Training improved, and doctors abandoned the most dangerous techniques. After it was established that this was not the case (4–6), 3 major questions arose. In addition, in a welfare state, people may have been disadvantaged or unemployed, but the fact that they had reasonable income from the government meant that at least their level of nutrition would be within acceptable limits. Read the rest of Laura Helmuth’s series on longevity. Forceps, episiotomies, anesthesia, and deep sedation were overused. This question is important because, unlike disease-specific mortality rates, no other mortality rates showed such a profound decline in the second half of the 20th century. Second, the criteria used to define a maternal death in the United States differed from those used in Britain. Whether it is the history of medicine, politics, war, or anything else, it is dangerous to assume that the determinants of events in the past will operate in the same way in the present. The data, however, need to be interpreted with caution for 2 reasons. High and low rates of maternal mortality have never corresponded to changes in economic conditions (6). Similar low levels of maternal mortality were achieved during the 1920s and 1930s in the United States by a remarkable service in the history of maternal care that was founded by Mary Breckinridge. The main factors that led to this decline seem to have been successive improvements in maternal care rather than higher standards of living. In 1800, women gave birth an average of seven times during their lives, and a survey of births in Illinois in the 1820s shows that 30 percent of women gave birth to 10 or more children. Cambridge: Cambridge University Press, 1981]. About 1 percent of women in the United States choose to give birth at home. In Sweden and Finland in 1800, for example, around 900 mothers died for every 100,000 live births [nearly 1-in-100]. By joining Slate Plus you support our work and get exclusive content. In this paper, the reasons for the high mortality before 1937 and its decline since that date are discussed. The death rate in the overall population started dropping at the end of the 1800s, and it dropped most dramatically during the first few decades of the 20th century. In the first few years, it was almost entirely due to the introduction of sulfonamides and later penicillin, and this applied to other countries as well. Too many doctors and midwives were chasing after a limited number of pregnant women, and they gained market share by touting dazzling new techniques and bad-mouthing their competitors. Irvine Loudon, Maternal mortality in the past and its relevance to developing countries today, The American Journal of Clinical Nutrition, Volume 72, Issue 1, July 2000, Pages 241S–246S, https://doi.org/10.1093/ajcn/72.1.241S. Plate 23 (left) shows a child in the womb with the umbilical cord. As nutrition improved, there were fewer women with rickets, which causes bone deformations; many obstructed births in the late 19th and early 20th centuries were caused by abnormal pelvic bones in the mother. One of the great victories of modern times is that childbirth doesn’t need to be natural, and neither does the maternal death rate. Some were incompetent, some were skilled. If the decline is plotted on a logarithmic scale, you get a straight line. The high rates of infant and maternal mortality created a culture of fear and superstition surrounding pregnancy and childbirth. And the pelvic girdle can’t get any wider or women wouldn’t be able to walk efficiently. Before the germ theory of disease, people suspected puerperal fever could somehow be contagious, and they knew that some midwives and doctors had worse records than others, but no one knew how it was transmitted. Bearing this many children in a time of questionable nutrition and medical care took its toll on the health of both women and babies. Many of these gadgets had an uncanny resemblance to medieval torture tools.”. You have to try to estimate the range of error in the data that you get, but without at least trying to do so I think you are hamstrung in trying to intervene. Infant mortality is known to be strongly related to social class; the highest rates are found among the working classes, whereas the lowest rates are among the professionals. (Psst, guys, you know what makes an excellent 35th birthday present for your partner? Midwives accuse doctors of endangering women by continuing to perform too many unnecessary procedures. The trend in maternal mortality rates in England and Wales between 1880 and 1980 was such that the rate of maternal mortality remained on a high plateau through the mid-1930s, after which there was an abrupt and steep decline (Figure 1). The United States said “this was a triumph of capitalism and modern medicine.” Australia said, “We Australians have always been the best.” Britain said, “It is the National Health Service.” Sweden and the Netherlands said, “It is our marvelous service.” Maybe each was right, but you can produce your own explanation. An example of this is shown in Table 2, which gives data for 1930–1932 (16). Historically, women died of puerperal fever (also called childbed fever, or postpartum sepsis, an infection usually contracted during childbirth), hemorrhage, eclampsia (dangerously high blood pressure and organ damage; that’s what killed Sybil on Downton Abbey), and obstructed labor. It was certainly true that before 1937—and probably thereafter—malnutrition associated with poverty was a surprisingly minor determinant of levels of maternal mortality. A leading American obstetrician in the 1920s, Joseph Bolivar DeLee (13, 14), wrote a paper entitled “The prophylactic forceps operation” in which he advocated that procedures for ordinary deliveries be changed to include anesthetizing every patient in the second stage of labor, delivering the baby with forceps, and manually removing the placenta using the “shoehorn maneuver.” His advice was heeded by many obstetricians and horrendous examples of iatrogenic mortality resulted. The sudden and dramatic decline in maternal mortality rates, which occurred after 1937, took place in all developed countries and eliminated the previously wide country-level differences in national mortality rates. It does not appear that there were any surveys on anemia in populations of expectant mothers before the 1930s and, even if there were, the accuracy of the measurements would be questionable because of the assessment techniques available at that time. Reliable, safe, and legal birth control allowed women to limit and time their pregnancies, and it led to a decrease in illegal abortions, a leading cause of death in pregnant women historically. Slate relies on advertising to support our journalism. The first ones were general practitioners who had no training and little experience in childbirth. She reports that women who choose home birth “value alternative and more embodied or intuitive ways of knowing.” Home-birth advocates say women are better off giving birth in a comfortable environment, letting nature take its course. The significance of the features described in the above section suggest that there were 3 main determinants, but not necessarily causes, of maternal mortality in the past: the social and economic status of birthing women, the standard of obstetric care, and the virulence of streptococcus. Anthropologist Holly Dunsworth and her colleagues found that broadening the pelvis wouldn’t actually interfere with walking, and they point out that gestation is actually pretty long in humans compared to other primates (even though newborns’ brains are relatively less developed).

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