Conclusion
The fall in MMR that began in the late 1930s was due to a number of factors, which followed one another but at slightly different rates in different countries. In England and Wales these were, in succession, the sulfonamides, blood transfusion, better obstetric care (in part associated with wartime organization), penicillin in 1944, and after the war a marked improvement in obstetric education.
The National Health Service hastened the adoption of a standard of obstetric care for everyone, which was available only to a minority before the war. The fact that this decline in MMR occurred throughout the developed world at much the same pace is a strong endorsement of the notion that clinical care is the main determinant of MMR. Some, however, would still maintain that the low maternal mortality today is due to good health, not medical technology. In this respect the experience of a religious group in Indiana in the 1970s is informative. This group rejected all orthodox medical care while engaging in the same middle-class occupations and earning the same incomes as their orthodox neighbors. Mothers received no prenatal care and were delivered without trained assistance. Their MMR was 100 times higher than the statewide rate.We have noted the high MMRs between 1900 and 1935. We may ask with the benefit of hindsight whether it would have been possible for countries such as Britain and the United States to have reduced their MMRs significantly. The answer is almost certainly yes, although it is probable that the MMRs seen in the 1950s would have been out of reach in the 1930s, because of the virulence of streptococcus and the absence of sulfonamides and penicillin.
A significant reduction in maternal mortality might have been achieved, however, through education. The medical curriculum should have attached as much importance to obstetrics as to anatomy, physiology, and biochemistry.
It would have been essential to demonstrate the need for a very high standard of antiseptic practice at every delivery. It would have been wise for every developed country to have established a national or regional maternity service based largely on the work of trained midwives undertaking the majority of normal deliveries at home. Maternity hospitals were necessary, of course, for the management of dangerous complications and high-risk cases, but they were not the best place for normal deliveries. The work of hospitals, general practitioners, and midwives should have been monitored by local maternal mortality committees, and care taken to establish close cooperation between all parts of the maternity service. Some of these reforms were beginning to be implemented by the late 1930s in Britain. None required knowledge that was not then available. The examples of the Kentucky Nursing Service, the Rochdale experiment, and the numerous successful outpatient charities and services were well known. The success of Scandinavia and the Netherlands, where most of the principles just outlined were in operation, was no secret.If such simple but potentially effective changes were not adopted, it was partly because no clear consensus existed as to the way obstetric care should be delivered. Even if there had been a consensus, it would have been impossible to compel medical personnel to change their ways.