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34
deaths happened to take place in that year. It should be remembered also
that as the birth-rate decreases so will each death have a greater purely
mathematical result upon the death-rate. It is no part of the duty of a
Medical Officer of Health to whitewash the Maternity Services, but it is his
duty to endeavour to ascertain in which direction they are failing and in
which direction they can be improved.Consequently I have very carefully
considered the circumstances of each death and the following is my considered
analysis.
In my opinion 9 of the 18 deaths were probably preventable and 9 were
probably unpreventable.
Probably preventable cases.
A. 7 cases of abortion.
6 cases as a result of sepsis.
I case due to action of drugs on the kidney.
3 cases were definitely suspicious of artificial means.
1 case was almost certainly accidental.
All 7 cases were probably preventable by the intelligent co-operation
of the mother by:—
(1) refraining from interfering with nature;
or (2) seeking medical advice immediately after abortion or by
more intelligent co-operation between the mother and the family
doctor.
B. 2 cases were admitted to hospital as emergency cases.
1 at no time attended an ante-natal clinic.
1 attended the ante-natal clinic but failed to seek immediate medical
advice on the sudden occurrence of persistent vomiting, the cause of
which had been unforeseen, her pregnancy having been perfectly normal
until then.
These 2 deaths might have been prevented by early treatment such
as could have been brought about by more intelligent co-operation of
the mother during the ante-natal period.
Probably unpreventable deaths.
6 deaths were definitely non-preventable.
With wisdom after the event there is a faint possibility that 3 deaths
might have been prevented:—