809MATERNAL MORTALITY IN CHILDBIRTH.

THE LANCET.

LONDON: : S’AT URDAY, APRIL 19, 1924.

MATERNAL MORTALITY IN CHILDBIRTH.THE publication of the Ministry of Health report

by Dr. JANET CAMPBELL upon the results of an inquiryinto the question of maternal mortality must serveto concentrate attention upon one of the most serious

problems which confronts the medical professionto-day. Whilst the general death-rate has beenreduced since the beginning of this century by almostone-third, and the infant mortality-rate during thefirst year of life actually halved, it is a matter ofconcern that the maternal deaths associated withchildbirth are practically the same to-day as theywere 20 years ago. That the problem is very realwill be appreciated from the fact that approximately3000 mothers in England and Wales lose their livesannually from what should be a purely physiologicalfunction. In a recent issue 1 we reviewed brieflyDr. CAMPBELL’S work, but the importance of theissues involved calls for a further reference to thisvaluable and painstaking report, a document whichshould be in the hands of all interested in the well-being of women and children, and which for thisreason has been issued at the modest price of Is.The factors in the causation of this excessive

mortality, as the report points out, are numerous

and complex. Puerperal sepsis in its various formsaccounts for by far the largest number of deaths.Next in order come the toxæmias of pregnancy, and

finally, haemorrhage takes its toll of victims. In allthese conditions it is obvious that factors are at workwhich, in the words of the report, " are more or lessdirectly controllable and should be controlled."In other words, the problem with which the countryis faced is rather one of organisation and educationthan of principles directly concerned with currentobstetric practice. That it is possible to conduct

midwifery satisfactorily, and with little or no maternalmortality, even in the humble and insanitary dwellingsof the very poor, is proved conclusively by the reportsof the extern departments of the various lying-incharities. In the clinical report of the RotundaHospital for 1922-23 recently issued we note that inthe extern department in a series of 1824 cases thematernal mortality was 0-21 per cent. In the samereport, dealing with the intern department, Dr. G.FITZGIBBON calls attention to the evil results ofbad midwifery in the following words : " Severalcases were admitted in a moribund state, while fivewere admitted profoundly septic after protracted orcomplicated labour." Of considerable interest inthis connexion is Dr. CAMPBELL’S observation thatinsanitary surroundings have probably much lessdirect influence upon puerperal mortality than isgenerally supposed, and that unless infection isintroduced frcm without it does not appear, thata woman who is accustomed to a low standard ofliving is more prone to develop sepsis after an ordinaryconfinement than one in a more hygienic dwelling.Even if this is the case, there can be little doubt,however, that uncleanliness and insanitary dwellingsmay and do spell disaster in the event of any obstetricaloperation being necessary. The practitioner con-

1 THE LANCET, April 5th, p. 716.

fronted with the treatment of a difficult complicationin the presence of insanitation, overcrowding, deficientwater-supply, or lack of effective lighting cannot applythose surgical principles which are so essential to

prevent disaster. It is in this connexion that adequateantenatal supervision is so all-important. In the

prefatory note by Sir GEORGE NEWMAN to the

Ministry’s report the fact is made abundantly clearthat no sound progress can be made in the reductionof maternal mortality apart from antenatal super-vision. It is an astonishing fact that the event ofchildbirth, the most clearly foreseen of all "ill-

nesses," is inadequately prepared for. How oftendoes an expectant mother

" book " with her selecteddoctor, midwife, or maternity home, but fails to sub-mit herself to the only safe method of control-

namely, systematic antenatal supervision Antenatal supervision implies a competent know-

ledge of all the accidents that may befall a womanduring her pregnancy and labour, and this requiresa very thorough training not only in theory but inpractical obstetrics. The General Medical Councilhas taken cognisance of this fact in its recent recom-mendations and resolutions in respect of the pro-fessional examinations, assigning to the training ofmidwifery and gynaecology a status not inferior tothat of medicine and surgery. The medical schools areto-day taking steps to put these resolutions into effect,and the practitioner of to-morrow will not be ableto say that he was taught surgery which he neverpractised and that he practised midwifery which hehad never been taught. With improvements in theeducation of the medical student, a better trainingof the midwife must go hand-in-hand. Inasmuchas the responsibility of the maternal welfare is sharedequally between the medical profession and themidwives, it is of the highest importance that thetraining of the latter should qualify them adequatelyto accept such responsibility. Since the passing ofthe Midwives Act in 1902 it is a matter for

regret that so little improvement, if any, has beennoted in the maternal statistics. In a series of 256unselected cases of puerperal fever recorded byDr. CAMPBELL, in an appendix to her report, it isnoted that 102 cases occurred in the practice ofmidwives alone, as against 86 in which delivery waseffected by a doctor. Figures such as this point tothe importance of securing for a pupil-midwife thebest possible training over a sufficiently long period.What this period should be is a question which hascontinued to engage the attention of the CentralMidwives Board since the Midwives Act was passed.There is no doubt that the original period of threemonths’ training was inadequate, and it is perhapsquestionable whether the present revised regulationsare sufficiently stringent to deal with the graveproblems involved. When it is remembered that

puerperal sepsis is the main cause of maternal mortalityto-day, and that it takes the medical and nursingprofessions many years to assimilate the tenets of

antiseptic and aseptic technique, it is asking a greatdeal of an uneducated woman to accept and practisethose canons at the end of a few months’ training.We are in absolute agreement with Dr. CAMPBELLin aiming at the total abolition of the so-calledhandy woman, and with the suggestion that thereshould be much closer cooperation between thedoctor and the trained midwife. Cooperation on thelines suggested by Dr. JOHN FAIRBAiRN of shifting .

to the midwife those parts of medical service whichare least essential, and relieving her of the responsi-bilities of those which are most essential, would goa long way in removing many evils which at present

810

exist. Every prospective mother should have thfadvantage of a considered medical opinion during herpregnancy, although the actual conduct of normallabour might safely be left in the hands of an efficientmidwife. In other words, it is the duty of the medicalprofession to prevent disaster, and prevention canonly be secured by adequate preparation and super-vision. Midwifery so conducted should not undulytax the time of any doctor, since antenatal and post-natal observations can, in the words of the report." be carried out without conflicting with the claimsof other patients " ; a very important factor in theday of the busy general practitioner. By contrastthe time and energy that have to be devoted to copingwith individual cases which, for whatever cause, havebeen allowed to progress too far without supervisionis great indeed. Such cases form the bulk of thoseto which the practitioner is summoned by the mid-wife in distress, and we propose shortly to issue aspecial supplement designed to help him to dealwith them. With the adoption of an improvedantenatal and midwifery service on cooperativelines between midwives and practitioners, increasedfacilities must also be provided for dealing withobstetric problems. Where danger is anticipatedthere should be no obstacle in securing the services ofadequate assistance whether it take the form ofaccommodation of a hospital bed, the provision ofefficient nursing, or the help of a skilled obstetrician.The report of the Ministry calls attention to the

fact that the returns of large cities such a,s Birmingham,Manchester, and Liverpool, where maternity workhas been organised over a long period, show thatsystematic efforts over the whole country wouldundoubtedly lead to an appreciable saving ofmaternal life and health. It should not be

impossible to overcome the financial and otherdifficulties involved in the building of a completematernity service. A great deal has been accom-plished within recent years in the reduction of infantmortality, and it can be anticipated with confidencethat a similar concerted effort would result in a likebenefit to the mothers of the nation. Dr. CAMPBELLis to be congratulated upon the work she has

accomplished in accumulating such a mass ofevidence and putting it forward in such a convincingmanner.

THE THERAPEUTIC SUBSTANCES BILL.ON April 8th the Therapeutic Substances Bill was

read a second time in the House of Lords. Under its

provisions the manufacture and sale, by those whoare not medical men, of vaccines, sera, salvarsan andits substitutes, insulin, and pituitary extract can onlybe carried out in this country under licence granted bythe Minister of Health, and importation from abroadis restricted in conformity. Few of the many vaccines.sera, toxins, antitoxins, and antigens are at presentcapable of accurate titration. The potency of

diphtheria and tetanus antitoxins, however, can bedetermined with a high degree of accuracy. In respect,of these substances, powers similar to those sought forunder the proposed Bill were secured in Germany in1896 and in the United States in 1902. Diphtheriatoxin to be used in the Schick test for susceptibilityand toxin-antitoxin mixtures for immunising purposesshould also be carefully evaluated before they are sold.There are, as yet, no accurate well-established m ;thodsfor determining the potency of therapeutic sera suchas anti-dysentery serum and anti-pneumococcicserum, and in the case of vaccines all that is possibleat present is to determine the number of organism:;

in a certain volume of the preparations. The firms

manufacturing antitoxins and vaccines in this countryare of high reputation and have supplied trustworthyproducts for many years, so that it may appear thatthe need for the control of the supply of these substancesis not urgent. At any time, however, similar productsmay be imported from abroad, and in the absence ofsuch legislation as is contemplated there is no m3ans ofensuring their purity and potency. There is reasonto suppose that steps to control all these preparationswill be welcomed by British manufacturers.For the remaining substances, except pituitary

extract, control of a temporary nature exists already;a fortuitous circumstance has in the case of salvarsanand insulin enabled advantage to be taken of thepatent laws to obtain a check on the manufacture.In the case of salvarsan, the circumstance was theoutbreak of war ; at that tim3 the supply of Germansalvarsan was cut off, and British manufacturers whohad facilities for making it applied to the Board ofTrade for licence to do so, in order to protect themselvesfrom the possibility of post-war litigation for infringe-ment of German patents. It was made a condition ofholding such licences that the products should besubjected to biological tests designed to excludeunduly toxic samples, to be carried out by the MedicalResearch Council. After the war this arrangementcam to an end, and as a result of Board of Tradenegotiations the manufacturers continued productionwith licences granted directly by the German patentees.Biological control of salvarsan and neo-salvarsanwould then have stopped but for the circumstance thatthe Ministry of Health was the largest purchaser ofthese substances ; on this account the German makerswere induced to insert in their licence to Britishmanufacturers a clause providing for biological controlof all products of this nature. At present, therefore,the accident of the war has enabled the Ministry ofHealth to persuade the German patentees to demandfrom the British makers biological control. To suchcircuitous courses does the absence of legislation lead.However, in a short time the salvarsan patents expire,and, as matters stand, the present checks will

disappear ; those who are familiar with the reportsof the Salvarsan Committee are aware that it will be

easy in that case for serious changes in the toxicityand therapeutic value of the preparations to occur,however carefully and conscientiously the chemicalpreparation is effected.

Control exists at present also for insulin, but againbecause of the accident that the original patent-holderis the University of Toronto, a body concerned to seethat the manufacture of insulin is carried out for

public rather than private interest. The patent rightsin this country were offered to and accepted by theMedical Research Council for the very reason that asno legislation such as this Bill contemplates existedin England, it was only by holding these rights thatany control over the efficiency and uniformity of theproduct sold could be maintained. There are thosewho have expressed doubts whether the part playedby the Medical Research Council made for a rapidand adequate supply of insulin to diabetics ; to such wemay recommend an inspection of the state of affairsin France, where, in the absence of central expertcontrol, the insulin supply still remains inadequate.untrustworthy, and expensive It is not sufficientlyrealised that the large-scale manufacture of productssuch as insulin and pituitary extract is a comparativelynew problem, which is almost as much outside the realmof a pure chem:st as is a surgical operation, so that eventhe largo manufacturers of drugs have been for themost part without the skill and experience necessary