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persistent vomiting and acute nephritis." This patient had every
ante-natal care, being an in-patient in a nursing home for weeks
before the confinement and having all skilled advice. Following
an induction of labour at which twins were born, she succumbed.
Another fatal case was one passed immediately to the care of the
hospital authorities, as she had a slight contraction of the pelvis.
After a total of eight ante-natal attendances and the advantages
of X-ray examination, an attempt was made to induce labour.
This failing, a caesarean section was performed, subsequent to which
the patient died of pneumonia. The remaining fatal case was
admitted to hospital two days before her confinement on account
of persistent vomiting. The vomiting soon ceased and a normal
labour followed, the patient, however, not recovering from the
shock. The death certificate read "puerperium, Ravnauds disease,
pregnancy." Possibly fuller ante-natal supervision would have
helped in this case.
The Departmental Committee on Maternal Mortality and
Morbidity found that in nearly one-half of the cases of maternal
death there was a " primary avoidable factor " which fell into one
of four groups, namely, (1) omission or inadequacy of ante-natal
examination; (2) error of judgment in management of the case;
(3) lack of reasonable facilities; (4) negligence of the patient or
her friends.
How far were these 14 cases preventable?—and here it is necessary
to protest against too literal an interpretation being made of
the ( ommittee's findings that one-half the deaths arc preventable,
wanted that in 50 per cent, of the fatal cases there was a " primary
avoidable factor," it does not necessarily follow that removal of
that laetor would have avoided the death. For instance, a case
has been mentioned of the patient whose urine, although clear four
times showed one day a trace of albumin ; three days later this
patient was dead of pyelonephritis. Had she been admitted to
hospital without any ante-natal examination, her death would
no doubt have been classed amongst those preventable, the
primary avoidable factor " beint: the omission or inadequacy of
ante-natal examination. To take another case, a patient is
admitted to hospital and on account of her small pelvis she has a
cesarean section performed ; she subsequently develops pneumonia
and dies. This death was obviously preventable in that careful
ante-natal supervision would have detected a small pelvis and an
induction would have been performed, this being another case where
the primary avoidable factor was omission or inadequacy of
ante-natel examination. Hut the case recorded above attended
for ante-natal examination eight times, X-ray photographs were
teken to assist in determining the relative size of the foetus and the
pelvis and an induction was attempted but did not come off.