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that the contrast is largely one between the county boroughs of the north and those
of the south. In the boroughs of Group B, however, a far higher proportion of
married women are employed, and the lower fertility of this group would appear to
be largely attributable to local economic conditions.
In a report by the Local Government Board on the provision made by public
health authorities in respect of maternity and child welfare issued in 1917, figures
are given, mostly for the year 1916, which show that 66 per cent. of the midwives
in the county boroughs of Group A were trained and that they attended 75 per cent.
of the births; the corresponding figures for Group B were 59 per cent. trained and
50 per cent. of births attended.
The metropolitan boroughs of Group A, with the exception of Greenwich, are
served by the foremost obstetricians of the day through St. Bartholomew's, the
London and Guy's hospitals, and their low maternal mortality has been attributed
to the maternity work of these hospitals. It is, however, evident from a comparison
of the percentage of illegitimate births in the two groups that other factors
of social rather than administrative significance are predominant. There has
not been any change in the maternity service of this area since 1910 which could
have lowered its efficiency, yet the mortality in childbirth per 1,000 births from
other causes than puerperal fever increased from 1.29 in 1911-14 to 1.36 in 1919-22
and to 1.73 in 1923-27.
Puerperal
fever.
In a report on maternal mortality in Aberdeen, 1918-27, with special reference
to puerperal sepsis by Drs. J. Parlane Kinloch, J. Smith and J. A. Stephen (Scottish
Board of Health, 1928), some interesting results are given of the bacteriological
findings in 88 cases of puerperal fever (p. 52). It is shown that in 83 instances in
which the result of the first blood culture is given as either sterile (61 instances)
or as showing the presence of streptococcus haemolyticus (22 instances) there were
12 fatal sterile cases (20 per cent.) and 17 (77 per cent.) fatal cases positive to this
streptococcus. Of 32 cases with sterile blood on first test, but with positive uterine
culture, 8 died (25 per cent.). The lower mortality associated with absence of
streptococcus haemolyticus from the blood when the uterine culture is positive may
be taken to indicate that resistance to general streptococcal infection is an important
factor.
The authors regard the higher incidence of puerperal sepsis in the practice of
doctors as contrasted with that of midwives as being "due to contagion, being
dependant in considerable part on a streptococcal carrier condition in doctors,"
and observe (p. 30) "there is reason to believe that the high incidence of puerperal
sepsis in maternity institutions in Aberdeen is due to contagion." In this connection
they say the most illuminating data so far as the Aberdeen statistics are concerned,
are contained in a tabular statement showing the effect of referring back to their
source cases sent into an institution by a doctor or midwife. "The figures show
that the sepsis rate in the practice of midwives is l.0 per 1,000 maternity cases, as
contrasted with 1.7 in the practice of doctors and 4.5 in in-patient institutional
practice " (p. 20). In view of the increasing confidence which is being shown in
maternal institutions the conclusions of the authors deserve close consideration;
the actual data (see Table XII, p. 46) are as follows:—