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Historical PerspectivesFrom: Cheri Van Hoover (cherivh@xdcr.com)Fri Mar 19 18:03:24 2004
Those interested in better understanding of the decline of maternal and infant mortality in the U.S. should read the very well researched and referenced text, Midwifery and Childbirth in America by Judith Pence Rooks, a past president of the American College of Nurse-Midwives. She is an epidemiologist with a background in public health and has worked at the CDC, in the Office of the Surgeon General, and for the U.S. Agency for International Development. Her scholarly research into the areas of maternal and infant mortality, both currently and historically, make her ideally suited for an analysis of these issues. A couple of exerpts: from pg. 30-31: "Early in this century, levels of both infant and maternal mortality in the United States were as high as they are in many developing countries now (Maine, 1991). Maternal mortality plateaued at a high level (600 to 700 deaths per 100,000 births) between 1900 and the mid-1930s and then began a steep decline coincident with the availability of antibiotics, blood transfusions, and drugs to treat pregnancy-induced hypertension (Maine, 1991; Loudon, 1992; AbouZahr & Royston, 1991). The most important contributing factor was the sudden availability of antibiotics... Similar drops in maternal mortality occurred throughout the Western industrialized world. The U.S., the Netherlands, and Britain experienced drmatic reductions in maternal mortality starting in the mid-1930s but had very different forms of maternity care: In the United States obstetricians delivered most of the babies in hospitals. In the Netherlands professional midwives delivered most of the babies in homes. Britain had both home and hospital births and used midwives, general practitioners, and specialist obstetricians. These differences had no apparent effect on the rate of maternal mortality (Maine, 1991)..." And this interesting data from the work of Mary Breckinridge's Frontier Nursing Service (FNS) in the remote regions of Appalachia in the first half of the 20th century. Breckenridge is considered the founder of American nurse-midwifery. She was the granddaughter of a U.S. Vice President (also Secretary of War for the Confederacy). FNS served one of the poorest population groups in the U.S., riding to births on horseback in the remote hill country. Most of their clients were poorly nourished and their homes lacked running water, basic plumbing, and adequate heat. pg. 46: "The Frontier Nursing Service kept careful statistics and evaluated its progress after every thousand births. All maternal and infant outcome statistics for FNS's first thirty years of operation (1925-1954) were better than for the country as a whole, despite extreme poverty in the area and a high proportion of pregnancies carried by women at the extremes of the childbearing age span and by women of very high parity. The biggest differences were in the maternal mortality rate (9.1 per 10,000 births for FNS, compared with 34 per 10,000 births for the United States as a whole) and low birth weight (3.8 percent for FNS, compared with 7.6 percent for the country) (Browne & Isaacs, 1976). In 1958 the Metropolitan Life Insurance Company of New York published a report which estimated that national implementation of services like those of the FNS would prevent at least 60,000 perinatal deaths each year (Metropolitan Life Insurance Company, 1958)." Another fascinating historical perspective can be gained from reading the Pulitzer Prize winner, A Midwife's Tale: The life of Martha Ballard, Based on Her Diary 1785-1812 by Laurel Thatcher Ulrich. Particularly interesting in this book are the tables on pages 171 and 173 which summarize the delivery data with contemporaneous maternal and infant mortality rates from Mrs. Ballard's work and the rates by a physician provider in her area a few years later and in London, Dublin, and the United States as a whole. I'm thinking a little more light and scholarly examination of this subject might help us all generate a bit less heat.
-- Cheri Van Hoover, CNM, MS Faculty OB/GYN Group University of California, San Francisco
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