NATIONAL CENTER 

For HEALTH STATISTICS 

PROPERW OF WE 

PUBLICATIONS %RANCH 

EDITORIAL LIB~~ 

VITAL and HEALTH STATISTICS 

ANAL~lCALSTUDIES 

Infantand Perinatal 

Mortality 

in Englandand 

Analysis of long-term and short-term trends in infant mortality by age at death, sex of child, cause, and geographic 

factors; stillbirth and perinatal mortality trends; role of 

various risk factors including maternal age and parity, multiple pregnancy, prior fetal loss, maternal stature, illegitimacy, and socioeconomic status; discussion of maternal and 

chi Id health services. 

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 

Public Health Service 

Health Services and Mental Health Administration 

Washington, D.C. ‘Novmitber 1968 
Public IJealth Service Publication No. 1000-Series 3-No. 12 

For sale by the Superintendent of Documents, U.S. Government Printing Office 

Washington, D. C., 90402 - Price 75 cents 
NATIONAL CENTER FOR HEALTH STATISTICS 

THEODORE D.WOOLSEY,Director 

PHILIP S.LAWRENCE, SC.D., Associate Director 

OSWALD K. SAGEN, PH.D.,,Assistant Director /or Health Statistics Development 

WALT R. SIMMONS,M.A.,Assistant Director for Research and Scientific Development 

ALICE M. WATERHOUSE, M.D.,Medical Consultant 

JAMES E. KELLY, D.D.S.,Dental Advisor 

EDWARD E. MINTY, Executive O/ficer 

MARGERY R. CUNNINGHAM, In/omzatiorz O//icer 

OFFICE OF HEALTH STATISTICS ANALYSIS 

IWAOM.MORIYAMA,Ph.D.,Director 

DEAN E.KRUEGER, Deputy Director 

Public Health Service Publication No. 1000-Series 3-No. 12 

.Library of Congress Catalog Card Number 68.62237 
FOREWORD


This report is one of a group of analytical studies designed to 

delineate the perinatal and infant mortality problem in the United States. 

Of particular interest is the fact that the United States is not alone in 

experiencing an important change in the infant mortality trend. For a 

number of other countries as well, infant mortality is no longer declining at its former pace. 

Although our primary concern is with the problem of perinatal and 

infant mortality in the United States, it was felt that much could be 

learned from the experience of other developed countries with advanced 

medical systems. In several of these countries, levels of infant mortality which are lower than that in the United States have been achieved. 

The National Center for Health Statistics arranged with a number of 

investigators to prepare comprehensive studies on perinatal and infant 

mortality in their own countries. Earlier reports evolving from these 

investigations appear in Series 3 of Vital and Health Statistics published 

by the Center: 

No. 4 Infant and Perinatal Mortality in the United Stated


No. 5 Infant and Perinatal Mortality in Scotland


No. 6 International Comparison of Perinatal and Infant Mor­


tality: the United States and Six West European Countries 

No. 8 Infant Mortality Problems in Norway 

No. 9 Infant and Perinatal Mortality in Denmark 

No. 11 Infant Loss in the Netherlands 

The present report for England and Wales completes this particular 

group of reports on infant mortality. 

The manuscripts from the individual countries were prepared for 

publication under the technical supervision of Helen C. Chase, Dr. P.H. 

The detailed technical 

responsibility for the 

and England and Wales 

responsibility for the 

methodology, findings, 

editing was shared by Dr. Chase who had primary 

reports from the United States, the Netherlands, 

and Miss Elizabeth W. Curran who had primary 

reports from Scotland, Norway, and Denmark. The 

and conclusions are those of the investigators. 

Iwao M. Moriyama, Ph.D.


Director


Office of Health Statistics Analysis


... Ill 
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CONTENTS 

Trends tiInfant Mortality and Stillbirths, l93O-63------------------------

Infant Mortality by Age---------------------------------

1930 Through l939------------------------------------------------

1940 Through 1949-------------

1950 Through l963------------------------------------------------

Infant Mortality by Sex----------------------------------------------


Trend of Stillbirth Rate


Stillbirths by Sex---------------------------------------------------


Causes of Death


Causes of Infant Death


Immaturity and Low Birth Weight


Pneumonia


Gastroenteritis


Col~genital Malformation


Causes of Stillbirth and Perinatal Death


Registered Causes, l96O-62----------------------------------------


British Perinatal Mortality Survey, 1958-----------------------------


Causes of Late Neonatal Death


Biologic and Environmental Factors


Maternal Age and Parity


Past Obstetric History


Maternal Stature


Illegitimacy


Geographic Area


Socioeconomic Class


Combined Effects


Pregnancy Complications and Disorders of Maturation


Preeclamptic Toxemia and Essential Hypertension


Bleeding


Weight Gain


Smoking


Anemia


Gestational Maturity


Gestational Maturity and Low Birth Weight


Classification of Birth Weight and Gestation


1 

3 

3 

4 

6 

7 

8 

9 

9 

9 

12 

15 

16 

16 

18 

18 

18 

24 

25 

25 

2’7 

27 

28 

28 

31 

32 

34 

34 

35 

36 

36 

36 

36 

37 

38 

v 
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CONTENTS—Con. 

Page 

Complications of Labor 

Induction of Labor 

Length of Labor 

Analgesia in Labor 

Method of Delivery 

Anesthesia for Operative Delivery 

Complications of Labor 

Multiple Pre~ancy 

Prophylactic Immunization in Infancy ------------------------------------

Diphtheria 

Pertussis 

Tetanus 

Poliomyelitis 

Sm;tllpox 

Measles 

Tuberculosis 

Imlnunization Schedules 

Outlook for the Future 

References 

Detailed Tables 

Appendix I. Definitions 

Appendix II. Registration and Notification Procedures 

Birth Registration 

Birth Notification 

Appendix HI. Health Services for Mothers and Children 

Maternity Services 

Pediatric and Child Health Services 

National Insurance Be~l(~fits 

40 

40 

41 

41 

42 

43 

43 

44 

45 

45 

45 

45 

45 

45 

46 

45 

46 

47 

48 

50 

73 

74 

74 

74 

75 

75 

76 

77 

vi 
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SYMBOLS 

Data not available


Category not applicable . . .


Quantity zero -


I Quantity morethan Obutless than O.(YL---- O.O 

Quantity more than Obut less than 0.5------ 0 

I 

I 

Fi,guredoe snotmeet standardsof 

* reliability or precision 

vii 
IN THIS REPORT detailed skztistics ave provided on infant and pevi -

natal movtality Yates j?om 1930 thvough 1963 in England and Wales. The 

analysis focuses on the lack of sizable decveases in these ~ates during 

the 1950rs and 1960?s, and the effects of vavious biologic and environmental pa.rametws of infant loss. Health services available for both 

mother and child are fully described. The Yole of the o bstetvician and 

pediatrician in velation to the pevinatal and infant loss problem in England and Wales is reviewed in light of the findings of the British Pevi ­

natul Mortality Survey of 1958, and suggestions for matemal and child 

cave are made. 

In the last 30 yeavs the infant mortality rate in England and Wales has 

fallen 65 pevcent from 60 in 1930 to 21 in 1963. The .greatev part of the 

fall has been in deaths during latev infancy. In 1963 nearly 60 percent 

of the ~eported perinatal deaths occuwed before the birth of the child. 

A jixrther 25pevcent occuvved duving the fivst day of life. The most jrequent patholo~”cal findings amongperinatul deaths are intrapavtum anoxia 

and/ov cerebval birth tvauma which ave potentially avoidable in the future. The postneonatal death vate has increased 11 pevcent since 1961. 

The major vesistant pvoblems of infant mortality are immaturity, pneumonia, and congenital malformations. 

To accelerate the vate of decline in penkdal movtality, incyeased emphasis on the p~oblem of infant mortality through further pediat~ic inves tigation and increased expert prenatal and intvanatal obstetric care 

is uvged. 

... VIII 
INFANT AND PERINATAL MORTALITY


IN ENGLAND AND WALES


Katherine M. Hirst, O. B. E., M. B. B.S., D. P. H.; Neville R. Butler, M. D., F. R. C. P.; and 

M. J. R. Dawkins, M. D., M.R.C.P.’ 

TRENDS IN INFANT MORTALITY The position is similar within the neonatal 

AND STILLBIRTHS, 1930-63	 death rate itself. This rate has fallen by 65 percent, from 40 in 1906 to 14 in 1963. But again 

England and Wales has, during the current the greater contribution to the fall has heen in 

century, shared with many other countries the deaths during the latter part of the neonatal period. 

experience of great reductions in the death rate In the early years of the century the proportion of 

associated with birth and infancy. Throughout early to late neonatal deaths was 3 to 2; by 1930 

the latter half of the 19th century the infant mor- it was about 5 to 2 and by 1963 it was 12 to 2 

tality rate remained more or less stationary at (table 2). 

about 150 deaths per 1,000 live births. In the 20th For stillbirths h reliable figures are not availcentury the rate fell by 85 percent, from 137.8 able until after 1927, the year in which stillbirths 

in the quinquennium 1901-5 to 21.1 in 1963 (table became registrable. Prior to this date, incomplete 

1). information which was derived from notification 

The greater part of the fall has been in deaths of births to Medical Officers of Health indicated 

during later infancy. In the early years of the cen- that, at least from 1918, stillbirths had not been 

tury postneonatal deaths accounted for two-thirds decreasing. In 1928, the first complete year of 

of the total infant mortality. By 1930, as a result registration, the stillbirth rate was 40; by 1963 

of a more rapid fall in postneonatal than in neo- it had fallen by 58 percent to 17. The consistent 

natal deaths, these two components of the infant decrease began in 1936, closely following the 

mortality rate were approaching equality. With start of the consistent decrease in the maternal 

the continuation of these trends, the original mortality rate, which had reached its highest 

position reversed, so that from 1950 onwards it point in 1934 (table 1). But whereas the stillis neonatal deaths that have formed approximately birth rate has fallen by 57 percent since 1936, 

two-thirds of the total. the maternal mortality rate has fallen by over 

93 percent since 1934. 

%. Hirstwus formerly with the I?ritish Ministry of Iiealth. b

The lVorld Health Organization recommends usc of the 

fir. Rutlor is Director, Ferinatal hiortality Survey of the Na- term “fetal death” for all ?refinancy terminations which show 

tional 13irthcluy Trust Fund and Professor of Child Health at no evidence of life after complete expulsion or extraction from 

Bristol (Inivcwsity; and Dr. Dawkins, whodied May 1965, was the mother; in European vital statistics, the term “stillbirth” 

senior Iocturer in Neorrutnl Pathology at the Institute of Child is used to denote such terminations at 28 or more weeks of 

Hculth of the University of London. gestation. -lld. 
The relatively slow reduction in early neonatal deaths and stillbirths is reflected in the 

perinatal mortality rate which in 1930 was 62 

and was only little more than halved to 29 by 

1963, whereas during this period the total infant 

mortality rate fell by almost two-thirds. 

Thus the overall picture of perinatal and 

infant mortality in England and Wales during the 

current century is one of a dramatic fall in deaths 

in later infancy, but one in which the diminishing 

stillbirths and neonatal deaths (especially in the 

first week) are still far short of an improvement 

comparable with that of later infancy. 

In the first 30 years or so of this century, 

it is likely that the fall in the infant mortality 

rate was the outcome of broadly based measures 

directly or indirectly affecting infant health. These 

may be summarized briefly as improvement in 

general hygiene and housing, better nutrition, 

more specialized training of doctors and nurses 

in obstetrics and pediatrics, and better education, 

especially the education of mothers in the care of 

young children. 

During this period there was considerable 

legislation bearing on infant health of which the 

most important items were the Midwives Act of 

1902 and the Maternity and Child Welfare Act of 

1918. The Midwives Act established midwifery 

as a profession. Thereafter no one but a certified 

midwife was permitted to attend, for gain, on a 

woman in childbirth (except, of course, doctors). 

The Act also set up the Central Midwives Board 

to control the training and practice of midwives. 

Following the creation of this specialized branch 

of the nursing profession, the great majority of 

normal confinements for the past 60 years have 

been undertaken in this country by skilled and welltrained midwives. 

The Maternity and Child Welfare Act gave 

local authorities power to make arrangements 

for the care of expectant and nursing mothers and 

of children under 5 years of age, subject to approval by the Ministry of Health. “Care” in this 

sense implied preventive and educational work 

for health but did not include domiciliary medical 

care. The Act stimulated the widespread development of maternity and child welfare centers and 

advisory home visiting of mothers and children 

by qualified Health Visitors, as well as many 

ancillary schemes concerning nutrition, hom~ 

help in confinement, day nurseries, convalescent 

care, and so on. Much of the Act built on work 

that had already been started by voluntary organizations and local authorities. The nationwide 

development of the maternity and child welfart 

services was the foundation of great improvement in child care and child health during the 

current century. 

Following the rapid fall in the death rat~ 

and the general improvement in child health, 

there has been, during the past 30 years or more, 

a gradual change in the approach to the probletr 

of infant mortality. The broad approach hasec 

on education, nutrition, hygiene, and medical anc 

nursing services is still needed to maintain the 

standards of good health for the whole infant 

population. It is now increasingly supplemented 

by more intensive study of the problems of special groups, special factors, or particular agc 

periods, deploying, as it were, shock troops or 

resistant focuses. Such examples may be mentioned as the study of the medical and nursing 

needs of premature infants and the medicosocia 

problems of illegitimate children. 

In the field of perinatal mortality, a fruitfu 

line of attack lies in the identification of highrisk groups by the study of biologic, geographic 

and social factors. An intensive demographic 

approach has been made possible at a nat iona 

level through the supplementation of officia 

vital statistics by more extensive background datt 

gathered on many thousands of pregnancies 

throughout England, Scotland, and Wales durin~ 

the 1958 British Perinatal Mortality Survey oi” 

the National Birthday Trust Fund. This Survej 

gathered data about the obstetric circumstance: 

and the sociobiologic background of 98 percenl 

(16,994) of the single births occurring in England, 

Scotland, and Wales during March 3-9, 1958, am 

of 94 percent (7,117) of the stillbirths and neonatal deaths in March, April, and May 1958. 

Further, with increasing medical knowledge especially in perinatal pathology which was alsc, 

investigated at a national level in the Britisl 

Perinatal Mortality Survey, there has been increasing accuracy in identifying pathologic cause: 

in perinatal and infant mortality. Thus, as some 

of the previously little-understood or ill-definec 

2 
causes of death are elucidated, the possibility 

of a specialized approach to resistant conditions 

increases. 

This report deals with the trends of mortality during the past three decades, especially 

since 1950, and in so doing will particularly 

identify and discuss the resistant elements in 

perinatal and infant mortality in Britain. Data 

are primarily taken from reports of the Registrar 

General, the Ministry of Health, and the British 

Perinatal Mortality Survey. Greater details concerning definitions are found in appendix 1, 

registration and notification procedures in appendix II, and health services in appendix HI. 

Infant Mortality by Age 

Table 2 gives the mortality rates in certain 

age groups for all infants from 1930 through 

1963. Figure 1 shows the trends of mortality 

during approximately the same period and in the 

same age groups for all infants (and also for 

stillbirths) with quinquennial averages expressed 

as percentages of the rates for 1929-33. Particularly notable is the increasing importance of the 

contribution of early neonatal death, especially 

first-day death, to infant mortality. While the 

early neonatal death rate fell by little more 

than two-fifths from 1930 to 1963, the late neonatal and the total postneonatal death rate fell 

by nearly four-fifths. 

Although by 1963 the first-day death rate 

had been diminished by nearly one-third since 

1?30, it has been virtually stationary since 1950. 

For the remainder of the first week the rate has 

maintained, on the whole, a steady fall. For late 

neonatal and postneonatal deaths, figure 1 demonstrates the slowing down, or reversal, of improvement in the war years and in the 1950’s. 

The trends of age-specific mortality and the 

conditions influencing these trends have shown 

differing characteristics in successive decades 

since 1930 and may be conveniently considered 

in more detail in these periods. 

1930 Through 1939 

In this decade the fall of the total infant 

mortality rate from 60 to 51 infant deaths per 1,000 

live births was entirely due to reduction of the 

deaths in later infancy, especially at 6-11 months. 

Neonatal mortality improved only slowly in the 

later years of the decade. Factors contributing to 

the improvement in postneonatal mortality were 

undoubtedly the well-organized child welfare 

services throughout the country, the increasing 

use of immunization against infectious diseases, 

and the development of chemotherapy in the latter 

part of the decade. 

These favorable developments in preventive 

and curative medicine offset to some extent the 

difficulties of a period of economic depression 

and high unemployment in the late 1920’s and 

early 1930’s. However, they operated mainly 

from the later neonatal period onward and so 

could have little effect on the early weeks of life. 

The neonatal mortality rate showed little 

change in the early 1930’s and did not begin its 

slow but steady downward trend until 1934, when 

the effects of the economic depression were 

beginning to recede. The improvement was accelerated by measures which were primarily 

directed toward the reduction of maternal mortality, but which also affected the closely related 

problems of neonatal mortality. The more dramatic appeal of rising maternal mortality in the 

1920’s and early 1930’s aroused a greater interest 

than might have been aroused by the stationary 

neonatal mortality rate, hidden as it was in the 

falling total infant mortality rate. Maternal mortality was intensively studied by many organizations and committees, notably the Departmental 

Committee on Maternal Mortality and Morbidity 

set up by the Ministry of Health. Its recommendations, published in 1930 and 1932, met with a 

ready response. Some of the administrative consequences were that the General Medical Council 

raised its requirements for obstetric training in 

medical schools; the Central Midwives Board 

took similar action in relation to the training of 

midwives, adding, among other things, instruction 

in the care of the newborn; local authorities and 

hospitals increasingly adopted the recommended 

higher standards relating to personnel, premises, 

and practice in prenatal clinics; and Parliament passed the 1936 Midwives Act which set up 

a nationwide service of salaried midwives to be 

paid by their local authority and placed on the 

3 
local authorities the duty of ensuring that there 

were sufficient midwives for the needs of each 

area. These measures, together with a notably 

heightened interest in all aspects of prenatal! 

and obstetric care, not only reduced maternal 

mortality but also neonatal mortality. 

Concurrent with advances in prenatal and 

obstetric care, there was increasing study of the 

needs and care of premature or low birth weight 

babies. The first hospital unit devoted solely to 

the care of premature infants was opened in 1931 

at the Sorrento Maternity Home in Birmingham 

and was soon followed by others. These units 

provided not only postgraduate experience for 

doctors but also training courses in domiciliary 

and hospital care for midwives. Local authorities 

increasingly appointed these specially trained 

midwives to nurse selected cases of prematurity 

at home in conjunction with family doctors. The 

rapid development of this specialized branch of 

pediatrics undoubtedly influenced neonatal mortality during this and subsequent decades. 

1940 Through 1949 

In this decade, infant mortality was influenced 

at first by the effects of war. The rate rose 

sharply in 1940 and 1941 but, in contrast with the 

previous decade, it was in later infancy that the 

effect was greatest. The mortality rate at 1 through 

5 months rose from 14.9 in 1939 to 21.0 in 1941 

and at 6 to 12 months from 7.3 to 10.1, whereas 

neonatal mortality was little affected. 

The direct effect of war (i.e., death by enemy 

action) was statistically slight, no doubt largely 

because of the evacuation of children from the 

target areas. The highest infant mortality rates 

due to “operations of war” were 0.3 and 0.4 in 

1940 and 1941. In the remaining war years this 

rate was never above 0.1. 

It is impossible to assess accurately the 

indirect effect of the many disturbances of war, 

but three factors must undoubtedly have affected 

the health of young children, namely, the widespread disruption of family life, the migration 

and mingling of large groups of the population 

evacuated from the cities to safe areas, and the 

dislocation of the normal health services. 

Under the Government Evacuation Scheme 

over 4 million people, mainly children, were 

evacuated from target areas to safer areas in the 

country. “As the conditions of war changed, there 

was an ebb and flow of evacuation. It is estimated 

that an additional 2 million people moved from 

their homes under private arrangements and a 

further million with the dispersal of certain 

industries and Government departments. Thus, 

throughout the war there was a constant mingling 

of classes and cultures. Inevitably, there were 

at first widespread improvisations to meet a 

situation which, though planned in advance, had 

never before been experienced. For the many 

families who elected not to be evacuated (or who 

returned from evacuation) there were long periods 

of hazardous nightly congregation in large airraid shelters, particularly in the autumn of 1940 

and again in the following spring. 

In the hospitals, the complexities of reorganization to meet the demands of war made it inevitable that the needs of civilians had low priority until experience revealed the extent of 

other needs. In addition, thousands of hospital 

bed: in London and other cities were lost as the 

result of bomb damage. 

In the public health and social welfare services almost the entire personnel of many local 

authorities were at times diverted wholly from 

their normal duties to organize and operate the 

Civil Defense Service and the evacuation scheme. 

A heavy burden fell on rural and smaller urban 

areas faced with the influx and reflux of the most 

vulnerable groups of the population. 

Family doctors not only found their work 

increased by recruitment of doctors to the armed 

forces and by the difficulties of hospitalization 

for the civilian sick, but were in addition widely 

absorbed into part -time work in the Civil Defense 

Service and in the multitude of medical problems 

arising out of evacuation. 

This dislocation of the health services together with the widespread disruption of family 

life and the migrations and congregations of the 

population, especially children, was reflected in 

the temporary rise in infant mortality. Indeed in 

all the circumstances it may be a matter for 

surprise that the rise was not greater and of 

longer duration. As expected, the rise was chiefly 

due to an increase in deaths from infective conditions, especially respiratory diseases, measles, 

and whooping cough, but there was no major explosion of infectious disease during these years. 

4 
Neonatal mortality during 1940 and 1941 was 

very little affected. There was a slight rise in the 

late neonatal death rate from 7.1 in 1939 to 8.3 

in 1940 and 1941, but the slow downward trend 

of the early neonatal death rate was barely halted. 

The explanation of the relative immunity of the 

neonate to the effects of war in 1940 and 1941 

may lie in the interaction of several factors. The 

most potent were the administrative measures 

[o protect the coming generation in times of 

danger as expressed in the Government’s food 

and evacuation policies. 

In the food rationing scheme, mothers and 

young children had high priority from the outset. 

From July 1940 expectant and nursing mothers 

and young children were supplied with at least 

1 pint of milk daily, or the equivalent in national 

dried milk for babies. This milk was supplied at 

cheap rates or free in needy cases. In 1941 adequate supplies of free or low-cost vitamin supplements were added in the form of an orange juice 

concentrate under lend-lease arrangements with 

the United States of America and national codliver-oil compound, or tablets of vitamins A and 

D for mothers. National dried milk and margarine, 

the principal dietary sources of fat during the 

war, were both fortified with vitamin D. Young 

children also had priority in the small and variable supply of eggs. These priority rations of 

essential foods played a vital part in maintaining 

nutrition for mothers and babies and undoubtedly 

safeguarded infant health from intrauterine life 

onward, during the years of serious food shortage. 

From the outbreak of war expectant mothers 

were included in the evacuation scheme, and in 

their case the arrangements proved of value not 

only as a safety measure. The mothers went to 

hostels and emergency maternity homes in the 

reception areas about 1 month before the expected 

date of confinement. Even when the air attacks 

diminished, these arrangements were continued 

as a means of relieving the shortage of maternity 

beds and personnel in the cities. Thus, throughout the war, many mothers who were in need of 

protection from physical danger, or who might 

have difficulty in arranging for their confinement, 

had tbe opportunity of rest, supervision, and confinement in circumstances where they and their 

newborn infants were buffered from the worst 

disturlxmces of war. Moreover, they were mainly 

mothers from the more congested urban areas, 

a group vulnerable to infant mortality. 

Another favorable influence on neonatal mortality was the persistence of the strong current 

of improvement in prenatal and obstetric care 

that had been stimulated in the previous decade. 

Doctors and midwives who had experienced higher 

standards of training initiated in the 1930’s were 

coming into practice. The last of the Government 

reports arising out of high maternal mortality 

was published in 1937, and appreciation of the 

value of skilled maternity care was enhanced by 

the special problems arising out of the war. 

Further, many of the women who were bearing children in the early 1940’s probably had 

some constitutional advantages over mothers of 

earlier years. There was a rapid rise in the marriage rate in the autumn of 1939 and through 1940, 

reaching a figure higher than any in the previous 

100 years. The rise was especially marked for 

younger women. For the first time in the 20th 

century the marriage rate of women of 20-24 

years exceeded that of women 25-29 years of 

age. These younger women not only had youth 

in their favor but also had passed through their 

infancy and childhood when the nutrition of children was improving rapidly. In particular, their 

infancy was a time of intensive attack on’ ‘summer 

diarrhea” and of research into the causes of 

rickets. Knowledge of the value of breast feeding 

and of hygiene and principles of artificial feeding 

was disseminated, mainly through child welfare 

centers, where dried milk was widely supplied at 

reduced prices. The infant mortality rate from 

diarrheal diseases fell from 20 in 1911-15 to 9 in 

1916-20. Rickets was also widely attacked through 

the teaching of dietetic principles, the supply of 

cod-liver oil, and prophylactic use of ultraviolet 

light at the child welfare centers. 

Thus, among women marrying in late 1939 

and in 1940 (many of them presumably coming to 

childbearing in 1940 and 1941), there were more 

younger women than previously, and presumably 

these younger women were better nourished in 

their own infancy and fewer of them suffered from 

postrachitic pelvic contractions. All of these 

factors would tend to counteract any adverse 

effects of war conditions on neonatal mortality. 

After 1941, infant mortality fell rapidly during the remainder of the decade. The fall was 

5 
interrupted only in 1945, when the end of the war 

brough~ its ow-problems. The cumulative effects 

of war brought an almost worldwide food shortage. 

In addition, in this country, families were returning to overcrowded conditions in war-stricken 

areas (not only due to housing damage but also 

to the complete cessation of new building for 6 

years), many hospitals were still at least partially 

out of action, there was a grave shortage of medical and nursing personnel pending demobilization, 

and the birth rate was rising. All these factors 

combined to halt the fall of the infant mortality 

rate in 1945. 

Apart from this brief check, the fall in the 

infant mortality rate was remarkable. Between 

1941 and 1950 the total rate was halved (from 

60.0 to 29.6) and in this period the early neonatal, 

late neonatal, and postneonatal death rates fell by 

approximately 27, 60, and 64 percent, respectively. This was achieved in a time of total war, 

followed by years of national financial stringency 

and food shortages and with the birth rate rising 

by 1947 to a higher level than at any time in the 

previous 30 years. The rapid fall in the infant 

mortality rate was in part due to the return to 

the previous pace of improvement as the country 

became adapted to the disturbances of war, in 

part to the continuance of priority food rationing 

throughout the war and for several further years, 

but above all, in the latter part of the decade, to 

the great advances in medical knowledge at this 

time. Antibiotic therapy, which was not available 

in this country for general civilian use until 

after the war, stands out as the most potent new 

weapon. In many fields, medical research yielded 

other new or improved weapons that contributed 

to the saving of infant life: the furtlier development of chemotherapy, the widening range of 

immunization, the elucidation of the cause of 

hemolytic disease of the newborn, the improvement in the techniques of blood transfusion, and 

the discovery of the relationship between congenital malformations and maternal rubella. 

It is probable that other less demonstrable 

medicosocial factors were also influencing the 

infant mortality rate, such as increasing education 

in child care and the beneficial effect of full employment arising out of the war, but there can be 

little doubt that the most potent factor was the 

enhanced power of the direct medical attack on 

disease. The main impact was on infective conditions that chiefly affect the late neonatal anc 

postneonatal periods. 

1950 Through 1963 

During the 1950’s infant mortality continuwl 

to fall, but at a much slower pace than in th( I 

1940’s. The rate fell by 27 percent from 30 in 

1950 to 22 in 1959, in contrast with the fall of 5[ 

percent from the peak of 60 in 1941 to 30 in 1950, 

The rapid recovery of those years came to a tern. 

porary halt in 1951. Thereafter improvement wall 

resumed relatively slowly throughout the re. 

mainder of the decade and the early 1960’s. 

The slowing down of the pace of improvement 

is apparent in all age groups, except 1-6 clay:: 

(fig. 1). Even in this group, there was a tempo 

rary halt in the trend around 1950 (table 2) which 

is masked by the qw”.nquennial character o t 

figure 1. 

The outstanding feature of this period is th{: 

virtual standstill of the first-day mortality rate, 

which has scarcely altered since 1950, fluctuating]; 

around 7.5. At the beginning of the 1950’s, first.. 

day deaths accounted for about one-quarter of all 

infant mortality; by the end of the decade th( I 

proportion was approximately one-third. Th( J 

cessation of improvement in such a large fractio]l 

of the total has put a strong brake on the fall or 

the infant mortality rate. 

Improvement in the late neonatal mortalit!l 

rate slowed down a little in the 1950’s, but by then 

it had already reached the low figure of three in. 

fant deaths per 1,000 live births. In postneonatal 

mortality the improvement in the rates not only 

slowed down in the mid-1950’s but by the 1960~s 

these rates had begun to show an upward trend. 

Thus, although the infant mortality rate il} 

1963 reached the lowest figure ever recordcl 1 

in this country, improvement has been slowe -

or absent in the last 10 or 12 years in all agi’ 

groups except 1-6 days. First-day deaths stanl I 

out as the most resistant and also numerical~~ 

the major problem. Postneonatal deaths, thougl I 

far fewer in number, present the new problem 0[ 

a rising trend. Trends of these rates in recent 

years will be considered in more detail in re 

lation to causes of death, factors influencin}~ 

variability y in the mortality rates, and the tren{ 1 

of the stillbirth rate. 

6 
---

-----

----

---

100 

r 

90 – 

80


70 – 

; 

:60 -

m 

m 

k 50
 N


m


= 

g 40
 1-


a 

(z 

30


Perinatal _
 20
 Stillbirth


Under I doy .-=-=, 

10 1-6 days ,,,,,,,,,,,,,


I


o~ ~..~ 1929- 1934- 1939- 1944- 1949- 1954- 1959-

1933 1938 1943 1948 1953 1958 1963


YEARS 

Fiqure 1. Ratios of quinquennial stil I birth, perinatal, 

1929-23: England and 

Infant Mortality by Sex 

For many years, certainly since the third 

decade of this century, the ratio of the male to 

the female death rate in the first year of life 

has varied very little. The excess of the rate for 

males over females has fluctuated around 30 

percent. But the sex ratios have changed in the 

different age groups (table A). Broadly, there 

has been a tendency for the index of male to 

female rates to rise in the early neonatal period 

and to fall in the postneonatal period, while in 

the late neonatal period the ratio has not changed 

appreciably.


The high proportion of male deaths at 1-6


days has remained a constant feature over the


years (table 3). This was due mainly to the high 

male mortality from two of the most frequent 

causes of death at this age— birth injury and 

postnatal asphyxia, for which the sex ratios in 

1959-61 were 185 and 165, respectively (tables 4


and 5). Two much less frequent causes, pneumonia


100-

90 – 

80 – 

70 – 

60 – 

50 – 

40 -

30 – 

o~ 1929- 1934- 1939- 1944- 1949- 1954- 1959-

1933 1938 1943 1948 1953 1958 1963


YEARS 

and infant mortal ity rates to rates for the period, 

V/al es, 1929-63. 

Table A. Sex ratios in infant mortality,


by age at death: England and wales, se­


lected years, 1936-62


I I I I


1960- 1950- 1940- 1936- Age at death 1962 1952 1942 1939


I Males per 100 females 

Under 1 day -- 131 128 125 124


1-6 days 143 146 139 132


28 days2 months 125 136 140 144 

3-5 months 119 118 130 132 

6-8 months--- 106 120 123 126 

9-11 months-- 111 107 117 122 

7-27 days---- 121 121 120 123


and congenital malformations of the heart also 

contributed. For these last twoconditions, the sex 

ratios for infant mortality at 1-6 days were, 

respectively, 180 and 158 in 1959-61. Birth injury also showed a somewhat higher than average 

7

sex ratio in first-day mortality (148), but in this 

age period the high sex ratio is offset by the lower 

sex ratio for congenital malformations of the 

central nervous system. 

The reduction of the male excess in mortality 

during the postneonatal period stems from the 

marked fall in mortality from all causes except 

congenital malformations. Malformation of the 

central nervous system is the only group of 

deaths in which the female rate is consistently 

higher than the male. As deaths from other 

causes have decreased, mortality from congenital 

malformations, with its high component of female 

deaths, has formed an increasingly larger proportion of postneonatal deaths with consequent 

reduction of the sex ratio for postneonatal deaths. 

Trend of Stillbirth Rate 

In 1928, the first complete year of stillbirth 

registration, the rate was 40 per 1,000 total 

births. It remained at 40 or 41 for 9 years, but 

dropped to 39 in 1937; since then the rate has 

fallen almost every year to 17.2 in 1963 (table 1). 

Although the fall has been almost continuous, 

the pace of improvement has not been consistent. 

It was relatively slow in the late 1930’s, much 

more rapid in the early 1940’s, then became almost stationary in the early 1950’s. The fall 

quickened again after 1957 though not quite so 

much as in earlier years. 

The trend of the stillbirth rate paralleled 

that of first-day mortality until about 1957, when 

the resumption of the decline in the stillbirth 

rate was not matched by a decline in first-day 

deaths (fig. 1). The favorable medical, environmental, and biologic factors that influenced neonatal mortality in the 1930’s and 1940’s were 

primarily operative prenatally and intranatally 

and thus were even more favorable in their effect 

on stillbirths. 

Mention should be made at this point of two 

circumstances relating to death or stillbirth 

certification which may have had some artificial 

effect on the trends in recent years. Prior to 

1948, financial maternity benefits were relatively 

small in amount and applied to a limited group of 

women, but after that date, substantial maternity 

benefits became payable to all women in childbirth. When little or no financial consideration 

arises in borderline cases of a birth around tht 

28th week of pregnancy, the doctor or midwife 

may be inclined to spare the parents the distress 

of registration and burial and may regard th~ 

outcome of the pregnancy as an abort ion. CWher 

substantial financial consideration is involved : 

borderline decision might be in the opposite direction. In the British Perinatal Mortality Survey 1 in one month (March 1958) 11 abortions hacl 

in fact been registered as stillbirths. Thus, ir 

1958, the effect of incorrect registration wa:: 

evidently trivial, but in earlier years the situatior 

may have occurred rather more frequently, thouglits effect was probably never more than marginal, 

The interpretation of the definition of “stillbirth” will also have had some influence. Doctors 

and midwives were free to put their own interpretation on the words “or show any other signs o‘ 

life” in the statutory definition of stillbirth. However, it has been traditional to regard as a stillbirth any fetus that does not breathe, that is, in 

effect, to disregard the words “any other sigtw 

of life.” The definition of stillbirth approved bjr 

the World Health Organization (WHO) in 195( 

particularized the other evidence of life as “beating of the heart, pulsation of the umbilical cord 

or definite movement of voluntary muscles. ” Tht 

WHO definition was not adopted in this country 

but received some publicity and provoked discussion. There was also discussion during th( 

1950’s of the pros and cons of certifying the 

causes of stillbirth (eventually begun in 1960) 

and rapid advance in the study of perinatal pathology. These developments focused attention on tht 

precise definition of stillbirth and no doubt startec 

a trend of regarding as liveborn some infants thal 

previously would have been considered stillborn, 

In 1960, supplies of the new stillbirth certificat~ 

(with cause of death) were issued to doctors anc 

midwives and the advisory notes therewith contained not only the statutory definition of stillbirth, but also, for the first time, a statemenl 

that “a child which has breathed or shown arq 

other sign of life, such as beating of the heart, 

pulsation of the umbilical cord, or definite moveCASused in this publication “abortion” is th~ (quivalmt 

of the World Health Organization Class “Early onrl intmm. 

diate fetal deaths” (fetal deaths of less than !2s cwnplctod 

weeks of gestation) .-Ed. 

8 

I 
ment of voluntary muscles is considered as liveborn for registration purposes.” This definite 

guidance on the interpretation of the English 

definition undoubtedly increased the trend for 

some stillbirths to be transferred to first-day 

deaths and contributed to the recent divergence 

of these two rates. 

Stillbirths by Sex 

Until recent years the male stillbirth rate 

has been consistently, but not greatly, in excess 

of the female rate (tables 6 and 7). In 1930 the sex 

ratio was 118 but it has gradually declined until 

in 1963 it was 105. 

In the absence of information regarding the 

ctiuses of stillbirth before 1960, it is only possible 

to surmise the trends that have reduced male 

stillbirths more than female. In 1961 the rates 

for males and females were about equal. The 

w~’11-known high proportion of female stillbirths 

due to congenital malformation of the central 

nervous system is confirmed by the sex ratio of 

48 for that cause group. Congenital malformation 

of the central nervous system is now the predominant cause of stillbirth, and there seems 

little reason to suppose that the stillbirth rate 

from this cause has altered much in recent years. 

On the other hand, stillbirths ascribed to birth 

injuries and difficulties in labor with a sex ratio 

of 125 is presumably linked with the higher average birth weight of males. Stillbirths from these 

causes probably have been reduced most by the 

improvement in prenatal and obstetric care. 

CAUSES OF DEATH 

The trends of mortality from 1950 onward 

are different from those of earlier years. Since 

the main tabulations of causes of death are presented only for the later period it will be convenient to consider causes of death before and 

after 1Q50 separately, discussing the later period 

in more detail. 

Causes of Infant Death 

1936 tllrot$qh 1949. — Prior to 1950 the principal decline in infant mortality was in deaths 

from infective conditions, which affected mainly 

the postneonatal period. After temporary halts 

or rises during the war years mortality from 

these conditions declined rapidly with the advent 

of antibiotic therapy (table B). Although for the 

whole of infancy, mortality from bronchitis and 

pneumonia was nearly halved, this was not so for 

pneumonia of the newborn. The steadiness of the 

rate for pneumonia of the newborn reflects the 

different etiology of deaths during the neonatal 

age period, and the more accurate certification of 

deaths that might previously have been ascribed 

to premature birth (Code 159 in the Fifth Revision 

of the International Statistical Classification). In 

1949 about one-third of the deaths from pneumonia 

of the newborn were certified as associated with 

premature birth. 

For conditions stemming from prenatal or 

intranatal influences that affect mainly the neonatal period, mortality in the aggregate declined 

considerably, though not so markedly as mortalit y stemming from postnatal influences (table 

C). The most striking feature is the halving of the 

death rate ascribed to premature birth, but undoubtedly this was partly the result of improved 

certification. The steadiness of the rate for 

birth injuries and the rise in the rate for asphyxia 

reflect increasing interest in neonatal pathology 

and increasing use of autopsies, resulting in “the 

tendency to prefer proved autopsy findings as the 

underlying cause to the less definite but etiologically more meaningful term such as immaturity. ” 2 

There were also marked falls in ill-defined conditions such as convulsions or congenital debility 

which reflect the same tendency. The rise in the 

rate for hemolytic disease, however, is more 

likely to have been due to improved clinical 

rather than postmortem diagnosis. 

Although the fall in death rate ascribed to 

premature birth was partly the result of transference to other rubrics, there was nevertheless 

a fall of nearly one-third in the combined group 

of premature birth, birth injuries, asphyxia, 

and hemolytic disease. Since the latter three are 

very frequently associated with premature birth, 

there was clearly a considerable reduction in 

deaths ascribed to or associated with premature 

birth. There is no evidence to relate this fall 

in mortality to a decline in the incidence of low 

birth weight babies. Data based on all births in 

England, Scotland, and Wales in one week in 1946 

9 
-----------------------------------------

------------------------------------------------ -----------------------------------

------------------------------- ---------------------------------

----------------------------------- ---------------------------------

-------------

-----------

-------------

Table B. Infant and neonatal mortality rates from certain infective diseases: England 

and Wales, selected years, 1936-49 

Cause of deathl 1949 1948 1943-45 1936-39 

Infant mortality Rate per 1,000 live births 

Whooping cough 0.5 0.6 0.8 

Measles 0.1 0.1 0.3 

Tuberculous diseases 0.2 0.3 0.5 

Bronchitis and pneumonia 5.8 6.3 9.3 

Enteritis and diarrhea 2.6 2.9 5.0 

Neonatal mortali.tv 

Pneumonia of newborn 0.9 0.9 

Enteritis and diarrhea 0.2 0.3 ::: 

lCausesof death classified according to the Fifth Revisi-onof the International List 

of Causes of Death, 1938. 

indicate that 7 percent of live births and 7.6per- The variability in estimates of the incidence


cent of all births were premature by the birth of congenital malformations makes it impossible


weight standard of 2,500 grams or less.s Using to relate the decline in mortality to a decline


the same standard, theMinistryofHealth reported in incidence with any certainty. The reduction


that the proportion of premature live births has of deaths during infancy was probably influenced


remained constant since 1953 at just under 7 by general improvement in pediatric care in-


percent, and for all premature births at just cluding antibiotic therapy, especially as the


under 8 percent. Reference has already been greater part of the fall wasafter 1945, There is,


made to the development of special services for however, some evidence that this was not the


the care of premature infants. The decreasing whole cause:


mortality rates associated with prematurity re-


fleet increasing skills inthis field and increasing


special facilities and specially trainedpersonnel. Infant movtcdity


Deaths ascribed to congenitalmalformations pe~ 1,000 live bivths 

affect both the neonatal and postneonatal periods. 

Roughly two-thirds of the deaths attributed to 1947-49 1937-39 

congenital malformations occur in thefirstmonth 

of life. The trend for total infant mortality due to Congenital hmrtd isease-- 1.6 2.() 

congenital malformations prior to 1950 isasfolIows: 

1949-------------------------


1948-------------------------


1947-------------------------


1946-------------------------


1943-45----------------------


1936-39----------------------


Ratepevl,OoO 

live bivths 

4.6 

4.4


4.9


5.4


5.7


6.2 

Monstrosity 0.1 0.2 

Hydrocephalus 0.2 0.3 

Spinabifida 1.1 1.8 

While antibiotic or other therapy mightwellsave, 

or postpone beyond infancy, some of the deathsof 

infants enfeebled by congenital heartdisease, this 

can hardly be envisaged as causinga similar fall 

in monstrosity and hydrocephalus and an even 

greater fall in spina bifida. lt is not known 

whether there was any change in the stillbirth 

10

-------- -------- -------- -------- -------- ----

----------------------------------------

----------------------------------------- --------------------- --------------------------------------

Table C. Infant mortality rates for selected prenatal and intranatal causes: England 

and Wales, selected years, 1936-49 

Cause of deathl 1949 1948 1943-45 1936-39 

Rate per 1,000 live births


Total 14.2 14.5 17.3 20.8 

Premature birth 7.6 8.4 11.9 15.5 

Birth injuries 2.6 2.5 2.7 

Postnatal asphyxia and atelectasis ;:: 2.2 2.1 

Hemolytic disease N 0.7 0.7 0.5 

lCauses of death classified according to the Fifth Revision of the International List 

of Causes of Death, 1938. 

rates from these causesatthattime since national 

figures for causes of stillbirth are not available. 

13ut, in Birmingham a si~ificant fall was observed in perinatal death due to anencephalus 

from 2.6 per 1,000 total births in 1940-44 to 1.8 

in 1945-49 and forspinabifida from 2.4to 1.9.4 

Perinatal loss virtually represents the incidence 

from anencephalus since scarcely any infant with 

this condition survives birth or early infancy, but 

whether this local observation represents the 

national trend can only be surmised. There may 

also have been some slightdeclineinthe incidence 

of congenital heart disease arising from the control of rubella in pregnancy. 

The gains from advancing skills in neonatal 

surgery for congenital malformations, though 

often individually dramatic, were statistically 

slight in comparison with the great numbers not 

yet amenable to surgery in infancy. The most 

notable gain was a sudden drop in the mortality 

from pyloric stenosis, from 0.4in1947to 0.2 in 

1948 and acontinuous fallthereafter,which probably reflects concurrent antibiotic therapy and 

improving techniques in anesthesia. 

Insummary, of the trends in causes ofdeath 

from about 1936 through 1949,the infantmortality 

rate declined 45 percent mainly due to declines 

of49 percent in deaths from infective conditions, 

33 percent in the group of deaths ascribed to 

premature birth, birth injuries, and asphyxia, and 

26 percent in deaths due tocongenital malformations. 

1950 thvough 1963.-–Mortality rates from 

1950-63 for the main causes of infant death 

(table 8), andofneonatal andpostneonatal deaths 

(tables 9 and 10) are shown separately. From 1950 

onward the terminology of the Sixth Revision of 

the International Statistical Classification (1948) 

was brought intousein Great Britian. Among other 

things, the rubrics “immaturity” (ICD 774 and 776) 

replaced the previous rubric “premature birth. ” 

In the 1950’s and early 1960’s infant mortality 

from infective conditions continued to decline, and 

by 1963, mortality from specific infections was 

numerically trivial. Mortality was almost nonexistent in the neonatal period and only meningitis 

presented appreciable numbers during the postneonatal period. Mortality from respiratory disease, chiefly pneumonia and bronchitis, continued 

to decline steadily until 1957. Since then there has 

been no consistent improvement. Mortality from 

gastroenteritis also fell steadily until 1959. Since 

then the rate has risen slightly, but the rate in 

1963 was still less than one-third of the 1950 

figure. 

The neonatal mortality rate for immaturity 

has continuously fallen while those for birth injuries and asphyxia have remained fairly steady. 

A new feature since 1950 is the absence of any 

improvement in mortality for the first day of life, 

due to the unchanging combined mortality from 

immaturity, birth injuries, and asphyxia. In 1959-

61 first-day mortality from this group contributed 

over one-quarter of all infant mortality. 

11

For hemolytic disease, the rise seen before 

1950 was no longer apparent and the rate has 

fallen fairly steadily since 1951. The fallreflects 

the advances in recent years inthe’ techniques of 

treatment and of prenatal diagnosis. The establishment of the National Blood Transfusion Service 

with regional laboratories during the war provided 

facilities for the diagnosis of isoimmunization as 

well as supplies of suitable blood for transfusion 

of infants with hemolytic disease. Rh testing of 

blood during pregnancy is now accepted, but is not 

invariably practiced. Nor are the arrangements 

for prenatal, natal, and postnatal care of affected 

babies fully coordinated in all areas. Improvement on these two points could certainly lead to a 

lower death rate from hemolytic disease, even 

without further research and new techniques. 

The groups of conditions under lack of care 

and accident (chiefly accidental mechanical suffocation) have also declined. Accidental mechanical 

suffocation is increasingly recognized as more 

often due to underlying disease rather than to 

accident. 

The rate for the whole group of congenital 

malformations has, in contrast with the previous 

decade, shown little change since 1951, rising 

slightly from 4.4 per 1,000 live births in 1950-

52 to 4.5 in 1959-61. 

From this brief review it is clear that the 

major or resistant problems of infant mortality 

in recent years are: (1) immaturity and the conditions that are associated with the stress of 

birth and with immaturity, especially in first-day 

mortality, (2) pneumonia, (3) gastroenteritis, and 

(4) congenital malformations. Consequently, these 

four groups will be considered in more detail. 

Immaturity and Low Birth Weight 

Deaths ascribed to immaturity, asphyxia, and 

birth injuries dominate early neonatal mortality. 

Although the combined early neonatal rate for 

these three conditions declined from 10.7 per 

1,000 live births in 1950-52 to 9.3 in 1959-61 and 

to 8.6 in 1962, they still account for about 70 percent of deaths in the first week of life. In first-day 

mortality these conditions account for about 75 

percent of the deaths, and the combined rate for 

these causes remained unaltered at 5.8 in 1950-

52 and in 1959-61, with only a slight fall to 5.4 in 

1962. 

Roughly half the deaths ascribed to birth injuries and two-thirds of those ascribed to asphyxia 

are certified as associated with immaturity. For 

some of the less frequent causes of early neonatal death the association with immaturity is 

even higher. For example, three-quarters of those 

assigned to ill-defined diseases of early infancy 

and nearly all the small group attributed to 

maternal toxemia (188 deaths in 1962) were 

associated with immaturity. 

The influence of immaturity on first-week 

deaths is seen more precisely in table D which 

shows the first-week death rates by sex for 1950 

and 1960. Early neonatal mortality influenced by 

immaturity has declined, but its contribution to 

the total early neonatal mortality has remained 

proportionately unchanged. Even the figures in 

this table take no account of immaturity associated 

with conditions not included in diseases of early 

infancy (e.g., congenital malformations) in which 

immaturity, if mentioned, is not coded though it 

may or may not have influenced mortality. 

The fall in the rates of deaths from ‘‘immaturity alone or primary” and the rise in those 

where immaturity is associated with diseases of 

early infancy indicate a continuation of the aforementioned trend of giving a more definite pathological finding as the primary cause of death 

and of recording immaturity on the death certificate as a contributory condition. The Registrar 

General noted in 1958 that in 56 percent of infant 

deaths from 5irth injuries and asphyxia, the 

cause of death had been certified after postmortem examination.~ 

Consideration of mortality rates among infants of low birth weight confirms the findings 

related to immaturity in certified causes of 

death. Tables 11 and 12 are based on figures 

derived from notifications of premature births 

(i.e., births of 2,500 grams or less) and published 

in successive Annual Reports of the Ministry of 

Health of England and Wales. 

First-day mortality of infants weighing 2,500 

grams or less has shown little consistent change 

from 1953 through 1963, which correspond with 

the halt in the decline of first-day mortality 

among registered causes of death in which immaturity is the dominant factor. It may be estimated that with an average of over 50,000 low 

weight live births annually and a first-day mortality rate of about 83 per 1,000 live births, them 

12 
--------- --------- ------- ------- ------- ---

-------- -------- -------- ---------

low birth weight babies contribute over 4,000 

deaths to the total of approximately 6,000 registered deaths on the first day of life. 

Although the pvopovtion, of low birth weight 

babies among live births remained unchanged at a 

little under 7 percent from 1953 to 1963, there 

was a considerable increase in the number’of such 

births primarily due to the rise in the total birth 

rate since 1955. Table 12 shows that the distribution of low birth weight babies by birth weight 

has also remained unchanged. Recently the number 

of babies in the weight group 1,000 grams or 

less has been recorded; these accounted for 4 

percent of the total live births of 2,500 grams or 

less in 1963,1964, and 1965. This same proportion 

was noted in the admittedly incomplete records 

in 1951 and 1952 and was recorded by Crosse in 

Birmingham in 1956 -58.6 

Although first-day mortality of low birth 

weight babies remained unaltered, total neonatal 

mortality in this group fell steadily by 17 percent 

from 1953 to 1963. The decline was roughly the 

same in all weight groups, except the lowest 

(1,500 grams or less) which fell by only 9 percent. 

Since total neonatal mortality is still declining, the full potential of increased obstetric and 

pediatric skills in the care of these low weight 

babies has probably not yet been reached. This 

was evident when the Ministry of Health surveyed 

the hospital and domiciliary facilities for the care 

of premature infants in 1957. For instance, of infants weighing less than 1,500 grams who were 

treated in hospital, only 45 percent were admitted 

to premature baby units which were staffed by 

midwives and nurses with special training and 

experience engaged full timle in care of premature. As a result the whole problem of prematurity was reviewed afresh by the Ministerts 

Advisory Medical and Maternity Committee, and 

their advice on comprehensive schemes for the 

care of premature infants and the prevention of 

prematurity was circulated to hospitals and local 

authorities. 

The need for good prenatal care, and for 

immediate admission to hospital of all women 

going into labor before the 37th week was advocated, even if prior arrangements had been made 

for confinement at home. Special attention was 

Table D. Mortality i-n the first week of life due to or associated with immaturity, by 

sex: England and Wales, 1950 and 1960 

1960 1950 

Cause of deathl 

Male Female Male Female 

Rate per 1,000 live births 

All causes 15.4 11.2 17.5 12.8 

Immaturity, or with mention of immaturity--774, 776,760-7732 6.4 10.0 

Immaturity alone or primary ------------------------774,776 ::; 3.2 5.9 i:: 

‘Immaturity associated with diseases 

of early infancy 760-7732 4.7 3.2 4.1 

Percent of total 

Immaturity, or with mention of immaturity-774,776,760 -7732 58 

lCauses of death classified according to the sixth Revision of the International 

Lists, 1948. 

2For each ICD code number , includes only that portion ending in .5. 

13 

2.8 
also drawn to the need for nondepressant maternal 

analgesia and anesthesia in premature labor, to 

the advantage of prophylactic episiotomy, and also 

for a prepared plan for the management of asphyxia after birth, Partly as a result of the recommendations of this Comittee, a comprehensive 

premature baby care program has been introduced 

in many areas to raise the general standard of care. 

Perhaps the greatest improvements have been in 

specialized medical supervision; in higher standards of nursery accommodation and equipment; in 

improved number, status, and experience of nursing staff engaged in premature baby care; in more 

satisfactory arrangements for resuscitation of 

infants in hospital; and in better transport provision, 

Most of the larger health authorities in 

Britain run a home-nursing service for premature babies, but immediate hospital admission 

is usually arranged when the birth weight is under 

2,000 grams (4 lb., 6 oz.). Immediate hospital 

admission is also arranged in the presence of any 

complication such as cyanotic attacks, convulsions, jaundice, or infection. The provision of 

special transport facilities has undoubtedly reduced the mortality among premature infants 

transported from home to hospital immediately 

after birth or later as emergency cases. These 

infants are usually transported in a heated ambulance provided by the Health Authority with provision for oxygen administration and also for care 

en route by a nurse proficient in premature baby 

care. 

Aftercare of low birth weight infants has also 

improved. Before discharge, a visit is usually 

made through the social services to ensure that 

home circumstances are satisfactory. Where possible, the mother spends the final few days in the 

premature unit either on a residential or daily 

visiting basis. Routine aftercare usually includes 

regular observation at infant welfare clinics or by 

health visitors. Supplements of iron and vitamins 

A, C, and D are given widely. Followup of low 

birth weight or other high-risk babies is carried 

out either in hospital clinics run by consultant 

pediatricians, or in some cases by the Local 

Health Authority Medical Officer or a general 

practitioner. 

Thus, better administration, better deployment of clinical skills, and further research may 

be expected to maintain the fall in neonatal mortality of premature infants. The decline may extend to all infants because special facilities 

primarily designed for the care of premature 

are now widely used for other infants at special 

risk. 

The lack of improvement in first-day mortality in all low birth weight groups, and in total 

neonatal mortality in the lowest weight group, 

suggests a “hard core” that has so far been little 

affected either by intranatal obstetric care or by 

immediate postnatal pediatric care. This group 

includes infants with severe congenital malformations, but necropsy reveals the most frequent 

causes of death as failure to maintain respiration 

because of lesions grouped under such terms as 

“pulmonary syndrome of the newborn” or ‘‘abnormal pulmonary ventilation. ” Whatever the 

nomenclature, or whatever the precise conditions 

included in these terms, all investigators agree 

that hyaline membrane or intraventricular hemorrhage are characteristic findings in necropsies on 

low birth weight infants. The British Perinatal 

Mortality Survey identified a group of neonatal 

deaths associated with premature delivery and 

often also with clinical respiratory distress which 

they entitled “respiratory distress syndrome. ” 

(See appendix I for definition.) Among low birth 

weight babies, 44 percent of the early neonatal 

deaths fell into this category. This incidence was 

eight times greater than among babies weighing 

more than 2,500 grams. In this series, the other 

frequent primary necropsy findings in low birth 

weight infants were congenital malformations (15 

percent), intrapartum a.noxia and/or cerebral 

birth trauma (12 percent), pulmonary infection 

(10 percent), and massive pulmonary hemorrhage 

(7 percent). In cases that fell into “respiratory 

distress syndrome” or intrapartum anoxia and/or 

cerebral birth trauma, the majority of first-week 

deaths occurred during the first 24 hours of life. 

Since first-day mortality is very largely a 

question of mortality of immature or low birth 

weight babies, the solution of this resistant problem apparently lies in (1) the prevention of premature delivery especially at very low gestations, 

and (2) the prevention or successful treatment of 

pathological conditions noted in early neonatal 

death in premature infants. 

14 
Some years ago it was thought that the former 

proposition offered the better hope of success. 

Yet, although the factors that predispose to prematurity have been recognized and have formed 

the basis of teaching for many years, the incidence 

of premature birth (both live birth and stillbirth) 

has remained unaffected, at least for the past 20 

years. Twenty years is, however, a short time 

for the observation of a condition in which biologic 

factors such as maternal age, parity, physique, 

sex ratio, birth spacing, and multiple pregnancy 

all play a part. Also to be considered are the 

complex effect of socioeconomic circumstances 

and the obscure etiology of many congenital malformations. Moreover, there is little information 

about the bearing of these factors on premature 

termination of pregnancy before the 28th week. 

A major breakthrough still awaits success in research on the causation and control of preeclamp -

tic toxemia, Yet even on present knowledge most 

inquiries on maternal and perinatal mortalit y still 

yield evidence of prenatal and obstetric care 

that has not yet reached the high standard required 

to minimize the dangers of toxemia. 

Although the problem of preventing prematurity remains unsolved, advances in the knowledge of intranatal and neonatal physiology and 

pathology now seem to hold out hope of reducing 

the intractable perinatal mortality of premature 

infants. There is as yet little prospect of any 

reduction in the deaths due to congenital malformations, but there is perhaps a reasonable 

prospect that anoxic states and respiratory syndromes may yield, at least to some extent, to the 

obstetric and pediatric techniques coming into use 

in the last few years for the prevention of anoxia 

and the resuscitation of the newborn. 

First-day mortality of low birth weight babies 

has fallen slightly in each of the last 3 years and 

reached its lowest level in 1963 (table 11). Among 

registered causes of death on the first day, the 

group ascribed to immaturity, birth injury, and 

asphyxia reached its lowest level in 1962 (the 

latest rate available). The changes are too slight 

to warrant any firm conclusion as yet, but there 

is at least a possibility y that they may reflect the 

most recent advances in the care of the premature infant. 

Pneumonia 

Infant mortality ascribed to respiratory diseases— influenza, pneumonia, bronchitis, and 

“other” respiratory diseases— fell from 5.7 per 

1,000 live births in 1950-52 to 3.6 in 1959-61, but 

all the improvement occurred prior to 1958. 

Since then there has been no consistent change 

in the rate. 

Pneumonia is predominant in the group of 

respiratory diseases, contributing 80 percent 

to the postneonatal deaths and over 90 percent to 

neonatal deaths. The cessation of improvement 

after 1957 occurred in both neonatal and postneonatal deaths. Among the latter the greater 

part of the mortality occurs under 6 months. The 

first rise in the postneonatal rate for many years 

followed an epidemic of “Asian flu” which affected 

this country for the first time in the winter of 

1957-58, but there have been no widespread influenza epidemics since then and the rise in 1958 

may have been coincidental. 

Postneonatal pneumonia is much more common in the low socioeconomic groups, and a 

lessening may be expected with better socioeconomic circumstances and increasing prophylactic use of welfare facilities. There is no reason to suppose that postneonatal deaths have 

increased from pneumonia following specific 

fevers such as pertussis or measles. Likewise, 

no evidence exists that staphylococcal or other 

bacterial pneumonias have shown an increased 

mortality. Many of those dying with previously 

resistant organisms are now responsive to the 

newer penicillins. 

The rapid advances in virology in the past 

10 years have thrown new light on the etiology 

of respiratory disease. Viral infection is now being increasingly demonstrated as a cause of respiratory disease, especially the respiratory 

syncytial virus in bronchiolitis in infancy. Localized winter epidemics ascribed to this infection 

have been reported in recent years and a low 

antibody response observed in young children. To 

a lesser extent other myxoviruses and influenza 

A and B and adenoviruses have also been incriminated. The relationship of viral infections 

with mortality is not yet entirely clear. 

15 
To sum up, there seems a strong probability 

that whereas antibiotic therapy has controlled the 

mortality of bacterial pneumonic infection, there 

is still a residual mortality from previously 

unrecognized viral infections which are unresponsive to antibiotics and that this is preventing, 

for the present, further improvement in the mortality from respiratory diseases in infancy. 

Some small part of the mortality ascribed 

to pneumonia is also probably a transference from 

accidental mechanical suffocation. Deaths ascribed to this cause rose to their highest level 

in 1947. Since then they have been steadily declining. Many investigations in this country, in the 

United States, and elsewhere have led to the recognition that fulminating illness is frequently the 

cause of sudden cot (crib) death, rather than accidental choking or smothering, and it is likely 

that an increasing number are now ascribed to 

acute respirator y conditions. In this country viral 

infection in lungs or elsewhere has not so far 

been demonstrated in cot death and the etiology 

is still uncertain in many of these deaths. 

Gastroenteritis 

As with pneumonia, mortality attributed to 

gastroenteritis declined steadily until 1958. Since 

then the rate has risen, especially in the postneonatal period, though it still is well below the 

level at the beginning of the decade. The greatest 

part of postneonatal mortality from this cause 

occurs before the 6th month of life. 

Gastroenteritis, as represented in certified 

causes of death, is a somewhat heterogeneous 

group which may include dietetic diseases, gastrointestinal infection, or the terminal event of 

other infections. This and the comparatively 

small numbers involved (55 neonatal deaths and 

395 postneonatal deaths in 1962) make it difficult 

to interpret the recent trend. 

Because of the rise in postneonatal mortality 

in the last few years, the Ministry of Health in 

1964 initiated a preliminary inquiry, requesting 

an investigation and report on each postneonatal 

death, from whatever cause, during that year in 

two cities and one count y area. When the results 

of the inquiry have been analyzed they will no 

doubt throw more light on the subject of postneonatal death including gastroenteritis and point the 

way for more widespread investigation if necessary. 

Congenital Malformation 

Mortality due to congenital malformation 

has not maintained the decline noted prior to 

1950. The total rate was 4.4 per 1,000 live births 

in 1950-52, 4.5 in 1959-61, and 4.6 in 1962. It 

may be noted that the rate was 4.4 in 1901-5 and 

at that time congenital malformation contributed 

about 3 percent of all infant mortality. Now, with 

the rate hardly altered, they contribute over 20 

percent. 

The steadiness of the rate for congenital 

malformation since 1950 is apparent in all age 

groups in the first year. There does not appear 

to have been any noticeable saving of life in the 

younger age groups leading to postponed deaths 

in the older groups. 

The group of deaths under the heading “other 

congenital malformations” shows a slight Iy rising 

trend, which is mainly due to an increase in deaths 

from “monstrosity.” The deaths included in the 

category “other malformations” in 1962 are given 

in table E. 

From registered causes of death, it is not 

possible to estimate the distribution of the various 

types of fatal malformations, because of the multiplicity of malformations in many cases and 

because of the frequent lack of postmortem 

examinations. 

All investigators agree that malformations of 

the central nervous system are the most frequent 

and this group presents some features of interest. 

Table 13 shows recent infant death and stillbirth 

rates due to major malformations of the central 

nervous system, together with the perinatal loss 

in 1962 by sex. The perinatal loss from anencephalus and monstrosity in 1961 and 1962 may 

be compared with the figure for anencephalus of 

2.3 per 1,000 total births in Birmingham in 1940-

47,7 and the same rate (2,3) in the perinatal 

Mortality Survey in England, Scotland, and Wales 

in March 1958.* Until information on the causes 

of stillbirth is available for a longer period it 

16 
Table E. Infant deaths due to selected 

congenital malformations: England and 

Wales, 1962 

I 

Congenital malformation Number 

Flonstrosity-------------------75~ 204 

Central nervous system (other 

than spins bifida and 

hydrocephalus)-------------753. 1 76 

Circulatory system (other than 

heart)---------------754.6, 754.7 206 

Cleft palate and harelip------755 9 

Digestive system: 

Pyloric stenosis----------756.O 33 

Imperforate anus----------756.l 

t)ther---------------------756.2 3:: 

Bones and joints--------------758 48 

Respiratory system----------759.0 66 

Skin------------------------759. 1 8 

Muscle----------------------759.2 

Other and unspecified-------759.3 2:: 

lCauses of death classified according 

to the Seventh Revision of the International Lists, 1955. 

may be premature to assume that the downward 

trend of infant deaths for spina bifida and the 

upward trend for monstrosity are indicative ofa 

changing trend in the total perinatal loss. 

Reference has already been made to the low 

sex ratio in malformations of the central nervous 

system which isstronglymarkedforanencephalus 

and spins bifida butmuchless soforhydrocephaIus (table 13). 

A seasonal variation for anencephalus was 

found in Birmingham in1940-47,with higherrates 

during October to March,8 but the national records of causes of death showed no seasonal 

variation for monstrosity in 1955-59. A winter 

rise that occurs in some other congenital realfcwmations seems explainable as due to intercurrent infection unhandicapped infants. 

Mortality from malformations of the central 

nervous system shows considerable geographic 

variation, even within England and Wales, witha 

descending gradient from northwest to southeast. 

For 1950-58 the average rate of female deaths 

from malformations ofthe centralnervous system 

mngecl from 2.4 in Wales and the northwest of 

England to 1.3 in the southeastern part of the 

country, and the male rate ranged similarlyfrom 

1.7 to 1.0. There is a similar gradient for other 

malformations (and, in fact, for most causes of 

infant mortality), but it is much more strongly 

marked for malformations of the central nervous 

system. The same steep gradient is also present 

for stillbirths due to centralnervous systemmalformations, the rates for Wale sandthenorthwe st 

being about double those in the southeast. This 

geographical distribution corresponds with the 

observation that anencephalus demonstrates “a 

decreasing gradient of frequency from Northern 

Ireland and Scotland to southern England.’’9 The 

reason for the distribution remains unexplained 

as yet, but it may be related toethnic differences 

in the population, or climatic or geological conditions since all the mountainous terrain liesin 

Wales andthe northwe st of England. 

Because the etiology of all buta small proportion of congenital malformations is still obscure, the prospect of effecting a reduction in 

their incidence remains slight as yet. Indeed, in 

the thalidomide tragedy of 1960-62 there was 

clearly a temporarily increased incidence of malformations, though apparently with no great effect on mortality. The hazards of newandpossibly teratogenic drugs or other chemical agents, 

the uncertainties of radiation risks, andthepossibility of viral risks other than rubella have 

made it imperative to supplement existing knowledge with national epidemiological information. 

With this end in view, the Ministry of Health 

introduced in 1964 voluntary notification, by doctors and midwives, of congenital malformations 

observed at birth for the compilation ofanational 

statistical register atthe General Register Office. 

In addition, Medical Officers of Health follow up 

the notifications and compile local nominal registers, kept up to date as additional information 

becomes available and so providing a basis for 

the continued supervision of each child, as well 

as a local statistical record. Several large towns 

have maintained local registers of this type for 

some years. The need for more information on 

congenital malformations also influenced the decision in 1960 to include a statement on cause in 

the registration of stillbirths. Nationwide infor17

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---------------------

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-----------------------

mat ion on incidence, supplementing the registration of deaths and stillbirths, has become an essential safeguard against the appearance of unforeseen 

factors in the etiology of congenital malformations. 

Causes of Stillbirth and Perinatal Death 

Registered Causes, 1960-62 

Registration of the cause of stillbirth was 

introduced in this country in October 1960. In the 

published national figures, causes are classified 

according to the International Classification of 

Diseases (ICD). With such recent introduction of 

the registration of cause, and having regard for 

the well-known difficulties of defining and classifying the causes of stillbirth, the information so 

far available is of limited value. 

Maternal conditions, principally toxemia and 

difficulties in labor, account for about 30 percent 

of stillbirths and placental and cord conditions 

for rather under 30 percent, but there is obviously 

considerable imprecision in the distinction between these two groups. Fetal conditions account 

for about 45 percent of stillbirths, with congenital 

malformations as the highest single cause, contributing roughly 20 percent of all stillbirths. 

Nearly 88 percent of the malformations affect the 

central nervous system. 

British Perinatal Mortality Survey, 1958 

Pathological information on a national basis 

was available for the vast majority of stillbirths 

and early and late neonatal deaths in March 1958, 

from the British Perinatal Mortality Survey. 1The 

pathological data are based on preceded reports 

which covered 96 percent of the stillbirths and 

neonatal deaths in hospitals, 91 percent of those 

in general practitioner maternity units, and 85 

percent of the deaths at home, all of which occurred in March 1958. This part of the inquiry 

was carried out at specially designated pathology 

centers and included necropsy by a standardized 

technique and full histological examination. A 

“primary necropsy finding” was agreed upon for 

each case, i.e., “the morbid anatomical finding 

considered to be least compatible with separate 

existence. ” The survey thus presents, for the first 

time, the national distribution of primary necropsy findings (table 14). Among stillbirths, the 

major necropsy findings were: 

Percent 

Congenital malformations 17.5 

Antepartum anoxia 17.4 

Antepartum death with no major lesion-- 17.0 

Intrapartum anoxia 30.8 

Intrapartum anoxia with cerebral birth 

trauma 7.8 

Cerebral birth trauma 1.7 

Isoimmunization 4.4 

First-week deaths were associated with a 

high incidence of findings related to premature 

delivery and which were considered typical of 

“respiratory distress syndrome” as defined in 

appendix I. These consisted of hyaline membrane 

(15.0 percent), intraventricular hemorrhage (6.4 

percent), and neonatal death with no histological 

lesion (8.7 percent), together making up a total 

of 30.1 percent. Lethal congenital malformations 

were found in 21.6 percent, delayed effects of 

intrapartum anoxia and/or cerebral birth trauma 

in 19.6 percent, pulmonary infection in 13.3 percent, and massive pulmonary hemorrhage in 5.9 

percent. This simple anatomic classification is 

based only on the major necropsy findings considered responsible for death. It forms a useful 

basis for examining the clinical associations of 

six major groups of pathological causes of perinatal death. 

Congenital malformation.—ln the British 

Perinatal Mortality Survey, lethal congenital 

malformations caused 5.8 perinatal deaths per 

1,000 total single births and comprised 19 percent 

of perinatal deaths (table 14). Perhaps the value 

of such a survey of congenital anomalies is mainly 

to show the distribution by bodily systems involved. In 415 perinatal deaths in March 1958 

due to malformations confirmed by necropsy, the 

following distribution was found: 

Percent 

Central nervous system 67 

Alimentary tract 24 

Urogenital system 24 

Skeletal system 21 

Cardiovascular system 2U 

Other systems 2(I 

18 
More than half the cases showed involvement of 

more than one system. Such a breakdown allows 

an estimate of the proportion in which surgery 

may be feasible. Nearly two-thirds of the babies 

dying with malformations of the cardiovascular 

sy Wem dso had malformations of other systems 

and the majority of the cardiac abnormalities were 

so gross as to make corrective surgery impracticable. “Curative” neonatal cardiac surgery is 

limited to straightforward cardiovascular lesions 

such as patent ductus arteriosus or coarctation 

of the aorta, but “salvage” surgery is now becoming increasingly possible, in particular for lesions 

such as ventricular septal defect or transposition 

of the great vessels to gain time for more 

radical procedures later. Any baby developing 

cardiac failure from congenital heart disease in 

the first month of life had an extremely poor prognosis. 

Neonatal surgery has made considerable 

strides in attempted correction of other malformations and up to 20 percent of severe anoma ­

licw recognized in the first week of life must now 

be considered potentially operable. Important 

among this group are those malformations connected with the alimentary tract, principally 

esophageal atresia (1 in 2,500 births in the British 

Survey) and diaphragmatic hernia (1 in 2 ,000), 

as well as rectal malformations, exomphalos, 

duodenal or other bowel obstructions, volvulus, 

meconium ileus, and Hirschsprung’s disease. 

Other operable anomalies include urogenital malform;ttiuns such as bladder-neck obstructions, 

or respiratory tract malformations such as 

chotinul atresia, congenital lung cyst, or Iobar 

cmphy sema, Currently meningomyelocele (incid~ww of 3 per 1,000) is “treated” by early deci~pping of the spinal sac, followed later by the 

insc’ rt ion of a Helter or similar valve to avoid 

tlw almost inevitable hydrocephalus. 

Provision is needed for major neonatal sur­

~cry for at least one in every 500 live births and 

results are proportionate to the skill of the oper ­

t~tur and the specialized facilities available. 10 

liarly diagnosis is paramount and depends on 

:+lcrtness on the part of family doctors, obstetriritms, pediatricians, and midwives. Transfer of 

infants over considerable distances seems to do 

little harm provided that the infant can be protected against heat loss and that an experienced 

nurse also travels in the ambulance. Highly 

trained medical and nursing personnel and staff 

can best be utilized in a regional surgical unit, 

such as in Liverpool, where since 1953 a special 

unit has served a region of approximately 3 million population. 11 This unit is situated at a children’s teaching hospital in a university center, 

thus ensuring the availability of specialist surgeons, pediatricians, pediatric anesthetists, 

pathologists, biochemists, radiologists, and various research workers needed for the advancement 

of neonatal surgery. 12’13 

Reviewing the development of pediatric surgery in relation to congenital malformations, the 

Chief Medical Officer of the Ministry of Health 

in his Annual Report for 1962 noted that’ ‘the success of the small number of specialized pediatric 

surgical departments which now exist cannot be 

disputed. 1114Until research throws more light on 

the causation of congenital malformations, surgery with the essential prerequisite of early and 

expert diagnosis remains the most fruitful but 

limited line of progress. Perhaps the other hope 

of reduction in mortality lies in more research 

on genetic and teratogenic influences. Chromo ­

somal aberrations probably account for less than 

10 percent of fatal perinatal congenital anomalies. 

Though teratogenic influences such as intrauterine rubella probably cause less than a further 

5 percent, there is a greater chance of their control. The use of gamma globulin prophylaxis 

early after exposure in pregnancy may reduce, 

but cannot eliminate, the latter danger. Recently 

several promising rubella vaccines have been 

developed and active immunization in the near 

future is a possibility. 

Hemolytic disease of new bovn. —In the British Perinatal Mortality Survey, stillbirth or early 

neonatal death from isoimmunization occurred 

in 1.3 per 1,000 total births, representing between 3 and 4 percent of the total. Nevertheless, 

the problem is quite an important one. Walker 15 

estimates that the overall incidence of babies 

in England affected by isoimmunization, fatal and 

nonfatal, is at least 6 per 1,000 births. Infant 

mortality in England and Wales attributed to 

hemolytic disease of the newborn fell from 0.7 

deaths per 1,000 live births in 1950 to 0.5 in 

1959-61. Walker and Mollison16 calculated that 

this figure should be no higher than 0.2 when ex19

change transfusion is used correctly. This goal 

could perhaps be achieved by better prenatal prediction leading to measures such as intrauterine 

transfusion or selective induction of labor, and, 

for severely affected liveborn infants, by extended 

or repeated exchange transfusion. 

New efforts at salvage must also be concentrated on the prevention of stillbirths, particularly 

in first affected pregnancies. Twice as many 

babies in the British Survey died from isoimmunization in the late fetal period as in the neonatal 

period. The overall risk of stillbirth among sensitized Rh negative women in Britain is about 15 

percent. Walker and Murray17 have shown that 

this risk varies according to the severity of the 

disease in any preceding siblings. With no previous affected infant the risk is 8 percent, rising 

to 20 percent where exchange transfusion has been 

necessary for a previous affected infant, and to 

50 percent if the preceding infant has been severely affected. If previous hydrops occurred, the 

risk was 70 percent, rising to 80 percent if more 

than one similarly affected infant had been born 

to that mother. This statistical prediction is used 

to guide management and to ensure supervision 

of these pregnancies. 

The first step inactive management is clearly 

to determine the Rh genotype. Yet in the control 

week of the British Survey the Rh group was not 

determined in 15.7 percent of pregnant women in 

Scotland, 8.9 percent in Wales, and 3.9 percent 

in England. The proportion was nearly double for 

women booked for delivery outside obstetric hospitals. A high-risk group which stood out in particular was grandes multiparae (parity 4 and 

over); Rh negative grandes multiparae had a 75 

percent higher total risk of losing their baby than 

Rh positive grandes multiparae, and one in three 

of all perinatal deaths of infants born to these 

women was due to isoimmunization. Yet one in 

nine of grandes multiparae was cared for without knowledge of her Rh genotype. 

Regular antenatal serological examination 

for antibodies is essential in order to forecast 

accurately the presence and severity of intrauterine hemolysis and to plan management accordingly. Spectrophotometric examination of amniotic fluid is said to give up to 85-95 percent 

accuracy of prediction of a severely affected infant and to be more accurate than antibody tests 

in confirming the presence or absence of an affected baby in utero. Taken in conjunction with 

the past clinical history and the results of antibody tests, amniocentesis provides a sensitive 

indication as to when induction or other obstetric 

procedure should be carried out. Most British 

obstetricians are loath to induce labor before the 

37th week of gestation because of technical difficulties and also because of the added danger of 

respiratory distress syndrome in the prematurely 

delivered infant. One method of tiding over severely affected babies until they are mature 

enough for induction is that of fetal intraperitoneal 

blood transfusion.*8 This is considered when 

amniocentesis and antibody tests in the 25th to 

34th week of pregnancy have indicated severe 

hemolytic disease. 

Among liveborn affected babies, as defined 

by a positive Direct Coombs Test on cord blood, 

only about 60 percent required exchange transfusion. In the United Kingdom as a whole, the 

indications for exchange transfusion are not standardized. If the criteria for immediate exchange 

transfusion are not met, the baby is observed 

carefully for abnormal signs and serial bilirubin 

estimation is carried out, with exchange transfusion if there is a rapid or progressive rise in 

bilirubin, or if the clinical condition deteriorates. 

Few deaths are now reported during exchange 

transfusion with modern techniques. Reexchange 

transfusion is usually performed if the bilirubin 

subsequently rises above 20 milligrams percent. 

These measures have made kernicterus very 

rare, and the majority of neonatal deaths from 

isoimmunization are in babies born so severely 

affected that exchange transfusion cannot be 

effective in time. 

Antepartum stil16iYth.—Antepartum stillbirth, which included stillbirth occurring after 

the 28th week of pregnancy but before the onset 

of labor which was not due to congenital malformations or isoimmunization, comprised 22.1 

percent of all perinatal deaths in the British Survey (table 14). The national frequency was 6.8 

perinatal deaths per 1,000 total single births. 

Hypertension, preeclampsia, antepartum 

hemorrhage, low social class, and prolonged 

pregnancy were all significant maternal associations. There is no doubt that intensive prenatal 

care and the use of induction in selected cases 

20 
could reduce perinatal mortality in this category. 

In particular, the too frequent instances of inadequate prenatal care or poor judgment in the 

selection of cases for consultant care in hospital 

clearly indicated a potential for salvage especially 

in many instances of preeclampsia. 

Intvapa?dwn anoxia ancJ/ov cevebval birth 

b-awna. —Evidence of asphyxia during labor 

ancl/or cerebral birth injury was much the most 

frequent finding in the British Survey, being responsible for 10.2 fatalities per 1,000 total single 

births and causing 32.9 percent of all perinatal 

deaths (table 14). These deaths are perhaps those 

most susceptible to improvement by better obstetric techniques. 

Anatomically these cases fell into three categories: (1) intrapartum anoxia, (2) intrapartum 

anoxia with cerebral birth trauma, and (3) cerebral birth trauma. These categories are defined 

in appendix 1. Since cerebral trauma is usually 

inflicted in attempts to deliver an anoxic baby, 

the maternal associations for all three categories 

are mainly similar and they can be considered 

for this purpose as one group. 

The following pregnancy and labor factors 

were shown to be significantly associated with an 

increased risk of perinatal death from intrapartum anoxia and/or trauma: 

(1)	 families of poor socioeconomic status, 

for example if the husband was an unskilled laborer 

(2) first and fifth or subsequent pregnancies 

(3)	 maternal age over 30 in primaparae and 

multiparae 

(4)	 previous perinatal death, previous live 

birth weighing 2,500 grams or less, or 

an antepartum hemorrhage in a previous 

pregnancy 

(5)	 maternal hemoglobin less than 60 percent in pregnancy 

(6) preeclampsia as defined by a diastolic 

blood pressure above 100 mm. Hg. at 

any time in pregnancy (mortality was 

increased substantially when hypertension was complicated by proteinuria) 

(7)	 antepartum or intrapartum hemorrhage 

and/or vaginal bleeding before the 2Sth 

week of gestation 

(8)	 onset of lalmr before 37 or after 42 

weeks of gestation, especially in the 

presence of hypertension 

(9)	 first stage of labor longer than 24 hours 

or second stage longer than 150 minutes 

(lo) breech presentation or prolapsed cord 

(11) baby substantially overweight or underweight for gestational age, especially 

if delivery occurred after 41 weeks’ gestation 

(12)	 baby weighing 2,500 grams or less or 

more than 4,500 grams, regardless of 

gestation age 

None of the babies whose deaths were due to 

intrapartum anoxia and/or trauma showed other 

anatomical abnormalities and 75 percent were 

of sufficient maturity to escape neonatal hazards 

associated with early delivery. Much, therefore, 

can be learned about avoiding these deaths from 

a careful consideration of the associations during 

pregnancy and labor listed above. In particular, 

prolapse or presentation of the cord, antepartum 

hemorrhage of all types, and breech delivery 

accounted for nearly two-thirds (61 percent) of 

the deaths from intrapartum anoxia and/or 

trauma. The first two offer little chance of improvement. However, the risk from breech delivery, which in the British Survey carried a 10 

percent fetal mortality in labor, can be reduced 

to less than 1 percent in expert hands. Earlier 

recognition of breech presentations, their correction if possible, and delivery by skilled obstetricians are clearly essential. 

Thirty-one percent of mothers losing their 

babies from intrapartum anoxia and/or trauma 

had both a raised diastolic blood pressure and 

prolongation of pregnancy beyond 42 weeks. Both 

preeclamptic toxemia and prolongation of pregnancy are associated with reduced choriodecidual 

blood flOW 19 and reduced fetal growth.lg’qo Fetal 

reserves necessary for survival from the inevitable anoxia of novmal labor are reduced, thus increasing the likelihood of death from anoxia in 

labor. Very careful prenatal observation including 

placental function tests is particularly indicated 

in the presence of moderate or severe hypertension. In such cases, induction of labor is indi21

cated anyway at or before term and early action is 

essential in the presence of minimal signs of fetal 

distress. 

The remaining 8 percent of mothers losing 

their babies from causes in this group suffered 

none of the abnormalities specified above. Death 

from this condition is therefore a rare event in 

cases with uncomplicated pregnancy and normal 

labor. 

Within the group intrapartum anoxia and/or 

trauma, cerebral birth trauma with or without 

anoxia was much less frequently encountered 

than uncomplicated intrapartum anoxia. In the 

survey, the early neonatal death rate for cerebral 

birth trauma, with or without anoxia, was 1.2 per 

1,000 live births. It is worth noting from official 

returns that the early neonatal death rate from 

Injury at birth (ICD 760,761) was 2.3 in 1959-61 

and has been at or above this figure for many 

years. Admittedly the ICD rubric includes all 

types of birth injuries, but the great majority are 

classed as intracranial and it would seem that 

the official rate overestimates the mortality from 

pathological cerebral trauma. This is probably 

partly due to certification without postmortem 

examination, to differing opinions on the interpretation of postmortem findings, and to difficulties and misinterpretations in coding. The 

terminology of modern neonatal pathology raises 

difficulties in coding within the present International Classification. The British Survey confirmed, for example, that many cases of intraventricular hemorrhage, a manifestation of extremely premature delivery, are coded as birth 

injury. A comparison (unpublished) was made 

among neonatal deaths occurring in March 1958 

in England, Scotland, and Wales of registered 

causes of death with primary necrops y findings 

as determined in the Survey. This showed that of 

316 neonatal deaths which had been classified as 

Intracranial or spinal injury (ICD 760) less than 

40 percent had true cerebral trauma at necropsy; 

as many as 25 percent of the total were cases of 

hyaline membrane or other pathological diagnoses 

known to follow premature delivery. 

Cerebral trauma was found less frequently 

in the British Survey than the official figures might 

suggest, but the danger of intrapartum anoxia is 

probably insufficiently appreciated. It was considered that this constituted the group with the 

greatest potential for salvage and emphasized the 

need for planned obstetric management as well 

as careful study of maternal associations and of 

placental structure and function. 

The Survey showed the need for wider use of 

resuscitative techniques. In as many as 26 percent 

of first-day deaths the newborn infant died as the 

result of intrapartum anoxia and/or trauma. Yet 

in this subgroup intratracheal incubation, aspiration, or intermittent positive pressure oxygen had 

been given in only 6 percent.gl Cerebral trauma 

was usually neither a contributory nor main factor 

in causing death, and among those dying of asphyxia, inhalation of thick meconium into the air 

passage was a frequent finding (33 percent). Cesarean section is often carried out for fetal 

distress, and an incubation rate of 24 percent was 

found to be necessary after cesarean section in 

one British obstetric unit, using as criterion 

for incubation the failure to establish respiration 

within 1 minute of delivery, or the presence of 

secondary apnea .22 In the Survey, the corresponding incubation rate was only 2 percent. 

Since 1958, a more positive attitude to resuscitation has been advocated increasingly in 

the United Kingdom. Barrie 23 advocates a 

“planned regime” leading up to intratracheal 

incubation with intermittent positive pressure 

oxygen and closed cardiac massage where necessary. Clearing of air passages, nasal oxygen, 

and mild peripheral stimulation are practiced 

initially but are supplemented by intratracheal 

incubation at once if the baby remains or becomes 

apneic, white, or’ flaccid. Stimulants have been 

mainly discontinued, apart from pethidine (meperidene)-antagonists, although sublingual nik ­

ethamide or vandid (vanillic acid diethylamide) 

are sometimes given. 

Respirato?’y distress synd~ome. —In the British Survey, the group of early neonatal death~! 

entitled “respiratory distress syndrome” comprised three necropsy categories, in each of whick 

the commonest associations were premature de. 

liver y and clinical respiratory distress. TIM: 

three necropsy categories were (1) atelectasisi 

with hyaline membranes, (2) intraventricula]’ 

hemorrhage, and (3) deaths without obvious pathological lesions other than atelectasis even 011 

histological examination of lungs. Clearly al [ 

babies dying in the first week who were borl[ 

22 
preterm (before 37 weeks) or who were of low 

birth weight did not fall into one or more of the 

tibove three categories. Many died from causes 

not directly associated with prematurity, for 

example, congenital malformations or isoimmunization. The frequency of early neonatal deaths 

from “respiratory distress syndrome” in the 

Survey was 3.3 per 1,000 total single births, which 

made up 30.1 percent of all early neonatal deaths 

(table 14). 

Management of babies with clinical respiratory distress is still, some years after the Survey, a supportive and largely empirical procedure. Many centers in the United Kingdom practice correction of any accompanying biochemical 

changes, such as low pH, respiratory and metabolic acidosis, and hypoglycemia. A lessening in 

incidence of clinical respiratory distress has been 

reported in recent years .24 Evaluation is proceeding of newer therapeutic weapons for severe 

cases, such as buffer agents, artificial ventilation, 

or use of increased atmospheric tension, but all 

recobmize that prevention of early delivery is the 

really important measure. 

The main association of hyaline membrane 

disease is known to be premature delivery. In the 

ahsenc e of precise indications, many obstetricians are now wary of inducing labor, and particularly of the use of cesarean section, when 

the gestation is less than 37 weeks. 

Among those deaths in the British Survey 

where no histological lesion was found were 

many small babies with primitive lung patterns 

on the borderline of viability. There is no official lower gestation or birth weight for babies 

who are not liveborn, nor any stipulations as to 

the minimum time of survival for inclusion in 

statistics in England, Scotland, and Wales. Differences in national definitions of viability may 

alter not only the total perinatal mortality, but 

also the contributions made to all perinatal deaths 

from the “respiratory distress syndrome” group. 

Efforts at salvaging the very immature baby born 

at around the 28th week of gestation have so far 

proved singularly disappointing. 

Pulmonary infection. —Pulmonary infection 

was considered to be the direct cause of early 

neonatal death in 1.5 per 1,000 total single births 

in the Survey (table 14). Among the early neonatal deaths it was a direct cause in 13.3 percent and a contributory cause of death in another 

6.6 percent. Infections other than pneumonia 

very rarely had a fatal outcome in the first 

week of life. 

The Survey revealed an increased risk of 

pulmonary infection when the membranes had been 

ruptured for more than 24 hours, or when there 

had been obstetric intervention in labor, prolonged 

labor, or maternal intrapartum pyrexia. Intrapar ­

tum administration of nontoxic antibiotics prophylactically for the at-risk baby at birth, especially where there has been any difficulty in 

establishing respiration, is a measure now widely 

employed. Cloxacillin and ampicillin in combination are popular in view of wide spectrum and low 

toxicity. Antibiotics which are potentially toxic 

to the neonate, such as chloramphenicol, novobiocin, sulfafurazole, or tetracycline are usually 

avoided. The Survey results showed that systemic 

antibiotic therapy should also be considered 

postnatally for any baby who develops signs of 

local infection, such as conjunctivitis, umbilical 

inflammation, or pyelitis, in view of the danger 

of rapid and widespread dissemination of infection. 

In the Survey, very small or immature infants often died with pulmonary infection. Efforts 

have been made to supplement the low level of 

inherited IgG gamma globulin found in such babies 

with injections of gamma globulin or to anticipate 

infect ion with prophylactic antibiot its. 

A more promising group for salvage consists 

of larger babies dying with pulmonary infection. 

In the British Survey, 53 percent of first-week 

deaths from pulmonary infection weighed over 

2,500 grams and 56 percent were of 36 or more 

weeks of gestation, being therefore of favorable 

birth weight and gestation for survival. Many had 

already survived fetal distress with meconium 

aspiration. Prevention of early neonatal pneumonia in the larger baby depends partly on anticipating the ‘long list of conditions associated with 

intrapartum anoxia and/or trauma. 

In the British Survey, pulmonary infection 

often spreads so rapidly that the time between the 

first symptom and death was a matter of only 

hours. The diagnosis was often obscured by the 

variability and protean nature of the clinical features. Cerebral irritation, hypothermia, vomit ing, nonspecific deterioration, or even sudden 

23 
----

-------

-----

---------- ----------------

collapse were more common manifestations of 

neonatal pneumonia than signs directly referable 

to the respiratory tract. This often led to delay 

in diagnosis and treatment, especially for babies 

born at home. There was a higher neonatal death 

rate from pulmonary infections (1.4 per 1,000 

total single births) in babies booked for delivery 

at home than in those booked for hospital delivery 

(1.1 per 1,000). 

Acquired infection was found to play only a 

minimal part in early neonatal as opposed to late 

neonatal deaths, whether in the hospital nursery 

or at home. The risk of acquired infection in hospital has been reduced by such measures as 

rooming-in of the baby with the mother, reduction 

of handling procedures such as bathing and other 

skin toilets, and the prophylactic use of antibacterial creams or dusting powders, e.g., hexachlorophene. Many United Kingdom maternit y hospitals have a standing cross-infection committee 

and undertake regular bacteriologic examination 

of nursery, patients, and staff. Treatment of nasal 

carriers may be effective with local antibiotics, 

e.g., neomycin, framycetin, or tyrothricin spray. 

The routine use is practiced in some nurseries 

of such antibiotics sprays as methicillin. 

Some points of interest emerge from a comparison of neonatal deaths in March 1958 registered as dying from pneumonia with those found 

to have pulmonary infection in the British Perinatal Mortality Survey in the same month. Only 

27 percent (71 out of 276) of babies registered 

as dying neonatally from pneumonia showed pulmonary infection as a major necropsy finding. In 

the remainder, necropsy revealed that the mature 

babies mainly died with intrapartum anoxia and/or 

trauma and the less mature with “respiratory 

distress syndrome. ” In a few instances, major 

internal congenital anomalies were present. Misleading conclusions as to the local and secular 

mortality trends of neonatal pneumonia may 

clearly result if allowance is not made for variations in quantity and quality of postmortem examination. 

What then were the registered causes of death 

in those found at postmortem to have pulmonary 

infection in March 1958? As many as 215 out of 

290 babies (74 percent) which were found to have 

pneumonia histologically had been registered as 

dying from other causes; of these, the most 

frequent causes registered were postnatal asphyxia and atelectasis, immaturity unqualified, 

brain or spinal injury, or hemorrhagic disease 

of the newborn. 

Causes of Late Neonatal Death 

In the British Perinatal Mortality Survey, 

late neonatal deaths accounted for only 2.5 deaths 

per 1,000 live births. There were only two major 

causes, congenital malformations and infections. 

Congenital malformations caused 45 percent 

of these deaths and were mainly central nervous 

system, cardiovascular, and urogenital malformations (table F). The need for early diagnosis 

and rapid transfer for expert surgical treatment 

of operable malformations has already been 

stressed. 

Infections accounted for 36 percent of all 

late neonatal deaths in the British Survey—the 

majority were in the lungs. Extrapulmonar y infection was almost unknown as a cause of early 

neonatal death and was a rare cause of death in 

the late neonatal period, accounting for only one 

late neonatal death per 5,000 live births. Very 

Table F. Percentage distribution of necropsies, and death rates at 7-27 days 

of age, by major findings: England, Scotland, and Wales, 1958 

[Neonatal deaths forMarch 1958 are relatedta bitthsestirnrded 

for the same month from the control week, March .3-9, 19ER] 

I Percent- I Late 

age neonatal Major finding distri- death 

I bution 

I 

rate 1 

Total with 

necropsies 

@ 

Lethal congenital 

malformations 45 ;.: 

Pulmonary infections - 26 

Other infect ions 10 0:2 

Massive pulmonary 

hemorrhage 0,1 

Other 0.3 

I 

lDeaths 7-27 days of age per 1,000 live 

births. 

24 
occasionally gastroenteritis, meningitis, brain 

abscess, or septicemia was found. Wider recognition of the need for lumbar puncture in any 

baby showing cerebral irritation or convulsions 

would lead to earlier diagnosis of meningitis. 

Infection was an important risk when a baby 

was transferred home from a maternity unit in 

poor condition, and was often due to a hospitalacquired penicillin-resistant staphylococcus. It 

was concluded that very careful examination of 

babies, particularly those of high-risk mothers, 

must be made before discharge from maternity 

hospitals. Careful observation is essential in the 

days immediately after home-transfer. Infection 

was particularly common in babies of grandes 

multiparae or where the family was of poor socioeconomic status. If evidence of infection is found 

in a baby after it has been sent home, it is vital 

to inform the maternity unit in which the birth 

took place, so that they may be aware of the 

potential source of an epidemic of sepsis. 

TWOother conditions are of interest in infant 

mortality, namely cot (crib) death and cold injury. 

Cook and Welch 95 found a well-defined cause in 

only 20 percent of cot deaths, including acute 

infections such as meningitis or septicemia, 

congenital heart disease, and renal congenital 

anomalies or renal vein thrombosis. In the remainder, no specific organisms or viruses were 

found on smear or culture, and no specific histology was present in lungs or elsewhere. They 

also made an epidemiological study and concluded that some of the nonspecific group might 

be due to cow’s milk allergy. An inquiry into 

sudden death in infancy by the Ministry of Health 26 

strongly suggested that unexpected death in infancy was associated with early bottle feeding 

and hypersensitivity to cows’ milk, the risk of 

suffocation by soft pillows, and recent infection. 

Avoidance of pillows for young infants and complete breast feeding for the first 2 weeks of life 

were recommended. 

Cold injury was first fully reported in19,S727 

and continues to contribute to neonatal and postneonatal mortality in Britain in winter months 

but may occur at any season in any climate. Clinically, the hypothermic infant may show refusal to 

feed, lethargy, edema, sclerema, bradycardia, 

facial erythema, and may be icy cold to the touch. 

The rectal temperature is below 95 degrees 

Fahrenheit, and this is recordable only with a 

low-reading thermometer. Among predisposing 

factors may be intrauterine growth retardation, 

infection, congenital heart disease, cerebral 

birth trauma, asphyxia, and hypothyroidism. This 

condition, rarely reported in the United States, 

sometimes responds if diagnosed early to slow 

warming up to 97 degrees Fahrenheit, with supportive steroid therapy, oxygen, and antibiotic 

cover, while attention should be paid to remedying 

hypoglycemia. 

BIOLOGIC AND ENVIRONMENTAL 

FACTORS 

Maternal Age and Parity 

Information on maternal age and parity has 

been available on birth registration since 1938. 

The influence of these factors on stillbirths and 

infant deaths is well documented and is particularly clearly defined in relation to stillbirths 

(table G). The risk of stillbirth increases with 

the age of mother except for the age group under 

20 years in which the slightly raised rate probably 

reflects the influence of illegitimacy and primiparity. The rising risk with rising age is present 

in all parities but is most marked for primiparae 

and for women who have lmrne three or more 

children. The influence of maternal age is more 

marked in stillbirths due to maternal conditions 

and placental and cord conditions than in those 

due to fetal conditions. Among maternal conditions, chronic heart disease and toxemia are 

especially influenced by age. 

Table H shows the stillbirth rate by parity 

in 1962. The figures relate only to legitimate 

births, because information about previous children is not sought on the registration of illegitimate births. These figures confirm the wellknown influence of parity, with a relatively high 

risk in the first birth, the lowest risk in the second birth, and thereafter a rising risk in succeeding parities. This pattern is present in all age 

groups, but the risk of the first birth and of the 

higher parities is most marked in older women. 

The risk of death in the first birth is particularly marked in those associated with toxemia. 

For stillbirths ascribed to this cause the rate in 

first births was 3.3, nearly 2?4times the rate in 

25 
---------------------------

--------------------------- ------------------------------

------------------------------

------------------------------

------------------------------

-------- ----------------------

------------------------

------------------------------

------------------------------------- ------------------------- --------------

---------------------------

----------------------------------------

----------------------------------- -----

----------------------------- -----------

--------------------- -------

-------------------------------

Table G. Stillbirth rates, by age	 of mother and cause of stillbirth: England and


Wales, 1962


Cause of stillbirth


Age of mother


~


All ages


Under 20 years


20-24 years


25-29 years


30-34 years


35-39 years


40-44 years


45 years and over


Rate per 1,000 total births


18.1 5.1 5.1 7,9 

15.7 4.4 3,9 7,3 

15.1 4.1 7,1 

15.6 4.1 ;:! 

20.1 5.9 5.9 ;:: 

28.2 10.9 

37.1 1;:: 1::2 13.8 

56.6 20:8 10,8 25;1 

lCauses of death classified according to the Seventh Revision of the International


Lists, 1955.


Table H. Stillbirth rates among legitimate births, by birth order and cause of still-


birth: England and Wales, 1962


Total number of previous live or


stillborn children
 All


causes


Cause of stillbirth


Placental
 Maternal and cord Fetal


conditions conditions conditions


(Y30-Y35) (Y36) (Y37-Y39)


Rate per 1,000 total births


Total


None
 -


;-------------


:----------------------------------------


:----------------------------------------


i----------------------------------------


9------------


10 or more


17.8 5.0 5.0 7.8


19.2 5.9 5.0 8.3


16.5 ::$ 4.8 

20.5 5.4 ;:: 26.8 2:; 10.8 

30.7 ;:: 9.9 12.3 

28.3 8.2 8.9 11.2 

3&.6 12.5 13.8 

33.7 11.2 11.6 

41.0 18.1 13.3 

39.5 16.6 12.5 10.4 

12.6 3.6 5.7


Icauses of death classified according to the Seventh Revision of the International


Lists, 1955.


26

second births (1.4). Stillbirths due to congenital 

malformations show comparatively little variation 

with age and parity. The variation is similar to 

that for all stillbirths but within a much narrower 

range. 

The influence of maternal age and parity on 

neonatal and postneonatal death, as well as on 

stillbirth, was demonstrated in a study of the 

records of infant deaths linked with legitimate 

single births in England and Wales in 1949.28 

A fall in the mortality risk from the first to the 

second birth was apparent for neonatal death 

only in mothers over 25 years of age, whereas 

it is a constant feature for stillbirths at all maternal ages. Neonatal mortality rose in the higher 

parities and higher age groups, but the rise was 

not so marked as for stillbirths at comparable 

parities and ages. The extremes of youth and age 

within the childbearing period are both unfavorable factors in neonatal mortality, but the adverse 

effect of youth is particula~ly marked in women 

of relatively high parities for their age, i.e., 

mothers under 20 years bearing their second or 

later child and mothers under 25 years bearing 

their third or later child. Heady and Morris 29 

showed that this relatively high risk of neonatal 

death for the children of young multiparae was 

present in the first week of life and influenced 

infant mortality on the first day and even the 

first few hours of life, in contradistinction to the 

low risk of stillbirth for young women in low 

parities. 

In postneonatal death, mortality rose with 

rising parity (again most markedly for the relatively young multiparae), and fell with increasing 

age in each parity except for mothers over 35 

years. 

Thus, for stillbirths, increasing maternal 

age is an adverse factor in all parities, but in 

neonatal death and still more in postneonatal 

death, increasing maternal age to some extent 

mitigates the adverse effect of rising parity. 

The study of the influence of age and parity 

in perinatal and infant mortality leads to the 

identification of certain high-risk groups, namely, 

women over 30 years of age having their first 

child, women over 35 years of age who have already had three or more children, and women 

over 40 years of whatever parity, all of whom 

are at higher than average risk of stillbirth. In 

addition, very young primiparae and young multiparae and women over 40 years have a higher 

than average risk of losing the baby by neonatal 

death; for the young multiparae the risk becomes 

more marked in the postneonatal period. The 

recognition of these and other high-risk groups 

influences not only clinical practice but also the 

planning and administration of maternity services 

and the prevent ive services for young children. 

Past Obstetric History 

A history of previous abortion, stillbirth, or 

neonatal death increases the risk of prenatal loss 

in subsequent pregnancies. The association of 

high parity with previous abortions seems to be 

particularly dangerous. Similarly a history of a 

previous low birth weight child is associated with 

an increase in perinatal mortality. The degree 

of the increased risk will vary with the cause of 

the previous perinatal loss. In the British Perinatal Mortality Survey in 1958 it was noted that 

a previous stillbirth or neonatal death multiplied the overall risk 2!4times and that a previous low birth weight baby doubled the risk. Previous toxemia, antepartum hemorrhage, or cesarean 

section was also associated with increased perinatal mortality in subsequent pregnancies, and 

here again the effect was aggravated by high 

parity. 

Maternal Stature 

The Survey in 1958 confirmed, on a national 

basis, the association of maternal height and 

perinatal loss noted in earlier studies in Aberdeen .30 Short stature has been interpreted as a 

failure to realize the full growth potential because of poor environment. In the Survey, women 

whose height was 65 inches or more formed 30 

percent of the total sample and the perinatal 

mortality of this group was 21 percent below the 

average. Women whose height was less than 62 

inches formed 22 percent of the total sample and 

the perinatal mortality of this group was 14 percent above the average. The proportion of tall 

women (height of 65 inches or more) was found 

to be lowest in the North zone (North West England, Scotland, and Wales), higher in the Central 

zone, and highest in the South zone. The propor27 
tion of tall women decreased from the professional 

to the unskilled socioeconomic groups. This class 

difference was present in each region and the 

regional difference, in each socioeconomic class. 

No particular cause of death was found to contribute disproportionately to the increased infant 

mortality among the offspring of short mothers. 

Illegitimacy 

For many years the proportion of illegitimate 

live births has been about 4 percent of all live 

births, except for increases during the two World 

Wars. During World War II the proportion rose 

to 7.0 percent and has never quite fallen to the 

prewar level since. In recent years the proportion 

has risen from 4.7 percent in 1955 to 6.0 percent 

in 1961. Illegitimate stillbirths also rose, from 

6.5 percent of all stillbirths in 1958 to 7.6 percent in 1961. Illegitimate births used to be associated with mortality rates far in excess of the 

average for all births, but the rates were improving before World War H and have since been 

greatly reduced. Among illegitimate infants, late 

neonatal and postneonatal mortality rates have 

declined more rapidly than the average; and these 

infants are now at no disadvantage, in terms of 

mortality, after the first week (table 15). This is 

partly the outcome of the medicosocial work for 

the unmarried mother and her child that has been 

undertaken for many years by voluntary organizations and local authorities, partly the mother’s 

improved economic circumstances helped by the 

maternity benefits payable since 1948, and, not 

least, partly the availability of medical care for 

mother and child without payment since 1948. 

Stillbirth and early neonatal mortality rates 

for illegitimate births, though much reduced, are 

still almve the average. A very high proportion 

of illegitimate births are first births; for example, 

76 percent of the illegitimate births in the British 

Perinatal Mortality Survey in 1958, compared with 

36 percent of the legitimate births were first 

births. On the other hand, unmarried mothers are 

younger than average; for example, in the same 

survey, 7 I. percent of unmarried mothers were 

under 25 years, compared with 34 percent of 

married mothers. Their youth should largely 

offset the high “first-birth risk” of stillbirth, 

though it may slightly increase the risk of early 

neonatal death. The crucial factor in higher perinatal mortality among illegitimate births is 

inadequate prenatal care arising from reluctance 

to seek medical advice. The problem is probably 

more widespread than the illegitimacy rate suggests. Not only were 6 percent of live births 

illegitimate in 1961, but a further 8 percent were 

extramaritally conceived and legitimated by marriage before the birth occurred. Reluctance to seek 

medical advice and consequent inadequate prenatal care is likely to be frequent in these pregnancies also. 

Thus, there is certainly the possibility of 

further reduction of perinatal mortality by the 

reduction of illegitimacy or by intensified care 

for the unmarried mother and her child. On the 

other hand, in view of the steady fall of perinatal mortality in illegitimate births it is not 

likely that the slight rise in illegitimacy in recent 

years can have appreciably affected overall perinatal mortality. 

Geographic Area 

Rates for live births, stillbirths, and perinatal and infant deaths, averaged for the 3 years 

1960-62 are presented for the standard regions of 

the country which have been devised for the purposes of the national statistical records of the 

General Register Office (table 16). Figure 

shows the standard regions in outline and illustrates the relationship of regional infant mortality to the national rates in 1960-62. The numbers on the map give the infant mortality rate 

of each region as a percentage of the national 

rate. The heavy line separates those regions with 

rates above and below the national rate, all the 

former lying in the northwestern part of the country and all the latter in the south and southeast. 

This demarcation has not altered in broad outline during the present century, though the regional difference has narrowed a little in the 

last 30 years. 

Reference to table 16 shows that the same 

pattern of variation holds for both the neonatal 

and postnatal components of the infant mortality 

rates and for the stillbirth and perinatal mortality rates. In each case the lowest rates are 

found in the southeastern part of the country and 

they increase in a northwesterly direction, 

28 

2 
The slow trend toward reducing the geographic difference has been due chiefly to the 

earlier impact of immunization and antibiotic 

therapy on postneonatal mortality in the northwestern part of the country where respiratory 

and other infective conditions are more frequent. 

The marked difference in mortality due to 

congenital malformations of the central nervous 

system (descending gradient from northwest to 

southeast) is a factor which is helping to maintain 

the regional variation in perinatal mortality. ‘ 

Since the northwestern part of the country 

is more industrialized, the difference in urban 

and rural infant mortality have a bearing on 

regional differences. Table 17 shows the mortality rates for six conurbations and also for 

the aggregated conurbations and for the aggregates of all other urban areas and all rural 

areas. Each conurbation contains several towns 

and urban districts of varying sizes grouped 

around one or more large cities, together forming 

one continuously urbanized area though comprising many local government areas. Their 

populations range from roughly 1-2% million, 

except for Greater London which has a population of 8 million. 

With the exception of Greater London, all 

the conurbations are in the north and west of 

the country (fig. 2). In addition there are many 

other smaller industrial aggregations in the 

northwest and in Wales. All these aggregations 

and conurbations (except London) owe their development to the industrial revolution of the 19th 

century, which affected England before any other 

country. In the space of a few decades, much of 

the country changed from agricultural communities with local interests and local markets to 

teeming industrial centers of worldwide trade. 

When the inventions and mechanizations of the 

18th and l%h centuries released the industrial 

upsurge, the potential for its development lay 

in the northwest, with its water power and coal 

fields. With industrial development came rapid 

urbanization and rapid increase in population: 

growth followed blindly on the demands of industry, with little or no regard for health and 

hygiene, until squalor and disease forced themselves on public attention. The worst of the 

resultant evils have by now been swept away, but 

many local authorities are still battling with a 

legacy of mean streets, bad housing, air pollution, and lack of open spaces resulting from the 

original, unconsidered structure of their townships. The description “urban” may still have 

very different implications when applied to an 

area that developed during the industrial revolution, to an area planned and built as a new town 

within the last 20 years, or to developments of 

intermediate years. 

The mortality rates for the conurbations and 

other urban areas show the southeast to northwest 

rising gradient. The rates for the rural areas are 

lower than those for urban areas, but they also 

show the same geographic gradient (table 17). 

Thus the higher the mortality of the northwestern 

part of the country, though no doubt influenced 

by a greater degree of urbanization (especially 

long-established urbanization), is certainly not 

dependent on this. 

In addition to the question of industrialization 

there are, even in a country as small as England 

and Wales, regional differences in climate and 

terrain that are worth noting in the context of 

infant mortality. The north of the country is, on 

the average, colder than the south. The west, 

especially the northwest, has a higher rainfall. 

With the rainfall go cloudier skies and less sunshine, which may be diminished still further in 

densely urbanized areas by air pollution. Much 

of the northwestern part of the country is mountainous and the rural areas are quite different 

in character from those in the southeast. Among 

the mountains of Wales and the Lake District and 

in the Yorkshire moorland country, transport is 

rather more difficult, medical and welfare services are not quite so readily available, climatic 

conditions are apt to be more severe, and altogether life tends to be rather more austere than 

in the rural areas of the southeast. Thus the 

northwestern part of the country presents some 

natural handicaps for the rural population, while 

some of its urban population still feels the longterm manmade handicaps left over from the industrial revolution. But as the evils of uncontrolled urbanization have been and still are being 

greatly reduced, so also modern transport and 

communications are improving conditions in 

even the most remote rural areas. Neither of 

29 
-;-. A 

\. .,,l~
Tyncslde Conurbation ~.. 

NORTHERN 

Ill Lh@

n (b) Sout” th cast - Lt31Ka ShlrC “’ 

,-fi”t, --~rbation 

(c) West Midlands 

conurbation 

F 

WALES 

115


/ 

u--­

$ONDON & SOUTH EASTERN j 

r SOUTH ,8WESTERN +/(-’ 

‘0 <

(d)	 Greater London 

conurbatian 

ENGLAND AND WALES =1.00 

Figure 2. Ratios of infant mortality rates for standard regions to the national rate: England and Wales, 1960-62,


30 
-----------------

-----------------

------------

these factors can be measured, but each must be 

I	 contributing to the reduction of regional differences in infant mortality. 

Socioeconomic Class 

After the 1911 census, the Registrar General 

introduced the grouping of occupations to form 

socioeconomic classes for the purpose of medicosocial analyses and research. Originally, occupations were grouped into eight categories, 

but in 1921 this was reduced to five and this regrouping has been continued. The percentage 

distribution of the population in the five socioeconomic classes as enumerated in the 1951 and 

1961 census is as follows: 

Social class 1961 1951 

I (I Iigh) 3.3 3.0 

11----------------------- 15.6 15.7 

111---------------------- 48.8 52.4 

i~r ---------------------- 20.2 16.9 

V (Low) . 7.7 11.9 

Not classified 4.4 

Married women were enumerated according to 

thehusband’s social class. In 1961, members of 

the armed forces and persons with inadequately 

described occupations were included in “not 

classified”; in 1951, the armed forces appeared 

in social classes I and III. 

The outstanding feature of infant mortality 

in relation to socioeconomic class is not somuch 

that there are differences between classes, but 

that there has been no narrowing of these differences in the past 50 years. Infant andperinatal 

mortality rates increase steadily from class I 

(high) to class V (low). The constancy of the class 

gradient was demonstrated by Morris and Heady31 

in a study of social and biological factors in infant mortality in 1949. It was shown that in 1911 

the neonatal mortality rates in class I and class 

V were, respectively, 26.8 and 42.5 and in 1949-50, 

13,5 and 21.9. Each rate had been halved and the 

relationship between them remained unaltered. 

Similarly in 1911, the postneonatal mortality 

rates in class I and class V were, respectively, 

2S.3 and 110.0; in 1949-50 the comparable rates 

were 4.9 and 17.9. Each had been reduced to 

about one- sixth of the earlier figure and the 

relationship between them remained unchanged. 

Proportionate reductions of similar magnitudes 

occurred in the rates for the intermediate classes, 

and the gradient remained virtually the same in 

1911, 1921, 1931-32, 1939, and 1949-50. 

The position is the same for stillbirths, for 

which rates by social class were not available 

until 1939. In the succeeding 10 years the stillbirth rate fell by about one-third in each social 

class, maintaining the same gradient as before. 

In 1949, the rate ranged from 15.7 in class I 

to 25.7 in class V. Morris and Heady showed 

that not only have the main social classes maintained their differentials, but so also have particular occupations despite changes of a totally 

different nature in the circumstances associated 

with those occupations. 31 

In the British Perinatal Mortality Survey, 

perinatal mortality ranged from 23 percent below 

average in the professional, managerial, and 

supervisory families to 28 percent al.mve average 

in the family of the unskilled worker (table 18). 

These differences are to some extent a reflection of differences in the age and parity makeup 

of different social classes. However, detailed 

factor analysis of this point 32 showed that adjustments for age and parity made no appreciable difference to the social class gradients 

in perinatal mortality. Regional variations in 

perinatal mortality were also not explicable in 

terms of the concentration of high social classes 

in the southern parts of the United Kingdom, because social class gradients persist in all regions. 

Analysis of the rural-urban perinatal mortality 

rates showed a slightly better rate for a given 

social class in rural compared with urban populations. 

Analysis within each social class of mortality rates for each major cause of death in the 

Survey of 1958 is shown in table 18. The increased 

mortality associated with low social class shows 

a disproportionately large contribution from the 

group with intrapartum anoxia and/or trauma and 

from lethal congenital malformations, in particular of the central nervous system. Surprisingly, 

there was little difference in the proportion of 

deaths from “respiratory distress syndrome” 

among the social classes. 

31 
The precise influences which increase perinatal mortality in the woman of low social class 

are difficult to evaluate. Poverty, unsuitable 

housing, poor nutrition both in childhood and adult 

life, poor physique, short stature, increased incidence of anemia, higher parity, shorter pregnancies, and smaller babies are all important 

factors. It also seems clear that maternity services are not utilized so well by women of low 

social class and that standards of prenatal care, 

bookings for hospital delivery, and medical supervision during labor are all lower in women of 

higher parity and low social class. 

The sociologic aspects of the Survey have been 

analyzed in broad outline by Illsley and Kincaid.33 

Among the more interesting of their conclusions 

is the fact that the gap in perinatal mortality 

between social classes I and V has actually 

widened in the last decade, despite the free 

availability of medical and welfare services, and 

despite higher wages and a rising standard of 

living. Clearly the sociologic factors contributing 

to perinatal mortality are not to be corrected in 

one generation. 

Attempts to explain the constancy over the 

years of the disparity between the socioeconomic 

groups lead to a wide field of social and demographic studies that can only be briefly mentioned. 

Improving social and economic conditions, and 

even improving medical skills, can give a quick 

return, in terms of health, only up to a point. 

There must inevitably be a time lag in improving what have been called the “capital assets” of 

community health, such as housing and education. 

Greater prosperity cannot suddenly change, for 

example, the bleak drabness of a mining village 

nor the congestion of an overcrowded town. Nor 

does it immediately alter the traditional way of 

life of a community which may determine its responsiveness to change, as for example by acceptance of hospitalization for confinement. Nor, for 

the adult women of a community, can it alter the 

preadult social and nutritional experience which 

has already determined their physique and stature. Thus, by reason of environment, culture, 

and constitution some time lag is inevitable in 

the response to economic and medicosocial leveling, though the continuance of the same degree of 

disparity for 50 years seems too long to be wholly 

explained on these lines. 

A part of the explanation probably lies in the 

movement between the socioeconomic classes. 

The relative size of the professional and technical 

group is increasing while the group of semiskilled 

and unskilled workers is tending to diminish, and 

the migration between the groups is such as to 

maintain disparity in mortality. It is common 

knowledge that members of a family handicapped 

by ill health may drift into less well-paid occupations, while the healthy will maintain or improve their status. Illsley and Kincaid33 have 

confirmed earlier studies in Aberdeen demonstrating that marriage may also have a selective effect. Women who marry men of the same 

or higher socioeconomic class differ from those 

marrying into a lower socioeconomic class. They 

are, on the average, taller; they have reached a 

higher level of education; and, if in work themselves before marriage, they have achieved a 

better occupation status. With these attributes 

goes a lower perinatal mortality. Thus the migration between classes, at least so far as it 

arises for reasons of health or marriage, will 

tend to intensify the relatively high mortality 

experience of the lower socioeconomic groups 

and, so, to maintain the disparity between the 

groups, or even to increase it, as was shown to 

have occurred in 1958. 

Combined Effects 

The study of environmental and biologic factors in perinatal mortality leads to two conclusions: (1) that the outcome of a pregnancy is influenced by circumstances which reach back over 

many years and shape the mother’s health, physique, and social experiences from her own conception onward and (2) that if the pregnancy is one 

with a higher than average risk of perinatal mortality it will require a commensurate high standard of care to minimize the risk, though it cannot 

alter the causal antecedents. 

The long-term influence probably provides 

the explanation of the halt in the fall of the perinatal mortality rate in the early 1950’s. The 

young women who were coming to the childbearing ages between 1950 and 1955 were themselves 

born in the late 1920’s and the early 1930’s. This 

was a period of industrial unrest, high and widespread unemployment, and severe economic de32 
pression. During this time the maternal mortal. 

ity rate, which had been fairly stable for15 years, 

began to rise andreached itsmaximumin 1934. 

The stillbirth rate wasnot known until 1927, but 

from then until 1936 it was virtually stationary, 

with its highest point in 1933. The early neonatal mortality rate had been slowly falling since 

1906 but came to a halt in the late 1920’s and 

rose a little to reach its highest point in 1933. 

All the obstetric indexes suggest that this was 

an unfavorable time for the neonate, particularly 

from 1929 to 1934. 

In these 6 or 7 years (1929-34) unemployment, poverty, and malnutrition were more widespread than in the preceding years and more so 

than they have ever been since then. It seems 

reasonable to assume that these years left their 

imprint on the physique of children born at this 

time. When they reached womanhood and childbearing that imprint was seen again in the perinatal mortality of their children. 

The short term influence of environmental 

and biologic factors should lead to the shaping 

of maternity services and obstetric care in relation to the high-risk groups. Some of these 

have already been noted in discussing the influence 

of age and parity, the most important ones being 

women over 30 years in their first pregnancy, 

women over 35 years who have already had three 

or more children, and all women over 40 years, 

with, in addition, the smaller groups of primigravidae under 20 y-m and younger multiparae 

with relatively large families for their age. To 

these groups must be added the small but very 

high-risk group of multiple pregnancy, the women 

who have previously had a stillbirth, neonatal 

death, or premature delivery, the unmarried 

mothers, and the women of short stature. Obviously a woman who has had any abnormality or 

difficulty in a previous pregnancy must also be 

regarded as at a higher than average risk subsequently, but most will probably fall into one 

or another of the groups already mentioned. In 

considering the perinatal mortality risk in all 

these groups added weight must be given ac -

cording to the area in which the mother lives and 

her socioeconomic class. 

These groups with a higher than average risk 

of perinatal death overlap one another and altogether account for about 70 percent of all births. 

It has been the policy of the Ministry of Health 

for the past 10 or 12 years that women in these 

groups should have their confinements in hospital and that maternity hospital beds should be 

sufficient to provide for 70 percent of all births. 

This figure has not yet been attained in all areas, 

Though it is surpassed in many large towns. 

In emphasizing the value of confinement in 

hospital it is not intended to imply that hospitalization, per se, is the most important factor, 

though obviously in many circumstances the 

facilities available in a well-equipped hospital 

may be essential. In this country, hospital maternity beds are under the charge of specialist 

obstetricians and therefore when a mother books 

for her confinement in hospital her prenatal and 

obstetric care becomes the responsibility of a 

specially qualified doctor whose whole time is 

devoted to obstetrics and gynecology. If, on the 

other hand, she has her confinement at home 

(or in a general practitioner maternity unit) then 

the responsibility for her prenatal and obstetric 

care rests with a doctor who is in general practice 

and whose experience in the field of obstetrics 

is therefore unavoidably slight by comparison 

with that of the full-time specialist. For this 

reason it is considered that only those women 

for whom a normal pregnancy and confinement can 

be confidently predicted, i.e., most of the second 

and third pregnancies under 35 years, should be 

confined at home, and that all those in the highrisk groups should be the responsibility of the 

specialist hospital services throughout their 

pregnancy and confinement. 

For many years confinement at home was the 

traditional custom in this country. In 1927, 85 

percent of all births occurred at home. Just before World War II, in 1938, the proportion had 

fallen to 60 percent. By 1950 it was 40 percent 

and in 1963, 33 percent. Thus in the space of 

25 years the proportions of home and hospital 

confinements have been reversed. This reversal 

of the tradition of earlier days, coupled with the 

lack of any new hospital building during World 

War II and for several years subsequently, began 

to put a considerable strain on the hospital 

maternity service by the 1950’s. This was intensified when the birth rate began to rise in 1955 and 

continued to rise thereafter. This rising pressure 

on hospital maternity accommodation has made 

33 
the selection of cases for hospital (i.e., specialist) care a matter of increasing importance in 

this country if the available facilities are to be 

used to the best advantage in terms of the prevention of perinatal mortality. The degree of 

selection that is necessary varies in different 

areas according to the available hospital beds. 

In the country as a whole the optimum selection has not yet been achieved, partly because of 

failure to appreciate fully the potential risk of 

perinatal mortality and partly because of the 

reluctance of some mothers, especially the older 

women with large families, to accept hospital 

confinement. Thus in 1959, of women who were 

over 35 years old and had four or more children, 

45 percent were confined at home, and among 

primigravidae over 35 years old, 16 percent 

were confined at home. In 1964 these two proportions had been reduced to 25 and 11 percent 

respectively, indicating improving, but by no 

means optimum, selection. Similar failure to 

arrange for specialist care in these and other 

high-risk groups was demonstrated in the Survey in 1958 and was associated with high mortality rates, especially in those cases for whom 

emergency admission to hospital had eventually 

to be arranged. 

Opinions differ in Britain as to whether all 

women should be encouraged to have their confinements in hospital and therefore whether the 

aim should be to provide sufficient hospital 

facilities for all births. But whatever the ultimate 

trend, the present position is that in most areas 

some degree of selection for hospital care is 

necessary. Further improvement of perinatal 

mortality will be influenced by the adequacy of 

the selection. 

PREGNANCY COMPLICATIONS AND 

DISORDERS OF MATURATION 

Preeclamptic Toxemia and Essential 

Hypertension 

This is probably the most important maternal 

association of perinatal death. No less than 27 

percent of women in the control week of the British Perinatal Mortality Survey had a diastolic 

blood pressure greater than 90 millimeters at 

some time in the last trimester (table 19). A 

retrospective diagnosis of toxemia, by the standard criteria of Eastman, was not possible in this 

Survey and the maximum diastolic blood pressure 

therefore was used. 

Increasing severity of diastolic hypertension 

was associated with substantial increase in perinatal mortality. Essential hypertension was diagnosed when diastolic blood pressure was above 

90 millimeters in the first half of pregnancy, 

and this was also associated with increased perinatal mortality. All other women with raised diastolic blood pressure in pregnancy were divided 

empirically into mild, moderate, and severe 

toxemia (table 19). All grades of toxemia, as 

compared with the normotensive state, were 

associated with some increase in the incidence 

of antepartum hemorrhage. Early delivery was 

significantly more frequent only when the diastolic pressure was greater than 110 millimeters 

or when toxemia was complicated by proteinuria. 

Analysis of the individual toxemic groups 

contributing to perinatal mortality shows that, 

for diastolic pressures up to 109 millimeters, 

the increase is entirely due to a rise in the 

proportion of fetal deaths before and during labor 

from antepartum stillbirth and from intrapartum 

anoxia and/or trauma. These are further increased in the severe category where in addition 

there is some increase in early neonatal deaths 

from “respiratory distress syndrome.” 

The increase in the “other” group found in 

severe toxemia was due to the syndrome of massive pulmonary hemorrhage which was virtually 

confined to the baby suffering from intrauterine 

malnutrition. Essential hypertension also produced an increase in “respiratory distress syndrome” deaths. 

It can be concluded that the effect of toxemia 

on the fetus was two-fold. First, severe toxemia 

was associated with an increase in premature 

delivery, with an inevitable death rate from the 

causes associated with preterm delivery. This 

increase can be partly attributed to accidental 

hemorrhage associated with the accompanying 

hypertension and also in part to induction for 

deteriorating hypertension. Secondly, placental 

reserve is reduced, leading to antepartum stillbirth or fetal death in labor from anoxia. 

A further important factor in perinatal mortality associated with toxemia was prolongation of 

pregnancy past term. The increase in perinatal 

34 
mortality in post term pregnancy was much 

accentuated in the presence of toxemia and this 

increase occurs in the category of antepartum 

stillbirth (fig. 3). Here the accurate assessment 

of maturity is obviously very important. Because 

of this hazard, most British obstetricians prefer 

to induce labor at term in women with toxemia. 

Induction before term is reserved for the severer 

grades, or when hypertension is complicated by 

proteinuria. Early induction may also be used 

when the fetus fails to grow. 

A vigorous attack upon the problem of late 

hypertension in pregnancy has been made in several British centers.:11 Careful control of weight 

gain, close prenatal supervision, and prenatal 

admission for rest if preeclampsia develops have 

reduced the incidence of proteinuria, eclampsia, 

and severe hypertension and thus have produced 

a fall in perinatal mortality. However, it is 

ANTE PARTUM STILLSIRTH 

— Hypertensive 

o~ Under 36 37 38 39 40 41 42 43+ 36 

PERIOD OF GESTATION IN WEEKS 

possible that intensive care to any high-risk 

group will reduce the perinatal mortality and 

the improvement may not be directly related to 

the reduction in blood pressure alone. Bed rest 

is known to improve uterine blood flow and prenatal admission will guarantee the immediate 

availability of an expert obstetrician in the event 

of an emergency. Since the 27 percent of women 

with toxemia or essential hypertension in pregnancy gave birth to very nearly half the perinatal 

deaths, this is a very obvious high-risk group. 

Bleeding


In the British Survey, 94 percent of women 

having single babies had no bleeding at all during 

pregnancy, and their infants experienced a low 

perinatal mortality and a low incidence of delivery before 36 weeks of gestation (table 20). 

20


INTRAPARTUM DEATH 

(anoxia with or without trauma) 

[


z Hypertensive 

mammmt Norrnotensive 

I 

I


o~ Under 36 37 38 39 40 41 42 43+ 

36 

PERIOD OF GESTATION IN WEEKS 

Figure 3, Per inatal mortal ity rates for antepartum sti11birth and intrapartum death and for hypertensive and


normotens ive mothers, by week of gestat ion: England, Scotland, and Wales, 1958.


(Perinatal deaths for March 1958 are related to births estimated for the same month from the control week,


March 3-9, [958)


35

The commonest form of bleeding was the 

threatened abortion (2.9 percent), which was 

defined as vaginal bleeding before the 28th week 

of pregnancy. This is probably a considerable 

underestimate of the true incidence of threatened 

abortion. Perinatal mortality was increased after 

threatened abortion at all gestations and even 

when no further bleeding occurred after 28 weeks. 

Accidental antepartum hemorrhage was diagnosed when a painful tender uterus was accompanied by vaginal bleeding or retroplacental 

clot. In 43 percent of cases of accidental hemorrhage, preeclamptic toxemia was also present. 

More than half the babies died, mostly at time 

of hemorrhage, or during the closely following 

labor. These events have all been classified as 

deaths from intrapartum anoxia and/or trauma. 

The strong association of accidental hemorrhage 

with early delivery is reflected by a large increase in deaths from “respiratory distress 

syndrome. ” 

Placenta previa was diagnosed when a lowlying placenta was felt on examination or seen at 

cesarean section. Perinatal mortality was considerably less than with accidental hemorrhage 

and was due mainly to a high death rate for intrapartum anoxia and/or trauma and an increase in 

the number of early neonatal deaths from “respiratory distress syndrome.” 

Unspecified antepartum hemorrhage is a 

residual group in which there was insufficient 

information to make a positive diagnosis of either 

accidental hemorrhage or placenta previa. This 

is the commonest type of bleeding in the last 

trimester, and its outcome is very similar 

to that of placenta previa. Its etiology is unknown 

but it includes undiagnosed placenta previa, 

marginal sinus rupture, and bleeding from extraplacental sites. 

Possible measures to counter the high perinatal mortality associated with antepartum 

hemorrhage depend on the type of hemorrhage. 

If the fetus in utero survives an accidental 

hemorrhage, a decision as to active intervention 

need not be based entirely on the former poor 

prognosis which characterized liveborn infants 

of low gestation. Improvement in perinatal mortalit y associated with placenta previa has been 

reported with rigorous bed rest for the remainder of the pregnancy. 

Weight Gain 

The association between excessive weight 

gain and increased incidence of maternal hypertension on the one hand and of low birth weight 

babies and increased perinatal mortality on the 

other hand is generally accepted in this country.’5 

Poor weight gain during pregnancy is also associated with an increased incidence of low birth 

weight babies and increased perinatal mortalit y.sr 

It is not yet clear whether the low birth weight 

babies associated with disorders “i weight gain 

are due to early delivery or to intrauterine growth 

retardation. 

Smoking 

The Survey confirmed the well-documented 

association of smoking in pregnancy with an increased incidence of low birth weight babies and, 

to a lesser extent, of curtailed gestation. ~~-~s 

There was significantly higher stillbirth and neonatal mortality among babies whose mothers 

regularly smoked one or more cigarettes per day 

after the 20th week of pregnancy. The difference 

in perinatal mortality between smokers and nonsmokers did not seem to be due to differences in 

age, parity, or social class. 39 

Anemia 

When the hemoglobin level during pregnancy 

was below 60 percent (8.9 grams), perinatal mortalit y in the Survey was nearly twice the national average. This excludes cases of anemia 

following antepartum hemorrhage. Lesser degrees of anemia were not associated with any 

increase in mortality. Anemia is strongly correlated with social class and high parity, both of 

which are also associated with high perinatal 

mortality. However, mothers with anemia are 

clearly another high-risk group deserving intensive care during pregnancy and labor. 

Gestational Maturity 

The problem of spontaneous premature labor 

represents a major unsolved etiologic factor in 

perinatal mortality. In at least half the cases in 

the Survey, the etiology of delivery before the 

36 
36th week was unknown. In one-third of the 

women delivering before the 36th week, essential 

hypertension or toxemia was present, with a 

high incidence of severe hypertension. One in 

six of these early deliveries was accompanied 

by antepartum hemorrhage. The influence of 

hydramnios is difficult to assess, but it seems to 

play only a small role in the initiation of premature labor. Variation in social class or parity 

had little effect on the incidence of premature 

delivery, but maternal age under 20 years 

significantly increased the incidence. The effects 

of gestational maturity on perinatal mortality 

in the Survey are shown in table 21. Analysis 

of individual causes of death shows that the 

largest contributor in the early weeks of the last 

trimester was neonatal death from “respiratory 

distress syndrome.” In labor, mortality was 

highest from intrapartum anoxia and/or trauma. 

The large “other” group in table 21 was due to the 

presence of congenital malformations (mostly 

anencephaly) delivered at low gestations. 

Perinatal mortality reached its minimum in 

women delivering at 40-41 weeks of gestation. 

IHalf the deaths at this optimal period were due 

to intrapartum anoxia and/or trauma. More babies died of this group of causes in this gestation 

interval (40-41 weeks) than died at all gestations 

from “respiratory distress syndrome.” Preterm 

delivery in the Survey was therefore numerically 

much less important as a factor causing perinatal 

mortality than intrapartum death at term. 

The increase in perinatal mortality after 

42 weeks of gestation was due largely to increases in the group intrapartum anoxia and/or 

trauma and in the rate for antepartum stillbirth. 

The adverse effects of hypertension associated 

with prolonged pregnancy in these two categories 

have already been noted (fig. 3). Accurate knowledge of the gestational age is clearly of major 

importance here. 

C&tational Maturitv and Low Birth Weight 

In studying pregnancy and labor complications associated with low birth weight (2,500 

grams or less), it must be realized that their 

incidence will vary according to length of gestation. In table 22, low birth weight babies are 

shown in three different gestational groups, and 

the incidence of some maternal factors is shown 

for each group. 

The important associations of the low birth 

weight baby delivered at or after the 39th week 

(the small-for-dates baby) were primiparity, low 

maternal stature (under 5 feet), hypertension in 

pregnancy, and fetal distress in labor. These 

were the maternal associations or complications 

which occurred more frequently in this gestation 

group than in the others. Conversely, among the 

deliveries of low birth weight babies before the 

36th week the complications that were more 

common in this group than in the other gestation 

groups were breech delivery and previous perinatal death. 

Table 23 shows for low birth weight babies, 

in the same three gestational groups as in the 

previous table, the causes of perinatal death, excluding macerated stillbirths and congenital malformations. Low birth weight babies born before 

the 36th week are seen to have very high perinatal 

mortality (37 percent). The two major causes 

of death were intrapartum anoxia and/or trauma 

and “respiratory distress syndrome” (i.e., hyaline 

membranes, intraventricular hemorrhage, or 

first- week deaths with no histological lesion). 

Together these two groups make up nearly threequarters of these deaths. In the intermediate 

gestations (36-38 weeks) the mortality dropped 

to 8.2 percent and intrapartum anoxia and/or 

trauma accounted for half of the deaths. Perinatal 

mortality in low birth weigh; babies was lowest 

(5.3 percent) in those who were of high gestation, 

and again death from intrapartum anoxia and/or 

birth trauma was the commonest individual cause. 

Good intrapartum as well as neonatal care is 

essential to the survival of the low birth weight 

baby at all gestations. 

The prognosis of surviving low birth weight 

babies also varies according to gestational age. 

Followup studies by McDonald 4°Y41 on 1,1OO 

babies weighing less than 1,800 grams revealed 

two clearly distinct varieties of neurological 

handicap at the age of 7 years, depending on ges ­

tational maturity. Low birth weight babies of low 

gestation showed increased risk of spastic diplegia, whereas low birth weight babies of higher 

gestation showed an increased risk of mental 

retardation, convulsions, or cataract. The former 

37 
may be due to immature state of development 

of the pyramidal tracts and related parts of the 

central nervous system. The latter may be 

related either to oxygen-lack during labor, known 

to be a danger for the glycogen-depleted smallfor-dates baby, or, for a similar reason, symptomatic neonatal hypoglycemia. 

The definition of the small-for-dates baby 

is urgently in need of clarification. Gruenwald 42 

has suggested two standard deviations below the 

mean weight for gestational age; Warkany and 

others 43 suggest a more stringent criterion of 

40 percent underweight. Both of these require 

accurate knowledge of gestational age and of 

mean weights for the appropriate ethnic group. 

In the past the difficulties of obtaining reliable 

information from the mother as to the date of 

the last menstrual period have been exaggerated. 

The usefulness of early assessment of maturity 

during pregnancy is worth reemphasizing. In 

general, in Britain obstetricians and pediatricians 

have been insufficiently aware of the special 

problem of the baby who is unexpectedly underweight for gestational age. The designation “good 

premature” which has been given to these babies 

in the past is not supported by their perinatal 

mortality. 

Classification of Birth Weight and Gestation 

When studying the effect of birth weight and 

gestational maturity, it is clearly an advantage 

to use recognized and reproducible groupings. The 

World Health Organization defines as low birth 

weight all babies weighing 2,500 grams or less 

at birth. Where the birth weight is not known, the 

baby is considered to be premature when the 

gestation period is less than 37 completed weeks 

(259 days or less). Material from the British 

Perinatal Mortality Survey has therefore been 

specially classified in the above WHO categories 

of birth weight and gestational maturity (table J). 

Babies of low birth weight (2,500 grams or less) 

and babies of full size (over 2,500 grams) were 

each subdivided according to whether they were 

delivered preterm (under 37 completed weeks) or 

at full-term (37 weeks and over). This produced 

four groups of babies, namely: low birth weight 

preterm, full-size preterm, low birth weight fullterm, and full-size full-term babies. The deaths 

were classified likewise with two omissions: 

congenital malformations and macerated stillbirths, in view of the special relationship of 

their birth weight to gestation. In 13 percent of 

the deaths included in the table and 11 percent 

of all births, gestation and/or birth weight was 

not known. 

Table J shows that nearly half of the preterm babies in the Survey were full-size by birth 

weight (over 2,500 grams). More than half of the 

low birth weight babies were born at or near 

full-term (37 weeks or more). These figures 

justify the use of the four gestation-birth weight 

groups referred to above. 

The ji.dl-size Jull - term baby accounted for 

81.2 percent of all single births. This group had 

a very small risk of stillbirth or neonatal death 

(less than 1 percent). The mortality is seen to 

be very much higher in each of the other three 

birth weight-gestation groups which together 

formed 7.9 percent of births but 47.1 percent of 

stillbirths and neonatal deaths (table J). The 

contribution to mortality made by these three 

high- risk birth weight -gestation groups differed 

according to the stage of labor and day of death. 

It was only 22 percent in the case of deaths in 

the second stage of labor, which conversely is 

a time when full-size full-term babies face their 

greatest danger due to risk of anoxia in labor. 

It rose to 66 percent between 30 minutes and 24 

hours, and 56 percent of deaths between 1 and 7 

days, 

The low birth weight b~eterm baby is seen 

in table J to have 8.0 percent risk of death in labor 

and a 16 percent mortality in the first week of 

life. The latter is mainly due to deaths from 

“respiratory distress syndrome. ” This group 

of low birth weight preterm babies made up 

55.1 percent of all those dying after 30 minutes 

but before the end of the first day of life, a 

period which has been understandably resistant 

to improvement in mortality. 

The fill-size pveterm babies are important 

since they are a high-risk group but are not 

officially premature by weight. This group had 

a first-week mortality which was over six times 

that of the full-size full-term baby (table J). 

The low bi~th weight jidl - term baby has a 

higher mortality than babies of similar gestation 

but average weight. They are the small- for-dates 

38 
----------------------------

----------------------------

-------------------------

------------------------------------

-----------------------------------

----------------------------

------------------------- ---------------------------

-----------------------------------

----------------------------

-------------------------

------------------------------------

-----------------------------------

Table J. Percentage distribution of births, stillbirths, and neonatal deaths by maturity; per­


centage distribution and death rates for stillbirths and neonatal deaths by maturity and time


of death: England, Scotland, and Wales, 1958


[In,lwlw totid
 Singlel)irths for control week, March 3-9,1958. Stillbirths and neonatal dwths for hlarch-May 1958 are ~lated to estimated births 

for the same months. Excludes macerated stillbirths and deaths from congenital malformations 

Index of maturity


grams than grams than 

2,500 2,500 

28-36 weeks 37 weeks 

and over Time of death Number Percent I Un2,500 More 2,500 More knowl+ 

1::s I grams 

i 

T$ 

grams 

I 

1::s


Percentage distribution by maturity


All births 16,994 100.0 2.7 2.1 3.1 81.2 1 10.8 

Total stillbirths and neonatal deaths--- 4,111 100.0 33.7 5.0 8.4 39.9 I 13.0


Stillbirths


First stage of labor------------------------ 1,172 100.0 29.1 8.1 42.3 14.2


Second stage of labor----------------------- 783 100.0 12.1 ::; 6.9 66.2 11.4


Neonatal deaths


Under 30 minutes 112 100.0 18.7 5.4 $;.; 17.9 

30 minutes-23 hours 978 100.0 55.1 ;:: 6.2 13.3 

1-6 days 828 100.0 39.7 3.9 12.8 31:5 12.1 

1-3 weeks 238 100.0 24.8 7.1 10.5 44.5 13.1 

Percentage distribution by age at death 

Total stillbirths and neonatal deaths--- 4.111 100.0 100.0 100.0 100.0 100.0 100.0 

Stillbirths


First stage of labor------------------------ 1,172 28.5 24.6 35.9 :;.: 30.3 31.2 

Second stage of labor----------------------- 783 19.0 6.9 13.1 . 31.6 16.5 

Neonatal deaths 

Under 30 minutes 112 3.7 

30 minutes-23 hours 978 2$: 3::: 2::; 1+:: 12:: 24.2 

1-6 days--------- 828 20.1 23.8 15.5 30.5 15.9 18.7 

L-3 weeks 238 5.8 4.3 8.3 7.2 6.5 5.8 

Rate per 100 specified deliveries


Total stillbirths and neonatal deaths--- 4,111 2.0 25.4 4.8 5.5 l.O 2.4 — 

Stillbirths


First stage of labor------------------------ 1,172 0.6 6.3 1.7 0.3 0.7 

Second stage of labor----------------------- 783 0.4 1.7 0.6 ;:; 0.3 0.4 

Neonatal deaths 

Under 30 minutes 112 0.1 0.4 0.3 0.1 0.0 

30 minutes-23 hours 978 0.5 9.9 1.0 0.1 ::: 1-6 days 828 0.4 6.0 ::; 0.4 

1-3 weeks 238 0.1 1.1 0.4 ::: ::: 0.1
 —


‘Birth weight and/or gestation not specified.


39

----------- ---------------------------------------

-------------------------------------- ---------------------------------------------- --------------------------------------------- ------------------------------------ ----------------------------------------------

---------- ------------------------------------------

--------

-------

------- ----- -------------

------------------

--------------

Table K. Percentage distributionof induced deliveries and stillbirth and neonatal


mo;;ali.tyrates, by indication for induction of labor: England, Scotland, and Wales,


[Includes total tingle births for control week, hlarch 3-9,1958. Stillbirths and neonatal deaths for Mrmch-May 1958 are related to 

estimated births for the same months] 

Percentage


Indication for induction of labor distribution


of induced


deliveries


Preeclamptic toxemia and essential hypertension 33.8


Prolonged pregnancy 37.2


Preeclamptic toxemia (essentialhypertension) and


prolonged pregnancy


Small pelvis


Rh antibodies


Antepartum hemorrhage


Unstable lie


Intrauterinedeaths and congenitalmalformations


Other conditions


Stillbirths


and neonatal


deaths per


100 total


births


3.5


2.3


2.0 

2.2 

2;:; 

1.7 

3.2 

babiesandtheirfateisinteresting
 inviewofthe


association withintrauterine malnutrition
 andthe


possibility ofsubsequent
metabolicchangesinthe


infant. Thisgroupofsmallfull-term
 babiescom-


prised3.1percentofallbirthsintheSurveybut


was responsible
forno lessthan30.5percentof


the deathsat 1-6 days of age, the periodof


maximum dangerofhypoglycemia.
The mortality


in labor and on the firstday of lifewas also


relatively high,thoughstill
much lessthanthat


ofpretermlowbirthweightbabies.


COMPLICATIONS OF LABOR 

Inductionof Labor 

Some form of medicalor surgical
induction


of laborwas used for 13 percentofmothersin


the BritishSurvey.The percentagedistribution


of the indications uedforinduction
 oflaborare


shown in tableK, withtheperinatal
mortality


associated witheachindication. Naturally,
 some


indications
 are associatedwitha highermor­


talitythan others.Hypertension
and prolonged


pregnancywere thecommonest indications.


The methods of induction
which were used


are shown in tableL. The traditional
 castor


oil,bath,and enema was most commonly used,


followedby highamniotomy.Mortality
compari-


Table L. Percentage distributionof in­


duced deliveries,by method of induction


of labor: England, Scotland, and Wales,


March 3-9, 1958


[Total single births OrrIY] 

Method of induction Percentage


distribution


Total---------------­


w


Low amniotomy alone 

High amniotomy alone 

Anmiotomy alone, site of 

rupture unspecified


Amniotomy and oxytocin


Oxytocin alone


Oil, bath, and enema with


oxytocin


Oil, bath, and enema with­


out oxytocin


15.4


20.0 

12.3


11.0 

4.8


8.4


28.2


sons of different methods of induction
are not


meaningfulbecauseofdifferent
 indications,mak­


ing itimpossibleto assessaccurately
therisks


of induction to thefetus.
Afterlmthlowandhigh


amniotomy,about1 in20 caseswas subsequently


delivered bycesareansection.Onechief
 hazardof


induction wouldtherefore
seem tobeanincreased


40 
cesarean section rate and its attendant risks. The 

neonatal death rate from pulmonary infection was 

twice as high after high amniotomy as after low 

amniotomy and rose progressively after 24 hours 

of life, The vexed question of whether induction 

is less dangerous to the fetus than prolongation 

of pregnancy past term44 could not be answered 

from the data- of the Survey because of difficulties in comparing criteria for induction in different centers. 

The problem of induction is closely connected with recognition of the failing placenta 

during the last trimester of pregnancy. This is 

difficult on clinical grounds and even by means 

of placental function tests. Serial measurements 

of urinary estriol levels are considered the most 

reliable tests in this country,45 although not all 

investigators agree as to their value .46 Persistently low levels or a fall from previously 

normal levels seem to be associated with reduced fetal growth47 and an increased perinatal 

mortality. However, these measurements are 

laborious and expensive and at present are really 

suitable only for choosing the optimum time of 

delivery in the known high-risk case. The problem of a simple test for the routine detection of 

placental dysfunction is as yet unsolved. 

Length of Labor 

The length of the first stage of labor was 6-24 

hours in 65 percent of primiparae in the Survey. 

Perinatal mortality was increased in primiparae 

when the first stage was less than 3 hours or 

more than 48 hours. Labors of less than 3 hours 

were more common in multiparae, again with a 

slight increase in perinatal mortalit y. In all births 

first stages longer than 24 hours were associated 

with increased perinatal mortality. In both primiparae and multiparae the increases in mortality 

with unfavorable length of labor were due largely 

to an increase in the number of deaths from intra ­

partum anoxia and/or trauma. 

The second stage of labor lasted less than 2 

hours in 83 percent of primiparae and in 92 percent of multiparae. Second stages of less than 

30 minutes were associated with an increased 

perinatal mortality in primiparae but not in 

multiparae. Mortality started to increase when 

the second stage lasted more than 2E hours in 

primiparae and 2 hours in multiparae. Once 

again the increased mortality was due to intrapartum anoxia and/or trauma. 

The interval of time between rupture of the 

membranes and delivery was less than 3 hours 

in 60 percent of all cases regardless of parity. 

Mortality started to increase when the membranes had been ruptured for more than 24 hours 

and in this case was largely due to an increase 

in the number of babies dying of pulmonary infection. There was also an increase in deaths 

from intrapartum anoxia and/or trauma, probably 

because of the association with prolonged labor. 

Analgesia in Labor 

In the Survey, the most commonly used form 

of analgesia was self-administered nitrous oxide 

and air (53.5 percent), which was associated with 

a perinatal mortality 36 percent below average. 

However, this combination was most commonly 

used in home delivery and therefore with a 

selected group, so it is not possible to evaluate 

its safety from these data. At present, nitrous 

oxide and oxygen is gradually replacing nitrous 

oxide and air, because of the possibility of 

serious hypoxia when equal amounts of nitrous 

oxide and air are used. 

Self-administered trilene was much less 

frequently used (22.6 percent), and its use was 

associated with a perinatal mortality only just 

below average. However, it was used more 

frequently in hospital deliveries, especially when 

maternal hypertension was present. Combinations 

of nitrous oxide, oxygen, and trilene were rarely 

used. One in five women received no volatile 

analgesics, for reasons ranging from rejection 

by the patient to lack of time or lack of availabilityy. 

The most commonly used analgesic drug administered in the last 12 hours of labor was 

pethidine (meperidine). In the last 12 hours of 

labor, 54.5 percent of all women received intramuscular pethidine with a perinatal mortality 

well below average. The administration of these 

physiological doses of pethidine appeared not 

to contribute to deaths which occurred immediately after birth from a combination of anoxia 

and respiratory depression. The use of morphia 

was virtually confined to cases of very pre -

41 
mature labor or accidental hemorrhage and was 

therefore naturally associated with a very high 

perinatal mortality. 

The administration ofpethidine, nitrous oxide and air, and trilene in this country is for the 

most part the responsibility of the midwife 

supervising the delivery. These methods of analgesia seem to be reasonably safe as far as the 

fetus is concerned. 

Method of Delivery 

Spontaneous vertex delivery occurred in 87.8 

percent of all single pregnancies in the Survey 

(table 24). Forceps delivery by the vertex occurred in 4.7 percent of all deliveries. Fourfifths of the forceps deliveries took place in 

hospitals; one in five was performed by a family 

doctor, either in the home or in a general 

practitioner maternity unit. Breech delivery occurred in 2.2 percent of all cases. One-third of 

breech deliveries were conducted by midwives, 

1 in 10 by family doctors, and the remainder by 

obstetricians. Cesarean section was required 

for 2.7 percent of women. Delivery was unattended 

in 2.1 percent of the pregnancies. 

Episiotomy was performed in one-third of 

primiparae and in about 6 percent of multiparae. 

Episiotomy has the advantages of shortening the 

second stage of labor and minimizing damage to 

the pelvic floor and is widely recommended by 

obstetricians in this country. Episiotomy was 

used more frequently in hospital deliveries and 

less frequently in the home, because of the 

difficulties of perineal repair in the home. The 

decision to perform an episiotomy is generally 

taken by the midwife, but lacerations and episiotomies must be repaired by doctors. 

Perinatal mortality was at its lowest in 

babies delivering by the vertex, with a slight 

increase in mortality when the occiput was 

posterior. Perinatal mortality was also lowest 

in low birth weight babies delivering spontaneously by the vertex (table 24). Forceps delivery 

was associated with a considerable increase in 

mortality, almost entirely due to an increase 

in the number of deaths from intrapartum anoxia 

and/or trauma. This is related to the indications 

for forceps delivery, since fetal distress was 

present in over one-third of the cases. In general, forceps are not used in Britain except in 

the presence of a specific indication for assisted 

delivery. 

Breech delivery was associated with a very 

high perinatal mortality. This was partly due to 

a large number of antepartum stillbirths and 

congenital malformations which were delivered 

by the breech. However, perinatal deaths from 

intrapartum anoxia and/or trauma and early 

neonatal death from “respiratory distress syndrome” were also very frequent after breech 

delivery. This was mostly due to the greater 

frequency of breech deliveries at low gestation. 

“Respiratory distress syndrome” was three times 

more frequent in breech deliveries weighing 

2,500 grams or less than in vertex deliveries 

of the same weight. However, breech delivery 

becomes progressively more frequent as the 

birth weight falls. It is, therefore, not possible 

to conclude that hypoxia associated with preterm 

breech delivery was a precipitating factor in the 

development of atelectasis with hyaline membranes. 

Cesarean section was associated with an 

increased perinatal mortality rate because of the 

indications for the operation. Death from intrapartum anoxia and/or trauma and early neonatal 

death from “respiratory distress syndrome” 

were the main causes. The mean birth weight 

of babies dying from hyaline membrane disease 

after delivery by cesarean section was significantly higher than that of babies dying of hyaline 

membrane disease after vaginal or breech delivery. Of the deaths due to hyaline membrane 

disease after cesarean section, 25 percent 

weighed more than 2,500 grams compared with 

12 percent of deaths from hyaline membrane 

disease after delivery by other routes. Early 

neonatal death from “respiratory distress syndrome” in babies weighing 2,500 grams or less 

was four times more common after delivery by 

cesarean section than after vaginal delivery. 

These facts are in agreement with the suggestion 

that delivery by cesarean section predisposes to 

the development of the “respiratory distress syndrome, t~48 However, these figures have not been 

adjusted for differences in the incidence of antepartum hemorrhage, or other emergencies leading 

to delivery by cesarean section. 

42 
-----------------------------

----------------------------------

--------------------------------------------

--------------------------------------------

------------------------------------------- -------- -------- -------- -------- -------

------------------------------------

------------------------------------------

The predominant indications for cesarean 

section are shown in table M, together with perinatal mortality of ce sarean sections. Mortality 

was lowest in sections for delay or disproportion 

in labor and was highest in association with 

placenta previa and severe hypertension. These 

differences are, of course, associated with large 

differences in gestation. More than half the 

cesarean sections were performed by consultant 

obstetricians and 97 percent took place in obstetric hospitals. 

Anesthesia for OPerative Delivery 

General anesthesia was used for 95 percent 

of the mothers in the Survey who were delivered 

by cesarean section; regional or spinal anesthesia 

was rarely used. It was not possible to compare 

anesthetics in relation to perinatal mortality since 

the prime determinants of mortality are the length 

of gestation and the indications for cesarean 

section. 

Forceps delivery was conducted under a 

general anesthetic in 59 percent of cases. Pudendal block was the commonest form of local anesthesia but was rarely used by the general practitioner. Greater use of pudendal block outside 

obstetric hospitals is indicated. 

Breech delivery was conducted without anesthesia in 58 percent of the cases. General anesthesia was used in 17 percent of breech deliveries and local anesthesia for the remainder. Once 

again the safe pudendal block was rarely used by 

the general practitioner delivering babies either 

at home or in the general practitioner maternity 

unit. 

Complications of Labor 

Malpresentations other than breech were 

rare in the Survey. Face, brow, or shoulder 

occurred in only 0.7 percent of all deliveries. 

Internal version for shoulder presentation was 

rarely used, but 30 percent of the infants thus 

presenting died during the perinatal period. 

The incidence of various types of fetal distress in all births during the control week of the 

Survey is presented in table N. Fetal brady ­

cardia (under 120 beats per minute) or tachy ­

cardia (over 160 beats per minute) was the most 

frequently detected sign of fetal distress and also 

the one with the lowest mortality. These figures 

do not suggest that the passage of meconium 

without alteration in the fetal heart can be safely 

ignored. 

Table M. Percentage distribution of cesarean sections and stillbirth and neonatal 

mortality rates, by indication for section: England, Scotland, and Wales, 1958 

[Includes total single births for control week, March 3-9, 1!358. ,%illbirtbs and neonatal deaths for March-kfay 1958 are related to 

estimated births for the same month:~ 

I I

I I Stillbirth 

and neonatal Percentage Indication for cesarean section distribution deaths per 

100 total 

births 

Total cesarean sections 100 ] 6,2 

I 

Elective section at term 

Fetal distress ;:; 

Delay in labor 

Placenta previa 13 15: 

Severe hypertension 

Disproportion in labor 

Other conditions 

6 

4 

10 

39.0 

0.9 

43

------- ------- ------- ------- -------- -------- -------- -------- --------- ------- ------- ------- -------

Table N. Percent of deliveries and stillbirth and neonatal mortality rates, by specified sign of fetal distress: England, Scotland, and Wales, 1958 

[Includes total single births for control week, hlarch 3-9, 1958. Stillbirths and neonatal deaths for hiarch:hlay 1958 are related to 

estimated births for the same months. Excludes macerated stillbirths and deaths from congenital malformations] 

Stillbirths 

Percent of and neonatal 

Si~ of fetal distress deliveries deaths per 

lo:=clgl . 

Prolapse or presentation of cord 0.3 34.0


Passage of meconium 0.9


Fetal bradycardia or tachycardia 2.0 :;;


Passage of meconium with fetal bradycardia or tachycardia--- 0,7 6,9


Multiple Pregnancy 

During the control week of the Survey, 1.2 

percent of all pregnancies weremultiple. Separation into monozygotic anddizygotic twins was not 

possible in this series. The perinatal mortality 

of single births, of the first twin (twin I), and of 

the second twin (twin 11) are shown intable 25. 

The combined mortality of twins exceeded 25 

percent. Multiple pregnancy was associated with 

a much higher incidence of early delivery and 

low birth weight than was single delivery. 

Comparisons of perinatal mortality in twin 

Iandtwin II reveal some interesting differences. 

Mortality from intrapartumanoxia and/ortrauma 

was nearly twice as high in twin 11, as also was 

therate ofearly neonataldeath from’’respiratory 

distress syndrome.” These differences lendsome 

support to the hypothesis thatintrapartum hypoxia 

predisposes to the development of respiratory 

distress in the prematurely born infant. Death 

from pulmonary infection, onthe other hand, was 

more common in twin L This lends indirect 

support to the hypothesis ofarelationship between 

prolonged rupture of the membranes and postnatal pneumonia. A higher incidence ofchorionitis in the placenta in twin I has been reported. 

Massive pulmonary hemorrhage (included inthe 

“other” group) was eight times more frequent in 

twins than in single births. Thisisfurther confirmation of an association of twin pregnancy with 

intrauterine growth retardation. 

Improvement in the very poor results for 

multiple pregnancies is obviously urgent. Most 

of these multiple pregnancies were in fact diagnosed before the onset of labor, but prenatal 

rest in the last trimester, which is considered 

desirable by some in this country,49 was by no 

means the rule. However, the Survey series was 

not large enough to assess the effect of bed rest 

between 30 and 36 weeks onthe outcome of twin 

pregnancy. The large differences in mortality 

between twins I and H suggest that the delivery 

of the second twin could be improved. Clearly 

the whole obstetric care of a twin pregnancy 

should be the responsibility of an experienced 

obstetrician, and especially the delivery of the 

second twin. 

The mortality in multiple pregnancy was at 

its lowest in babies delivered just before term, 

Prolongation of pregnancy 7 days beyond term 

was associated with a two-fold increase in perinatal mortality. This is in accordance with the 

conclusion of Brown and Dixon that the pregnancies of women bearing twins should not be 

allowed past term.iy 

44 
PROPHYLACTIC IMMUNIZATION 

IN INFANCY 

Diphtheria 

No deaths from diphtheria were reported in 

the first year of life (or at any age) in 1965 and 

in the same year there were only 25 notifications 

of this disease at any age. These rates and those 

in the remainder of this section apply to England 

and Wales. Average annual notifications at all 

ages from 1933-42 had totaled 55,125 cases, with 

2,783 deaths. Immunization with diphtheria toxoid 

was introduced in certain areas during the 1930’s 

and extended as a nationwide program in 1942. 

It is now given mainly in the first year of life 

as part of primary immunization with DTP vaccine (triple prophylactic against diphtheria, tetanus, and pertussis). 

Pertussis 

Infant deaths from whooping cough in 1965 

numbered 15 out of a total at all ages of 21 deaths. 

This emphasizes that the major risk for this 

infection, though now slight, is mainly to young 

infants. Yearly notifications at all ages averaged 

around 90,000 for the period 1954-57, with an 

annual average of 101 deaths, of which an average 

of 71 deaths took place in infants under 1 year 

of age. After the advent of widespread whooping 

cough immunization in the late 1950’s the average 

annual notifications between 1963 and 1965 had 

dropped to 26,400, of which approximately 10 

percent were under 1 year. Whooping cough 

immunization is given as early as possible in the 

first year of life, usually as part of a course of 

DTP vaccine (triple prophylactic). 

Tetanus 

In 1965, 21 deaths from tetanus were registered, none of which were under the age of 1 

year. A full course of immunization with tetanus 

toxoid is encouraged in infancy again as part of 

course of DTP vaccine. Administration of a full 

course of tetanus toxoid renders unnecessary 

the prophylactic use of tetanus antitoxin (horse), 

whi;h produces each year in Britain dangerous 

hypersensitivity reactions in susceptible individuals. Half the cases of clinical tetanus in Britain 

give no history or evidence of an entry wound. 

Poliomyelitis 

There were no infant deaths from poliomyelitis reported in 1965. only 3 fatalities from 

acute poliomyelitis were recorded at all ages 

during that year, together with 16 deaths from 

late effects of poliomyelitis. In the years 1953 

to 1955, before poliomyelitis immunization was 

introduced, the average yearly poliomyelitis notifications were 4,279, with an average of 247 

deaths. This fell by 1963-65 to an annual average 

of 60 notifications with an average of 29 deaths, 

of which 25 were due to late effects. The first 

year of life is considered the optimum time for 

producing active primary immunity against poliomyelitis. The oral attenuated Sabin trivalent 

vaccine was introduced off icially in 1962 and is 

preferred to Salk-type killed polio-vaccine. 

Smallpox 

In Great Britain, routine smallpox vaccination is no longer compulsory. Smallpox vaccination has recently come under criticism in view 

of the rarity of the disease and the possibility of 

severe vaccination reactions. ~o Nevertheless, 

smallpox vaccination still has a prominent place 

in the official childhood immunization program, as 

it is considered that this diminishes the hazards 

which would accompany primary vaccination if 

postponed until later in life. Moreover, a highly 

protected community is thought to provide a 

reservoir of immunity which may limit the spread 

of smallpox during occasional epidemics. The 

modified variola virus-vaccine, treated with glycerol and phenol, presently in use, is known 

to carry a small though definite risk of provoking 

generalized vaccinia, vaccinal encephalopathy, or 

eczema vaccinatum. Wynne - Griffith51 has studied 

the reported cases of postvaccinal encephalopathy 

and of generalized vaccinia reported after primary vaccination in England and Wales between 

1951 and 1957. The incidence of vaccinal encephalopathy was highest during the first year of 

life (15.8 per million with a mortality of 8.7 per 

million); it was lowest in the age group 1 to 4 

years (2. 1 per million with no deaths) and rose 

45 
again over 15 years of age (28.7 per million with 

2.9 deaths per million). A similar pattern was 

evident for generalized vaccinia. It has, therefore, been recommended that routine smallpox 

vaccination in the United Kingdom be postponed 

until the second year of life. As a result, in 1965 

only 33 percent of children under 2 years of age 

received primary vaccination and vaccination 

figures are low at all ages. 

Measles 

The justification for protection against measles in economically advanced countries like 

Britain lies not in the mortality risk but in the 

high prevalence and high morbidity rate of the 

disease during childhood. Though both killed and 

living (attenuated) measles vaccines have been 

officially available since 1965 for doctors wishing to use them, this has not been followed by a 

national campaign for mass measles vaccination, 

mainly because of uncertainty about the duration 

of immunity and a possibility of increased adult 

susceptibility. A simple and effective regime 

consists of a single intramuscular dose of attenuated vaccine, given from the age of 9 months 

upward, but pyrexia or rash are occasionally 

troublesome though harmless complications. 

Measures employed to reduce such reactions 

include further attenuation, simultaneous administration of gamma globulin, or the prior 

injection of one or two doses of killed vaccine 

before administration of the attenuated vaccine. 

Tuberculosis 

BCG vaccination of tuberculin-negative subjects with freeze-dried vaccine is offered routinely to children in England and Wales prior 

to leaving school. For infants and young children, 

this measure is at present reserved for tuberCU1OUScontacts or other at-risk groups. Widespread BCG vaccination of the newborn, as in 

Scotland, is thought desirable by some. 

Immunization Schedules 

Recommended immunization schedules in the 

United Kingdom are designed with five main objectives. These are to provide the highest protection against each disease, to cover the age of 

greatest risk, to give minimal reaction rates, to 

ensure the fewest number of visits, and thus tcl 

enable maximal acceptance rate. The immunizations are given either by the family doctor or at 

the local authority clinic. In most areas it is 

considered preferable to complete the primary 

immunization course against diphtheria, tetanus, 

and pertussis, using triple prophylactic (DTP 

vaccine), within the first 6-9 months of life. 

Oral trivalent poliovaccine (OPV) can be given at 

the same visits as DTP vaccine. The youngest 

age at which effective primary immunity can be 

established depends mainly on the level of inherited maternal antibody. High levels may 

blanket the effect of active immunization in the 

early months of life. This is particularly important when weak antigens are favored, as in the 

United Kingdom where plain vaccines and fluid 

toxoids are used. It is partly for this reason that 

two alternative immunization schedules are permitted by the Ministry of Health.bz In the first, 

a primary course of DTP vaccine is given at 3, 

4, and 5 months of age. Three doses of trivalent 

OPV are given between 7 and 11 months of age. 

Six visits are thus necessary in the first year of 

life. These six visits can be cut to three if the 

OPV is given simultaneously with the injection 

of DTP vaccine.~s However the primary course 

of DTP vaccine which is used currently in the 

United Kingdom in plain (nonadsorbed) form, 

is often started at 1 to 2 months of age, as the 

injection of killed pertussis organisms enhances 

the antigenic effect of fluid diphtheria toxoid. In 

such cases, a fourth reinforcing dose must be 

given during the second year of life. 

The alternative immunization scheme recommended officially in the United Kingdom is based 

on the fact that insufficient lasting active immunity 

may be produced when antigens are given before 

6 months of age. In this schedule, trivalent OPV 

is fed between 6 and 10 months at monthly imervals for three doses. This is followed by two 

injections of plain DTP vaccine at monthly intervals between 11 and 13 months of age. This is 

an effective regime, but disadvantages include 

the number of visits and the limited value in 

reducing the peak mortality or morbidity of 

pertussis, which occurs in the first year of life. 

It is therefore not very popular. 

46 
OUTLOOK FOR THE FUTURE 

Perinatal death has declined slowly but 

steadily over the past 35 years chiefly because 

of the application of principles based on empiricism, rather than on etiology. Until research 

throws light on the causation or control of congenital malformation, premature delivery, and 

preeclamptic toxemia, there is little prospect of 

dramatic change, but theempirical approach can 

still be expected to bring considerable improvement. 

Apart from congenital malformations the 

problem of perinatal death is almost wholly 

obstetric. Whether it is viewed as the safeguarding of high-risk groups or as the prevention 

of deaths from anoxia, trauma, and respiratory 

failure, the most important factors are the experience, skill, and judgment of the professional 

attendant. Consequently, medical teaching and 

government policy are based on the need to 

ensure that the groups of mothers whose offspring are known to have a higher than average 

risk of perinatal mortality come under the 

supervision of obstetric specialists throughout 

pregnancy and childbirth. Such mothers should 

be booked for confinement in hospital, which 

presumes a sufficiency of maternity beds and the 

cooperation of family doctors, midwives, and the 

mothers themselves. For the country as a whole, 

sufficient beds are not yet available because the 

sudden and partly unpredicted rise of the birth 

rate from 1955 to 1964 outran the increasing provision of maternity units. Consequently, earlier 

discharge from hospital has become expedient in 

many areas until additional maternity beds become available. Meanwhile, careful selection 

for consultant care in hospital is not yet fully 

carried out. Perinatal mortality may be expected to continue improving as selection improves and as more beds become available in 

maternity units under consultant supervision. 

After the perinatal period, the prevention 

of mortality becomes much less empirical. Some 

part of neonatal mortality has the same background as perinatal mortality; death from congenital malformations remains intractable and the 

control of viral infection is still in the future. 

But, in general, as the infant grows older etiology 

is clearer and mortality controllable. It is not a 

question, as in the perinatal period, of attempting to minimize risks but of preventing the preventable. The number of failures is small and 

postneonatal death is uncommon. Because these 

deaths are relatively few the technique of individual confidential investigation, which proved 

successful in maternal mortality, can be and is 

being used for postneonatal death. By this means 

avoidable factors that may have contributed to a 

death can be identified. They may be of local 

or national significance and may indicate a need 

for action to ensure that the medicosocial services and the full range of preventive and curative 

medical care are available, are known to be 

available, and are used. 

Congenital malformation remains the one 

cause of perinatal and infant mortality for which 

there seems scant chance of improvement in the 

foreseeable future, despite the advances in genetics. Surgery seems unlikely to effect more than 

slight improvement. Since man has begun to add 

to his environment teratogenic agents that he 

cannot fully control, the epidemiology of congenital malformation has become of prime importance, but with a view to safeguarding against 

increase,” rather than promising decrease. As 

other causes of infant mortality steadily decline, 

congenital malformation still remains an intractable problem in western countries. 

47 
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England J. Med. 246(15):561-568, Apr. 10, 1952, 

31Morris, J. N., and Heady, J. A.: Mortality in relation to 

the father’s occupation. Lancet 1:554-559, Mar. 1955. 

32Fe1dstein, M. S., and Butler, N. R.: Analysis of fac@r~ 

affecting perinatal mortality. Brit. J. Pre v. & Social hfed. 

19:128-134, July 3,1965. 

33111sley, R., and Kincaid, J. C.: Social correlations of 

perinatal mortality, in N. R. Butler and D. G. Bonham, Perinatat hfoTtatity. Edinburgh. E. & S. Livingstone, Ltd., 1963. 

34Theoba1d, G. W.: Symposium on toxaemia. J. ~bstet. G 

Gynaec. Brit. Comm. 69:1056-1057, Dec. 1962. 

35 Baird, D. G.: The epidemiology of prematurity. J. Pediat. 

65(6):909-924, Dec. 1964. 

36 Simpson, W. J.: A preliminary report on cigarette smoking 

and the incidence of prematurity. Am. J. Obst. & Gymc. 73(4): 

808-815, Apr. 1957. 

37Low~, C. R.: Effect of mothers’ smoking habits on birth ‘ 

weight of their children. Brit. M. J. 2:673-676, oct. 1959. 

38Herriot, A., BilIewicz, W. Z., and Hytten, F. E.: Cigarette smoking in pregnancy. Lancet 1:771-773, Apr. 1962. 

3gButler, N. R.: Low birthweight and prematurity. J. Ob,st 

& Gynaec. Br-it Comm 72:1001-1003, Dec. 1965. 

40McDonald, A. D.: Fits in children of very low birth 

weight. Develop. Med. and ChildNeuro8. 6:144-148, Apr. 1964. 

48 
REFERENCES-Con. 

‘ilhicDonnld, A. D.: The aetiology of spastic diplegia. 

Dt-t~l>lop,ilcd. and Child Neurot. 6:227-285, June 1964. 

‘p2@renwald,P. : Chronic fetal distrees and placental in­

~ufficioncy, Bio?, Neonat. 5:215-265, 1963. 

‘4;~Warkurry,,J., hionroe, B. B., and’Sutherland, B. S.: Intruutorinu growth retardation. A.M.A. Am, J. Dis. Child. 102: 

24!1-279, ,4ug. 1961. 

‘%ihtmrd, G. F.: The choice between death from postmuturity and death from induction of lahour. Lancet I:64-66, 

Jnrr. 19tN, 

45Booth, R, T., andotbers: Urinary oestriolas an index of 

plncrmtal function and foetal viability, resultsin normal pregnuncy.J, Obstct. &Gynaec. Brit. Comm.71:266-271, Apr. 1964. 

46 COY10,M. C+,, and Brown, J. B.: Urinary excretion of 

“ostriol during pregnancy. J. Obstet. & Gyneac. BTit. Comm. 

70: Y2i5-231, Apr. 1963. 

~7hfurtin, J. D., and Hnhnel, R.: Urinary oestrogenexcreticm and retarded intrauterine growth of the foetus. J. OfMtet. 

LI flynaca, Brit, Comm. 71:260-265, Apr. 1964. 

‘%shor, R., McLean, F., errd Maughan, G. f3.: Respiratory 

distress syndrome in infants delivered hy cesarean section. 

Am.J.otI,$t, & Gynec. 88(6) :808-815, June 1964. 

4gBrown, E. J., and Dixon, H. G.: Twin pregnancy. J. 

Obstet. &-Gynaec. Brit. Comm. 70:251 -257, Apr. 1963. 

5~euro10gical complications of smallpox vaccination. 

Btit. Med. J. 2:1345-1347, Nov. 1964. 

51Wynne-Griffith, G.: [n Proceedings of a Symposium on 

Immunisation in Childhood. Edinburgh. E. &S. Livingstone, 

Ltd., 1960. p. 29. 

52Ministryof Health: Active immunisation Against Infsctious Disease. Immunisation “Schedules P &Q. London. 

H.hL’S.O., 1963. 

58But1er, N. R,., and others: Further ob~ewations on vaccination in infancy with oral poliomyelitis vaccine o,nd diphtheria-tetanus-pertussis vaccine. Brit. }1. J. 2:41&3.422,Aug. 

1964. 

54Douglas, J., Edgar, W., and Home, K.: The Bradford 

Maternity ”Scheme, Areviewof 2X years progress. Med. Off~. 

CVI:333-337, Dec. 1, 1961. 

55Pinker, G. D., and Frazer, A. C.: Early discharge of 

maternity patients. Wt. M. J. 2:99-100, July 11, 1964. 

~ 

000 

49 
--------------------------------------------------------------

Table 1.


2.


3.


4.


5.


6.


7.


8.


9.


10.


11.


12.


13.


14.


15.


16.


17.


18.


19.


20.


21.


22.


23.


24.


25.


DETAILED TABLES 

Number and rates for live births, perinatal deaths, stillbirths, and infant and


maternal deaths: England and Wales, 1901-63-------------------------------------


Infant mortality rates, by age: England and Wales, 1930-63----------------------


Infant mortality rates, by sex and age: England and Wales, 1930-63--------------


Average annual infant mortality rates, by age, sex, and cause of death: England


and Wales, l95O-52--------------------------------------------------------------


Average annual infant mortality rates, by age, sex, and cause of death: England


and Wales, 1959-61


Live birth, perinatal, stillbirth, and infant mortality rates for males: England


and Wales, l9Ol-63--------------------------------------------------------------


Live birth,perinatal, stillbirth,and infant mortality rates for females: England


and Wales, l9Ol-63--------------------------------------------------------------


Infant mortality rates, by cause of death: England and Wales, 1950-63-----------


Neonatal mortality rates, by cause of death: England and Wales, 1950-63---------


postneonatal mortality rates, by cause of death: England and Wales, 1950-63-----


Neonatal and first-day mortality rates among low birth weight infants, by birth


weight: England and Wales, l953-63----------------------------------------------


Number and percentage distribution of low birth weight infants, by birth weight:


England and Wales, l953-63------------------------------------------------------


Perinatal, stillbirth, and infant mortality rates for specified congenital mal­


formations of the central nervous system, by sex: England and Wales


1959-61, and l962-------------------..-------------------------------~--?!?!;??~


Number and percentage distribution of perinatal deaths and perinatal mortality


rates, by time of death and primary necropsy findings: England, Scotland, and


Wales, March l958---------------------------------------------------------------


Stillbirth and infant mortality rates for all births and illegitimate births, by


age at death, and index numbers: England and Wales, selected years, 1936-61-----


Average annual live birth, perinatal , stillbirth, and infant mortality rates, by


standard regions: England and Wales, 1960-62------------------------------------


Average annual live birth, perinatal, stillbirth, and infant mortality rates, by


conurbations and urban and rural aggregates outside conurbations: England and


Wales, l96O-62------------------------------------------------------------------


Percentage distribution of births for each social class, by pregnancy outcome:


England, Scotland, and Wales, March 1958----------------------------------------


Percentage distribution of births, by mother’s blood pressure and maternal com­


plications, and by pregnancy outcome: England, Scotland, and Wales, March 1958--


Percentage distribution of births,by typeof bleeding and maternal complicat~ons,


and by pregnancy outcome: England, Scotland, and Wales, March 1958--------------


Percentage distribution of births, by period of gestation and by pregnancy out-


come: England, Scotland, and Wales, March 1958----------------------------------


Incidence of perinatal death risk factors among low birth weight infants, by


period of gestation: England, Scotland, and Wales, March 3-9, I.g58---------.----


Percentage distribution of births for each gestation group,by pregnancy outcome:


England, Scotland, and Wales, March 1958----------------------------------------


Percentage distribution of births,by birth weight and method of delivery, and by


pregnanCy outcome: England, Scotland, and Wales, Wrch 1958---------------------

Incidence of short gestation or low birth weight , and percentage distribution of


births, by pregnancy outcome for plurality groups: England, Scotland and Wales


March l958----------------------------------_-_--_------------------~----------2


Page


51


52


53


54


55


56


57


58


60


60


62


62


63


64


65


65


66


67


68


68


70


71


71


72


72


50

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

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---

---

---

---

---

---

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---

Table 1. Number and rates for live births, perinatal deaths,stillbirths,and infant and maternal deaths:


England and Wales, 1901-63


Live birthsl


Year Rate per 

Number 1,000 

population 

1963------ 856,232 18,2


1962------ 838,736 18.0


1961------ 811,281 17.6


1960------ 785,005 17.2


1959------ 748,501 16,5


1958------ 740,715 16.4


1957------ 723,331 16.1


1956------ 700,335 15.6


1955------ 667,811 15.0


1954------ 673,651 15.1


1953------ 684,372 15.4


1952------ 673,735 15.3


1951------ 677,529 15.4


1950------ 697,097 15.8


1949------ 730,518 16.9


l!948------ 775,306 18.1


1947------ 881,026 21.1


1946------ 820,719 20.2


1945------ 679,937 17.9


1944------ 751,478 19.9


1943------ 684,334 18,1


1942------ 651,503 17.0


1941------ 579,091 14.9


1940------ 590,120 14.8


1939------ 614,479 14.9


1938------ 621,204 15.1


1937------ 610,557 14.9


1936------ 605,292 14.8


1935------ 598,756 14.7


1934------ 597,642 14.8


1933------ 580,413 14.4


1932------ 613,972 15.3


1931------ 632,081 15.8


1930------ 648,811 16.3


1926-30--- 16,7


1921-25--- $;;$: 19.9


1916-20--- ,766,747 21.5


1911-15--- 23.9


1906-10--- ,:%:;::; 26.3


1901-5---- 1,693,269 28.2


Perinatal deaths Stillbirthsl Infant deaths [sternal deaths


Kate per late pe] iate per Mte per


Number 1,000 Numb er 1,000 Number 1,000 ?umber 1,000


total total live total


births births )irths 2 births


25,498 29.3 15,000


26,352 30.8 15,464


26,495 32.0 15,727


26,294 32.8 15,819


26,070 34.1 15,901


26,502 35.0 16,288


26,792 36.2 16,615


26,334 36.7 16,405


25,579 37.4 15,829


26,248 38.1 16,200


25,808 36.9 15,681


25,834 37,5 15,636


26,487 38.2 L5,985


26,690 37.4 L6,084


28,369 38,0 L6,947


30,546 38.5 L8,399


36,428 40.3 21,795


37,369 44.3 22,915


31,639 45,2 L9,333


34,404 44.5 ?1,306


33,785 47,9 21,262


35,081 52.1 22,383


32,829 54.7 20,87fj


35,390 57.7 ?2,779


37,390 58,5 ?4,320


37,835 58.6 24,72!3


38,252 60.2 {4,806


38,300 60.8 ?5,045


38,618 61.9 ?5,435


38,733 62.2 !5>209


$8,388 63.4 !5,084


&0,244 62.8 !6,471


to,914 62.1 !6,933


11,844 61.9 !7,577


17.2 18,042


18.1 18,187


19.( 17,393


19.E 17,118


20.E 16,629


21.5 16,685
 22,5 16,720
 7_2+~ 16,554


23.2 16,613


23.5 17,160


22.4 18,324


22.7 18,555


23.0 20,223


22.6 20,817


22.7 23,882


23,2 26,766


24.1 36,849


27.2 33,541


27.6 31,959


27.6 33,455


30,1 33,431


33.2 32,258


34.8 34,550


37.2 33,892


38.1 31,190


38.3 32,724


39.0 35,175


39.7 35,425


40.7 34,092


40.5 35,017


41.4 36,960


41.3 39,933


40.9 41,939


40.8 38,908


24,103


91,082


!38,782


.74,338


)39,136


546,845


21.1 243 0,3


21.7 299 0.4


21.4 274 0.3


21.8 310 0.4


22.2 290 

22.5 328 M 23.1 333 0.5 

23.7 374 

24.9 405 ::: 

25.4 446 0.7 

26.8 495 0.7 

27.6 ;;; 29,7 M 29.6 620 0.9 

32.4 727 1.0


33.9 811


41.4 1,060 H
 42.9 1,209


46.0 1,260 :::


45.4 1,492 1.9 

49.1 1,620 2,3 

50.6 1,672 2.5 

60.0 1,678 2.8 

56,8 1,641 2.7 

50,6 1,997 3.1 

52.8 2,096 3.2 

57.7 2,142 

58.7 2,431 ::; 57.0 2,590 4.2 

59.3 2,880 4.6 

62.7 2,737 4.5 

64.5 2,683 

65.7 2,706 ::; 60.2 2,855 4.2 

67.6 4,111 4.3 

74.9 4,932 

90.9 5,518 2:; 

108.7 7,453 4.0


117.1 .7,208


137.8 !0,028 ?:;


Iprior to 1939, births were allocated to the year Of registration; beginning with 1939, to the year


of birth.


~For 1901-25, infant mortality rates are based on,births registered in the year specified. For 1926-


56, rates are based on related live births, iOeO, births during the associated and preceding year to
 which the infant deaths relate. For 1957-63, rates are based on live births occurring in the year spec­


ified.


51

-----------------------------------------------

-----------------------------------------------

-----------------------------------------------

--------------------------------

----------------------------------------------

-----------------------------------------------

-----------------------------------------------

-----------------------------------------------

-----------------------------------------------

-----------------------------------------------

-----------------------------------------------

-----------------------------------------------

-----------------------------------------------

-----------------------------------------------

-----------------------------------------------

I

1 

Table 2. Infant mortality rates, by age: England and Wales, 1930-63


1 

Jnder
 Year I days


l963-----------------------------------------------12,3


1962 13.0


1961 13.3


1960 13.3


l959-----------------------------------------------13.6


l958-----------------------------------------------13.8


l957-----------------------------------------------14.1


1956 -----.-----.---- 14.2


l955-----------------------------------------------14.6


1954 14.9


1953 14.8


l952-----------------------------------------------15.2


1951 15.5


1950 15.2


l949-----------------------------------------------15.6


l948-----------------------------------------------15.6


l947-----------------------------------------------16.5


1946 17.8


l945-----------------------------------------------18.0


l944-----------------------------------------------17.5


l943-----------------------------------------------18.3


1942 19,6


1941 20.7


1940 21.:


l939-----------------------------------------------21.>


l938-----------------------------------------------21.1


l937-----------------------------------------------22,C


1936 21.9


l935-----------------------------------------------22.C


l934-----------------------------------------------22.7


l933-----------------------------------------------22,5


l932-----------------------------------------------22.4


1931 22.1


1930 22.(


lFor 1930-56, rates are based on related live births.


births occurring in the year specified.


I I 

Under 6-11


1 day months


Rate per 1,000 live birthsl


7.2 5.1 2.0 5,1 1.8 

7.4 5.6 2.1 4.8 1,8 

7.6 5.7 2.1 4.4 I*7 

7.5 5.8 2.2 4,6 1.6 

7.6 6.0 2.3 4.5 1.8 

7.5 6.3 2.4 4,6 1,7 

7.6 6,5 2,4 4,8 1,9 

7.4 6.8 2.6 5.0 1,8 

7,6 7.0 2.6 5.5 2,1 

7.6 7.4 2.8 5.6 2.1 

7.4 7.4 2.9 6.4 2.7 

7.6 7.6 3.2 6,7 2.6 

7.5 8.0 3,3 7.7 3,2 

7.2 8.0 3.3 8.0 3,1 

7.6 8.0 3.7 9.2 3.8 

7.8 7.9 4.1 10.3 3.9 

7.8 8.7 6.2 12,9 5.7 

8.7 9.1 6.7 13.2 5.2 

9.0 9.0 6.8 15.2 6,1 

8,8 8.8 6.9 15,0 6.1 

9.1 9.2 6.9 16.6 7,3 

9.6 10.0 7.7 16.2 7.2 

10,1 10.6 8.3 21,0 10.1 

9,8 11.5 8.3 17,5 9,7 

10.3 10,9 7.1 14.9 7.3 

10,3 10.8 7.1 15,5 9,0 

10.8 11.2 7,8 17,7 10,3 

10.7 11.3 8.2 17.6 10,9 

10.7 11.3 8.4 16.8 9.8 

10.9 11.8 8.7 16.6 11.3 

11.0 11.8 9.3 18.4 12.2 

10.6 11.8 9,2 19.8 13,2 

10.4 11.7 9.5 20.0 14,2 

10.4 11.6 8.9 17.6 11.7 

For 1957-63, rates are based on live


52

Table 3. Infant mortality rates, by sex and age: England and Wales, 1930-63


Male Female 

Year 

Under Under 1-6 7-27 28 days- 6-11 Under Under 1-6 7-27 28 days- 6-11 

7 days 1 day days days 5 months months 7 days 1 day days days 5 months months 

Rate per 1,000 live birthsi 

1963------- 14.0 8.0 6,0 2,1 5,7 1.9 10.4 6,4 4.0 1.8 4.5 1.7 

lY62------- 14,9 8.4 6.5 2.3 5,4 1,8 10,9 6.3 4.6 1.9 4.2 1.7 

1961------- 15.1 8.5 6,6 2.2 4,8 1,7 11,3 6.6 4,6 1,9 4.0 1.7 

1960------- 15,4 8,5 6.8 2.4 5,0 1.7 11.2 6,5 4,7 2,0 4.2 1,5 

1959------- 15,3 8.2 7,1 2.4 5.0 1,9 11.8 6.9 4,9 2,2 4.1 1.7 

L958------- 15.7 8.4 7.3 2.6 5.1 1.9 11.7 6,5 5,2 2.1 4.2 1.6 

1957------- 16.2 8.5 7.6 2.5 5.1 2.0 11.8 6.6 5.2 2.3 4,4 1.8 

1956------- 16.3 8.3 8.0 2.9 5.7 1.9 11.9 6.3 5.6 2.4 4,4 1.6 

1955------- 16.7 8.5 8.2 2.8 6.1 2.4 12.4 6.6 5.7 2.5 4.8 1.9 

1954------- 17.1 8.3 8.8 3.1 6,2 2.3 12.6 6.8 5.8 2.5 5.0 1.9 

1953------- 16.8 8,1 8.6 3,1 7.0 2,9 12,7 6.7 6.0 2,6 5.8 2.4 

1952------- 17.2 8.3 8,9 3.4 7.4 2.8 12.9 6,8 6,2 2,9 5.7 2.5 

1951------- 18.0 8.5 9.5 3.6 8.6 3.5 12.9 6,5 6.4 3.1 6.8 3.0 

1950------- 17.5 8,1 9,4 3.7 9.0 3.4 12.8 6,3 6,5 2.9 7.2 3.0 

1949------- 17.9 8,7 9.2 4.0 10.6 4.4 13.3 6.6 6.7 3.3 8.0 3.7 

1948------- 17.8 8.9 8.9 4.4 11.8 4.6 13.4 6.6 6.8 3.7 9.0 4.0 

19479------- 18.6 8.8 9.8 6,9 15.0 6.2 14,5 6,9 7.6 5.5 11.4 5.2 

1946------- 20.1 9.8 .0,3 7.4 13.8 4.8 15.0 7.4 7.6 5.8 10.6 4.0 

1945------- 20.3 9,9 .0,4 7.5 17,5 7.2 15.7 8,2 7.6 6.0 13.5 5.9 

1944------- 19,3 9.5 9.8 7.6 16.6 6,0 15.5 7,9 7.6 6.0 12.5 5.3 

L943------- 20.4 9,9 .0,5 7.5 18.9 7,7 16.1 8.2 7.9 6,3 14.1 6.5 

1942------- 21.9 10.6 .1.3 8.3 18.0 7.1 16,9 8.4 8.5 6.9 13.5 6,o 

1941------- 23.5 11.0 ,2.4 9,1 23.5 10.9 17.7 9,0 8.7 7.4 17.6 9.2 

1940------- 24.3 10,8 .3.5 9.0 20,7 11,1 18.3 8.7 9.5 7.6 14.6 8,9 

1939------- 23.7 11.2 .2.4 7.7 17.2 8.1 18.7 9.4 9.4 6.4 12.8 6.7 

L938------- 23.8 11.4 ,2.4 8.0 17.8 9,9 18.3 9,0 9.3 6.4 12.8 8.1 

1937------- 24.4 11.8 .2.5 8.5 20,4 11.4 19.5 9.7 9.8 7.0 14.6 9,0 

1936------- 24.8 11.9 ,2.9 9.3 20.2 11.9 18.8 9.3 9.5 7.1 13.7 9.7 

1935------- 24.9 12.0 2.9 9.3 19.1 10.7 19.0 9.5 9.5 7.5 14.4 8.7 

1934------- 25.6 12.1 3.6 9.6 18.4 11.8 19.5 9.7 9.8 7.8 14.2 10.0 

1933------- 25.9 12.2 .3.7 0.4 21.5 14.1 19.8 9.9 9.9 8.2 15.8 11.4 

1932------- 25.8 11.9 3.9 0.2 22.6 14,8 18.9 9.3 9,6 3.1 17.2 12.1 

1931------- 25.1 11.6 3.5 0.7 23.4 16.0 19.0 9.1 9.9 3.2 16.8 13.0 

1930------- 25.0 11.7 3.3 0.2 20.3 12.7 18.9 9.1 9.8 7.6 14.5 10,4 

]j7~~ 1930-38, rates are based on births registered in the year specified; for 1939-63, rates are 

based on births occurring in the year specified. 

53

---

-------------------------------------

----

-----------------------------

-------------------------------------

--------------------------

-----------

-------------------------------------

--------------------------

------------

Table 4. Average annual infant mortality rates, by age, sex, and cause of death: England and Wales, 1950-52


——— .,, 

Cause of death Under Under Under 1-6 7-27 28 days- 6-11 Sixth Revision of International Lists, 1948 I 1 year 7 days 1 day days 5 months months 

d— —. -. 11 – -—-~ 

days __.J-_ Both sexes Rate per 100,000 live births


All causes 2,909 743 329 749 304
 —


Influenza ---------------------------------480-483


Pneumonia ---------------------------------490-493,763


Bronchi tis------------------------------------5OO-5O2


Other respiratory diseases ------------470 -475,510-527


Gastritis and duodenitis --------------------------543


Gastroenteritis -------------------------------57l,764


Spina bifida and meningocele----------------------75l


Congenital hydrocephalus--------------------------752


Congenital malformations of heart---------754 .O-754.5


Congenital malformations of genitourinary system-- 757


Other congenital malformations---Re~inder of 750-759


Birth injury ----------------------------------760,761


postnatal asphyxia and atelectasis----------------762


Pemphigus and sepsis of newborn--------------- 766-768


Hemolytic disease of newbom----------------------77O


~maturity------------------------------------774, 776 

Accidental suffocation---- ------------------E921 -E925


Lack of care of infant-------------T -------------E926


Other accidents----------------Re~lnder Of E8130-E999


All other causes Residual


Male


8’


4;2 252


64 43
 16 9


13;	 8&


23


:: 13


150 47


15


134 3:


270 4


339 8


10 &


70 2


570


82 :;


14 Q


5


4:? 132


All causes I 3,275 836


Influenza-------------------------------------48O-483


Pneumonia ---------------------------------490-493,763


Bronchi tis------------------------------------5OO-5O2


Other respiratory diseases ------------470 -475,510-527 I


Gastritis and duodenitis 543 I


Gastroenteritis ------------------------------- 571,764 \


Spina bifida and meningocele----------------------75l ,
 Congenital hydrocephalus --------------------------752


Congenital malformations of heart---------754 .0-754.5


Congenital malformations of genitourinary system-- 757 I


Other congenital malformations ---Remainder of 750-759 I


Birth injury --. -------------------------------760,761 ~


Postnatal asphyxia and atelectasis----------------762


Pemphigus and sepsis of newborn---------------766-768


Hemolytic disease of newborn----------------------77O


I-turity------------------------------------774,776


Accidental suffocation ----------------------E921-E925


Lack of care of infant---------------------------E926


Other accidents -.--------------Remainder of E800-E999


All other causes .-----------------Residual


Female I


11 

5;: 276


72 51


17 10


~


15+ 100


74 19


1% i;


1;; 4:


334 .4_


399 9


12 ~


6% 1+


94 70


16
 %


4:: 142


All causes I 2,522 =&-650 657


Influenza-------------------------------------48O-483


PneumOnia-- ------. ------------------------490-493,763


Bronchitis ------------------------------------5OO-5O2 ~


Other respiratory diseases ------------470 -475,510-527


Gastritis and duodenitis 543 ~


Gastroenteritis -------------------------------571,764 ,


Spina bifida and meningocele----------------------75l


Congenital hydrocephalus --------------------------752


Congenital malformations of heart---------755 .O-754.5 ~


Congenital malformations of genitourinary system--757 !


Other congenital malformations ---Re~inder Of 750-759


Birth injury --.-------------------------------760,761 I


Postnatal asphyxia and atelectasis----------------762


Pemphigus and sepsis of newborn ---------------766-768 I


Hemolytic disease of newbom----------------------77O


1mturity------------------------------------774,776


Accidental suffocation----------------------E92l-E925


Lack of care of infant ---------------------------E926


Other accidents ----------------Remainder of E800-E999


All other causes .---.------------Residual


4;! 

55 

14 Q 

10% 

109 1? 

9 

1:; 15 

J


201 

275


8


4:8


69


13


3::


NOTE: %tes based upon less than an annual average o; ~0 deaths are underscored as a warning tO ‘Sers


that the smallness of the experience may affect their significance.


54

-------------------------------------

-------------------------------------

-------------------------------------

Table 5. Average annual infant mortality ratea, by age, sex, and cauae of death: England and Wales, 1959-61


Cauae of death Under Under Under 1-6 7-27 28 days- 6-11


Sixth Revision of International Lists, 1948 1 year 7 days 1 day days days 5 months months


Both sexes


All causes


Influenza-------------------------------------48O-483


pneumania------------------.--------------49O-493,763


Bronchitis------------------------------------5OO-5O2


Other respiratory diseases------------4527475,5lO-527


Gastritis and duodenitia--------------------------543


Gustroenteritia-------------------------------57l,764


Spins bifida and meningocele----------------------75l


Congenital hydrocepha lua--------------------------752
 Congenital malformations of heart--------- 755.O-754.5


Congenital malformations of genitourinary system--757
 !3ther congenital malformations---Remainder of 750-759


Birth injury ----------------------------------76O, 761
 Postnatal asphyxia and atelectasis----------------762


PemphiSua and sepsis of newborn--------------- 766-768
 Humolytic diseaae of newborn----------------------77O


Immaturity ------------------------------------774,776


Accidental suffocation----------------------E92l-E925


Laclc of care of infant---------------------------E926
 Other sccidents----------------Remainder of E800-E999


All other causes-----------------------------Residual


Male


All causea


lnfluenza-------------------------------------48O-483


Pneumonia ---------------------------------49O-493, 763


Bronchitis------------------------------------5OO-5O2


Other respiratory diseaaes------------4527475,5lO-527


Gaatritis and duodenitis--------------------------543


Gastruenteritis----- T---------------- _-------- 57l,764


Spins bifida and menmgocele----------------------75l


Congenital hydrocepha lua--------------------------752
 Congenital malformations of heart--------- 755.O-754.5


Congenital malformations of genitourinary system--757


Other congenital malformations---Remainder of 750-759


Birth injury ----------------------------------76O,76l


Postnsta L asphyxia and atelectssis----------------762


Pemphigus and sepsis of newborn--------------- 766-768


Hemolytic disease of newborn----------------------77O
 Immaturity ------------------------------------774,776


Accidental suffocation----------------------E92l-E925


Lack of care of infant---------------------------E926


Ckher accidents----------------Reminder of E800-E999


All other causes-----------------------------Residual


Female


All causea


lnfluenza-------------------------------------48O-483


Pneumonia ---------------------------------490-493,763


Branchitis------------------------------------5OO-5O2


Other respiratory diseases------------4527475,5lO-527


Gastritis and duodenitis--------------------------543


(Mstroenteritis -------------------------------57L,764


Spi.na bifida and meningocele----------------------75l


Congenital hydrocepha lus--------------------------752


Congenital malformations of heart--------- 755.O-754.5


Congenital malformations of genitourinary system--757


Other congenital malformations---Remainder of 750-759


Birth injury ----------------------------------76O, 761


Postnatal asphyxia and atelectaai.s----------------762


Pemphigus and sepsis of newborn--------------- 766-768


Hemulytic diseaae of newborn----------------------77O


Tmmaturity------------------------------------774,776


Accidental suffocation----------------------E92l-E925
 Tack of care of infant---------------------------E926


Other accidents----------------Remainder of E800-E999 ALL other CaUSeS-----------------------_-----Residual 

Rate per 100,000 live births


2.181 758 582 218 453 170


29;


46


12


4:


82


56


151


18


143


244


343


8


3:!


42


6


2;?


2,431


6


332


51


13


Q


2:


1%


25


L47


300


401


10


4X


48


6


2:;


1.916


Q 0 25+ 30 3Z 40 1 

11 -i -f T- 3 3+ I -z 

16 3-Z f?; 10 11 140 33 28 

10 1 2 138 37 2i 184 72 8 280 98 6 

7 2 4 

lT z 

3:: 111 15 

36 > 5 + 

z
 2;: 48 23


NOTE : Rates based upon less than an annual average of 20 deaths are underscored as a warning to users


that the smallness of the experience may affect their significance.


55

---

---

---

---

---

---

---

---

---

---

---

---

Table 6. Live birth, perinata1, stillbirth, and infant mortality rates for males: England and


Wales, 1901-63


Perinatal Infant
 Year Live birthl mortalityl.~ Stillbirth mortality2


Rate per 

1,000 

population 

Rate per 1,000 

total births 

Rate per 

1,::)tve 

.. 

1963------------------------------------------ 19.3 31.4 17.6 23.7 

1962------------------------------------------ 19.1 32.8 18.1 24.5 

1961------------------------------------------ 18.7 33.8 19.0 23.9 

1960------------------------------------------ 18.3 34.7 19.6 24.5 

1959------------------------------------------ 17.6 35.9 20.9 24.5


1958------------------------------------------ 17.5 37.2 21.8 25.3


1957------------------------------------------ 17.2 38.4 22.6 25.8


1956------------------------------------------ 16.7 39.3 23.4 26.8


1955------------------------------------------ 16.1 39.9 23.6 28.1


1954------------------------------------------ 16.3 40.5 23.9 28.7


1953------------------------------------------ 16.6 39.4 23.1 29.8


1952------------------------------------------ 16.4 40.4 23.6 30.8


1951------------------------------------------ 16.6 41.8 24.3 33.8


1950------------------------------------------ 16.8 40.7 23.7 33.6


1949------------------------------------------ 17.7 41.1 23.7 36.8


1948------------------------------------------ 18.9 41.7 24,3 38.7


1947------------------------------------------ 21.8 43.5 25.3 46.8


1946------------------------------------------ 20.5 48.0 28.4 46.1


1945------------------------------------------ 17.0 48.5 28.8 52.5


1944------------------------------------------ 18.9 47.5 28.8 49.4


1943------------------------------------------ 17.3 51.3 31.5 54.4


1942------------------------------------------ 16.6 55.3 34.1 55.3


1941------------------------------------------ 14.7 59.1 36.5 67.0


1940------------------------------------------ 15.0 62.4 39.0 65.1


1939------------------------------------------ 15.8 62.5 39.8 56.6


1938------------------------------------------ 16.1 63.1 40.2 59.5


1937------------------------------------------ 15.9 64.6 41.2 64.7


1936------------------------------------------ 15.9 65.8 42.1 66.2


1935------------------------------------------ 15.8 66.7 42.9 63.9


1934------------------------------------------ 15.8 67.2 42.7 65.4


1933------------------------------------------ 15.3 68.5 43.8 71.8


1932------------------------------------------ 16.3 68.8 44.2 73.4


1931------------------------------------------ 16.9 68.1 44.2 75.2


1930------------------------------------------ 17.4 67.8 44.0 68.2


1926-30--------------------------------------- 17.8 76.6


1921-25--------------------------------------- 21.3 85.6


1916-20--------------------------------------- 24.8 100.6


1911-15--------------------------------------- 25.5 121.4


1906-10--------------------------------------- 27.7 129.0


1901-5---------------------------------------- 29.7 151.4


lPrior to 1939, births were allocated to th year of registration; beginning with 1939, to the


year of birth.


~prior to 1939, mortality rates are based on births registered, and subsequently on births


occurring in the year specified.


56

---------------------------------------

---

---

---

---

---

---

---

---

---

---

---

---

Table 7. Live birth, perinatal, stillbirth, and infant mortality rates for females: England and


Wales, 1901-63


Perinatal Infant
 Year Live birthl mortalityl,2 Stillbirth mortality


R~t;oer Rate per
 Rate per 1,000 l,C)K/t~sve
 total births
 pop~lation


1963------------------------------------------ 17.2 27.0 16.8 18.3


1962------------------------------------------ 16.9 28.8 18.1 18.7


1961------------------------------------------ 16.5 30.1 19.1 18.8


1960------------------------------------------ 16.1 30.8 19.9 18.9


1959------------------------------------------ 15.4 32.2 20.7 19.8 

1.958------------------------------------------ 15.4 32.7 21.2 19.6 

L957------------------------------------------ 15.1 33.9 22.3 20.3 

1.956 ------------------------------------.----- 14.7 34.1 22.4 20.3 

1955------------------------------------------ 14.1 34.8 22.7 21.5 

1954------------------------------------------ 14.2 35.4 23.1 22.0


1953------------------------------------------ 14.5 34.1 21.7 23.6


1952------------------------------------------ 14.4 34.4 21.7 24.1


1951------------------------------------------ 14.4 34.3 21.8 25.7


1950------------------------------------------ 14.9 33.9 21.4 25.9


1949------------------------------------------ 15.7 34.6 21.6 28.3


1948------------------------------------------ 16.8 35.1 22.0 30.1


1.947------------------------------------------ 19.2 37.0 22.9 36.6


1946------------------------------------------ 18.0 40.4 25.8 35.3


1945------------------------------------------ 14.9 41.8 26.5 41.1


1944------------------------------------------ 16.6 41.3 26.3 39.3


1943------------------------------------------ 15.2 44.3 28.7 42.9


1942------------------------------------------ 14.5 48.6 32.2 43.3


1941------------------------------------------ 13.1 50.0 32.9 51.9


1940------------------------------------------ 13.3 52.8 35.2 49.4


1939------------------------------------------ 13.9 54.3 36.2 44.6


1938------------------------------------------ 14,1 53.8 36.2 45.5


1937------------------------------------------ 13.9 55.6 36.7 50.2


1936------------------------------------------ 13.9 55.4 37.3 50.4


1935------------------------------------------ 13.8 56.7 38.5 49.6


1934------------------------------------------ 56.8 38.1 51.4


1933------------------------------------------ 58.0 39.0 55.2


1932------------------------------------------ 56.5 38.4 56.3


1931------------------------------------------ 55.7 37.4 57.1


1930------------------------------------------ 55.6 37.4 51.4


1926-30--------------------------------------- 15.7 58.7 

1921-25--------------------------------------- 18.6 66.0 

1916-20--------------------------------------- 18.8 78.7 

:;’3;-::--------------------------------------- 22.4 97.3 

24.9 104.7 

1901:5---------------------------------------- 26.8 123.8 

lpriOrto 1939, births were allocated to the year of registration; beginning with 1939, ‘0 the


yeur of birth.


2Prior to 1939, mortality rates are based on births registered, and subsequently on births


occurring in the year specified.


57

--------------------------------------------------------------------------------

Table 8. Infant mortality rates, by cause of death: England and Wales, 1950-63


Cauae of death


Sixth Revision of International Lists, 1948


All causes


Tuberculosis of menlnges and central nervous system------------------------------------------OlO


Other tuberculoais---------------------------------------------------------------OOl-OO8,Oll-O~g


Congenital syphilis--------------------------------------------------------------------------o2o 

Whooping cough-------------------------------------------------------------------------------O56 

Meningococcal infections---------------------------------------------------------------------O57 

Acute poliomyelitia---------------------------------------------------------------.------O8O,O8l 

Measles '-------------------------------------------------------------------------------------O85


Other infective and parasitic diseases--------------------------------------Remainder of 001-138


Malignant neoplasms (including neoplasms of lymphatic and hematopoietic tissues)---------l4O-2O5


Diseases of the endocrine glands------------------------------------------------------.--25O-27~


Hemorrhagic conditions---------------------------------------------------------------295, 296,77]


Vascular lesions affecting central nervous system----------------------------------------33O-334


Meningitis, except meningococcal and tuberculosis--------------------------------------------34C


Inflammatory diseases of central nervous system except meningitis------------------------34l-342


Diseases of ear and mastoid process------------------------------------------------------39O-398


Influenza'-------------------------------------------------------------------------------48O-483


Pneumonia----------------------------------------------------------------------------49O-493, 76?


Bronchitis'------------------------------------------------------------------------------5OO-5O2


Othez respiratory diseases-------------------------------------------------------47O-475,5lO-52J


Gastritis and duodenitis---------------------------------------------------------------------543


Gastroenteritis '-------------------------------------------------------------------------57l, 764


Diseases of the skin and cellular tissue-------------------------------------------------69O-7l6


Spina bifida and meningocele-----------------------------------------------------------------75l


Congenital hydrocephalus---------------------------------------------------------------------752


Congenital malformations of heart2---------------------------------------------------754.O-754.5


Congenital malformations of genitourinary system---------------------------------------------757


Other congenital malformations----------------------------------------------Remainder of 751J-759


Birth injUy-----------------------------------------------------------------------------76O,76l


Postnatal asphyxia and atelectasis----------------------------------------------------.------762


Pemphigus and sepsis of newborn----------------------------------------------------------766-768


Hemolytic disease of newborn-----------------------------------------------------------------77O


Immaturity'------------------------------------------------------------------------------774, 776 

Accidental falls-----------------------------------------------------------------------E9oo-E9o4 

Accident by fire or hot substance------------------------------------------------------E9l6,E9l7 

Obstruction by inhalation or ingeStiOn-------------------------------------------------E92l,E922 

Accidental mechanical suffocation------------------------------------------------------E924,E925


Lack of care of infant----------------------------------------------------------------------E926


Other accidents-----------------------------------------------------------Remainder of E800-E965


All other causes----'-------------------------------------------------------------------Residual


‘For Ig50-56, rates are based on related live births. For 1957-63, rates are baaed on live


births occurring in the year specified.


‘For 1950-57, includes cause-of-death numbers 754.0-754.4.


NOTE: Rates based upon fewer than 20 deaths are underscored as a warning to users that the


smallneas of the experience may affect their significance.


58

Table 8. Infant mortalityrates, by csuse of death: England and Wales, 1950-63—Ccm.


1963 L962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950


Rate per 100,000 live birthsl


2,113 2,168 ?,144 2,181 2,222 2,253 2,311 2,375 2,491 2,542 2,682 2,759 2,966 2,963
 —— —-—. .—
 ­


‘Q ~ ~ g L g Q ~ ~ ~ 2 j_ 8 6


Q ~ ~ ~ ~ ~ ~ ~ 2 4 T 4 6 11
 —


Q g & ~ g ~ 3 3_ 4 

3 ~ ~ 3 _2_ & 9 9 9 14 24 17 40 38 

7 7 7 6 8 10 11 10 11 15 18 17 15 14 

0 0 1 1 1 0 1 2 1 8 

3 0 < 1 T 2 Y T z T F 7 1- 10 

9 lF 8 lT 10 l.- 8 17 8 lT 14 11 11 11 

7 7 7 7 7 8 8 6 7 7 7 9 8 7 

6 7 5 4 5 6 6 6 7 8 8 8 8 6 

26 29 24 27 30 35 27 33 33 34 30 28 35 29 

3 2 2 4 3 2 3 4 2 2 2 2 2 4 

16 19 19 16 15 1; 20 18 1; 1- 2; 17 2T 22 

3 4 4 ~ 3 5 3 3 4 ~ 3 4 4 7 

7 7 4 5 7 5 6 9 10 10 14 10 17 20 

4 5 4 3 9 4 11 4 7 4 11 5 24 11 

334 311 285 307 297 310 301 331 347 353 431 448 509 463 

54 49 39 46 52 47 40 45 53 49 63 56 67 67 

17 12 13 11 12 14 12 13 14 14 14 13 17 17 

0 0 1 0 0 0 0 0 1 1 2 3 2 2 

47 57 4T 4Z 47 37 47 4T 6; 67 97 101 12T 16; 

~ 1 2 1 1 2 3 3 3 3 5 7 6 7 

83 6~ 77 8? 87 97 101 109 113 112 92 100 92 81 

17 53 56 57 55 47 47 50 51 50 43 50 42 50 

158 163 L52 149 151 151 159 159 147 158 153 150 144 155 

21 21 18 21 15 18 20 16 19 16 14 15 13 16 

140 151 143 141 143 142 135 126 132 132 127 141 129 131 

228 222 252 232 247 244 253 264 268 270 262 272 282 255 

294 319 326 341 362 357 372 340 345 355 349 349 344 321 

9 7 10 8 7 9 11 10 8 11 11 10 10 10 

40 42 41 47 48 51 51 50 54 68 59 65 74 71 

334 356 373 391 385 400 430 455 475 476 518 535 570 599 

4 3 3 ~ 3 ~ 2 ~ 2 ~ ~ ~ ~ ~ 

3 3 ~ ~ 3 2 ~ ~ ~ 3 _2_ 3 ~ 2 

29 30 27 24 25 27 28 36 36 37 32 39 41 44 

17 19 15 17 19 24 22 27 27 27 29 36 43 40 

7 5 6 4 7 7 8 6 9 8 12 14 15 12 

8 6 6 6 5 6 5 5 6 4 6 5 5 3 

171 173 160 154 150 147 135 160 178 184 178 193 217 238 

59

--------------------------------------------------------------------------------

---------------------------

--------------------------------------------------------------------------------

-------------------------------- ----------------------------------------------------

-----------------

-------- ----------------------------------------------------------------

---------------

Table 9. Neonatal mortality rates, by cause of death: England and wales, 1950-63
 .


Cause of death


Sixth Revision of International Lists, 1948


All causes


Influenza-....-.----.-..----.-------------------------------------------------------------48O-48.


Pneumonia ------------------------”-- -----------------------490-493,763


Bronchitis--------------------------------------------------------------------------------5OO-5O2


Other respiratory diseases--------------------------------------------------------47O-475,5lO-527


Gastritis and duodenitis--- ....---.--.---.--.--------------------.----------.-----------------543


Gastroenteritis --.-.------.-.--...-.--.--.-.-----------------------.------..--------------571,764


Spins bifida and meningocele------------------------------------------------------------------75l


Congenital hydrocephalus---------;------------------------------------------------------------752


Congenital malformations of heart ----------.-----------------------------------------754.o-754.5


Congenital malformations of genitourinary system---------------------------------~------------757


Other congenital -lfo=tions-----------------------------------------------Rema~nder of 750-759


Birth injury--.-...-----.-----------------------------------------------------------------76O,;;;


Postnatal asphyxia and atelectasis ---------.........---------------------------------------.--


Pemphigus and sepsis of newbom-----------------------------------------------------------766-768


Hemolytic disease of newbom------------------------------------------------------------------77O


Imaturity--------------------------------------------------------------------------------774,776


Accidental suffocation--.--..--- ......--.-.-..-----.------------------------.----.----.-E92l-E925


Lack of care of infant---------------------------------------------------------;-------------E926


Other accidents------------------------------------------------------------RemaLnder of E800-E999


All other causes-.-..---...--------------------------------------------------------------Residual


lFor 1951-56, rates are based on related live births. For 1950 and 1957-63, rates are based on


live births occurring in the year specified.


‘For 1950-57, includes cause-of-death numbers 754.0-754.4


NOTE: Rates based upon fewer than 20 deaths are underscored as a warning to users that the


smallness of the experience may affect their significance.


Table 10. Postneonatal mortality rates, by cause of death: England and Wales, 1950-63


I 

Cause of death 

Sixth Revision of International Lists, 1948 I 

All causes
 I 

Influenza---------------------------------------------------------------------------------48O-483


Pneumonia ---------...-.-----.----.----------------------------------------------------49O-493,763


Bronchitis--------------------------------------------------------------------------------5OO-5O2


Other respiratory diseases--------------------------------------------------------47O-475,5lO-527


Gastritis and duodenitis----------------------------------------------------------------------543


Gastroenteritis --.-.-.--------------------------------------------------------------------57l, 764


Spina bifida and meningocele------------------------------------------------------------------75l 

Congenital hydrocephalus ----------------.---------------......752 

Congenital malformations of heart2 754.0-754.5


Congenital malformations of genitourinary system-------- ----------------------757


Other congenital malfo=tions-----------------------------------------------Re~inder of 750-759


Birth injurY------------------------------------------------------------------------------76O,76~


postnatal asphyxia and ate~ectasis------------------------------------------------------------762


3?emphigusand sepsis of newborn -----------------------------------------------------------766-768


Hemolytic disease of newbo~------------------------------------------------------------------77~


Immaturity --”----- 774,776


Accidental suffocation------------------------------------------------------------------E92l-E925


Lack of care of infant---------------------------------------------------------;-------------E926


Other accidents------------------------------------------------------------Re~~nder of E800-E999


All other causes--------..------------------------- -----------------------Residual


See footnotes at end of table 9.


60

---

---

---

---

---

---

---

---

---

---

Table 9. Neonatalmortality rates, by cause of death: England and Wales, 1950-63-Con0


1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950


Rate per 100,000 live birthsl


1,509 1.534 1.553 1,682
 — _


9: 1A


4	 4


3 3


6 

4; 6; 

30 27 

95 86 

1:: 107 $; 

222 232 260 

316 323 337 

7 9 7 

3;; 3% 4:; 

4 5 7 

5 6 

5 

15; 14* 13; 149 -— 

1>830 1,887 1,853
 — .


g ~ 136 140 12+ 

4 5 

3 : J_ ; 10 14 1% 

63
 :; 24


85 84 92


8 8 9 

83 

2:; 2;; 

341 335 

9 8 7 

5% 5<; 5;:


10 10 13


14 15 12


5


16: 17:


Table 10. Postneonatalmortality rates, by cause of death: England and Wales, 1950-63—Con.


1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950


Rate per .100,000live birthsl


610 628 I 634 637 666 763 774 911 924 1,097 1,133
 —
 —


4


20; 23; 242


36 49 46


9 T 10 12


%


23


72


3:


4


+


1;: 148 158


L + 

+ + -G 

45 55 59 

_Q + +

-L

31:	 3;; 3;;


51 63 64


10 13 13


~


9* 10+ 152 

32 29 

19 18 

64 61 64 

4:	 4? 4:


5


8 1:


+ + +


12 14 16 

65 75 72 

J_ _Q + 

1:: 2;; 

61

---------------------------------------------

---------------------------------------------

Table 11. Neonatal and first-day mortality rates among low birth weight infants, by birth weight;


England and Wales, 1953-63


?,500grams 1,500 grams 1,501-2,000 2,001-2,250 2,251-2,500
 or less or less grams grams grams


Year


Jnder Under Under Under Under Under Under Under Under Under


28 24 28 24 28 24 28 24 28 24


lays hours days hours days hours daya hours days hour~~


I -1_ —. 

Rate per 1,000 live births in specified weight group


1963---------------------- 128 80 626 444 162 90 60 30 31


1962---------------------- 133 83 656 475 163 92 64 30 36


1961---------------------- 139 84 651 447 170 96 70 34 36


1960---------------------- 138 85 665 469 173 95 73 36 34


1959---------------------- 142 85 663 461 184 100 71 31 38


1958---------------------- 142 81 669 449 183 93 69 31 41


1957---------------------- 144 82 665 443 177 93 71 31 41


1956---------------------- 146 82 666 442 184 93 80 32 39


1955---------------------- 149 82 682 445 188 90 81 31 39


1954---------------------- 152 82 685 449 199 91 81 34 44


1953---------------------- 155 84 687 441 201 97 79 32 41


Table 12. Number and percentage distribution of low birth weight infants, by birth weight: Eng­


land and Wales, 1953-63


1,500


Year Number rotal grams


1: s


!Fz!!@:


Percentage distribution


l963---------------------------------------------
56,172 100 11 18 21 ~9

l962---------------------------------------------
55,999 100 11 17 21 :0 

1961 54,632 100 12 18 20 !0 

1960 52,633 100 11 18 20 :0 . 

l959---------------------------------------------50,310 100 12 17 20 51 

l958---------------------------------------------50,742 100 11 18 20 !!1 

l953-57------------------------------------------
 235>295 100 12 18 20 !10

——


NOTE : Percentages do not always add to 100 percent because of rounding.


62

----------------------------- -----

------------------------ -----------------------------

---------------------------------

------------------------ ------------------------ ----

Table 13. Perinatal,stillbirth, and infant mortality rates for specified congenital malformations 

of the central nervous system, by sex: England and Wales, 1950-52, 1959-61, and 1962 

Cauae of death and year


= 

SPINA BIFIDA


Perinatal


1962-----------------------------


Stillbirth


1962-----------


Infant


1962---------------------------------------------------------------


1959-61------------------------------------------------------------


l95O-52------------------------------------------------------------


HYDROCEPHALUS


Perinatal


l962---------------------------------------------------------------


Stillbirth


l962---------------------------------------------------------------


Infant


1962------------------------------


1959-61------------------------------------------------------------


l95O-52------------------------------------------------------------


A’NENCEPHALUSAND MONSTROSITY
 ——.


Perinatal


1962------------------------------------------------------ --_------


ANENCEPHALUS


Stillbirth


l962---------------------------------------------------------------


MONSTROSITY


Infant


1962-----------


1959-61------------------------------------------------------------


l95O-52------------------------------------------------------------


iate per 1,000 total births 

0.6 0.5 0.7 

0.4 0.3 0.4 

Rate per 1,000 live births


0.5 0.9 

N 0.7 1.0 

0.9 I 0.7 1.1 

late per 1,000 total births


0.8 0.8 0.8 

0.6 0.7 0.6 

Rate per 1,000 live births


0.5 

0.6 ::: %; 

0.5 I 0.4 0.5 

<ate per 1,000 total births 

2.1 1.2 3.0 

1.8 1.0 2.7 

Rate per 1,000 live births


Xl_!!lx


63 
---------------

-----

-------------

-------------

---------

---------

---------------

Table 14. Number and percentage distribution of perinatal deaths and perinatal mortality rates, by time


of death and primary necropsy findings: England, SCOtl Id, and wales, ~~ar~h1958


[Mmtality rates me based cmtotidbirths or live births in the month of March ostirmtc?d from data for the control week Mwch :1.!1, I!IW-] —.— —.--L .- .--— = —. _—-

Perinatal deaths Stillbirths Under 7 days


Primary necropsy Rate Rate Rate


finding ‘ercent- per ‘ercent- per ercent- per


(umber ,gedis- .,000 Number ge dis- .,000 umber ge dis- ,000


tribution tribution :otal tribution live


Total---------


Without necropsy-


With necropsy----


Congenital malforma­


tion


Isoimmunization


Antepartum anoxia---


Antepartum death (no


major lesion)------


Intrapartum anoxia--


Intrapartum anoxia


and cerebral birth


traume


Cerebral birth


trauma


Hyaline membrane----


Intraventricular


hemorrhage


Neonatal death (no


histological


leaion)------------


Pulmonary infection-


Massive pulmonary


hemorrhage


Other


:ota1


}irths ~irths irtha


2,358 33.2 1,526 . . . 21.5 832 . . . 12.0 — — — 

170 . . . 2.4 119 . . . 1.7 51 . . . 0.7 

2>188 100.0 30,8 1,407 100.0 19.8 781 100.0 11.3 

415 19.0 5.8 246 17.5 3.5 169 21.6 2.4 

95 4.3 1.3 62 4.4 0.9 33 4.2 0.5 

245 11.2 3.4 245 17.4 3.4 ... ... ... 

239 10.9 3.4 239 17.0 3.4 ... ... ...


501 22.9 7.1 433 30.8 6.1 68 8.7 1.0


151 6.9 2.1 110 7.8 1.5 41 5.3 0.6


68 3.1 1.0 24 1.7 0.3 44 5.6 0.6


117 5.3 1.6 ... ... ... 117 15.0 1.7


50 2.3 0.7 ... . . . ... 50 6.4 0.7 

68 3.1 1.0 ... . . . ... 68 8.7 1.0 

104 4.8 1.5 ... . . . ... 104 13.3 1.5 

46 2.1 0.6 ... . . . ... 46 5.9 0.7 

89 4.1 1.3 48 3.4 0.6 41 5.2 0.5 

Source: N. R. Butler and D. G. Bonham, Perinatal Mortalitv, E.& S. Livingstone, Ltd., Edinburgh and 

London, 1963. (Adapted from table 65.) The authors are indebted to the National Birthday Trust Fund 

and the publishers for permission to use the data. 

64

-------------------

--------------

--------------

--------------------

--------------------

--------------

----------------------

Table 15. Stillbirth and infant mortality rates for all births and illegitimate birtha, by age


at death, and index numbers: England and Wales, selected years, 1936-61


_ 

1936- ~961 1936- 1940-
 Age at death	 1939 I

1939 1944 1960 1961 1

Stillbirths


Total births--------------------


Illegitimate births-------------


Under 7 days


Total births--------------------
 Illegitimate births-------------


7-27 daya 

Total births--------------------
 Illegitimate births-------------


28 days-n months


Total births--------------------


Illegitimate births-------------


Ratel Index number 

38.8 19.0 

49.6 24.2 

100 

100 

83 

80 

59 

58 2; 51 

50 

49 

49 

21.6 13.2 100 89 66 61 62 

34.4 17.5 100 82 55 53 51 

100 ;; 32 29 

1;:; ::; 100 ;: 21 24 

25.6 6.1 100 96 27 25 24 24 

41.6 5.8 100 86 17 17 17 14 

‘Stillbirth rates are per 1,000 totsl births; other rates are per 1,000 live births.


Table 16. Average annual live birth, perinatal, stillbirth, and infant mortality rates, by stand-


Standard region


England and Wales----


Northern


East and Weat Yorkshire----


North Western


North Midland


Midland


Eastern


London and South Eastern---


Southern-------------------


South Western


Wales


ard regions: England and Wales, 1960-62


Live birth Perinatal I Stillbirth


Rate per


1,000 {ate per 1,000 total births


population


17.6 31.9 18.9


18.5 35.2 21.2


17.6 33.2 19.8


18.3 35.8 21.1


17.9 31.7 19.6


18.5 33.2 20.1


17.9 28.3 16.9


16.6 28.9 16.6


18.2 27.6 16.0


16.5 29.9 18.1


17.0 37.3 22.6


infant mortality


=


Rate per 1,000 live births


21.6 15.3 6.3


24.0 16.9 7.1


23.4 16.1 7.4


25.6 17.5 8.1


21.0 14.6 6.4


22.0 15.5 6.5


18.1 13.2 4.9


19.5 14.4 5.2


19.3 13.6 5.7


19.1 13.9 5.2


24.9 17.7 7.2
 m ‘


65

----------------

-------------------

-------------

------

-----------------

--------------

-------------

-------

------------

Table 17. Average annual live birth, perinatal, stillbirth, and infant mortality rates, by con-
 Urbations and urban and rural ag~regates outside conurbations: England and Wales> 1960-62


Infant mortality


Area Live birth


England and Wales----


Conurbation


Total


Tyneside


West Yorkshire


South East Lancashire


Merseyside


West Midlands


Greater London


Outside conurbation


Urban areas with population


of 100,000 and over


Urban areas with population


of 50,000-99,999----------


Urban areas with population


under 50,000--------------


Rural districts


= -

Rate per


1,000 Rate per 1,000 total births ate per 1,000 live births


population


17.6 31.9 18.9 21.6 15.3 6.3


17.9 32.2 18.6 22.4 15.9 6.6


18.5 35.2 21.2 24.0 16.9 7.1


17.5 33.0 19.3 23.9 16.1 7.8


18.3 35.5 20.6 26.1 17.7 8.4


20.9 36.9 21.3 27.4 18.1 9.3


19.0 33.2 19.8 22.2 15.6 6.6


16.9 29.3 16.6 19.8 14.7 5.1


17.5 32.8 19.3 23.0 16.2 6.9 

17.5 32.1 19.4 21.4 15.0 6.4 

17,4 32.1 19.5 21.3 15.0 6.3 

17.3 30.4 18.4 19.7 14.2 5.5 

66

-------------------

--------------

------

----------------

-----------

------------------------------

Table 18. Percentage distribution of births for each social class, by pregnancy outcome: England,


Scotland, and Wales, March 1958


[lllLILIcI,w
 tot,ll Sinc]e births for control
 week,March3.9, 1958. Perinatzl deaths for Ilarch 195$ are related to p<!io;ated births for the same nmnt~

I IV
 III v
 Pregnancy outcome and Professional 11 Part ly


cause of death and Super- Skilled skilled Unskilled ~;::Y­


managerial visory workers workers workers


i I I I I 

Percentage distribution 

Total births 100.0 — 100.0 100.0 100.0 100.0 100.0

Survivors2----------------------- 98.0 97.1 96.7 96.7 95.8 95.3 

Perinatal deaths3---------------- 2.0 2.9 3.3 3.3 k.2 4.7 

Cause of death: 

Antepartum stillbirth 0.5 0.5 0.7 0.8 0.7 1.0 

Intrapartum anoxia and/or trauma--- 0.7 0.9 1.0 0.9 1.3 1.6 

Respiratory distress syndrome 0.2 0.3 0.3 0.3 0.4 0.4 

Pulmonary infection 0.0 0.1 0.1 0.2 0.2 0.3 

Congenital malformations 0.1 0.5 0.6 0.5 0.8 0.7 

Other 0.5 0.6 0.6 0.7 0.8 0.7 

‘Includes illegitimate births and those for which social class of father is unspecified.


%urvivors include liveborn infants who survived the first week of life.


:lperinataldeaths include stillbirths and liveborn infants who died within the first week of


life.


67

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----------------------

---------------------------------

-----------------------------------------

------------------------

----------------------------

--------------------

-------------------------------------

-------------------

Table 19. Percentage distribution of births, by mother’s blood pressure and maternal complica­


tions, and by pregnancy outcome: England, Scotland, and Wales, March 1958


fincludes total single births for control week, hkwch 3-9,1958. Perinata~deatbs for March 1958 are related to estimated births for the same! month] 

Mother’s maximum diastolic blood pressure level


in late pregnancy


Total


Normotensive (89 mm or less)--------------------------


Mild toxemia (90-99 mm)-------------------------------


Moderate toxemia (100-109 mm)-------------------------


Severe toxemia (110 mm or higher) and all cases with


90 mm or higher and proteinuria


Essential hypertension with or without proteinuria----


Other and unspecified


Total births


Percentage


distribution


100.0 

64.7


15.7


3.6


5.6


2.6


7.8


Maternal complication


I 

Early delivery


::$gg (gestation of


28-35 weeks)


, 

Percent of total births


in specified group


3.1 \ 3.2


2.5 2.8


3.4 2.5


3.4 1*5


4.5 5.:


3.8 3.2


6.1 7.2


lSurvivorS include liveborn infants who survived the first week of life.


Zperinatal deaths include stillbirths and liveborn infants who died ‘ithin the first week of


life.


Table 20. Percentage distribution of births, by type of bleeding and maternal complications, and 

by pregnancy outcome: England, Scotland, and Wales, March 1958 

[See headnote orr table 19] 

Bleeding in pregnancy


Total


No bleeding during pregnancy


Threatened abortion only


Accidental antepartum hemorrhage


Placenta previa


Unspecified antepartum hemorrhage


Maternal complication


Total births
 Early delivery


Hypertension	 (gestation of


28-35 weeks)


Percentage Percent of total births


distribution in specified group


100.0 27.5 34.4 

94.0 27.3 2.7 

2.9 26.7 3.6 

0.4 43.3 37.3 

0.5 28.8 18.8 

2.2 31.3 14.5 

lSurvivors include liveborn infants who survived the first week of life.


2Perinatal deaths include stillbirths and liveborn infants who died within the first week of


life.


68

Table 19. Percentage distribution of births, by mother’s blood pressure and maternal complica­
 tions, and by pregnancy outcome: England, Scotland, and Wales, March 1958—Con.


[Includos ktolsingle birthsfor control week, March 3-9,1958. Perinat.al deaths for hiarch 1958 are related to estimated births for the same month] 

Cause of death


Perinatal
 Total births Survivorsl deaths2 Antepartum Intrapartum Respiratory Pulmonary other


stillbirth anoxia and/or distress infection
 trauma syndrome


Percentage distribution


100.0 

100.0 96.7 3.3 

10000 97.6 2.4 

100.0 97.0 3.0 

100.0 95.6 4.4 

100.0 92.0 8,0 

100.0 95.7 4.3 7

93.1 6.9 

0.7 1.0 0.3 0.1 1.1


0.4 0.7 0.2 0.1 1.0 

0.6 1.1 0.1 0.1 1.1 

1.3 1.5 0.2 0.1 1.3 

2.7 2.5 0.8 0.3 1.7 

1.0 1.1 0.7 0.1 1.4 

1.2 2.1 1.0 0.3 2.3 

Table 20. Percentage distribution of births, by type of bleeding and maternal complications,and 

by pregnancy outcome: England, Scotland, and Walesj March Igss—con, 

[See headnote011 table 19]


Cause of death


Perinatal
 Total births Survivorsl
 deaths2 Antepartum Intrapartum Respiratory Pulmonary other


stillbirth anoxia and/or distress infection
 trauma syndrome


Percentage distribution 

100.0 96.7 3.3 0.7 1.0 0.3 ==4==== 

100.0 97.3 2.7 0.6 0.7 0.2 0.1 1.1 

100.0 92.5 7.5 1.1 1.7 2.4 0.4 1.9 

100.0 44.3 55.7 6.8 35.4 5.7 1.4 6.4 

100.0 88.3 11.7 5.1 2.7 0.6 3.3 

100.0 86.8 13.2 2.9 5.0 1.8 0.7 2.9 

t 

69

--------

--------

--------

--------

--------

--------

--------

-----------

Table 21. Percentage distribution of births, by period of gestation and by pregnancy outcome:


England, Scotland, and Wales, March 1958


[Includes total single births for control week, March 3-9, 1958. Perimtal deaths for March 1958 are related to estimated births for the same monthl

~ 

?ercent­


age Peri- Period of ~istri- rotal Survigestation bution >irths vorsl d?a%2
 )f total


births


Perce 

T~ta13------ 100.0 100.0 96.8 3.2 

Cause of death


I I I


Ante- Intra- Respira- Pulnlo
- partum nary
 Partum anOxia di:;;;ss infec- Other
 still-


birth	 and/or syndrome tion


trauma


I I I I 

age distributi(


0.7 1.0 0.3 I 0.1 1.1 

13.2 14.4 17.6 3.8 17.8 

13.7 9.9 12.7 0.6 19.0 

7.1 5.4 .5.7 1.2 13.3 

5.5 4.9 1.2 0.5 7.3 

2.0 1.7 0.4 0.2 2.8 

0.4 0.6 0.0 0.1 0.7 

0.2 0.7 0.0 0.1 0.4 

0.4 1.2 0.1 0.2 0.7 

0.8 1.3 0.6 0.3 1.6


28-29


30-31


32-33


34-35


36-37


38-39


40-41


weeks 

weeks 

weeks 

weeks 

weeks 

weeks


weeks


0.2 100.0 33.2 66.8 

0.5 100.0 44.1 55.9 

0.8 100.0 67.3 32.7 

1.7 100.0 80.6 19.4 

6.1 100.0 92.9 7.1 

28.4 100.0 98.2 1.8 

43.0 100.0 98.6 1.4 

11.5 100.0 97.4 2.6 

7.7 100.0 95.4 4.6


42 weeks and over-­


Gestation un­


certain


l~urvivorS include liveborn infants who survived the first week Of life.


2Perinatal deaths include stillbirths and liveborn infantS who died within the first week of


life.


3Excludes gestations under 28 weeks.


70

----------------------------------------------------------------

-----------------------------------------------------

-----------------------------------------------------------------

----------------------------------------------

------------------------------------------------------------

---------------------------------------------------------

-------------------------------------------------------------

------------------------------------------------------ --------------------------------------------------------------------

Table 22. Incidence of perinatal death risk factors among low birth weight infants,by period of


gestation: England, Scotland, and Wales, March 3-9, 1958


~ncl.des total skglebirths
 weighing 2,500 grmns or Iess] 

Period of gestation


Risk factor 39 q:’= 36-38 weeks 

weeks and
 ueeks
 over


Percent


Total	 100.0 100.0 100.0 — — — 

Hypertension in mother 25.0 36.0 37.0 

Primiparae 38.0 41.0 48.o 

Previous perinatal death--------------------------------------------------- 18.0 14.0 9.0 

Height of mother under 5 feet 4.0 8.0 10.0 

Fetal distress in labor---------------------------------------------------- 2.5 3.5 5.9 

Breech delivery 17.0 4.2 3.8 

NOTE: Percentages for the periods of gestation add to more than 100.0 because more than one
 risk factor may occur in a single infant.


Table 23. Percentage distribution of births for each gestation group, by pregnancy outcome: Eng­


land, Scotland, and Wales, March 1958


~rILludoH tcittd single births weighing 2,500 grams or less for control week, March 3-9,1958. Perinatril deaths for March 1958 are related to estimoted births for the same month. Excludes macerated stillbirths and deathe from congenital malformation] 

Period of gestation 

Pregnancy outcome and cause of death Under 39


36-38 weeks
 36 weeks and
 weeks
 over


I Percentage


distribution


Total births 100.0 100.0 100.0


Survivors* 63.0 91.8 94.7 

Perinatal deaths2------------------------------------------------------ 37.0 8.2 5.3 

Cause of death: 

Intrapartum anoxia andlor trauma----------------------------------------- 13.0 4.1 2.1 

Respiratory distress syndrome-------------------------------------------- 15.0 1.6 0.8 

Pulmonary infection 

Other ;.; 

. :.; . !:2 

lSurvivors include liveborn infants who survived the first week of life.


2Perinatal deaths include stillbirths and liveborn infants who died within the first week of


life.


71

--------

-------

---------

--------------------

-----

------

--------

----------

----- --- --- --- --- ---

------------------------

------- ---------- -----------

--- ----- ----- ------------- -----

------ -------------- --------

------------------------ ---------------------------

---- -- --------- -

------------------ ------- ----- --

Table 24. percentage distribution of births, by birth weight and method Of delivery, and by PregnancY


outcome: England, Scotland, and Wales, ‘arch 1958


~ncl.des total single birtbs for co.tml week, March 3.9, 1958. Perinatal dewhs for March 1958 are related to estimated births for tbe same month] 

Cause of death


Percent 1 I I
 Peri-
 Birth weight and method of Total Survi- natal Ante- Intra- Respira- Pulmo -
 of delivery total births vors deaths2 partum tory nary births ::;ylm .-
 anoxia Other
 distress infec­


birth and/or syndrome tion
 trauma


I I I 

Percentage distribution 

All birth weights--- 100.0 100.0 96.7 3.3 0.7 1.0 0.3 0.1 1.1 

Spontaneous vertex, 

occipito-anterior 85.4 100.0 97.8 2.2 0.6 0.6 0.2 0.1 0.7 

Spontaneous vertex, 

occipito-posterior 100.0 97.1 0.3 0.9 0.5 0.2 1.0 

Forceps to vertex ::? 100.0 95.7 ::: 3.0 0.1 0.1 1.1 

Breech 2.2 100.0 75.5 24.5 ::; 8.6 2.3 0.4 8.2 

Cesarean section ---------- 2.7 100.0 93.2 0.1 2.1 2.5 0.3 1.8 

Other and unspecified 2.6 100.0 83.1 12:! 1.8 3.2 1.4 0.4 10.1 

Births of 2,500 

grams or less 6.7 100.0 73.3 26.7 1.0 9.6 

Spontaneous vertex,


occipito-anterior 4.9 100.0 80.0 20.0 1,4 

Breech -------------------- 0.6 100.0 38.1 61.9 1.4 2::? 

Cesarean section 100.0 66.0 34,0 0.9 16.5 

Other and unspecified M I I 

Isurvivor- include livebO~ infants who survived the first week ‘f life”


2perinatal deaths include stillbirths and livebOrn infants who died within the first week of life.


Table 25. Incidence of short gestation or low birth weight, and percentage distribution ‘f births Y by


~regnancY outcome for plurality groups: England, Scotland, and Wales, March 1958


~CC hmdnot’a on table 24] 

Twin births


pregnancy outcome and cause of death Single birth
 I Twin I Twin 11 

I I 

I Percent	 of births in specified


plurality group


Births of 28-35 weeks of gestation 3.2 17.6 17.6


Births of 2,500 grams or less - 1 6.7 50.5 57.8


I Percentage distribution


Total births


Survivors - -------- -.- -


Perinatal deaths2
 ‘--:::::::::~


Cause of death: 

Antepartum stillbirth ----.-- 0.7 1.9 3.9 

Intrapartum anoxia andfor trauma 1.0 2,3 3.8 Respiratory di5tress ~wdrome 0.3 1.6 2.9 

Pulmonary infection .--.--- .--.--.----.-- 0.1 1.4


Other ---.-.--..--..----- 1.1 3.8 M


See footnotes on table 24.


72


r 
APPENDIX I 

DEFINITIONS 

Live bi?’th: There is no legal limitation of the period 

of gestation at which a birth may be regarded as live. 

The criterion is that the child shows signs of life after 

complete expulsion from its mother, whatever the 

period of gestation. The changing interpretation of the 

words “signs of life” is discussed on page 8. 

Stillbirth: “A stillborn child means a child which has 

issued forth from its mother after the 28th week of 

pregnancy and which did not at any time after being 

completely expelled from its mother breathe or show 

any other signs of life, and the expression ‘stillbirth’ 

shall be construed accordingly. ” d 

Total bivths: All live births and stillbirths. 

A bcwtion: Expulsion from the uterus of a dead fetus 

before the completion of 28 weeks of pregnancy. 

Infant death: Death of a Iiveborn infant under the age 

of 1 year. 

Neonatal death: Death of a Iiveborn infant under the age 

of 4 weeks (less than 28 days). 

.Rwly neonatal death: Death of a Iiveborn infant under 

the age of 1 week (less than 7 days). 

Late neo?takd deatlt: Death of a live born infant aged 1 

week or over but under 4 weeks (7 through 27 days). 

Postneonatal death: Death of a Iiveborn infant aged 4 

weeks or over but under 1 year (28 days through 11 

months). 

dBirtl]s ~tnd Deatlls Registration Act, 1926. 

Pwinakzl deaths: Stillbirths and early neonatal deaths. 

Causes of death (as defined in the British Perinatal 

Mortality Survey, 1958, based on necropsy findings): 

Antepaytum stillbirth includes stillbirths occurring after the 28th week of pregnancy but before 

the onset of labor, which were not due to congenital malformation, isoimmunization, or other 

necropsy lesion except the changes of asphyxia. It 

includes the necropsy findings ‘‘antepartum stillbirth with no lesion” and “antepartum anoxia. ” 

Intvapavtum anoxia and/ov cevelwal birth trauma 

includes intrapartum anoxia, manifested by small 

hemorrhages on the visceral pleura and pericardium, and in the cortex of the thymus with 

congestion of all viscera, especially the liver, 

spleen, and adrenal medulla. Gross meconium 

aspiration, aubcapsular hematoma of liver, mesenteric and perirenal hemorrhages, interstitial emphysema, or pneumothorax were also sometimes 

present. Microscopy of the lunga confirmed the 

presence of hemorrhages and in most cases 

showed evidence of inhalation of amniotic debris 

and meconium into alveolar ducts, bronchi, and 

alveoli. This group also includes cerebral birth 

trauma with evidence of subdural hemorrhage 

associated with laceration of the falx, tentorium, 

or great cerebral vein. 

Respiratory distwss syndrome includes atelectasis 

with pulmonary hyaline membranes; intraventricuIar hemorrhage, often coexisting with pulmonary 

hyaline membranes; and babies without obvious 

pathological lesions even on histological examination of the lungs. 

73 
APPENDIX II 

REGISTRATION AND NOTIFICATION PROCEDURES 

Birth Registration 

A birth, whether a live birth or a stillbirth, must 

be registered within 42 days of the occurrence. This is 

usually done by one of the parents. The registrar records the date and place of birth, the sex of the infant, 

the name and place of residence of the parents, and the 

father’s occupation. Since 1938 additional confidential 

information is obtained for statistical purposes only 

and is not entered in the Births Register, namely, 

the father’s age, the mother’s age and (in legitimate 

births) the date of marriage, whether previously married, and the number of previous children, liveborn or 

stillborn, by the present and previous marriages. 

In the case of a stillbirth the informant must normally give the registrar a statutory certificate signed 

by a doctor or midwife stating that the child was not 

born alive. Since October 1960 in England and Wales, 

the doctor or midwife is required to state the cause of 

the stillbirth on this certificate. (In Scotland, registration of cause of death for stillbirths started in 1939.) 

Information is also requested on birth weight and the 

estimated duration of the pregnancy, 

Certificates of stillbirth, including cause, were 

signed by midwives in 37 percent of the stillbirths in 

the fourth quarter of 1961 and in 14 percent of those 

in the third quarter of 1962. 

Birth Notification 

A birth, whether a live birth or a stillbirth, must 

be notified to the local Medical Officer of Health withir 

36 hours of the occurrence. This is usually done b} 

the midwife or doctor on forms provided by the loca 

public health department, stating the date and plain 

of birth, the sex of the infant, and the names and plac( 

of residence of the parents. 

Since 1944 the doctor or midwife has been askecl 

to state on the notification form the birth weight if i. 

was 2,500 grams or less. From 1953 the birth weigh 

has been requested in all cases. Since 1964 the docto~” 

or midwife has been asked to record on the notification 

form any congenital malformation observed at birth. 

000 

74 
APPENDIX Ill 

HEALTH SERVICES FOR MOTHERS AND CHILDREN 

Maternity Services 

An expectant mother usually, in the first place, 

consults her family doctor (or general practitioner) 

and decides with him whether to have her confinement 

at home or in hospital. 

If the mother is to be confined at home she books 

a Keneral practitioner and a midwife and they cooperate 

in the prenatal care. In the great majority of cases 

the midwife conducts the delivery, with the doctor in 

supervisory attendance, or on call if required, and 

visiting subsequently for postnatal care. The midwife 

attutds the mother and baby for at least 10 days after 

[Ilc’ confinement. 

Domiciliary consultation with an obstetric specialist is ~rranged if required. An obstetric emergency 

t~v~m (comprising an obstetrician and an experienced 

hospital midwife, with a car carrying equipment) is 

~lvailable at the principal maternity hospital in most 

towns and can be summoned by a general practitioner. 

It is particularly valuable in cases where urgent treatment is need~>d before the patient can be moved to hospital, 

A mother may obtain the services of a “home 

h.,lpc’r” m undertake the household work during her 

Iy ing - in period, ond for this a charge is made according 

tt} tht’ puticmt’s means. 

It’ th~, mothur is to he confined in a general practit i[mer mut~rnit y unit, arrangements will be made by 

IICI doctor and the matron of the unit for their coopc’ration in prenatal care and for the delivery. A 

gt’llc$~:+l practitioner maternity unit is a small unit, 

usually of not more than 25 beds, which is staffed by 

rnidwivcs but has no resident medical staff. Medical 

responsibility is undertaken by general practitioners. 

If a mother is to be confined in hospital, the hos­

,pir;tl accepts responsibility for prenatal care, the deli v.,ry, and immediate postnatal care which will be 

carried out by the hospital doctors and midwives under 

the’ direction of a consultant obstetrician. 

A posttmtal stay of 10 to 14 days in hospital has 

lIL$LT1customary for many years, but this period has 

1XU3~mu progrc’ssively less in recent years, until by 

1965, 43 percent of hospital cases were discharged 

within a week after delivery, due mainly to the need 

for delivery of more high-risk cases in hospital and 

the current bed shortage. The expedient is being used 

of 48-hour discharge in an increasing number of cen ­

ters. 54 On followup, no apparent detriment has been 

shown in mother or baby in terms of fatalit ies or readmission to hospital.s~ Careful selection must be made 

of babies suitable for 48-hour discharge and close cooperation with general practitioners and domiciliary 

midwives is essential. The findings of the British Perinatal Mortality Survey suggest that the proportion of 

suitable babies may be no higher than 25 percent of all 

hospital births, 

In most hospitals a consultant pediatrician is attached to the maternity unit, cooperating with the obstetricians in prenatal and postnatal care and undertaking the supervision of premature infants and others 

requiring special care. The concept of a specialist “neonatal pediatrician” has now been introduced successfully in a few areas. 

Table I, derived from data in the British Perinatal 

Mortality Survey in 1958, shows the part played by the 

various medical and nursing personnel in the actual delivery. It does not indicate responsibility for prenatal 

care and the general supervision of the pregnancy and 

confinement. 

Considering all medical personnel together, doctors 

delivered just under 14 percent of the total births and 

were present at the birth in a total of 27 percent. In 

the births at home, doctors delivered 6 percent and 

were present at 19 percent of births. A doctor would 

most probably have seen the patient at some time 

during labor in a further proportion of home births, 

In hospital births a doctor would certainly have seen 

the patient during labor and, if not actually present at 

birth, would be available within minutes if required. 

At actual delivery, a midwife was the senior person present in SO percent of all births, and this proportion is approximately the same for births in hospital, 

in general practitioner units, or at home. 

A midwife is a fully trained state-registered nurse 

who has taken further training for 1 year in midwifery. 

75 

I 
-----

------

---------

--------

Table I. Percentage 

place of delive;y 

England, Scotland, 

Accoucheur 

Total 

Consultant or 

registrar 

House officer---

General 

practitioner---

Ni.dwi.fe 

Pupil midwife 

or tnedical 

student 

No trained 

person presentdistribution of births, by 

according to accoucheur: 

and Wales, Ftarch 3-9, 1958 

11 Place of delivery 

All 

births Hos - practi- ~ome 

pital tioner 

unit 

II I I 

General 

Percentage distri.buti-on 

100 100 100 100 

6 10 2 

3 6 

11 6 

5: 3: 78 70 

32 48 8 20 

2 4 

After passing the examinations of the CentralMidwives 

Board, she is entitled to the designation’ ‘State Certified 

Midwife,” 

The practice of midwifery is strictly governed by 

the rules of the Central Midwives Board which, among 

other things, make it obligatory for a midwife, when 

-practicing on her own responsibility, to call for medical 

aid for any abnormality during pregnancy, labor, orthe 

puerperium. 

A midwife may, on her own responsibility, administer simple sedatives, e.g., bromides and chloral 

hydrate, and also certain other drugs, e.g., pethidine 

(meperidene) and ergometrine (ergonovine maleate), 

provided she has received instruction in the use of 

such drugs. She may also, with the same proviso, 

supervise the patient’s use of self-administered analgesia, e.g., nitrous oxide and air. She may not, on her 

own responsibility, administer anesthesia. She may perform an episiotomy but must summon medical aid for the 

repair of an episiotomy or a perineal laceration. She 

may not undertake any instrumental delivery. 

Pediatric and Child Health Services 

After the mother’s discharge from hospital, or after 

the midwife ceases attending herathome, sheis visited 

by a health visitor who continues to visit the home until 

the child reaches school age. 

A health visitov isafully trained state-registered 

nurse who has also taken a short course in midwifery 

and 9 months’ training in the public health and medicosocial aspects of nursing (especially in relation to 

mothers and children) leading to the examination flm 

the Health Visitor Certificate. 

Health visitors’ principal duties are advisilg 

mothers and supervising the progress of young children, by visiting homes and child welfare clinics. With 

the inception of the National Health Service their duti.;s 

were widened to include health educational work fm 

the whole family. In recent years they have been working increasingly in cooperation with general practitioners. 

When the child is a fewweeks old most mothers 

commence attending their local maternity and child 

welfare center. These centers are provided by local 

authorities and staffed by medical officers, hea~th 

visitors, and midwives. Their function is to provide 

advice and supervision of the child’s health (physicid, 

mental, and emotional) at routine child welfare sessions 

and also special activities such as mothercraft, prenatal exercise classes, immunization, dental clinics, 

screening tests for deafness, and special supervision 

of handicapped children. Treatment is not norma Uy 

undertaken except that ofasimpleand mainly preventive 

nature. About 80 percent of babies attend a child wt :1-

fare center. 

Under the Welfare Foods Service, expectant and 

nursing mothers and children under 5 years of age can 

obtain a pint of milk per day at a reduced price fr{ )m 

their usual dairyman by means of tokens supplied by 

the Ministry of Pensions and National Insurance. Otl-er 

welfare foods can be obtained at maternity and ch [ld 

welfare centers. These are dried milk (as an alter~[ative to liquid milk and at an equivalent price), orange 

juice, cod-liver oil, and tablets of vitamins A and C at 

cost price. Welfare foods can be obtained free of cha]ge 

in needy cases. 

In the event of illness a sick child is usually fi :st 

seen by the family doctor. If nursing care at home is 

required he calls on the visiting home nursing service 

which is provided everywhere by local authorities, If 

required, the doctor arranges a domiciliary consul .a ­

tion with a pediatric specialist. If hospital care is ‘equired the child is admitted to a children’s hospi .al 

or a childrents ward in a general hospital under the 

care of a consultant pediatrician. 

All facilities that have been mentioned, except 

home help and welfare foods, have been available without charge as part of the National Health Service since 

its inception in 1948. Alternatively, arrangements :an 

be made for a doctor, either a general practitio ler 

or a consultant, to undertake any of this work cn a 

private fee-paying basis, whether at home, in a private ‘ 

nursing home, or in the private wards of a hospi :al, 

but such arrangements are made in only a small number 

of cases. 

In the National Health Service the hospital md 

general practitioner services are financed and organized 

nationally, with regional delegation of administrate on. 

Home midwifery, home nursing, and the preventive md 

76 
cdttcatiund health services (including welfare centers 

imd health visitors) are financed partly nationally and 

part ly locally and are organized and administered by 

local government authorities. 

National Insurance Benefits 

A maternity grant is payable to a mother on the 

birth of her child, provided she or her husband have 

fulfilled tie conditions regarding insurance contributions. At the 1964 rate of exchange, this grant of $22 was 

000 

approximately equal to 62 U.S. dollars. Additional grant 

can be claimed if more than one child is born. A maternity allowance of $4 (about $11) per week is payable 

to a mother who has been employed and who gives up 

her work because of pregnancy. The allowance is for 18 

weeks, beginning 11 weeks before the expected week of 

the confinement. Family allowances are payable to all 

parents with more than one child: 8 shillings (about 

$1.10) per week for the second child and 10 shillings 

(about $1.40) per week for each subsequent child. 

k U , S, GOVERNMENT PRINTING OFFICE: 1968 -342043/2!3 

77 
OUTLINE OF REPORT StKlts FOR VITAL AND HEALIH Statistics 

Public Health Service Publication No. 1000 

Series 1.€ Progvams and collection ~vocedu>,es. — Reports which describe the general programs of the National 

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, 

and other material necessary for understanding tbe data. 

SeYies 2.	 Data evaluation and methods ~.esea)-ch. —Studies of new statistical methodology including: experimental tests of new survey methods, studies of vital statistics collection methods, new analytical 

techniques, objective evaluations of reliability of collected data, contributions to statistical theory. 

SeYies 3.	 il?la~ytical studies. — Reports presenting analytical or interpretive studies based on vital and health 

statistics, carrying the analysis further than the expository types of reports in the other series. 

Sevies 4. Docu}nents a)zd Conlmittee }-epo~ts. — Final reports of major committees concerned with vital and 

health statistics, and documents such as recommended model vital registration laws and revised birth 

and death certificates. 

Series 10.	 Data jvom the Health Inte).lielo Sllroey. —Statistics on illness, accidental injuries, disability, use of 

hospital, medical, dental and other services, and other health-related topics, based on data collected 

in a continuing national household interview survey, 

Sevies 11.	 Data frofn the Health Examination Suy[ey.- Data from direct examination, testing, and measuren~ent of national samples of the population provide the basis for two types of reports: (1) estimates 

of the medically defined prevalence of specific diseases in the United States and the distributions of 

the population with respect to physical, physiological. and psychological characteristics; and (2) 

.~nllysis of relationships among the v.~rious me~surernents without reference to an explicit finite 

universe of persons. 

Sevies 12.	 Data from the Ins titutional Population .% rl,eys. - Statistics relating to the health characteristics of 

persons in institutions, and on medical, nursing. and personal care received, based on national 

samples of establishments providing these services and samples of the residents or patients. 

SeVies 13.	 Data ,f)>o?n the Hospital L)i.sc}lavge Su~,vey. —statistics relating to discharged patients in short-stay 

hospitals, based on a sample of patient records in a national sanlple of hospitals. 

SeYies 14.	 Data on l~ealth vesowces: manpowey and facilities. — Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health 

manpower occupations, hospitals, nursinv h(~mes, and outpatient and other inpatient facilities. 

SeYies 20.	 Data on )novtality .—Various statistics on mortality other than as included in annual or monthly 

reports —special analyses by cause of death, age, and other demographic variables, also geographic 

and time series analyses. 

Sevies 21.	 Data on natality, marviage, and divo~ce. —\7arious statistics on natality, marriage, and divorce other 

than as included in annual or monthly reports —special analyses by demographic variables, also 

geographic and time series analyses. studies of fertility. 

SeVies 22.	 Data fvom tJ~e .~ational Natality and Mortality Suvveys. —Statistics on characteristics of births and 

deaths not available from the vital records, based on sample surveys stemming from these records, 

incluchng such topics as mortality by socioeconomic class, medical experience in the last year of 

life, characteristics of pregnancl. ~,tc. 

For a list of titles of reports published in these series, write to: Office of Information 

National Center for Health Statistics 

U.S. Public Health Service 

Washington, D.C. 20201