Deaths in childbed from the eighteenth century to 1935.

The history of maternal deaths in England from the earliest records in the 1700s to 1935, concentrating on the influence of medical practice, is recounted. The rate lay between 4 and 5 per 1000 until 1935, with the advent of sulfa antibiotics to prevent puerperal infections. The practice of midwifery by men began in the early 17th century in Britain, but attendance at normal labors by medical practitioners, that is, surgeon-apothecaries, did not become common, and then only in urban areas, until 1730. The use of forceps became widely known about that time, and lying-in hospitals were begun. Obstetrics was held in contempt by professionally educated and registered physicians and apothecaries, however, because of the immodesty and messiness of the work and the long hours involved. Estimates of maternal mortality, from the 1st recorded unselected series, in the late 18th century range from 5-29/1000. Some of the high figures are from specialists in obstetrics, who treated complicated cases. From these data the maternal death rate was estimated at about 25/1000 among unassisted women. Some institutions achieved results better than the national average in the 1920s, suggesting that by the end of the 18th century, a fairly good understanding of childbirth had been reached. At that time the overall forceps rate was conservative, less than 1% compared to 15% now. Use of the perforator, hook and crochet, and manual dilatation of the cervix had been abandoned. In the 19th century, lying-in hospitals became more common and their death rates were higher, probably due to less conservative methods, up to as high as 85/1000, until the advent of antisepsis in 1880. Nevertheless, hospital births were the minority, amounting to 15% in 1927, 54% in 1946, 87% in 1970, 98.8% in 1980. Sepsis, due to casual use of sterile technique, remained the cause of half the total deaths until 1937. It is difficult to assess the contribution of toxemia or obstructed labor in maternal deaths. Rickets was a common cause of obstructed labor, and there are recorded epidemics of both. Similarly, abortion-related deaths are even more difficult to estimate, because of poor reporting. In evaluating the undiminished maternal death rate before 1935, the author believes that maternal survival is remarkably resistant to the ill effects of socioeconomic deprivation, but is very sensitive to the good and bad effects of medical intervention. Hence, there is evidence that the rural and poor in some cases had better results that those given the best medical assistance, especially with regard to puerperal sepsis. The midwifery laws of 1902 provided for training of midwives, and slowly corrected quality of care, as well as hostility between midwives and physicians. The current maternal death rate is about 0.1/1000.