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25
No allowance has been made in regard to the percentage of sterile women, as
no reliable figures are available. The percentage is no doubt higher among the
well-to-do, and therefore affects the comparativity of the figures for different social
classes. So far as birth control plays any part in reducing fertility there must be
added to the proportion of naturally sterile women a proportion (and, one may
suppose, a considerably increased proportion) of sterile marriages.
A factor which is of great importance in the problem of maternal mortality is
one upon which no information is available, namely, the effect of the spacing of
confinements. The normal rhythm of conception at the ages of higher fertility is
about two years, and any reduction or increase in this interval may be attended
with increased risk to the mother a shorter interval giving less opportunity of
recuperation while a longer interval brings conditions physiologically more approximating
to primiparity. The result of prolonging the normal interval by restriction
is to increase the maternal risk stated per 1,000 births.
The proportion of unwilling mothers must be increased in time of economic
stress and unwillingness may prejudice the normal risk and thus if it is granted
that economic conditions are the cause of the declining birth rate, the inverse relation
of fertility and maternal mortality will tend to be accentuated.
Reasons have been advanced in earlier reports for the view that economic
conditions are in the main the cause of the decline in the birth-rate and since it is
here shown that there is an inverse relationship between fertility and the maternal
mortality rate per 1,000 births, it follows that this rate will tend to be sustained unless
the birth rate increases. The question of the increased burden of parenthood is
discussed in the report of the Medical Officer for 1926, p. 5, to which reference should
be made.
Summary.—The facts revealed by the foregoing examination may be summarised
as follows:—
(1) The conspicuous decrease in maternal mortality in the period 1901-1910
is associated with improved midwifery, but with the complete displacement of the
untrained midwife the scope of further decrease in maternal mortality necessarily
became more limited (pp. 12, 13).
(2) Mortality in childbirth is shown to vary with the general death-rate (pp.13,16)
but the rapid fall in the birth-rate discloses that fertility is the specific factor in
maternal mortality (p. 13).
(3) Marked changes in the fertility-rate mask the effects of later enlargement
of the scope of administrative action in regard to maternal and child welfare
(p. 13).
(4) Pre-natal causes of death increase relatively in importance with advancing
age, while post-natal causes decrease (p. 15). Corrected figures show that the risk in
childbirth is lowest among mothers under 20 years of age, and increases rapidly
with age (p. 15).
(5) No general change has occurred in the relative mortality from pre-natal,
natal and post-natal causes in 1921-25 as compared with 1911-15, but an increase
has occurred from pre-natal causes among women under 25 years of age (p. 17).
(6) It is made clear that birth-control may have considerable effect upon the
maternal mortality rate per 1,000 births (pp. 16,25). The influence of the size
of family on the maternal mortality rate is discussed (p.16).
(7) The mortality from all other causes than childbirth among young married
women has decreased, while the death-rate of young single women has increased
in 1921-25 as compared with 1911-15 (p.18).
(8) Economic conditions are the governing factor in local variations of fertility
and thus of maternal mortality (pp. 19, 20).
(9) The" carrier" hypothesis of convection of puerperal fever infection, and
the resistance factor, are discussed (pp. 20,22).