A survey of maternal deaths in Maryland

It must be evident from these figures which have been briefly summarized that a considerable number of women in the last three years lost their lives in the counties of Maryland without satisfactory care before or during childbirth. These women are for the most part not the very young or the old in years, but in the majority of instances the lives that were lost were those of married women living in normal homes and frequently mothers of older children. In other words, they comprise a group that cannot be lost without great loss in many ways to their families and to the communities in which they lived. A surprisingly large percentage of the deaths resulted from premature births among women who had not been under medical advice. Careless and ignorant midwives were associated with these maternal deaths in only a small proportion of these cases. The impression we have received from this review of maternal deaths in the counties of Maryland is that they were due directly or indirectly to the ignorance or indifference of the people themselves. Help from physician or midwife was rarely called for until alarming and dangerous complications had arisen and the physician was obliged to take emergency measures under unfavorable conditions. The patients who were reported to have died in hospitals were almost without exception admitted extremely ill when there was but little that could be done to save them. The apparent acceptance on the part of families and the public of the many deaths in childbearing as a matter which cannot be changed, deserves serious consideration. For until this attitude is altered and it is recognized generally that when a woman is in competent hands early in her pregnancy the dangers of childbearing are greatly lessened, we shall continue to lose many lives unnecessarily. Certainly it is most desirable that those undertaking obstetric work should have adequate training and experience. This matter is receiving attention by many medical faculties. However, a review of the maternal deaths here presented shows that but few of them could have been saved by more skilled hands at the critical period in which the physician was first called. Already sepsis or toxemia or other complication was so far developed as to render the best treatment unavailing. We were not able to determine in our series how much of the delay in calling in a doctor was due to the desire to save money. This seems to have been a factor in a considerable number of instances. Certainly the usual fee in the counties for obstetric service is a moderate return for the value of this service. Moreover, it is a charge which can be anticipated and saved for, as is not true of sudden or unexpected illness. We are told, however, that the cost of illness cannot be defrayed out of the available income in the case of about one-third of the American homes and presumably this is true also of the cost of bearing children. When the dangers of procrastination are not understood, the doctor's services are dispensed with as long as possible. Obstetric service is provided free of all charge by private practitioners in many instances, greatly to the credit of the physician; but this is not fair to either doctor or patient who may not want to be a receiver of charity. In the rural sections there is no obstetric service available to the indigent such as is offered to the corresponding group in Baltimore through the Johns Hopkins Hospital and the Hospital of the University of Maryland and other clinics. Hospital beds, free or at moderate cost, are provided in the county hospitals. There is still much unwillingness to make use of them for normal cases. If there were a general demand for such accommodation, the beds would prove far too few. It would seem then that there is need in each county for some organized plan by which obstetric service could be furnished at little or no cost to those families of very moderate means. From such families come most of our maternal deaths at present. It is hardly reasonable to expect a physician whose practice covers a large area to undertake gratis the care of widely separated normal obstetric cases. If the private physician is to continue to do this charity work, he should receive from the county or elsewhere an adequate financial return. It is the custom of a number of doctors in the counties to use midwives whom they know to be capable and clean in their obstetric practice among the poor. The midwife in Europe, as is well known, occupies a more important position than with us. There she delivers nearly all normal cases and calls upon the physician only when difficulties arise. Our midwives in Maryland are far below those in Europe in education and training. However, the older ones are dying out and the newer ones have had some instruction and have passed a qualifying examination. The standard among them would be greatly raised if a carefully selected number could be received in some of our county hospitals and given instruction and practical experience. This could be arranged with but little expense to the hospital. It is conceivable that a physician with an active obstetric practice might make use of three or four midwives resident in different communities covered by his practice for delivering normal cases under his supervision. It would be advisable that he make at least one complete physical examination and be ready to respond if unforeseen difficulties appeared. There are now public health nurses in every county who are willing to visit any indigent expectant mothers at the request of a physician, give them such prenatal instruction as the physician desires and report to him at regular intervals. In two counties prenatal clinics have been organized with the approval of the profession for the examination and advice of indigent expectant women. We have received monthly reports from one of those prenatal clinics. The patients are either referred by local physicians or are indigent women, found by the public health nurses, who had made no arrangement for their care before or during labor. Of some 50 of these cases at least 10 were suffering from conditions which probably would have resulted fatally except for the care received at the clinic. Thus far there have been no maternal deaths. Would it not be possible in each county for the physicians themselves, or if they desire it, with the assistance of an experienced obstetrician, to organize a similar clinic where indigent expectant mothers may be examined early in their pregnancy, receive prenatal advice, and be helped to make suitable arrangements for their labor? To such a clinic the local physician might care to refer certain of his own patients and examine them himself. Probably many midwives could be encouraged to send their patients to such a clinic for examination and prenatal advice. A regular prenatal clinic in a county could readily be made a useful teaching center for physicians and so of mutual advantage both to the patient and to the profession. It has been suggested that a wider use in the counties of maternity insurance would bring improvement to the conditions it is so desirable to remedy. It is to be feared, however, that the group it seems especially necessary to help, would not be willing, perhaps not able, to pay the necessary premiums. It is quite evident that the profession cannot be, and the public ought not to be, satisfied with the present state of affairs. Through some plan, such as the more frequent use of the county hospital, the use and supervision of selected midwives, the prenatal clinic, maternity insurance, or the employment of the public health nurses, the physician might be able to supply at less sacrifice of his own valuable time and at less financial cost to his patient of moderate means, satisfactory prenatal and natal care, both of which seem desirable from the study of the maternal deaths. The fundamental part of any plan, however, for better service, is the necessity of bringing home to each prospective father and mother in the State, and to every community, that not to attempt to furnish every expectant mother with at least a minimum of medical care during her waiting period and at the hour of labor, is little short of criminal negligence. It is recognized that excellent and early care of the expectant mother and skilled obstetric service will not save all women in childbearing, but it is confidently believed it would result each year in the salvage of one-third of the lives of mothers, and one-third of the potential infant lives now being lost before or shortly after birth. This is certainly a goal worth striving for.