toxemias have all been important. Convulsive attacks have been largely eliminated where prenatal care is well established. Proper nutrition is 110~ recognized as most essential in the prevention and correct,ion of certain disorders which complicate pregnancy. These are a few examples of the value of such care. So far as drugs are concerned notable adrances have been made in chemoand biotic therapy and their influence upon the course of infections is great but they should not lead us to slight or ignore the preventive measures which accomplished so much in reducing mortality before their advent. The use of blood is now so commonplace that it is difficult to realize the present safety and availability compared with the situation a few decades ago. Clood banks are most essential and their establishment requires foresight,. Obstetric hemorrhages are often not only sudden but profuse and n1a.y he rapidly fata, unless blood of the proper type and in sufficient quantity is promptly available. These efforts require cooperation, as do many others, such as mortality studies. Such a one was the three-year study of maternal mortality in New York C’ity published in 1930 by the New York Academy of Medicine. This work had a definite effect in reducing maternal mortality by pointing out the preventability of many such deaths. Many of the leaders in education who have been interested in securing better maternal care, with a resultant reduction of maternal, fetal, and neonatal deaths, have been instrumental in developing such studies by means of state and local committees. Such committees are cooperative in their work as medical practitioners, both general and special, health agencies, hospitals, and other interested agencies must work together. Death certificates with clinical data and autopsy reports and all pertinent data available are studied to determine as accurately as possible the factors causing the deaths of mothers, fetuses, and infants in the neonatal period. These studies are primarily educational and prophylactic as they seek to remedy the conditions which brought about the casualty. This may be due to the patient’s negligence, to professional mismanagement, to lack of proper facilities, or may have been unavoidable. Such appraisals have been very important m the reduction of mortality by correcting errors or deficiencies. The purpose of this paper has been to present a discussion of the factors which have contributed to the remarkable reduction which has occurred in the mortality associated with maternity. The spot,ty character of results at the
28
SDAIK.
\I,1 I. Olht. & Gym. ILlI!.. 19c1
present time indicates that further reductions are possible in certain geegraphic as well as in some medical areas. Perhaps the optimal or new it has been attained in certain favored plaves but, there are many much less i’a\-ot*cd areas. There is no other field of medicine in which t.he lives of two or more individuals are so intimately associa.ted an<1 so dependent ul)ul\ the tyl>e r)f care which is received. The loss of any one of the individuals should be Wgarded as a failure but,, with our present knowledge, not all can be saved from disabi1it.y or death. There are still many areas in which OUJ’ knowledge is incomplete and there are still many segments of our population which do not receive t,he full benefit, of the application of our present knowledge. The reduction of mortality suggests tha.t morbidity has also been ent lmt specific data about this are not available and were not within the scope of this paper. Tn some instances disability itlay result for mother or illt'ilrlt in C~SVS ilk which, without improved care, tle;tth would haye resulted. During the past 50 years st,atistical tlata have undergone marked changes both as t,o their form and completeness, as well as accura.cy. This applies part.iclularly to birth and tlea.th certificates of mothers. fetuses, ant1 early or neonatal infants. I have made no at.tempt to snlqmrt stat,ements with elaborat,e statistical tables or graphs. Some statistical data have heen given from various sources which seem bo support the evidence relative to certain factors. It wonltl Ilot have been feasible to give all the factors and some have been omitted either intentionally or otherwise. There could be much personal difference as t.o the It various factors and as to the influence of certain agencies or activities. would have been difficult even to enumerate all of the activities of governmental and voluntary agencies t,o sap nothin, 1~of evalua.ting their influence. It has been possible to give a picture of the faders with which my personal experience is most familiar. In conclusion it could be stated that in times past some taboos al)out, certain conditions and diseases have seemetl to check progress in preventicnl. This has been particularly true of reproductive processes about which the e&rcational souxes were fsr from ideal. Muc.h cha.nge has taken 1)lace in Ihis regard. It is probable that t,he widespread showing of “The Birth of iI Bi11)y” as an educational film had something to do with improved maternity care. dust. how far sex education shoultl go and how it should IW har~cllrtl, 1 ani but :I sensible and not prepared to discuss, nor is it germane to this paper, appropriat~e knowletlge of the processes of human reproiiuction should l)e acquired at the appropriate time in a proper atmosphere. References Vital
Statistics-Special Reports. Sstional Summaries. U. S. Department of Healt.11, Education and Welfare. Maternal Mortality in Fifteen States, Children’s Bureau h’o. 223. Minnesota Department of Health: Maternal, Infant and Childhood Mortality, 1950. Drs. E. D. Calvin! Edwin F. Daily, W. T. Dannreuther, W. J. Dieckmann. H. I,. Dunn, Palmer Flndley, I”. C. Irving, H. B. Matthews, R. D. Mussey, H. C. Taylor, Jr.: and F. E. Whitacre: Personal communications.