Statistical Comparison of Birth Attendants
(Physician and Midwife) and
Validation of the Midwifery Model of Care
The problems of under-reporting of mortality by physicians.
Õ The vital statistics of childbirth in the community in general are reasonably open to considerable suspicion. Deaths from puerperal infection are often crowded in under the heading of typhoid or pneumonia by the doctor, or an unrecognized rupture of the uterus goes down on the certificate as postpartum hemorrhage, or later as peritonitis. On the other hand, hospital statistics are unavoidably exaggerated both in the frequency of abnormalities and in the death rate, on account of the contamination of the figures by the great number of serious referred cases.[1917-A; Harrar MD] ^130
Õ Conclusions based on statistical studies must be accepted very charily when they deal with deaths in childbirth, for the figures are particularly liable to error. Every since such data have been collected, doctors have been prone to omit from death certificates the fact that the case was associated with pregnancy, or they have actually falsified the records to escape any stigma with might accrue to them . ...... Because of the labor and expense involved, bureaux of vital statistics have ordinarily accepted the death certificates of pregnant and puerperal (intra and postpartal) without checking their accuracy. However, such a check has been made in a few special investigations. In 1933 an error of 17.8 % was found in maternal death certificates in New York City; in 1934 an error of 21.6 % was found in Philadelphia and of 12.6 % in those of the fifteen States specially selected for study by the Department of Labor." [ 1937-A, p. 329 ^131-
Õ Dr. Ira Wile, NYC "In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives. [1911-G, p.246] ^132
Õ Though we cannot make an exact comparison between the maternal mortality in the United States and that in European countries, we can at least make a rough comparison. All who have studied the problem agree that the rate for Holland, Norway, Sweden, Denmark is far superior to our own. Why? It cannot be because of our ignorance, for in the scientific phases of obstetrics, America is one of the worlds leaders; it must be due to a difference in the patients themselves and differences in the way that pregnancy and labor are conducted in the two regions. [1937-A] ^133
Õ What about the conduct of labor in the two regions? Here is the major differences lie. In the first place, ... at least 10 percent of labors in this country are terminated by operation. In the New York Report 20 percent of the deliveries were operative, with a death rate of more that 1 in each 100 of the operated, and 1 in 500 of those who delivered spontaneously. The Scottish Report states (Scotland has a higher maternal mortality than our own): In as high a proportion as 24 percent of all birth recorded during the six months intensive survey delivery was not spontaneous. Fifty-one percent of all the maternal death in Scotland occurred in the 24 percent in which the labor was operative. Let is compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. In Sweden the interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland ..... it is under 1 percent. [1937-A] ^134
Õ What is responsible for this vast difference in operative rates? There are many factors: the woman of Holland and Scandinavian are by nature better equipped for spontaneous parturition. Analgesics and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted. And midwives are trained to look upon birth as a natural functions which rarely requires artificial aid from steel or brawn. [1937-A] ^135
Õ We have had a small but convincing demonstration by the Frontier Nursing Service of Kentucky of what the well-trained midwife can do in America. .... The midwives travel from case to case on horseback through the isolated mountainous regions of the State. There is a hospital at a central point, with a well-trained obstetrician in charge, and the very complicated cases are transferred to it for delivery.[1937-A]^136
Õ "In their first report they stated that they have delivered over 1000 women with only two deaths -- one from heart disease, the other from kidney disease. During 1931 there were 400 deliveries with no deaths. Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company, after analyzing the work of the Frontier Nurse(midwives), made the following statement on May 9, 1932:
The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe. If such service were available to the women of the country generally, there would be a savings of 10,000 mothers lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life. ^137
What are the advantages of such a system? It makes it economically possible for each women to obtain expert delivery care, because expert midwife is less expensive than an expert obstetrician. Midwives have small practices and time to wait; they are expected to wait; this what they are paid for and there they are in no hurry to terminate labor by ill-advised operative haste." [1937-A] ^138
Õ In 1927, 2875 midwives delivered 78,647 Swedish women, an average of 27 to 28 cases per year for each. ..... Midwives can be better coordinated, better disciplined, and better supervised by governmental agencies. Such a system does not obviate the necessity for expertly trained obstetrician. They also must deliver the abnormal and complicated cases. What it does is to displace the general practitioner, who is scarcely trained at all in obstetrics, by an expertly trained woman. [1937-A] ^139
Õ Maternal Mortality: It appears that the maternal mortality in Newark among midwife cases is no higher than in the city as a whole and really lower than in many other cities of countries. In the study of Maternal Mortality for the Children's Bureau at Washington Dr. Meigs gives the following rates: [1917-B; LevyMD, p.41] ^140
Puerperal (maternal) deaths per 1000 live births
Italy 1910-13 2.4 1 in 417 For the principal cities in the registration area of the United States in 1910 the rate varied from 1 in 500 mothers in Fall River and Worcester to 1 in 178 mothers delivered in Grand Rapids. In Newark in 1914 the maternal mortality was 5.3 per 1000 births; in 1915, 3.6 and in 1916, 2.2. In other words, in 1914, 1 in every 188 mothers lost her life in childbirth, while in 1916, 1 in every 454 mothers lost her life in childbirth. These figures indicate that there has been a considerable reduction in maternal mortality in the three years that the Department of Health has maintained supervision over midwifery, and that in 1916, with approximately 50 per cent of births attended by midwives, the rate of the city of Newark was among the lowest in the country. [1917-B; LevyMD, p.42]^141 Hungary 1908-11 3.6 1 in 277 England & Wales 1910-14 3.7 1 in 270 New Zealand 1910-14 4.0 1 in 250 Austria 1910-12 .5.0 1 in 200 Ireland 1911-14 5.2 1 in 192 Switzerland 1909-12 5.3 1 in 188
City Rate per 1000 births Newark 2.2 1 in 454 MATERNAL DEATHS IN 1916 PER 1000 BIRTHS FOR
CERTAIN LARGE CITIES IN THE UNITED STATES
We determined the influence of midwifery practice on maternal mortality in a more direct way. We followed up, until one month after birth, 586 mothers who had received prenatal observations from our department and then were delivered by midwives. In this group, one mother died, showing a record better than that of the city as a whole. We also investigated forty-one puerperal deaths reported by physicians to determine if there was any foundation for the impression that puerperal deaths that occurred in the hospitals or in the practice of physicians are the result of midwifery incompetence, ignorance and neglect, the cases being referred, it is claimed, to hospitals or physicians when all the mischief has been done. Of the forty-one cases it developed that in only ten had a midwife been in attendance at any time and in no instance did the doctor claim that the midwife was in any way responsible for the result. [1917-B; LevyMD, p. 42] ^142
Buffalo 3.2 1 in 312 Detroit 3.7 1 in 270 New York 4.6 1 in 217 St. Louis 5.2 1 in 192 Cleveland 5.6 1 in 180 Boston 6.5 1 in 143 Baltimore 6.8 1 in 147 Philadelphia 7.0 1 in 143
When we recall that midwives attend 50 percent of all the births and as much as 88 percent of some foreign born groups living in congested quarters, there seems to be little ground for the charge of high maternal mortality among the midwives, at least in Newark. [1917-B; LevyMD, p. 42] ^143
Infant Mortality: If the midwife is the cause of much infant mortality, Newark should have a high infant mortality rate, for midwives attend 50 percent of all our births and from 55 to 88 percent of foreign born mothers.
In 1916 the infant mortality rate in: Newark 89.6 Is the infant mortality higher among infants whose mothers are attended by midwives? To determine this fact we traced the attendant at birth of 1247 infants that died during 1915 and 1916, and found quite the reverse was true. Midwives attended 49 percent of the births, and had been the attendant at birth of only 49 percent of the of the deaths under one year; physicians attended 39 percent of the births and had been the attendant at birth of 36 percent of the deaths under one year; hospitals delivered 12 percent of the births but had attended 15 percent of the deaths under one year.[1917-B, Levy,MD p. 43] ^145
New York 93.1 St. Louis 94.0 Philadelphia 101.0 Boston 104.0 Cleveland 106.9 Pittsburgh 109.2 Detroit 112.8 Buffalo 113.9 Baltimore 118.1
[1917-B; Levy.MD, p. 43] ^144
That the infant mortality is lower among the midwife cases and highest in the hospital is shown better by the following rates. [1917-B, Levy,MD p. 43] ^146
INFANT MORTALITY FOR INFANTS ATTENDED AT BIRTH.
By midwives . . . . . . . 70.7 per 1000 births.
By physicians . . . . . . .74.3 per 1000 births.
In hospitals . . . . . . . . 97.4 per 1000 births.
It may be argued that the effect upon the infant of good and poor obstetrics would appear principally in the deaths under one month of age and that in this group we will find the highest mortality among the births attended by midwives. Strangely enough, it appears that especially in this age group the infant mortality is lowest for infants attended by midwives and highest among those delivered by hospitals. .... hospitals delivered 20 % of the babies that died under one month of age but attended only 12 % of the births of the city.[1917-B; LevyMD; p.44] ^147
These results will be better appreciated, perhaps, if presented somewhat differently. Of the babies attended by midwives, 25.1 per 1000 ... died before the age of one month; of those attended by physicians, 38.2 per 1000 .... died before the age of one month; and of those delivered in hospitals, 57.3 per 1000 died before the age of one month.[1917-B; Levy, MD p. 44] ^148
These figures certainly refute the charge of high mortality among the infants whose mothers are attended by midwives, and instead present the unexpected problem of explaining the fact that the maternal and infant mortality for the cases attended by midwives is lower than those attended by physicians and hospitals. [1917-B, Levy,MD; p. 44^149
It is of special interest to note here again that very few of the Italian mothers are delivered in hospitals; that 88 percent are delivered by midwives; that 85 percent of primiparae of Italian mothers are delivered by midwives and that the infant-mortality rate of babies of Italian mothers is one of the lowest of all national groups. [1917-B; LevyMD, p. 46] ^150
Table I Maternal and Infant Mortality Among Mothers Who Received Prenatal Supervision from Child Hygiene Division and Were Delivered by Midwives, Newark, N.J., 1916. [1917-B; LevyMD, p. 46] ^151
Total Number Mothers delivered by midwives -- 586
Midwife-attended Maternal Deaths: 1 Midwives Rate -- 1.7 City-wide rate -- 2.2*
Deaths of babies under 1 month -- 5 Midwives Rate ------ 5 City-wide rate -- 8.5
Stillbirths (attended - midwives) -- 4 Midwives Rate --- 6.8 City-wide Rate --41.7 **
**polio epidemic summer of 1916
"...in 1921 the maternal death rate for our country was higher than that of every foreign country for which we have statistics, except that of Belgium and Chile."1925-A; HardinMD, p.347 ^152
"The International Year Book of Care and Protection of Children: gives emphasis to the fact that the Untied States has still a higher rate of maternal mortality than any other of the principal countries of the world and that pregnancy causes more deaths among women ages 15-40 years of age than any other disease except tuberculosis. Twenty five thousand women die in the United States every year from direct and indirect effects of pregnancy and labor. Three to 5% of all children die during delivery and thousands of them are crippled." 1925-A .p. 350] ^153
"I feel that the statement cannot be controverted that there die annually in the US as a direct and indirect result of confinement, 20,000 women annually. If we think what a furor would be raised in the community if yellow fever were to take off 20,000 human beings in one year, and on the other hand contemplate the equanimity with which the public views this annual loss of 20,000 mothers, the comparison is striking. [1911-B; DeLeeMD] ^154
The babies: Hundreds of thousands of babies are permanently crippled, either mentally or physically, as the result of improper obstetrical management of their births, and in a goodly proportion the infant becomes blind as the result of carelessness. I wish, however, to emphasize this point, that the number of children becoming blind is very small to the number that are killed and injured by bad obstetrical practice. [1911-B; DeLeeMD] ^155
On the basis of the (birth) registration areas, which is 53% of the total population, it is estimates that there were born ...in 1918 2,664,685 babies, including 91,665 stillbirths (3.44%). Of the babies born alive, 10% died before the end of the first year, so that including stillbirths about 350,000 out of the total number perished---13% or 1 out of every 8. [1922-A; ZeilgerMD, p.405] ^156
Statistics (Howard) show that the stillbirth rate ... is 60% higher than Stockholm (2.16%); New York (4.38%) and Philadelphia (4.39%) and 35% higher than Birmingham, (England) (3.24%) and over 100% higher than ...Stockholm.[1922-A; ZeilgerMD, p.405] ^157
As to maternal mortality, ...during 1913 about 16,000 women died..; in 1918, about 23,000...and with the 15% increase estimated by Bolt, the number during 1921 will exceed 26,000. Maternal mortality in the country when compared with certain other countries, notable England, Wales and Sweden is according to Howard appallingly high and probably unequaled in modern times in any civilized country. (T)hese rates ...of 88.48 per 10,000 birth are on a par with those of Sweden 110 years ago; are 75% higher than those of England and Wales 60 years ago; are 120% higher than England and Wales in 1911-1915 and exceed the rates of England and Wales for 1918 by nearly 75% for puerperal fever and 150% for all other afflictions of the puerperal state combined. Howard shows also that New York Citys rates 46.11, which is much lower than that of any other American city, is 35% higher than that for Birmingham, England (33.49).[1922-A; ZeilgerMD, ^159
As early as 1875-77 in the Royal Maternity Charity of London, out of 9,019 deliveries of women in their homes, but 21 women died or 2.3 per 1000 deliveries; in the work of the Maternity Center Association of NYC, there were 9 maternal deaths in 4,496 confinements or an incidence of 2 per 1000; and in the Pittsburgh Maternity Dispensary out of 3,384 confinements but 6 women died or 1.7 per 1000 deliveries. [1922-A; ZeilgerMD, p. 405] ^160
Out of 5,000,000 mothers and babies exposed (to childbirth) 4,000 per 100,000, 4% or 1 out of 25".[1922-A; ZeilgerMD, p. 407] ^161
2 1/2 million childbearing women = 2 1/2 % population with 24,000 maternal deaths and 360,000 perinatal deaths annually. p.405 Death rate from TB 150,00 annually --- a rate of 150 per 100,000. p. 407 -- 200 mothers & babies per 100,000. p.406 [1922-A; ZeilgerMD, p.405,6,7] ^158
In countries having the lowest infant and maternal mortality rates, national birth and death registration has been in existence for a long time : Sweden since 1749, France and Norway since 1801; Prussia since 1816; England and Wales since 1838; and New Zealand since 1871. Efficient administrative measures and the education of the people have brought the birth and death statistics in these countries to a high degree of completeness. .... As it appears, the position of the United States among the civilized nations of the world, in regard to infant and maternal mortality, is just about what might have been expected from our birth and death registration (which was very low). [1922-A; ZeilgerMD, p. 408] ^162
Pittsburgh also had in 1920 a maternal mortality rate of 9.6 per 1,000 (149 in 15,508) ---a rate of 9% higher than the birth registration area in 1918 and 109% higher than NYCs rate of (4.6) for the same period (NYC had a midwifery system). [1922-A; ZeilgerMD, p.409] ^163
1911 - 1915 -- total number of mothers delivered by midwifery students
Deliveries by midwife students 2,731 In hospital -- 966 in home -- 1,765
Maternal Mortality Total number: 6 rate: 0.21%
Hospital 3 pneumonia, hemorrhage, ruptured uterus Home 3 ruptured uterus, puerperal sepsis, pelvis abscess
Perinatal Mortality Total -- 29
[1915-A; EdgarMD p. 99] ^164
The conservative nature of our teaching at the Bellevue School for Midwives, is shown by the fact that in the first fours of its existence ... forceps were used only 67 time in 2,731 cases or once in each forty cases, a forceps percentage of 2.4%. [1915-A; EdgarMD p. 100] ^165
While we believe our death rate to be low, both in our outdoor confinements (home-based care) and in our regular indoor applicants, it is disconcerting to find that even in these selected groups the predominating cause of death is puerperal infection. [#1] The one element of mortality in obstetrics, of which we are inclined to boast, and that we ought to have most certainly under our control, causes more than twice as many deaths as any other single complication. There were twenty-three deaths from puerperal infection among the 23,130 regular applicants confined indoor, and fifty-nine deaths puerperal infection among the 69,081 outdoor confinements; a mortality of 0.95 per thousand (Hosp) and 0.85 per thousand (home), respectively.
In the deaths occurring among the postpartum admissions and the emergency labors handled by a succession of midwives and doctors before admission, considerably more than one-third died of puerperal infection.
Eclampsia ranks second [#2] on the list as a cause of maternal death, accounting for ten deaths among the indoor regular applicants, or 0.43 per thousand (hospital) confinements and for twenty-six deaths on the outdoor (domiciliary) service, or 0.37 per thousand confinements.
The third [#3] most frequent cause of death is peritonitis after the performance of Cesarean section. 13 occurred among the 23,130 indoor regular applicants and 3 among the 69,081 outdoor cases referred to the hospital for Cesarean. These deaths might reasonably be included under the heading of puerperal infection.
Next in importance come [#4] rupture of the uterus and placenta previa.
Our results in placenta previa are better among the indoor regular applicants than among the outdoor, and of late years all cases of placenta previa occurring on the outdoor service are transferred indoor, if possible, for delivery. Five died of placenta previa among the indoor regular applicants, 0.26 per thousand, and twenty-five among the outdoor applicants, or 0.36 per thousand. Of ruptured uterus, there were five deaths indoor and twenty deaths outdoor, or 0.26 per thousand and 0.28 per thousand.
Deaths [#5] from nephritis, broken cardiac compensation, pneumonia, shock and exhaustion from prolonged labor, and postpartum hemorrhage rank next. Then come deaths from shock and hemorrhage after Cesarean section, tuberculosis, acute toxemia of pregnancy without convulsions, and accidental hemorrhage, they are in the order named.
The lesser causes, [#6] explaining from one to three deaths each, are abdominal pregnancy, rupture of the vaginal vault* (following forceps delivery), pulmonary embolism* and thrombosis, cerebral hemorrhage, appendicitis complicating late pregnancy, suicide in acute mania,carcinomatosis, brain tumor, sarcoma of the liver, and ether and chloroform narcosis*. (*deaths which were a direct result of operterative interventions)