Determinants of Maternal Mortality

Although the immediate causes of maternal deaths are not disputed, the factors that determined MMRs are much more debatable. They fall broadly into two groups: clinical factors and socioeconomic, political, and geographic factors.

Clinical factors were associated with the type and standards of obstetric care provided by the birth attendant. Standards of obstetric care were deter­mined by a number of factors, including the status of obstetrics and thus the quality of education and training, the type of birth attendant (specialist obste­trician, general practitioner, trained or untrained midwife, etc.), the place of delivery (home or hospi­tal), and current fashions in the management of normal and abnormal pregnancies and labors.

Nonclinical factors included the attitudes and ex­pectations of women about the conduct of childbirth, together with socioeconomic considerations: family income, nutrition, housing and hygiene, the ability to command and pay for obstetric care where private care predominated, and the provision of maternal welfare schemes by local and national government or charities where they existed.

Some historians have suggested that high MMRs in the past were due largely to social and economic deprivation. Others have asserted that the responsi­bility lay not with poverty per se, but with the stan­dards of obstetric care available to the poor. Poor standards of care might result from ignorance and lack of training. Poor practice might also, and often was, caused by negligence, laziness, hurrying, and dangerous, unnecessary surgical intervention by trained practitioners. Poor practice, therefore, was not confined to untrained midwives or even to the often-maligned general practitioners; it was often found among specialist obstetricians following the procedural fashions of their time.

Clinical and nonclinical factors were not mutually exclusive.

Yet in spite Ofbewildering variety, it is the task of the historian to generalize, and to try to assess the relative importance of all such factors in different populations at different times, allowing for differ­ences in the ways that populations are described. Europeans tend to describe populations in terms of social class; North Americans in terms of national­ity, race, and color. One can suggest with reasonable confidence, however, that black mothers as a whole in the United States would have shared with the lower social classes in Britain a greater than aver­age likelihood of suffering from malnutrition, chronic disease, and the general ill-effects of poverty. Did they suffer a high MMR as a consequence? Two lines of evidence suggest that social and economic factors were much less important determinants of maternal mortality than might be expected.

A series of reports from cities in Britain, dating from the 1850s to the 1930s, revealed that MMRs were higher among the upper classes than the lower. These findings were confirmed by the Registrar Gen­eral’s analysis of maternal mortality by social class for England and Wales for the years 1930—2. This showed that the MMR for social classes I and II (professional and managerial) was 44.4, while for social class V (unskilled workers) it was 38.9.

In the United States there was no doubt that the MMR was much higher (usually by a ratio of 3 to 1) among black women than white. A few investiga­tions were carried out on the relationship between income and maternal mortality.

The second line of evidence might be called experi­mental. It came from programs in which a high standard of obstetric care was provided in regions of social and economic deprivation. The classic exam­ple was the Rochdale experiment. In 1929 Rochdale (a town in Lancashire) had an exceptionally high MMR of slightly more than 90 deaths per 10,000 births. Andrew Topping, a physician serving as the new officer of health, undertook a vigorous reform of obstetric care during a period of severe economic depression. The MMR was reduced in a few years from one of the highest in England to one of the lowest. There was no change in the social and eco­nomic environment during the experiment.

A similar experiment was the establishment of the Kentucky Frontier Nursing Service by Mary Breckinridge in the 1920s. Highly trained nurse­midwives, traveling on horseback, delivered babies of women who lived in great poverty in isolated mountain terrain and suffered from a high rate of chronic illness and malnutrition. An astonishingly low MMR was achieved solely by good obstetric practice — about one-tenth of the rate among women delivered by physicians as private patients in the hospital in Lexington, the nearest town.

The countries showing the lowest MMRs - the Netherlands and Scandinavia - ran maternity ser­vices based on a strong tradition of home deliveries by highly trained midwives. In Britain a very low MMR was achieved by a similar group, the Queen’s Institute Midwives. The records of outpatient chari­ties in Britain and the United States showed repeat­edly that the establishment of a free or low-cost obstetric outpatient service in areas of severe socio­economic deprivation could result in low MMRs, even when deliveries took place under appalling con­ditions. Therefore, although there were maternal deaths in which anemia, malnutrition, and chronic ill-health must have been contributory factors (and it seems likely that they contributed to the high MMR in the Deep South of the United States), the weight of evidence suggests that the standard of obstetric care was usually the most important deter­minant of the MMR. Because hospital delivery car­ried the danger of cross-infection as well as the likeli­hood of surgical interference in normal labor, it was usually safest before the mid-1930s to be delivered at home by a trained midwife or by a medical practi­tioner who was conservative in his or her attitudes toward obstetrics and meticulous in antiseptic prac­tice. The irony is that the rich often sought what they considered the “best” obstetric care in plush private hospitals and paid for it with the added risk of iatrogenic maternal mortality.