View report page

16
In addition to the effect of the rapid fall in the birth-rate, the Annual Report
referred to shows that there is also to be taken into account the fluctuation in the
mortality from puerperal fever necessarily associated with its infective character.
The deaths from puerperal fever form about 40 per cent. of the total deaths in childbirth.
Taking the figures for England and Wales, in preference to those for London,
in order to eliminate accidental fluctuations due to smallness of numbers, it is found
that in the twenty-two years 1911-1932, the death-rate per 1,000 live-births from
puerperal fever has varied from 1.26 to 1.92, a range of .66, whereas the rate for all
other deaths in child-birth varied from 2.43 to 2.74 or by .31 only. The fluctuations
in the puerperal fever rate is closely associated with the movement of the deaths from
erysipelas. In fig. 1, the death-rate from erysipelas among women in England and
Wales in the years 1919-1933 is contrasted with the puerperal fever mortality in this
period. It will be seen that the erysipelas death-rate has increased considerably
since 1924, and that concurrently there has been an increase in the puerperal fever
rate. In the upper part of the diagram the curves for the two diseases are shown
separately and in the lower section the annual fluctuations of the same figures are
shown as a percentage of the average for the whole period. The latter gives a clearer
picture of the relative movements of the two rates. The diagram is practically a
continuation of that shown facing page 25 on the Annual Report for 1928 (Vol. III),
for the period 1900-1927, with which it is in general agreement. It would seem,
therefore, that the erysipelas deaths furnish a means of testing how far specific
measures to reduce the puerperal fever mortality have met with success.
The downward course of the birth-rate tends to exaggerate the effect of certain
factors in the method used to assess the maternal risk, and this to such an extent
indeed that it becomes imperative to consider closely the validity of the basis of the
present measure of maternal mortality.
The maternal mortality rate is arrived at by dividing the number of births
registered into the number of deaths recorded as due to pregnancy and parturition :
that is to say, deaths from miscarriage and abortion are included, but not the total
number of miscarriages and abortions among which they have occurred. Statistically,
therefore, the measure is unsound, because, while the births necessarily, in general,
relate to pregnancies of more than 28 weeks gestation, the deaths include all deaths
before the 28th week of pregnancy and consequently all abortions, even of single
women, of which latter a far greater proportion are septic than of married women.
It appears from an examination of such records of maternal deaths in London
for the years 1931-33 as are available that in two London boroughs 26 per cent. of the
deaths due to puerperal fever and other accidents of childbirth occurred among
single women. The same figures show that in London as a whole, 10 per cent. of the
total maternal deaths occurred among single women. It is evident, therefore, that the
published mortality figures cannot be relied upon for comparative purposes.
It accordingly appears to be desirable that the maternity and child welfare
authorities should make use of the information which they obtain in the course of their
administrative duties to differentiate between deaths due to live-births and stillbirths
on the one hand, and deaths due to abortion or miscarriage on the other ; and,
having done so, to state the maternal risk in the former class as representing the
maternal risk of their administrative area as compared with others. It is, moreover,
very desirable that the maternal mortality following still-birth should be separately
stated, as the problems arising in this class of case are, in certain respects, different
from those of live-births. In an appreciable proportion of maternal deaths associated
with still-birth, there is some condition of the mother which either directly caused the
still-birth or hindered the normal termination of pregnancy.
In the Council's general hospitals there were 11,385 births during 1932 ; of
these 469 or 4.1 per cent. were still-births. The corresponding percentage
for London, as a whole, for that year was 3.1 ; the higher proportion in the Council's
hospitals probably indicates a tendency in practice to send to hospital cases where
pre-natal death of the foetus is suspected, or where the case is complicated by an